Publications by authors named "Julie Ayre"

20 Publications

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Perceived public health threat a key factor for willingness to get the COVID-19 vaccine in Australia.

Vaccine 2021 Aug 5. Epub 2021 Aug 5.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.

Background: Vaccination rollout against COVID-19 is underway across multiple countries worldwide. Although the vaccine is free, rollout might still be compromised by hesitancy or concerns about COVID-19 vaccines.

Methods: We conducted two online surveys of Australian adults in April (during national lockdown; convenience cross-sectional sample) and November (very few cases of COVID-19; nationally representative sample) 2020, prior to vaccine rollout. We asked about intentions to have a potential COVID-19 vaccine (If a COVID-19 vaccine becomes available, I will get it) and free-text responses (November only).

Results: After adjustment for differences in sample demographics, the estimated proportion agreeing to a COVID-19 vaccine if it became available in April (n = 1146) was 76.3%. In November (n = 1941) this was estimated at 71.5% of the sample; additional analyses identified that the variation was driven by differences in perceived public health threat between April and November. Across both surveys, female gender, being younger, having inadequate health literacy and lower education were associated with reluctance to be vaccinated against COVID-19. Lower perceived susceptibility to COVID-19, belief that data on the efficacy of vaccines is 'largely made up', having lower confidence in government, and lower perception of COVID-19 as a public health threat, were also associated with reluctance to be vaccinated against COVID-19. The top three reasons for agreeing to vaccinate (November only) were to protect myself and others, moral responsibility, and having no reason not to get it. For those who were indifferent or disagreeing to vaccinate, safety concerns were the top reason, followed by indecision and lack of trust in the vaccine respectively.

Conclusions: These findings highlight some factors related to willingness to accept a COVID-19 vaccine prior to one being available in Australia. Now that the vaccine is being offered, this study identifies key issues that can inform public health messaging to address vaccine hesitancy.
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http://dx.doi.org/10.1016/j.vaccine.2021.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8339499PMC
August 2021

Impact of diagnostic labels and causal explanations for weight gain on diet intentions, cognitions and emotions: An experimental online study.

Appetite 2021 Dec 26;167:105612. Epub 2021 Jul 26.

Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, 2006, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, 2006, Australia. Electronic address:

Disease labels and causal explanations for certain symptoms or conditions have been found to have both positive and negative outcomes. For example, a diagnosis of polycystic ovary syndrome could conceivably motivate a person to engage in weight management, which is the recommended first line treatment. Furthermore, doctors may feel more comfortable discussing weight when linked to a medical condition. However, such a diagnosis may elicit feelings of increased anxiety, perceived severity and reduced sense of control. Mixed findings are also evident for impacts of genetic explanations on psychosocial outcomes and behaviours. Using hypothetical scenarios presented in an online survey, participants were asked to imagine that they were visiting their general practitioner due to experiencing weight gain, irregular periods, and more pimples than usual. Participants were randomised to receive different diagnostic labels ('polycystic ovary syndrome', 'weight' or no label/description) and causal explanations (genetic or environmental) for their symptoms. Primary outcomes assessed included intention to eat a healthier diet and perceived personal control of weight (average score on scale 1-7 across 3 items). Secondary outcomes included weight stigma, blameworthiness, worry, perceived severity, self-esteem, belief diet will reduce risks and menu item choice. Participants were 545 females aged 18-45 years (mean = 33 years), living in Australia, recruited through a national online recruitment panel. The sample was overweight on average (BMI = 26.5). Participants reporting a PCOS diagnosis were excluded from analyses. We found no main effects of the label or explanation on intention to eat healthier or perceived personal control of weight. For secondary outcomes, those given the genetic explanation reported higher weight stigma (range 1-7; MD = 0.27, 95%CI: 0.011,0.522), greater worry (range 1-7; MD = 0.27, 95%CI: 0.037,0.496), lower self-esteem (range 10-40; MD = 1.26, 95%CI: 0.28 to 2.24) and perceived their weight as more severe (range 1-7; MD = 0.28; 95%CI: 0.05,0.52) than those given the environmental explanation, averaged over disease label given. These findings further highlight the deleterious effects of genetic explanations on psychosocial outcomes and reinforce the need for caution when communicating the aetiology of weight-related health issues.
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http://dx.doi.org/10.1016/j.appet.2021.105612DOI Listing
December 2021

Contextualising COVID-19 prevention behaviour over time in Australia: Patterns and long-term predictors from April to July 2020 in an online social media sample.

PLoS One 2021 29;16(6):e0253930. Epub 2021 Jun 29.

Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.

Background: In Australia in March 2020 a national public health directive required that non-essential workers stay at home, except for essential activities. These restrictions began easing in May 2020 as community transmission slowed.

Objectives: This study investigated changes in COVID prevention behaviours from April-July 2020, and psychosocial predictors of these behaviours.

Methods: An Australia-wide (national) survey was conducted in April, with monthly follow-up over four months. Participants who were adults (18+ years), currently residing in Australia and who could read and understand English were eligible. Recruitment was via online social media. Analysis sample included those who provided responses to the baseline survey (April) and at least one subsequent follow-up survey (N = 1834 out of a possible 3216 who completed the April survey). 71.7% of the sample was female (n = 1,322). Principal components analysis (PCA) combined self-reported adherence across seven prevention behaviours. PCA identified two behaviour types: 'distancing' (e.g. staying 1.5m away) and 'hygiene' (e.g. washing hands), explaining 28.3% and 24.2% of variance, respectively. Distancing and hygiene behaviours were analysed individually using multivariable regression models.

Results: On average, participants agreed with statements of adherence for all behaviours (means all above 4 out of 7). Distancing behaviours declined each month (p's < .001), whereas hygiene behaviours remained relatively stable. For distancing, stronger perceptions of societal risk, self-efficacy to maintain distancing, and greater perceived social obligation at baseline were associated with adherence in June and July (p's<0.05). For hygiene, the only significant correlate of adherence in June and July was belief that one's actions could prevent infection of family members (p < .001).

Conclusion: High adherence to COVID prevention behaviours were reported in this social media sample; however, distancing behaviours tended to decrease over time. Belief in social responsibility may be an important aspect to consider in encouraging distancing behaviours. These findings have implications for managing a shift from government-imposed restrictions to individual responsibility.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253930PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241082PMC
July 2021

Developing performance-based measures of health literacy: A narrative case study and checklist of considerations.

Patient Educ Couns 2021 Jun 11. Epub 2021 Jun 11.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.

Research in health literacy is fundamentally impacted by our ability to adequately assess the construct. Although various measures of health literacy have been developed, there are few reflective discussions of the challenges and learnings from the instrument development process. This is somewhat surprising given that health literacy is a multi-dimensional and contested concept (with inherent measurement challenges), and that there are important practical considerations owing to the fact that people completing health literacy assessments may have lower general literacy (i.e. ability to read and write) and English-language skills. This paper discusses our learnings from developing a performance-based measure of parenting health literacy skills (the Parenting Plus Skills Index). The performance-based instrument is characterised by its grounding in health literacy as asset, with items spanning Nutbeam's functional, communicative and critical health literacy skills, and was designed chiefly to capture improvements resulting from health literacy skills training. This paper elucidates critical junctures in the development process, particularly regarding the conceptualisation and operationalisation of the construct. We also outline our approach to addressing practical measurement issues (e.g. administration time; item difficulty). In summarising these, we offer a 13-item checklist to inform the development of health literacy instruments for other health contexts or health conditions.
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http://dx.doi.org/10.1016/j.pec.2021.06.015DOI Listing
June 2021

The Psychological Impact of Hypertension During COVID-19 Restrictions: Retrospective Case-Control Study.

JMIRx Med 2021 Jan-Mar;2(1):e25610. Epub 2021 Mar 30.

Sydney Health Literacy Lab, School of Public Health Faculty of Medicine and Health The University of Sydney Sydney Australia.

Background: It is unclear how people with hypertension are responding to the COVID-19 pandemic given their increased risk, and whether targeted public health strategies are needed.

Objective: This retrospective case-control study compared people with hypertension to matched healthy controls during the COVID-19 lockdown to determine whether they have higher risk perceptions, anxiety, and vaccination intentions.

Methods: Baseline data from a national survey were collected in April 2020 during the COVID-19 lockdown in Australia. People who reported hypertension with no other chronic conditions were randomly matched to healthy controls of similar age, gender, education, and health literacy level. A subset including participants with hypertension was followed up at 2 months after restrictions were eased. Risk perceptions, anxiety, and vaccination intentions were measured in April and June.

Results: Of the 4362 baseline participants, 466 (10.7%) reported hypertension with no other chronic conditions. A subset of 1369 people were followed up at 2 months, which included 147 (10.7%) participants with hypertension. At baseline, perceived seriousness was high for both hypertension and control groups. The hypertension group reported greater anxiety compared to the controls and were more willing to vaccinate against influenza, but COVID-19 vaccination intentions were similar. At follow-up, these differences were no longer present in the longitudinal subsample. Perceived seriousness and anxiety had decreased, but vaccination intentions for both influenza and COVID-19 remained high across groups (>80%).

Conclusions: Anxiety was above normal levels during the COVID-19 lockdown. It was higher in the hypertension group, which also had higher vaccination intentions. Groups that are more vulnerable to COVID-19 may require targeted mental health screening during periods of greater risk. Despite a decrease in perceived risk and anxiety after 2 months of lockdown restrictions, vaccination intentions remained high, which is encouraging for the future prevention of COVID-19.
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http://dx.doi.org/10.2196/25610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078439PMC
March 2021

Type 2 diabetes self-management schemas across diverse health literacy levels: a qualitative investigation.

Psychol Health 2021 Apr 30:1-21. Epub 2021 Apr 30.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.

Objective: The aim of this study was to explore how people with diabetes and diverse health literacy levels conceptualise their experience and efforts to engage in self-management behaviours (their self-management 'schemas').

Design: A qualitative design was applied.

Methods: Twenty-six people in Sydney, Australia, took part in semi-structured interviews, which were audio-recorded and coded using Framework analysis.

Results: Half the participants (54%) had limited health literacy, whereas 38% adequate health literacy (using Newest Vital Sign). Regardless of health literacy, people described how monitoring increased self-management awareness and signalled periods of low self-management ('lulls'). Accounts of monitoring to sustain motivation were more apparent for participants with adequate health literacy. Most participants described simple and flexible rules (e.g. use artificial sweeteners; eat in moderation). Two schemas related to 'lulls': a 'problem-solving orientation' depicted lulls as inevitable and was associated with varied coping strategies; a 'willpower orientation' attributed lulls to lack of 'willpower,' and described willpower as a main coping strategy.

Conclusion: There is considerable variation in how people think about their diabetes self-management and the strategies they use. Health literacy may contribute to some of this variation. Self-management interventions could benefit from depicting motivation as fluctuating and challenging ideas about willpower and self-blame.
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http://dx.doi.org/10.1080/08870446.2021.1909023DOI Listing
April 2021

The impact of theory-based messages on COVID-19 vaccination intentions: a structured summary of a study protocol for a randomised controlled trial.

Trials 2021 Apr 29;22(1):311. Epub 2021 Apr 29.

University of Glasgow, Glasgow, UK.

Objectives: Uptake of vaccination against COVID-19 is key to controlling the pandemic. However, a significant proportion of people report that they do not intend to have a vaccine, often because of concerns they have about vaccine side effects or safety. This study will assess the impact of theory-based messages on COVID-19 vaccination intention, drawing on the Necessity-Concerns framework to address previously reported beliefs and concerns about COVID-19 vaccination, and assess whether hypothesised variables (illness coherence, perceived necessity and concerns) mediate change in vaccination intention.

Trial Design: Prospective, parallel two-arm, individually randomised (1:1) trial.

Participants: Adults aged over 18 years, living in Scotland and not vaccinated for COVID-19. A quota sampling approach will be used with the aim of achieving a nationally representative sample on gender, region and ethnic group, with oversampling of individuals with no educational qualifications or with only school-level qualifications.

Intervention And Comparator: Intervention: Brief exposure to online text and image-based messages addressing necessity beliefs and concerns about COVID-19 vaccination. Comparator: Brief exposure to online text and image-based messages containing general information about COVID-19 and COVID-19 vaccination.

Main Outcomes: Primary outcome: Self-reported intention to receive a vaccine for COVID-19 if invited, immediately post-intervention.

Secondary Outcomes: Self-reported COVID-19 illness coherence, perceived necessity of a COVID-19 vaccine and concerns about a COVID-19 vaccine, immediately post-intervention.

Randomisation: Quasi-randomisation performed automatically by online survey software, by creating a variable derived from the number of seconds in the minute that the participant initiates the survey. Participants starting the survey at 0-14 or 30-44 seconds in the minute are allocated to the intervention and 15-29 or 45-59 seconds to the comparator.

Blinding (masking): Participants will not be blinded to group assignment but will not be informed of the purpose of the study until they have completed the follow-up survey. Investigators will be blinded to allocation as all procedures will be undertaken digitally and remotely without any investigator contact with participants.

Numbers To Be Randomised (sample Size): A total of 1,094 will be randomised 1:1 into two groups with 547 individuals in each.

Trial Status: Protocol version number 1.0, 26 February 2021. Recruitment status: Not yet recruiting, set to start April 2021 and end April 2021.

Trial Registration: ClinicalTrials.gov, NCT04813770 , 24 March 2021.

Full Protocol: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
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http://dx.doi.org/10.1186/s13063-021-05277-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082050PMC
April 2021

Positive outcomes associated with the COVID-19 pandemic in Australia.

Health Promot J Austr 2021 Apr 16. Epub 2021 Apr 16.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.

Issue Addressed: To investigate whether Australians have experienced any positive effects during the COVID-19 pandemic.

Methods: National online longitudinal survey. As part of a June 2020 survey, participants (n = 1370) were asked 'In your life, have you experienced any positive effects from the COVID-19 pandemic' (yes/no) and also completed the World Health Organisation-Five well-being index. Differences were explored by demographic variables. Free-text responses were thematically coded.

Results: Nine hundred sixty participants (70%) reported experiencing at least one positive effect during the COVID-19 pandemic. Living with others (P = .045) and employment situation (P < .001) at baseline (April) were associated with experiencing positive effects. Individuals working for pay from home were more likely to experience positive effects compared to those who were not working for pay (aOR = 0.45, 95% CI: 0.32, 0.63, P < .001) or who were working for pay outside the home (aOR = 0.40, 95% CI: 0.28, 0.58, P < .001). 54.2% of participants reported a sufficient level of well-being, 23.2% low well-being and a further 22.6% very low well-being. Of those experiencing positive effects, 945/960 (98%) provided an explanation. The three most common themes were 'Family time' (33%), 'Work flexibility' (29%) and 'Calmer life' (19%).

Conclusions: A large proportion of participants reported positive effects resulting from changes to daily life due to the COVID-19 pandemic in Australia.

So What: The needs of people living alone, and of those having to work outside the home or who are unemployed, should be considered by health policymakers and employers in future pandemic preparedness efforts.
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http://dx.doi.org/10.1002/hpja.494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250613PMC
April 2021

Concerns and motivations about COVID-19 vaccination.

Lancet Infect Dis 2021 02 15;21(2):161-163. Epub 2020 Dec 15.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.

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http://dx.doi.org/10.1016/S1473-3099(20)30926-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832277PMC
February 2021

COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey.

J Med Internet Res 2021 01 7;23(1):e23805. Epub 2021 Jan 7.

The University of Sydney, Sydney, Australia.

Background: Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined.

Objective: This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time.

Methods: This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020.

Results: Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation.

Conclusions: The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.
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http://dx.doi.org/10.2196/23805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800906PMC
January 2021

People's Experiences and Satisfaction With Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study.

J Med Internet Res 2020 12 10;22(12):e24531. Epub 2020 Dec 10.

Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, Australia.

Background: In response to the COVID-19 pandemic, telehealth has rapidly been adopted to deliver health care services around the world. To date, studies have not compared people's experiences with telehealth services during the pandemic in Australia to their experiences with traditional in-person visits.

Objective: This study aimed to compare participants' perceptions of telehealth consults to their perceptions of traditional in-person visits and investigate whether people believe that telehealth services would be useful after the pandemic.

Methods: A national, cross-sectional, community survey was conducted between June 5 and June 12, 2020 in Australia. In total, 1369 participants who were aged ≥18 years and lived in Australia were recruited via targeted advertisements on social media (ie, Facebook and Instagram). Participants responded to survey questions about their telehealth experience, which included a free-text response option. A generalized linear model was used to estimate the adjusted relative risks of having a poorer telehealth experience than a traditional in-person visit experience. Content analysis was performed to determine the reasons why telehealth experiences were worse than traditional in-person visit experiences.

Results: Of the 596 telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was "just as good as" or "better than" their traditional in-person medical appointment experience. On average, respondents perceived that telehealth would be moderately useful to very useful for medical appointments after the COVID-19 pandemic ends (mean 3.67, SD 1.1). Being male (P=.007), having a history of both depression and anxiety (P=.016), and lower patient activation scores (ie, individuals' willingness to take on the role of managing their health/health care) (P=.036) were significantly associated with a poor telehealth experience. In total, 6 overarching themes were identified from free-text responses for why participants' telehealth experiences were poorer than their traditional in-person medical appointment experiences, as follows: communication is not as effective, limitations with technology, issues with obtaining prescriptions and pathology results, reduced confidence in their doctor, additional burden for complex care, and inability to be physically examined.

Conclusions: Based on our sample's responses, telehealth appointment experiences were comparable to traditional in-person medical appointment experiences. Telehealth may be worthwhile as a mode of health care delivery while the pandemic continues, and it may continue to be worthwhile after the pandemic.
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http://dx.doi.org/10.2196/24531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732356PMC
December 2020

Effects of health literacy, screening, and participant choice on action plans for reducing unhealthy snacking in Australia: A randomised controlled trial.

PLoS Med 2020 11 3;17(11):e1003409. Epub 2020 Nov 3.

Sydney Health Literacy Lab, Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia.

Background: Low health literacy is associated with poorer health outcomes. A key strategy to address health literacy is a universal precautions approach, which recommends using health-literate design for all health interventions, not just those targeting people with low health literacy. This approach has advantages: Health literacy assessment and tailoring are not required. However, action plans may be more effective when tailored by health literacy. This study evaluated the impact of health literacy and action plan type on unhealthy snacking for people who have high BMI or type 2 diabetes (Aim 1) and the most effective method of action plan allocation (Aim 2).

Methods And Findings: We performed a 2-stage randomised controlled trial in Australia between 14 February and 6 June 2019. In total, 1,769 participants (mean age: 49.8 years [SD = 11.7]; 56.1% female [n = 992]; mean BMI: 32.9 kg/m2 [SD = 8.7]; 29.6% self-reported type 2 diabetes [n = 523]) were randomised to 1 of 3 allocation methods (random, health literacy screening, or participant selection) and 1 of 2 action plans to reduce unhealthy snacking (standard versus literacy-sensitive). Regression analysis evaluated the impact of health literacy (Newest Vital Sign [NVS]), allocation method, and action plan on reduction in self-reported serves of unhealthy snacks (primary outcome) at 4-week follow-up. Secondary outcomes were perceived extent of unhealthy snacking, difficulty using the plans, habit strength, and action control. Analyses controlled for age, level of education, language spoken at home, diabetes status, baseline habit strength, and baseline self-reported serves of unhealthy snacks. Average NVS score was 3.6 out of 6 (SD = 2.0). Participants reported consuming 25.0 serves of snacks on average per week at baseline (SD = 28.0). Regarding Aim 1, 398 participants in the random allocation arm completed follow-up (67.7%). On average, people scoring 1 SD below the mean for health literacy consumed 10.0 fewer serves per week using the literacy-sensitive action plan compared to the standard action plan (95% CI: 0.05 to 19.5; p = 0.039), whereas those scoring 1 SD above the mean consumed 3.0 fewer serves using the standard action plan compared to the literacy-sensitive action plan (95% CI: -6.3 to 12.2; p = 0.529), although this difference did not reach statistical significance. In addition, we observed a non-significant action plan × health literacy (NVS) interaction (b = -3.25; 95% CI: -6.55 to 0.05; p = 0.054). Regarding Aim 2, 1,177 participants across the 3 allocation method arms completed follow-up (66.5%). There was no effect of allocation method on reduction of unhealthy snacking, including no effect of health literacy screening compared to participant selection (b = 1.79; 95% CI: -0.16 to 3.73; p = 0.067). Key limitations include low-moderate retention, use of a single-occasion self-reported primary outcome, and reporting of a number of extreme, yet plausible, snacking scores, which rendered interpretation more challenging. Adverse events were not assessed.

Conclusions: In our study we observed nominal improvements in effectiveness of action plans tailored to health literacy; however, these improvements did not reach statistical significance, and the costs associated with such strategies compared with universal precautions need further investigation. This study highlights the importance of considering differential effects of health literacy on intervention effectiveness.

Trial Registration: Australia and New Zealand Clinical Trial Registry ACTRN12618001409268.
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http://dx.doi.org/10.1371/journal.pmed.1003409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608866PMC
November 2020

Learners' experience and perceived impact of a health literacy program in adult basic education: a qualitative study.

Public Health Res Pract 2020 Jun 30;30(2). Epub 2020 Jun 30.

Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia;

Objectives and importance of the study: Adult literacy programs aim to empower learners to participate more effectively in everyday life. This includes programs with health content embedded in curricula to target health literacy. Adult learners who attend these programs represent a heterogeneous population, but include a high proportion of hard-to-reach or socially disadvantaged groups in terms of age, ethnicity, educational background, language and prevalence of learning disabilities. In 2014, we conducted a cluster-randomised controlled trial of a health literacy program in adult basic education classes across New South Wales, Australia. This paper reports findings from a qualitative study exploring learners' experience of the course and its perceived impact on their lives, as well as their understanding and confidence about health.

Study Type: Qualitative interview study.

Method: We conducted semistructured interviews as part of the evaluation of the 18-week health literacy program, with participants purposively recruited from six health literacy classes (n = 22). Researchers trained in qualitative methods interviewed adult learners either face to face or over the phone using a topic guide. Data was analysed using the Framework method, a matrix-based approach to thematic analysis.

Results: The majority of interviewees were female, lived in metropolitan areas and were from non-English-speaking backgrounds. Most had existing self-reported health problems and inadequate functional health literacy. Most participants described positive impacts of the health literacy course on their language, literacy and numeracy skills, functional health literacy skills, and health knowledge. They also reported being able to translate this into health actions including interacting with providers, accessing and using healthcare, and managing health and illness (e.g. making healthier food choices). Learners also described positive social outcomes of the course, including feelings of connectedness and interpersonal trust within a new network of learners, and reported sharing new knowledge with others in their communities.

Conclusions: The findings add value to existing limited evidence that has demonstrated the untapped potential of adult basic education to develop health literacy skills among socially disadvantaged groups. Learners valued the opportunity to share experiences in structured group learning, and reported confidence to transfer new knowledge into their home and wider social network.
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http://dx.doi.org/10.17061/phrp29231909DOI Listing
June 2020

Embedding a Health Literacy Intervention Within Established Parenting Groups: An Australian Feasibility Study.

Health Lit Res Pract 2020 03;4(1):e67-e78

Background: A significant proportion of new parents in high-income countries have lower health literacy, but few health literacy interventions exist for this group.

Objective: This study investigated the feasibility of delivering health literacy content within existing postnatal parenting groups.

Methods: Multicenter feasibility study using a seven-group pre-test post-test design. Parents older than age 16 years with children between age 4 and 26 weeks with sufficient English fluency were invited to participate in a 4-week health literacy program (four 2-hour sessions) delivered by trained facilitators (e.g., child and family health nurses). Mixed-methods evaluation was used, with quantitative data analyzed descriptively and qualitative data (e.g., focus groups, observations, interviews) analyzed using the Framework approach.

Key Results: Our health literacy program was successfully delivered at six sites in New South Wales, Australia, in 2018. Our recruitment strategy was successful in reaching diverse learners (N = 73), many who were born in a country other than Australia. However, few had limited health literacy as assessed by a subjective, single-item measure, and only half completed the follow-up questionnaires. High baseline knowledge, skills, and confidence among participants limited the potential for change in these quantitative outcomes but shed light on the utility of different measurement instruments in this context. Qualitative analyses suggested that the health literacy program aligned well with the institutional objectives of child and family health services and was acceptable to learners from diverse cultural backgrounds. However, in its current form, it may be perceived as too simple for learners with higher levels of education and literacy.

Conclusions: Our study has offered practical insights into the feasibility of embedding a health literacy intervention into established postnatal parenting groups and shown how program resources and facilitator training could be adapted to make the program more suitable for a range of learners and better support facilitators. [HLRP: Health Literacy Research and Practice. 2020;4(1):e67-e78.] PLAIN LANGUAGE SUMMARY: This study looked at the feasibility of delivering a 4-week health literacy program to new parents using existing postnatal parenting groups in New South Wales, Australia. Although the program was generally acceptable to learners and facilitators, this study offers several strategies to further improve the program so that it better supports facilitators and suits a wider range of learners.
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http://dx.doi.org/10.3928/24748307-20200217-01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065833PMC
March 2020

How readable are Australian multilingual diabetes patient education materials? An evaluation of national English-language source texts.

Public Health Res Pract 2020 Mar 10;30(1). Epub 2020 Mar 10.

Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, NSW, Australia.

Objective: Multilingual patient education materials (PEMs) in Australia are normally prepared initially in English (source text) and then translated into other languages. The aim of this study was to evaluate whether the source texts for publicly available multilingual diabetes PEMs in Australia were written at the reading level recommended by health literacy guidelines (eighth-grade reading level).

Study Type: Nonexperimental descriptive study.

Methods: All publicly accessible multilingual fact sheets on diabetes self-management from the Diabetes Australia and National Diabetes Services Scheme websites were collected. Readability was analysed using five different readability indices: Flesch Kincaid Grade Level (FKGL), Gunning Fog Score (GFS), Coleman Liau Index (CLI), Simplified Measure of Gobbledygook Index (SMOG) and Automated Readability Index (ARI). The average number of syllables per word and the average number of words per sentence were also calculated.

Results: The average reading grade level of included PEMs was above Grade 10 (mean 10.4; standard deviation [SD] 0.9). The average number of syllables per word was 1.5 (SD 0.1), and the average number of words per sentence was 17 (SD 0.9).

Conclusions: English-language source texts for national multilingual diabetes PEMs examined in this study were written at a readability level significantly higher than that recommended in health literacy guidelines. This was likely due to the use of polysyllabic words and complex medical terms, which are especially problematic when they are not defined. Improving readability of English-language source texts may help to ensure that the translated PEMs are more readable and accessible to their target readers. In conjunction with addressing other features that can make written materials easier to understand, this may help to better support diabetes self-management.
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http://dx.doi.org/10.17061/phrp3012002DOI Listing
March 2020

Validation of an Australian parenting health literacy skills instrument: The parenting plus skills index.

Patient Educ Couns 2020 06 20;103(6):1245-1251. Epub 2020 Jan 20.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia. Electronic address:

Objective: Existing instruments for assessing health literacy skills in parents have limited scope to inform the design and evaluation of health literacy interventions. In this study we aimed to develop and validate a new performance-based measure of health literacy for Australian parents, the Parenting Plus Skills Index (PPSI). The instrument aimed to assess functional, communicative and critical health literacy skills.

Methods: The PPSI was developed in three phases: 1) Modified Delphi Expert Panel to provide feedback on 34 initial items; 2) Evaluation of psychometric properties of each item using a multidimensional item response theory model in a sample of Australian adults of parenting age (20-44 years) (N = 500); 3) Assessment of subset of items in an independent sample (N = 500).

Results: Following the three phases, 13 items were included in the final instrument. Participants scored on average 8.9/13 (69 %). The instrument demonstrated acceptable reliability (r = 0.70) and was significantly correlated with other performance-based health literacy instruments.

Conclusions: The PPSI is a validated 13-item performance-based instrument that assesses health literacy skills for parents in an Australian setting.

Practice Implications: The PPSI fills an important gap in available health literacy instruments that may be useful for facilitating development and evaluation of health literacy interventions.
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http://dx.doi.org/10.1016/j.pec.2020.01.012DOI Listing
June 2020

Implications for GP endorsement of a diabetes app with patients from culturally diverse backgrounds: a qualitative study.

Aust J Prim Health 2019 Nov 13. Epub 2019 Nov 13.

Although many diabetes self-management apps exist, these are not tailored for people from culturally and linguistically diverse (CALD) backgrounds. This study aimed to explore GP perceptions of how diabetes app features could help GPs better support their patients from CALD backgrounds. Twenty-five semi-structured interviews with GPs in Western Sydney explored attitudes towards a proposed app's suitability for CALD patients. Interviews were audio-recorded, transcribed and coded using Framework Analysis. Theme 1 explored the implications of perceptions that patients' health literacy is dependent on the language used. Theme 2 explored the influence of messaging from sources that share the patient's language and culture (including misinformation from community sources). Theme 3 described the suitability of the app platform for CALD patients, and its potential challenges in this group. GPs perceived that a diabetes app could be useful for providing support to patients from CALD backgrounds. Findings suggest app features should be optimised to address existing challenges that GPs face and carefully consider strategies for recruiting CALD patients. It is important that GPs feel comfortable promoting an app to their CALD patients to help increase participation rates by people in the CALD community.
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http://dx.doi.org/10.1071/PY19062DOI Listing
November 2019

Accounting for health literacy and intervention preferences when reducing unhealthy snacking: protocol for an online randomised controlled trial.

BMJ Open 2019 05 28;9(5):e028544. Epub 2019 May 28.

Faculty of Medicine and Health, Sydney School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia.

Introduction: Health literacy describes the cognitive and social skills that individuals use to access, understand and act on health information. Health literacy interventions typically take the 'universal precautions approach' where all consumers are presented with simplified materials. Although this approach can improve knowledge and comprehension, its impact on complex behaviours is less clear. Systematic reviews also suggest that health literacy interventions underuse volitional strategies (such as planning) that play an important role in behaviour change. A recent study found volitional strategies may need to be tailored to the participant's health literacy. The current study aims to replicate these findings in a sample of people who have diabetes and/or are overweight or obese as measured by body mass index, and to investigate the most effective method of allocating an action plan to a participant to reduce unhealthy snacking.

Methods And Analysis: We plan to recruit approximately 2400 participants at baseline. Participants will receive one of two alternative online action plans intended to reduce unhealthy snacking ('standard' action plan or 'literacy-sensitive' action plan). Participants will be randomised to a method of allocation to an action plan: (1) random allocation; (2) allocation by health literacy screening tool or (3) allocation by participant selection. Primary outcome is self-reported serves of unhealthy snacks during the previous month. Multiple linear regression will evaluate the impact of health literacy on intervention effectiveness. The analysis will also identify independent contributions of each action plan, method of allocation, health literacy and participant selections on unhealthy snacking at 4-week follow-up.

Ethics And Dissemination: This study was approved by the University of Sydney Human Research Ethics Committee (2017/793). Findings will be disseminated through peer-reviewed international journals, conferences and updates with collaborating public health bodies (Diabetes New South Wales (NSW) & Australian Capital Territory (ACT), and Western Sydney Local Health District).

Trial Registration Number: ACTRN12618001409268; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2018-028544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549624PMC
May 2019

Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study.

JMIR Mhealth Uhealth 2019 01 16;7(1):e11885. Epub 2019 Jan 16.

Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.

Background: The health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user's primary care physician (PCP).

Objective: This study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services.

Methods: Researchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient's primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor.

Results: Our analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation.

Conclusions: This study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process.
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http://dx.doi.org/10.2196/11885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352005PMC
January 2019

Randomized trial of planning tools to reduce unhealthy snacking: Implications for health literacy.

PLoS One 2019 17;14(1):e0209863. Epub 2019 Jan 17.

Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, NSW, Australia.

Objective: Guidance to address health literacy often focuses on health education rather than tools to facilitate action, despite action being important for self-management. This study evaluated an online intervention informed by health literate design principles and behavior change theory to reduce unhealthy snacking.

Methods: 440 participants were recruited online and randomized to an intervention: 1) Health-literate action plan (guided implementation intention); 2) Standard action plan (self-guided implementation intention); 3) Education (healthy snacking fact-sheet). The primary outcome was self-reported unhealthy snacking. Follow-up was at 1 month.

Results: 373 participants (84.8%) completed follow-up. Half the sample had adequate health literacy (52%), and the other half had low (24%) or possibly low (25%) health literacy, as measured by Newest Vital Sign (NVS). At follow-up, lower health literacy was associated with more unhealthy snacks and there was no overall difference between intervention groups. However, participants with lower health literacy who used the health-literate action plan reported less unhealthy snacking compared to the standard action plan; the reverse was true for those with higher health literacy scores (b = 1.7, p = 0.03). People scoring 2 points below the mean NVS (M = 3.4, SD = 2.0) using the health-literate action plan reported eating 8 fewer serves of unhealthy snacks, whereas people scoring 2 points above the mean NVS reported eating 6 more serves of unhealthy snacks using the same tool.

Conclusions: These findings suggest that the universal precautions approach currently recommended for health information may be less effective for facilitating action than tailoring to health literacy level.

Trial Registration: ANZCTR identifier: ACTRN12617001194358.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0209863PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336265PMC
November 2019
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