Implementing Change: It's as Hard as it Looks

With increasing efforts to put evidence-based medicine into daily practice, it has become apparent that current ad hoc implementation strategies do not result in desired outcomes. There is a need to evaluate and further develop evidence-based implementation strategies that are effective and efficient. To begin this effort, the authors recognize the importance of integrating implementation into program development rather than treating it as an afterthought to be achieved through promotion and encouragement. Reviewing three empirical frameworks, derived from experience with continuous quality improvement (CQI) programs, guideline and practice change implementation, and disease management programs, the authors identify four key factors for successful program development and implementation. The four factors are: aligning the program with the strategic goals of the organization; obtaining active senior leadership commitment, including allocated resources; securing the appropriate infrastructure to facilitate integration of recommended actions into daily practice; and setting up systematic communications with all involved stakeholders. The authors reviewed randomized clinical trials that compared single and combined implementation approaches to determine whether experimental results would confirm the empirical findings. The results of these clinical trials demonstrated that when organizational commitment, in the form of allocating sufficient resources and/or providing a facilitating infrastructure, is lacking, programs are not successfully implemented. The studies did not explicitly evaluate the concept of strategic alignment of goals or communication strategies. Considering these findings, the authors wonder whether it is worthwhile to develop programs in settings that lack the major success factors, since they are likely to fail to be implemented widely. Before reaching this conclusion, they recommend more research to identify more clearly the nature of the success factors and their relative importance in achieving the desired outcomes of disease management programs.Disease management programmes, Pharmacoeconomics

Health literacy, social support, and health: a research agenda

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects health status and health service utilization. Moreover, studies have shown significant variation in individual adaptation to health literacy problems. This article proposes research hypotheses to address two questions: (1) What are the causal pathways or intermediate steps that link low health literacy to poor health status and high utilization of expensive services such as hospitalization and emergency care? (2) What impact does social support have on the relationships between health literacy and health service utilization? Empirical studies of health literacy are reviewed to indicate the limitations of current literature and to highlight the importance of the proposed research agenda. In particular, we note the individualistic premise of current literature in which individuals are treated as isolated and passive actors. Thus, low health literacy is considered simply as an individual trait independent of support and resources in an individual's social environment. To remedy this, research needs to take into account social support that people can draw on when problems arise due to their health literacy limitations. Examination of the proposed agenda will make two main contributions. First, we will gain a better understanding of the causal effects of health literacy and identify missing links in the delivery of care for patients with low health literacy. Second, if social support buffers the adverse effects of low health literacy, more effective interventions can be designed to address differences in individuals' social support system in addition to individual differences in reading and comprehension. More targeted and more cost-efficient efforts could also be taken to identify and reach those who not only have low health literacy but also lack the resources and support to bridge the unmet literacy demands of their health conditions.USA Health literacy Social support Health information Health service utilization

Racial differences in medication adherence: A cross-sectional study of Medicare enrollees.

Elderly African Americans reported that they followed physician instructions on how to take medications less frequently than did elderly whites, even after adjusting for differences in demographic characteristics, health literacy, depression, and social support

Effects of health literacy on health status and health service utilization amongst the elderly

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects health status and health service utilization. With a sample of 489 elderly Medicare patients in a Midwestern city in the USA, we explored the intermediate factors that may link health literacy to health status and utilization of health services such as hospitalization and emergency care. We expected to find that individuals with higher health literacy would have better health status and less frequent use of emergency room and hospital services due to (1) greater disease knowledge, (2) healthier behaviors, (3) greater use of preventive care, and (4) a higher degree of compliance with medication. Using path analysis, we found, however, that health literacy had direct effects on health outcomes and that none of these variables of interest was a significant intermediate factor through which health literacy affected use of hospital services. Our findings suggest that improving health literacy may be an effective strategy to improve health status and to reduce the use of expensive hospital and emergency room services among elderly patients.Health literacy Health Health service utilization Health status USA Elderly

The Roles of Low Literacy and Social Support in Predicting the Preventability of Hospital Admission

BACKGROUND: Prior studies found higher hospitalization rates among patients with low literacy, but did not determine the preventability of these admissions or consider other determinants of hospitalization, such as social support. This study evaluated whether low literacy was a predictor for preventability of hospitalization when considered in the context of social support, sociodemographics, health status, and risk behaviors. METHODS: A convenience sample of 400 patients, admitted to general medicine wards in a university-affiliated Veterans Affairs hospital between August 1, 2001 and April 1, 2003, completed a face-to-face interview to assess literacy, sociodemographics, social support, health status, and risk behaviors. Two Board-certified Internists independently assessed preventability of hospitalization and determined the primary preventable cause through blinded medical chart reviews. RESULTS: Neither low literacy (<seventh grade) nor very low literacy (<fourth grade) was significantly associated with preventability of hospitalization. In multivariable analysis, significant predictors of having a preventable cause of hospitalization included binge alcohol drinking (P≤.001), lower social support for medical care (P<.04), ≤3 annual clinic visits (P<.005), and ≥12 people talked to weekly (P<.023). Among nonbinge drinkers with lower social support for medical care, larger social networks were predictive of preventability of hospitalization. Among nonbinge drinkers with higher support for medical care, lower outpatient utilization was predictive of the preventability of hospitalization. CONCLUSIONS: While low literacy was not predictive of admission preventability, the formal assessment of alcohol binge drinking, social support for medical care, social network size, and prior outpatient utilization may enhance our ability to predict the preventability of hospitalizations and develop targeted interventions