Participants with the lowest health literacy levels do not benefit from either a pictorial brochure or video designed to increase knowledge of HIV/AIDS and HIV testing

Theoretical Background and research questions/hypothesis:

Identifying methods to improve health knowledge for patients with the lowest health literacy abilities is an important clinical challenge. We created an HIV/AIDS and HIV testing video and pictorial brochure aimed to improve HIV/AIDS and HIV testing knowledge for emergency department (ED) patients with varying levels of health literacy. We hypothesized that the video would improve HIV/AIDS and HIV testing knowledge more than a content-equivalent pictorial brochure among all ED patients, and particularly those with the lowest health literacy abilities.

Methods:

We recruited a random sample of 18-64-year-old, HIV uninfected, English- or Spanish-speaking patients at four EDs in Alabama, California, Ohio and Rhode Island. Participants were randomly assigned to watch a video or review a pictorial brochure. Before and after watching the video or reviewing the pictorial brochure, participants completed an assessment of their HIV/AIDS and HIV testing knowledge on a 25-item scale. Health literacy was measured using the Short Assessment of Health Literacy (SAHL). Based on SAHL guidelines for health literacy scoring, we stratified participants into three health literacy groups: lowest (SAHL score<11), lower (SAHL score 11-14) and higher (SAHL score>14). We examined the changes in scores for these three groups using Fisher’s exact test and three-way ANOVA.

Results:

Among the 1328 participants, 13% had lowest health literacy, 36% had lower health literacy, and 51% had higher health literacy. Baseline HIV-related knowledge scores were similar across health literacy groups (lowest health literacy: 14.7 (95% CI: 14.0, 15.3), lower health literacy: 14.0 (95% CI: 13.6, 14.4), and higher health literacy: 14.8 (95% CI: 14.4, 15.1)). After watching the video or reviewing the pictorial brochure, the lowest health literacy group’s HIV/AIDS and HIV testing knowledge scores did not increase (∆ 0.1: 95% CI: -1.0, 0.73). In comparison, the lower health literacy group’s scores increased 2.8 points (95% CI: 2.3, 3.3), and the higher health literacy group’s scores increased 4.1 points (95% CI: 3.7, 4.5) (overall test comparing all three groups, p<0.001). Within health literacy groups, changes in score were similar for video vs. pictorial brochure: lowest (video: 0.2, 95% CI: -1.0, 1.5 vs. pictorial brochure: -0.5, 95% CI: -1.7, 0.7); lower (video: 2.9, 95% CI: 2.3, 3.6 vs. pictorial brochure: 2.8, 95% CI: 2.0, 3.5); and higher (video: 4.5, 95% CI: 3.9, 5.0 vs. pictorial brochure: 3.7, 95% CI: 3.1, 4.3).

Conclusions:

The efficacy of this HIV/AIDS and HIV testing knowledge intervention was strongly associated with health literacy levels. Contrary to our expectations, ED patients with the lowest health literacy abilities did not benefit more from the video, and did not benefit significantly from either the video or the pictorial brochure.

Implications for research and/or practice:

Low health literacy limits patients’ ability to benefit from standard educational interventions. Patients with the lowest health literacy abilities need improved educational interventions.