Impact of health literacy on shared decision making for prostate‐specific antigen screening in the United States

Abstract

BackgroundCurrent guidelines endorse shared decision making (SDM) for prostate‐specific antigen (PSA) screening. The relationship between a patient's health literacy (HL) and SDM remains unclear. In the current study, the authors sought to identify the impact of HL on the rates of PSA screening and on the relationship between HL and SDM following the 2012 US Preventive Services Task Force recommendations against PSA screening.MethodsUsing data from the 2016 Behavioral Risk Factor Surveillance System, the authors examined PSA screening in the 13 states that administered the optional “Health Literacy” module. Men aged ≥50 years were examined. Complex samples multivariable logistic regression models were computed to assess the odds of undergoing PSA screening. The interactions between HL and SDM were also examined.ResultsA weighted sample of 12.249 million men with a rate of PSA screening of 33.4% were identified. Approximately one‐third self‐identified as having optimal HL. Rates of PSA screening were found to be highest amongst the highest HL group (42.2%). Being in this group was a significant predictor of undergoing PSA screening (odds ratio, 1.214; 95% confidence interval, 1.051‐1.403). There was a significant interaction observed between HL and SDM (P for interaction, <.001) such that higher HL was associated with a lower likelihood of undergoing PSA screening when SDM was present.ConclusionsIn the uncertain environment of multiple contradictory screening guidelines, men who reported higher levels of HL were found to have higher levels of screening. The authors demonstrated that increased HL may reduce the screening‐promoting effect of SDM. These findings highlight the dynamic interplay between HL and SDM that should inform the creation and promulgation of SDM guidelines, specifically when considering patients with low HL.

Health literacy and shared decision making in prostate cancer screening: Equality versus equity

“…Men in the highest health literacy group reported the highest rates of PSA screening (42.2%; 95% confidence interval [95% CI], 40.5%‐43.9%). Screening rates among men reporting a discussion of the advantages with or without a discussion of the disadvantages of screening reported similarly high rates of PSA screening (48.4%‐49.4%), whereas those reporting no discussion had the lowest rates of PSA screening (8.2%) 4 . In regression analyses adjusted for available demographic and socioeconomic factors, those men with the highest health literacy reported the greatest odds of undergoing PSA screening (odds ratio [OR], 1.214; 95% CI, 1.051‐1.403), with higher educational level (OR, 1.444; 95% CI, 1.144‐1.822), higher income (OR, 1.463; 95% CI, 1.085‐1.972), and health care provider recommendation for screening (OR, 6.128; 95% CI, 5.272‐7.124) found to be associated with greater odds of undergoing PSA screening 4 .…”

“…Screening rates among men reporting a discussion of the advantages with or without a discussion of the disadvantages of screening reported similarly high rates of PSA screening (48.4%‐49.4%), whereas those reporting no discussion had the lowest rates of PSA screening (8.2%) 4 . In regression analyses adjusted for available demographic and socioeconomic factors, those men with the highest health literacy reported the greatest odds of undergoing PSA screening (odds ratio [OR], 1.214; 95% CI, 1.051‐1.403), with higher educational level (OR, 1.444; 95% CI, 1.144‐1.822), higher income (OR, 1.463; 95% CI, 1.085‐1.972), and health care provider recommendation for screening (OR, 6.128; 95% CI, 5.272‐7.124) found to be associated with greater odds of undergoing PSA screening 4 . Upon further interaction testing between health literacy and SDM, Nguyen et al found that higher health literacy was associated with a lower likelihood of undergoing PSA screening when SDM was present, although maximal SDM remained significantly associated with a greater likelihood of PSA screening across all health literacy levels 4 .…”

“…Overuse of medical jargon, minimal patient‐physician rapport, and factors such as racial concordance between the patient and provider may impact the process further 2,3 . For these reasons, Nguyen et al 4 should be commended for their attempt to better understand how health literacy impacts SDM.…”

“…In their article in this issue of Cancer , Nguyen et al 4 examined the influence of health literacy on PSA screening rates in a cross‐sectional study using a weighted sample of 12.249 million men in the Behavioral Risk Factor Surveillance System (BRFSS) data set. In this data set, health literacy was measured using the BRFSS Health Literacy module and the extent of SDM was measured using self‐reported responses to 2 questions focused on whether the advantages and disadvantages of screening were discussed.…”

“…In regression analyses adjusted for available demographic and socioeconomic factors, those men with the highest health literacy reported the greatest odds of undergoing PSA screening (odds ratio [OR], 1.214; 95% CI, 1.051‐1.403), with higher educational level (OR, 1.444; 95% CI, 1.144‐1.822), higher income (OR, 1.463; 95% CI, 1.085‐1.972), and health care provider recommendation for screening (OR, 6.128; 95% CI, 5.272‐7.124) found to be associated with greater odds of undergoing PSA screening 4 . Upon further interaction testing between health literacy and SDM, Nguyen et al found that higher health literacy was associated with a lower likelihood of undergoing PSA screening when SDM was present, although maximal SDM remained significantly associated with a greater likelihood of PSA screening across all health literacy levels 4 . Based on these findings, the authors discussed potential explanations, including patient requests for PSA screening among men with the highest health literacy, an increasing willingness of health care providers to discuss screening with those patients with greater health literacy, and a potential “knee‐jerk” response to agree to PSA screening after discussing the advantages and disadvantages 4 .…”