Ethnic Differences in Health Literacy, Self-Efficacy, and Self-Management in Patients Treated With Maintenance Hemodialysis.

Background: There is a gap in research investigating the potential impact of ethnicity on health literacy, self-efficacy, and self-management in patients treated with maintenance hemodialysis (MHD). Objective: To explore (1) the associations between health literacy, self-efficacy, and self-management among outpatients with kidney failure receiving treatment with MHD, and (2) the differences in health literacy and self-efficacy based on characteristics of ethnicity (ie, physical resemblance and proficiency in the language of the host population), known to be associated with health care access and health outcomes. Design: Cross-sectional. Setting: Outpatients receiving MHD at 7 adult hemodialysis centers in Calgary, Alberta from September 2014 to December 2014. Patients: Participants were grouped into 2 groups based on a proposed 4-quadrant framework of a multicultural society. Quadrant 1 comprised outpatients with physical resemblance and first language of the host population (ie, white and English as a first language), whereas quadrant 4 participants comprised outpatients with physical resemblance and first language not of the host population (ie, non-white and first language other than English). A total of 78 patients (nQ1 = 44, nQ4 = 34) were included. Measurements: Heath literacy, self-efficacy, and self-management were measured using the Health Literacy Questionnaire (HLQ), Strategies Used by People to Promote Health (SUPPH), and Patient Activation Measure-13 (PAM-13), respectively.
Methods: Convenience sampling was used to recruit participants at each of the 7 adult hemodialysis centers. All participants completed a study package, which included a demographic questionnaire, HLQ, SUPPH, and PAM-13. Spearman rho was calculated to identify correlations between patient activation level and HLQ and SUPPH scores. Independent t tests were performed to identify differences in HLQ and SUPPH scores between Q1 and Q4 participants. Stepwise regression was performed in other analyses to identify predictor variables of patient activation level.
Results: Statistically significant correlations were identified between patient activation level and the health literacy domains of "ability to actively engage with health care providers" (rHLQ6= .535, P < .001), "ability to find good health information" (rHLQ8 = .611, P < .001), and "understanding health information well enough to know what to do" (rHLQ9 = .712, P < .001). There was a statistically significant difference between Q1 and Q4 participants in the health literacy domain of "ability to find good health information" (P = .048). "Understanding health information well enough to know what to do" and "actively managing health" were included in the final stepwise regression model, F(2, 72) = 32.232, P < .001. Limitations: The cross-sectional design limits the generalizability of the results. The small sample size limits the power to identify significant associations and differences. Although English was not the first language of Q4 participants, all were proficient in English, meaning potential differences of a key subgroup of Q4 (ie, those who did not speak any English) were not captured.
Conclusion: The HLQ allowed for the creation of a health literacy profile of patients with end-stage kidney disease receiving treatment with MHD. The findings suggest possible associations between specific domains of health literacy and patient activation. Outpatients' representative of Q4 receiving treatment with MHD appear to struggle more with finding good health information, which may leave them at a disadvantage in the early phases of their self-management efforts. The findings highlight potential opportunities to better tailor patient care to support patients in their self-management, particularly for patients from ethnic minority backgrounds.

Introduction

Background

At least 4 million people in Canada live with chronic kidney disease (CKD). More than 40 000 have progressed to end-stage kidney disease (ESKD) representing a 33% increase in ESKD since 2010. Notably, there is a greater risk of CKD progression among non-whites compared with whites.[2,3] The CKD progressed to ESKD requires kidney replacement therapy, often in the form of maintenance hemodialysis (MHD). Active patient participation in self-management activities plays an important role in achieving optimal health for those receiving MHD. Those activities include managing complex medication regimens; attendance at dialysis which typically entails 4-hour sessions 3 to 4 days per week; making significant diet modifications to adhere to low sodium, potassium, protein, and phosphorous restrictions; significantly restricting daily fluid intake; and managing other comorbidities (eg, diabetes) associated with ESKD. Managing these activities in addition to activities of daily living can be overwhelming.

Health literacy comprises the “cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.” Self-efficacy is the belief an individual has about his or her ability to execute actions to achieve a desired outcome. Higher health literacy and self-efficacy have been shown to positively influence self-management behaviors in chronic disease populations[5,6] and specifically related to kidney disease.[7,8] However, limited health literacy is common among those with kidney disease. Furthermore, there is a paucity of research examining how health literacy and self-efficacy may be impacted by ethnicity in patients with ESKD receiving treatment with MHD.

As the burden of kidney disease and its progression continues to grow in Canada, the need to identify best practices to support patients with their self-management has become more urgent. Understanding how ethnicity can influence self-management behavior is especially important in a multicultural society such as Canada. A better understanding can guide health services and providers to provide patient-centered care that is equity-oriented.

Objectives

The objectives of this study were to analyze (1) the potential relationships between health literacy, self-efficacy, and self-management among patients with kidney failure receiving treatment with MHD; and (2) differences in health literacy and self-efficacy based on characteristics of ethnicity (ie, physical resemblance and proficiency in the language of the host population), known to be associated with health care access and health outcomes.

Methods

Study Design

This work was part of a master’s thesis which used a cross-sectional design to explore associations between health literacy, self-efficacy, and clinical markers of self-management in patients receiving kidney replacement therapy by MHD between September 2014 and December 2014 in Calgary, AB. This study was reviewed and approved by the Conjoint Health Research Ethics Board (CHREB) at the University of Calgary.

Setting

There are 7 adult hemodialysis sites in Calgary, AB. Participants were recruited, at morning, afternoon, and evening HD sessions at each site. Recruitment and data collection occurred between September 2014 and December 2014 and lasted 1 to 2 weeks at each center. The number of beds ranged from 9 to 30, with a median of 15. Patients typically receive MHD 3 to 4 days per week with morning, afternoon, and evening sessions usually lasting 3 to 4 hours. Nocturnal sessions were offered at one site; however, recruitment did not occur at this session.

Participants

Participants were included if they were at least 18 years of age and had received regular MHD for a minimum of 3 consecutive months at the time of recruitment. Figure 1 represents a proposed framework of a multicultural society highlighting 2 key characteristics that have been shown to impact health care outcomes and patient decision-making. Participants were eligible if they were characteristic of quadrant 1 (Q1) or quadrant 4 (Q4). Participants were limited to Q1 and Q4 as these 2 quadrants exhibit the greatest difference in the framework and would presumably highlight the greatest contrast between the variables of interest.

Figure 1.

Framework of a multicultural society.

Participants were excluded from the study if they had one or more hospital admissions or received peritoneal dialysis or nocturnal hemodialysis within 3 months prior to the date of recruitment. Participants were also excluded if they received MHD for less than 3 months from the date of recruitment.

Convenience sampling was used to recruit participants receiving MHD treatment. The HD staff nurses assisted with recruitment. Nurses approached potential candidates first, at the start of their dialysis session, and asked if they would like to receive information about the study. If the potential participant agreed, they received further information from the researcher and, if still interested, completed the screening questionnaire (Supplement 1). If the potential participant met the screening criteria and still agreed to participate, informed consent was obtained, and participants were given the study package to complete. Participants had the option to complete the package during their HD session or to take the package home to complete and return it to the researcher at their next dialysis session. Assistance, from the researcher, to complete the study package during the HD session was available upon request.

Variables

Health literacy and self-efficacy were included in the analysis as the independent variables, whereas self-management was considered the dependent variable of interest. Ethnicity was defined in terms of the 2 key characteristics identified in the above framework (Figure 1). In the context of Alberta, Canada as the host population, visible majority and language of the host population is represented as white and first language of English (Q1); visible minority and first language not of the host population is represented as non-white and a first language other than English (Q4).

Data Measurement

The study package included an investigator-designed demographic questionnaire (Supplement 2), the Health Literacy Questionnaire (HLQ), Strategies Used by People to Promote Health (SUPPH), and Patient Activation Measure-13 (PAM-13). The HD nursing staff had identified Mandarin and Vietnamese as languages commonly spoken among the patients receiving MHD and the HLQ and PAM-13 were already available in simplified Chinese and Vietnamese. Therefore, the remaining documents were translated to simplified Chinese and Vietnamese using a professional translation service then back translated by 2 lay people and 2 translation professionals. Any discrepancies noted were sent back to the professional translation service for correction. Translations to other languages were not possible, due to time constraints.

Demographic questionnaire

Data collected from the demographic questionnaire included ethnic background, primary language spoken at home, age, gender, marital status, education, employment status, CKD etiology, other chronic health conditions, years on hemodialysis, and the number HD sessions attended per week.

Health literacy

The HLQ, a 44-item instrument, measures 9 domains of health literacy: (1) feeling understood and supported by health care providers, (2) having sufficient information to manage my health, (3) actively managing my health, (4) social support for health, (5) appraisal of health information, (6) ability to actively engage with health care providers, (7) navigating the health care system, (8) ability to find good health information, and (9) understanding health information well enough to know what to do. Questions were asked on a 4-point Likert-type scale for domains 1 to 4 and scores ranged from 1 to 4. Questions were on a 5-point Likert-type scale for domains 6 to 9 and scores ranged from 1 to 5. The domain scores are not summed together. Instead, each scale forms a stand-alone score and together the scales generate a health literacy profile of individuals, groups, and populations. Higher scores indicate greater health literacy for the given domain.

Self-efficacy

The SUPPH is a 29-item self-report scale, based on self-efficacy theory, that measures self-care self-efficacy in hemodialysis patients. The SUPPH is scored for 3 dimensions: (1) positive attitude, (2) stress reduction, and (3) making decisions. Questions were asked on a 1 to 5 Likert-type scale and scores are generated by the summation of all items across the dimension. The overall score is the sum of the dimension scores with a higher score indicating greater self-care self-efficacy.

Self-management

The PAM-13 was used to measure self-management. The PAM-13 provides a score from 0 to 100 that corresponds to 1 of 4 levels of patient activation: (1) believes active role important, (2) confidence and knowledge to act, (3) taking action to maintain or improve one’s health, and (4) staying the course under stress. A higher activation level indicates a greater capacity to participate and persist in managing one’s own health and health care.

Bias

Given time constraints and potential recruitment rate, convenience sampling was felt to be the most feasible approach for participant selection. In an effort to reduce selection bias, participants were recruited from all 7 adult HD sites in Calgary, at all morning, afternoon, and evening HD sessions.

Study Size

The a priori sample size was calculated of 50 participants per group based on the recruitment goal of 20 cases per independent variable (HL and SE) for regression analysis in the larger study and a potential attrition rate of 20%.

Statistical Methods

All statistical analyses were completed in SPSS v. 22.

Descriptive statistics were used to report demographic characteristics, HLQ, SUPPH, and PAM-13 scores for both groups. Spearman rho was calculated to identify weak (r = .10-.29), moderate (r =.30-.39), or strong (r = .50-1.0) associations between HLQ and PAM-13 scores as well as SUPPH and PAM-13 scores. Pairwise exclusion was used to manage missing data in the correlation analyses. Independent t tests were used to identify differences in health literacy and self-efficacy scores between Q1 and Q4 participants. Missing data points were pro-rated for the SUPPH leading to one case missing the subscale scores for “decision-making” and “stress reduction” and an additional case missing the subscale score for “stress reduction.” Stepwise regression was performed to explore which health literacy variables accounted for the most variance in patient activation level. The SUPPH scores were not included to prevent singularity in the regression analysis. At each step, p = .05 was set as entry criteria and p = .1 was used to set a limit on the total number of variables included in the final model. Listwise exclusion of cases was used to handle missing data.

Results

Of the 139 individuals initially approached, 39 declined to participate, 18 were excluded because they did not meet the inclusion criteria, and 4 returned incomplete study packages. A total of 78 participants were included in the study (nQ1 = 44; nQ4 = 34). Figure 2 outlines the recruitment in a flow diagram.

Figure 2.

Recruitment flow diagram.

Descriptive Data

Demographic characteristics

Q1 participants identified as Canadian, American, European, or “other” backgrounds. Twenty-eight of the participants grouped in Q4 (82.4%) self-identified their ethnicity as Asian, South Asian, or Pacific Islander. The remaining Q4 participants (17.6%) indicated their ethnicity as being from other backgrounds; grouping was not specified further to maintain participant anonymity. All Q4 participants indicated English was not their first language. However, all were proficient in English and opted to complete the study package in English including those who were initially offered study packages in simplified Chinese or Vietnamese. Two participants from Q4 received assistance from the family members, whereas 18 participants from Q1 received assistance from the investigator.

Table 1 presents the demographic profile of study participants. The average age among Q1 participants was 63.5 (SD = 13.9) and the average age among Q4 participants was 59.4 (SD = 12.4). Twenty-three (52.3%) participants from Q1 and 25 participants (73.5%) from Q4 were male. Fifteen (34.1%) participants from Q1 and 18 (52.9%) from Q4 indicated completing postsecondary education. Twenty-four participants from Q1 (54.5%) and 14 (41.2%) from Q4 were retired. Diabetes (nQ1 = 17; nQ4 = 11) and/or high blood pressure (nQ1=12; nQ4 = 12) were common causes of kidney disease in both groups. The average number of years on hemodialysis was 4.4 years for Q1 participants and 3.5 years for Q4 participants. Dialysis attendance was an average 3 days per week for both groups. Among Q1 participants, 12 (27.3%) indicated having depression or anxiety compared with 5 (14.7%) Q4 participants.

Table 1.

Q1 and Q4 Participant Characteristics.

	Q1 (n = 44)	Q4 (n = 34)
Age a , mean (SD)	63.5(13.9)	59.4(12.4)
Gender
Male	23 (52.3%)	25 (73.5%)
Female	21 (47.7%)	9 (26.5%)
Marital status
Partnered	21 (47.7%)	28 (82.4%)
Unpartnered	21 (47.7%)	5 (14.7%)
No response	2 (4.5%)	1 (2.9%)
Living status
Live alone	6 (13.6%)	5 (14.7%)
Live with others	29 (65.9%)	21 (61.6%)
No response	9 (20.5%)	8 (23.5%)
Highest level of education
High school	17 (38.6%)	15 (44.1%)
Some postsecondary	10 (22.7%)	0 (0.0)
Postsecondary	15 (34.1%)	18 (52.9%)
No response	2 (4.5%)	1 (2.9%)
Employment status
Employed	4 (9.1%)	8 (23.5%)
Unemployed	13 (29.5%)	11 (32.4%)
Retired	24 (54.5%)	14 (41.2%)
No response	3 (6.8%)	1 (2.9%)
Cause of kidney disease a
Diabetes	17 (40.5%)	11 (32.4%)
Hypertension	12 (28.6%)	12 (35.3%)
Autoimmune disease	7 (16.7%)	4 (11.8%)
Other	10 (23.8%)	6 (17.6%)
Unknown	5 (11.9%)	8 (23.5%)
Chronic health conditions
Arthritis or chronic pain	26 (59.1%)	14 (41.2%)
Cardiovascular	22 (50.0%)	10 (29.4%)
Depression or anxiety	12 (27.3%)	5 (14.7%)
Other	17 (38.6%)	9 (26.5%)
Average number of years on HD b , mean (SD)	4.4 (6.3)	3.5 (2.9)
Average number of HD sessions per week c , mean (SD)	3 (0.6)	3 (0.3)

nQ1 = 42.

n = 74.

n = 77.

Main Results

Q1 and Q4 participants both had a median patient activation level 3 (interquartile range: 2-3) corresponding to “taking action to maintain or improve one’s health.”

Health literacy and self-efficacy correlations with self-management

Spearman rho correlation revealed a positive moderate association between patient activation level and the “ability to actively engage with health care providers” (HLQ scale 6; rHLQ6 = .535, P < .001). There was also a positive moderate association between patient activation level and the “ability to find good health information” (HLQ scale 8; rHLQ8 = .611, P < .001). There was a strong positive correlation between “understanding health information well enough to know what to do” (HLQ scale 9) and patient activation level (rHLQ9 = .712, P < .001). The associations between self-efficacy and patient activation were significant but weak (Table 2).

Table 2.

Health Literacy and Self-Efficacy Correlations With Patient Activation Level.

	Spearman rho	P value
Health Literacy Scores
Domain 1. Feeling understood and supported by health care providers	.333	.003*
Domain 2. Having sufficient information to manage my health	.400	<.001*
Domain 3. Actively managing my health	.471	<.001*
Domain 4. Social support for health	.308	.007*
Domain 5. Appraisal of health information	.472	<.001*
Domain 6. Ability to actively engage with health care providers	.535	<.001*
Domain 7. Navigating the healthcare system	.487	<.001*
Domain 8. Ability to find good health information a	.611	<.001*
Domain 9. Understanding health information well enough to know what to do	.712	<.001*
Self-Efficacy Scores
Total SUPPH	.352	.002*
SUPPH Scale 1 Positive Attitude	.353	.002*
SUPPH Scale 2 Stress Reduction	.315	.006*
SUPPH Scale 3 Making Decisions	.391	<.001*

Note. SUPPH = Strategies Used by People to Promote Health.

nQ1 = 43; nQ2 = 34.

P ≤ .05.

Health literacy and self-efficacy differences

Table 3 displays the differences in health literacy and self-efficacy scores by quadrant. There was a statistically significant difference between Q1 and Q4 participants for HLQ domain 8 “ability to find good health information” (MQ1 = 4.07, SD = .53; MQ4 = 3.81, SD = .57; P = .048) suggesting finding up-to-date health information from a variety of sources was a greater struggle for quadrant 4 participants than for quadrant 1 participants. However, the magnitude of the difference between the 2 groups was small (mean difference = .25, 95% confidence interval: .00028 to .50; Cohen’s d = 0.472). Q1 participants scored higher than Q4 participants in all HLQ domains, except domain 5, “appraisal of health information” (MQ1 = 2.89, SD = .419; MQ4 = 2.91 SD = .493). However, these differences were not significant.

Table 3.

Health Literacy and Self-Efficacy Differences by Quadrant.

	Q1 (n = 44)	Q4 (n = 34)	P value
	Health Literacy Scores	Mean (SD)	Mean (SD)
Domain 1. Feeling understood and supported by health care providers	3.11 (0.535)	3.10 (0.320)	.899
Domain 2. Having sufficient information to manage my health	3.05 (0.329)	3.03 (0.421)	.851
Domain 3. Actively managing my health	3.08 (0.374)	3.06 (0.416)	.838
Domain 4. Social support for health	3.03 (0.503)	3.01 (0.476)	.818
Domain 5. Appraisal of health information	2.89 (0.419)	2.91 (0.493)	.841
Domain 6. Ability to actively engage with health care providers	4.19 (0.571)	4.05 (0.438)	.247
Domain 7. Navigating the healthcare system	4.01 (0.584)	3.91 (0.523)	.437
Domain 8. Ability to find good health information	4.07 (0.532) a	3.81 (0.568)	.048*
Domain 9. Understanding health information well enough to know what to do	4.15 (0.636)	3.92 (0.591)	.105
Self-Efficacy Scores
Total SUPPH (/145)	102.1 (27.6) a	98.0 (25.6) b	.51
SUPPH Scale 1 Positive Attitude (/80)	58.1 (16.6)	54.5 (15.9)	.34
SUPPH Scale 2 Stress Reduction (/50)	33.5 (10.2) a	32.8 (9.9) b	.76
SUPPH Scale 3 Making Decisions (/15)	11.1 (3.4) a	9.6 (3.2) b	.05

Note. SUPPH = Strategies Used by People to Promote Health.

n = 43.

n = 33.

P ≤ .05.

Both groups had moderate overall SUPPH scores (MQ1 = 102.1, SD = 27.6; MQ4 = 98.0 SD = 25.6) indicating moderate perceived self-confidence in maintaining a positive attitude, stress reduction, and decision-making related to alternative treatments. Like the HLQ domains, Q1 participants scored higher than Q4 participants for all SUPPH scores. There was weak evidence to suggest a statistically significant difference in “making decisions” between quadrant 1 and quadrant 4 participants (MQ1 = 11.4, SD = 3.4; MQ4 = 9.6 SD = 3.2 P = .05).

Other analyses

The stepwise regression equation was reached in 2 steps. The final model identified “understanding health information well enough to know what to do” (HLQ scale 9) and “actively managing health” (HLQ scale 3) as predictors of patient activation level, F(2, 72) = 32.232, P < .001. The raw regression coefficient (B), the standard error (SE), the standardized regression coefficient (β), the correlation coefficient (R), and the squared semipartial correlation coefficients (sr2) are outlined in Table 4 for the predictor variables. The coefficient of determination (adjusted R2) of the final model is also included. “Understanding health information well enough to know what to do” (HLQ scale 9) accounted for 25% of the variance of patient activation level (sr2= .256) and “actively managing health” (HLQ scale 3) accounted for 4% of the variance (sr2 = .038).

Table 4.

Stepwise Regression Predicting Patient Activation Level.

Model 2	B	SE	β	R	sr 2	Adjusted R2
Constant	−2.691	.719
Understanding health information	.878	.148	.564	.659	.256
Actively managing health	.541	.238	.217	.465	.038	.458

Discussion

Associations between health literacy, self-efficacy, and self-management were examined among patients with ESKD receiving treatment with MHD. Differences in health literacy and self-efficacy by key characteristics of ethnicity known to impact health and health care were also examined. Nearly a quarter of all participants indicated having depression or anxiety; however, this was represented by a higher proportion of participants in the Q1 group compared with Q4 group. Patient activation level of both Q1 and Q4 participants corresponded to an ability to take action to maintain or improve health. The median patient activation levels did not correspond to an “ability to stay the course during times of stress.” By using the HLQ, a health literacy profile among patients with ESKD receiving MHD was generated and multiple dimensions of health literacy could be measured. There were moderate associations between patient activation level and the health literacy domains of “ability to actively engage with health care providers” and “ability to find good health information,” and a strong association with “understanding health information well enough to know what to do.” On the contrary, the associations between patient activation level and self-efficacy were weak. There was a statistically significant difference between Q1 and Q4 participants in the health literacy domain of “ability to find good health information.” In additional analyses, “understanding health information well enough to know what to do” and “ability to find good health information” contributed to the variance of patient activation level.

Many of the respondents who indicated having depression or anxiety belonged to Q1. However, specific signs and symptoms of depression or anxiety (eg, irritability, fatigue, restlessness) were not included on the questionnaire, which could have impacted some participant responses if they were not aware of what the signs and symptoms of depression or anxiety entail. The difference between Q1 and Q4 might also be attributed to differences in how mental health is perceived. Previous reports have pointed to stigma toward mental health problems as a common phenomenon among ethnocultural and racialized populations. Previous research has also identified that ethnic minorities are also less likely to use mental health services compared with whites. While reporting of mental health problems and use of mental health services occur less often in ethnic minority groups, there is evidence to suggest that when mental health is assessed in minority groups, there can be higher degree of severity of mental illness experienced in general and specifically in the ESKD population. Damery et al note that not all patients with ESKD who experience emotional distress want support and not all patients with ESKD who want support want it from their kidney health care providers. Nonetheless, providers should pay close attention to screening for depression and anxiety, particularly among ethnic minority patients, as they may be less likely to voice their concerns.

Previous research has demonstrated that interventions aimed at developing coping skills in patients with kidney disease can decrease depression and anxiety and these effects can persist over time.[24,25] However, current self-management resources for these patients have been found to be lacking in the provision of emotional management resources. Moreover, there appears to be a gap in investigating if the impact of such interventions translates to persistent positive self-management behaviors even during times of distress. Identifying best practices to help patients receiving MHD develop coping skills is worth investigating further, given the indication by both groups of an ability to take action with their self-management (patient activation level of 3), but not necessarily an ability to stay the course with their self-management under stress (patient activation level of 4).

The overall moderate association between “ability to engage with health providers” and patient activation highlights the importance of the patient-provider encounter. The difference between Q1 and Q4 participant scores for this health literacy domain was not statistically significant in the current study. However, this may be attributed to Q4 participants being English proficient, demonstrated by the fact that all opted to complete the surveys in English. Limited English-proficient and non-English HD patients were not captured in this study sample meaning the experience of a key Q4 subgroup was not included. Previous research has demonstrated language barriers do impact patient-provider encounters by altering patient perceptions about their health. A study by Gany et al found that among immigrant and migrant cancer patients, those whose language of preference was not English were more than twice as likely to have incorrect knowledge of their cancer diagnosis compared with their English-speaking counterparts. Language barriers can also impact provider perceptions regarding patient encounters. For example, Sandal et al conducted a qualitative study examining health professional perceptions of barriers to discussing living kidney donation with patients with CKD. Patient-level barriers noted by health providers included cultural background and language barriers as factors that made discussing living kidney donation difficult for health providers. Face-to-face interactions have been identified as the second most common method of delivering self-management information to patients with CKD, in Canada. If language barriers create difficulties for providers, the quality of the patient-provider encounter can be significantly diminished.

Professional translation services and newer technologies, such as virtual remote interpretation services, offer potential solutions to addressing this barrier. Nonetheless, providers should be aware of their own communication style to ensure their verbal communication with patients is at an appropriate level. Effective strategies to verify patient understanding include using “teach-back method” and “chunking.” In the case of the latter, information is broken down into smaller “chunks” and reviewed over multiple sessions. This is supported by a qualitative study, by Ferreira da Silva et al, which analyzed interview data of patients from 5 Canadian hemodialysis centers receiving in-center hemodialysis, their caregivers, and health providers. The researchers explored the barriers and solutions to delivery of information related to hemodialysis and identified patients felt overwhelmed with the amount of information they received when first initiating hemodialysis which made it difficult to retain. Patients suggested delivering the information gradually rather than all at once. Providers also expressed concern about the amount information given to patients initiating dialysis and did make attempts to try to break the information down. Provider perceptions about their communication with HD patients compared with patient perceptions about communication with their providers is an area that could be further explored. This may reveal valuable information about gaps in provider communication that impact patient experiences and the patient-provider relationship.

The associations between patient activation with “ability to find good health information” and “understanding health information well enough to know what to do” are not surprising. Accessing the right information and having the ability to synthesize that information to make informed choices contributes to greater empowerment and better patient decision-making. A qualitative study by Donald et al interviewed CKD patients stages 1 to 5 (though not receiving kidney replacement therapy) and their caregivers across Canada to identify their self-management needs. Among the themes identified, participants indicated that knowledge leading to awareness and understanding of subjects including kidney disease, diet, and physical and mental health consequences of the kidney disease contributed to empowerment. In the current study, there was no appreciable difference between Q1 and Q4 participants’ ability to “understand health information well enough to know what to do.” However, the statistically significant difference between Q1 and Q4 participants’ “ability to find good health information” does suggest Q4 patients may be at a disadvantage at the very first step of their self-management efforts. In the same study by Donald et al, participants indicated that while access to information contributed to activation, this information needed to be timely, meaningful, the right amount, and relevant to their needs. Participants in that study were predominantly white and English-speaking, thereby limiting the generalizability of their results. However, given the difference identified between Q1 and Q4 participants’ “ability to find good health information” in the present study, it should be considered that not only is access to information important, but patients with kidney disease who are representative of Q4 could potentially be at a greater disadvantage in finding meaningful and culturally relevant information to meet their needs. Many clinics across Canada offer CKD self-management resources that have been developed or modified to meet local, individual, and ethnocultural needs, but a gap still exists in content (eg, emotional management, general CKD knowledge, symptom management) and most resources are only offered in English. Furthermore, Ferreira da Silva et al also identified the importance of ensuring education materials meet the needs of a culturally diverse dialysis population. As the amount of available information has drastically increased and intensified over time, navigating misinformation and disinformation to access usable content has become more important. Resources and interventions should be contextually tailored and culturally relevant to facilitate equitable access to self-management supports for ethnic minority patients and families.

Limitations

First, the cross-sectional design and use of convenience sampling limits the generalizability of the results. Second, the final sample size for each group was smaller than the a priori sample size calculation, limiting the power to identify significant associations between variables or group differences. Third, while English was not the first language of Q4 participants, these participants were still proficient in English. The perspectives of completely non-English participants were not captured again limiting the generalizability of the results. Fourth, while moderate to strong associations were identified between some domains of health literacy and patient activation level, correlation does not equal causation. Furthermore, correlations in unadjusted analyses should be interpreted cautiously due to the risk of confounding by other variables including education level and socioeconomic status, both of which are associated with limited health literacy in CKD. Finally, in stepwise regression, the variables are ordered and entered by statistical software meaning it is not guaranteed the best predictors have been selected or that unimportant predictors have been excluded.

Conclusions

Limited health literacy represents considerable concern in the kidney disease population.[9,34] By using the HLQ, a health literacy profile of patients with ESKD receiving MHD can be created to examine relationships between specific health literacy domains with patient self-management behaviors. It also offers an opportunity to examine possible differences by selected markers of ethnicity. The relationships identified in the current study may add further support to the body research that has identified links between health literacy and self-management among patients with kidney disease. However, study replication involving more dialysis centers to increase the sample size and to capture Q4 participants who do not speak any English would be needed to confirm the results of the current study.

The HLQ is a useful instrument in that can be used to help facilitate the planning and provision of equity-oriented health services. In that regard, considerations should be made for how to incorporate the cultural and linguistic needs of this diverse patient population to avoid a pattern of exclusion that may lead to inequitable health and health care.

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Supplemental material, sj-docx-1-cjk-10.1177_20543581221086685 for Ethnic Differences in Health Literacy, Self-Efficacy, and Self-Management in Patients Treated With Maintenance Hemodialysis by Uchenna Ibelo, Theresa Green, Bejoy Thomas, Sandra Reilly and Kathryn King-Shier in Canadian Journal of Kidney Health and Disease