Interim Chair of Biostatistics
Associate Professor of Biostatistics
Dr. Melody Goodman’s efforts seek to understand the social risk factors that contribute to health disparities in urban areas, with the goal of developing culturally competent, region-specific, and evidence-based solutions through collaborative activities with community members, community-based organizations, faith-based organizations, and other community health stakeholders. The purpose of her work is the development of solutions for improving health in minority and medically underserved communities.
Dr. Goodman conducts applied biostatistical and survey research for community-based interventions and health disparities research with a strong focus on measurement. Additionally, through academic-community collaborations, she implements, evaluates, and enhances the infrastructure of community-engaged research, in order to mitigate health disparities. As such, Dr. Goodman is the Principal Investigator of a Patient-Centered Outcomes Research Institute (PCORI) grant that aims to validate and implement a quantitative survey measure to assess the level of community engagement in patient-centered outcomes research (PCOR) and clinical effectiveness research (CER) studies from the community stakeholder perspective.
Previously, Dr. Goodman has been subcontracted by the National Human Genome Research Institute/NIH to analyze patterns of beliefs about the genetic causation of health conditions and health behaviors among community health center patients. She was the Principal Investigator on a NIH Partners in Research grant entitled Community Alliance for Research Empowering Social change (CARES). With numerous funders supporting her work, she has published over 70 peer-reviewed journal articles.
BS, Economics and Applied Mathematics & Statistics, State University of New York at Stony Brook, Stony Brook, NYMS, Biostatistics, Harvard University, Cambridge, MAPhD, Biostatistics (Minors: Social Determinants of Health Disparities and Theoretical Statistics), Harvard University, Cambridge, MA
Honors and awards
Siteman Cancer Center “Rock Doc” (2013)Satcher Health Leadership Institute - Morehouse School of Medicine, Community Health Leadership Institute Intensive Cohort II (2013)Women of the Year - Health, National Coalition of 100 Black Women, Inc. - Suffolk Chapter (2010)President’s Award for Teaching Excellence - Stony Brook University (2009)President’s Award for Excellence in Team Achievement - Stony Brook University (2008)
Areas of research and study
BiostatisticsCommunity HealthCommunity-based Participatory ResearchDissemination and Implementation of Evidence-based ProgramsHealth DisparitiesHealth EquityMinoritiesMinority HealthQuantitative Research
Cross-sectional and longitudinal effects of racism on mental health among residents of Black neighborhoods in New York CityKwate, N.O.A., & Goodman, M.
Journal titleAmerican Journal of Public Health
Objectives. We investigated the impact of reported racism on the mental health of African Americans at cross-sectional time points and longitudinally, over the course of 1 year. Methods. The Black Linking Inequality, Feelings, and the Environment (LIFE) Study recruited Black residents (n = 144) from a probability sample of 2 predominantly Black New York City neighborhoods during December 2011 to June 2013. Respondents completed self-report surveys, including multiple measures of racism. We conducted assessments at baseline, 2-month follow-up, and 1-year follow-up. Weighted multivariate linear regression models assessed changes in racism and health over time. Results. Cross-sectional results varied by time point and by outcome, with only some measures associated with distress, and effects were stronger for poor mental health days than for depression. Individuals who denied thinking about their race fared worst. Longitudinally, increasing frequencies of racism predicted worse mental health across all 3 outcomes. Conclusions. These results support theories of racism as a health-defeating stressor and are among the few that show temporal associations with health.
Diagnostic accuracy of self-reported racial composition of residential neighborhoodHidalgo, B., Kaphingst, K.A., Stafford, J., Lachance, C., & Goodman, M.
Journal titleAnnals of Epidemiology
Purpose: To examine the diagnostic accuracy of self-reported measures of individuals' perceptions of the racial and ethnic composition of their communities with objective data (i.e., census) as the criterion standard and assess differences in concordance in subjective and objective measures of segregation by race and ethnicity. Methods: We examined data from 943 adult community health center visitors in Suffolk County, New York to assess differences between self-reported racial composition of current neighborhood and 2010 U.S. Census data. A cross-sectional convenience sample was obtained; questionnaires were used to compare participant responses about the racial composition of their current neighborhood and their town of residence. Results: Respondents who self-identified as white were more likely to self-report racial composition of their neighborhood consistent with 2010 Census estimates. Relative to census estimates, 93.1% of blacks overestimated the proportion of their current neighborhood that was black, and 69.8% of Hispanics overestimated the proportion that was Hispanic. Conclusions: There were statistically significant differences between the participants' self-reported neighborhood racial composition and census data across race and ethnicity groups. Future studies are needed to validate self-reported measures of individuals' perceptions of the racial and ethnic composition of their communities to examine the association between individual segregation experience and health.
Do subjective measures improve the ability to identify limited health literacy in a clinical setting?Goodman, M., Griffey, R.T., Carpenter, C.R., Blanchard, M., & Kaphingst, K.A.
Journal titleJournal of the American Board of Family Medicine
Background: Existing health literacy assessments developed for research purposes have constraints that limit their utility for clinical practice, including time requirements and administration protocols. The Brief Health Literacy Screen (BHLS) consists of 3 self-administered Single-Item Literacy Screener (SILS) questions and obviates these clinical barriers. We assessed whether the addition of SILS items or the BHLS to patient demographics readily available in ambulatory clinical settings reaching underserved patients improves the ability to identify limited health literacy. Methods: We analyzed data from 2 cross-sectional convenience samples of patients from an urban academic emergency department (n = 425) and a primary care clinic (n = 486) in St. Louis, Missouri. Across samples, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine- Revised (REALM-R), Newest Vital Sign (NVS), and the BHLS. Our analytic sample consisted of 911 adult patients, who were primarily female (62%), black (66%), and had at least a high school education (82%); 456 were randomly assigned to the estimation sample and 455 to the validation sample. Results: The analysis showed that the best REALM-R estimation model contained age, sex, education, race, and 1 SILS item (difficulty understanding written information). In validation analysis this model had a sensitivity of 62%, specificity of 81%, a positive likelihood ratio (LR+) of 3.26, and a negative likelihood ratio (LR-) of 0.47; there was a 28% misclassification rate. The best NVS estimation model contained the BHLS, age, sex, education and race; this model had a sensitivity of 77%, specificity of 72%, LR+ of 2.75, LR- of 0.32, and a misclassification rate of 25%. Conclusions: Findings suggest that the BHLS and SILS items improve the ability to identify patients with limited health literacy compared with demographic predictors alone. However, despite being easier to administer in clinical settings, subjective estimates of health literacy have misclassification rates >20% and do not replace objective measures; universal precautions should be used with all patients.
Effect of Health Literacy on Decision-Making Preferences among Medically Underserved PatientsSeo, J., Goodman, M., Politi, M., Blanchard, M., & Kaphingst, K.A.
Journal titleMedical Decision Making
Introduction. Participation in the decision-making process and health literacy may both affect health outcomes; data on how these factors are related among diverse groups are limited. This study examined the relationship between health literacy and decision-making preferences in a medically underserved population. Methods. We analyzed a sample of 576 primary care patients. Multivariable logistic regression was used to examine the independent association of health literacy (measured by the Rapid Estimate of Adult Literacy in Medicine-Revised) and patients' decision-making preferences (physician directed or patient involved), controlling for age, race/ethnicity, and gender. We tested whether having a regular doctor modified this association. Results. Adequate health literacy (odds ratio [OR] = 1.7; P = 0.009) was significantly associated with preferring patient-involved decision making, controlling for age, race/ethnicity, and gender. Having a regular doctor did not modify this relationship. Males were significantly less likely to prefer patient-involved decision making (OR = 0.65; P = 0.024). Discussion. Findings suggest health literacy affects decision-making preferences in medically underserved patients. More research is needed on how factors, such as patient knowledge or confidence, may influence decision-making preferences, particularly for those with limited health literacy.
Effects of racial and ethnic group and health literacy on responses to genomic risk information in a medically underserved populationKaphingst, K.A., Stafford, J.D., McGowan, L.D.A., Seo, J., Lachance, C.R., & Goodman, M.
Journal titleHealth Psychology
Objective: Few studies have examined how individuals respond to genomic risk information for common, chronic diseases. This randomized study examined differences in responses by type of genomic information (genetic test/family history) and disease condition (diabetes/heart disease), and by race/ethnicity in a medically underserved population. Methods: 1,057 English-speaking adults completed a survey containing 1 of 4 vignettes (2-by-2 randomized design). Differences in dependent variables (i.e., interest in receiving genomic assessment, discussing with doctor or family, changing health habits) by experimental condition and race/ethnicity were examined using chi-squared tests and multivariable regression analysis. Results: No significant differences were found in dependent variables by type of genomic information or disease condition. In multivariable models, Hispanics were more interested in receiving a genomic assessment than Whites (OR = 1.93; p < .0001); respondents with marginal (OR = 1.54; p = .005) or limited (OR = 1.85; p = .009) health literacy had greater interest than those with adequate health literacy. Blacks (OR = 1.78; p = .001) and Hispanics (OR = 1.85; p =.001) had greater interest in discussing information with family than Whites. Non-Hispanic Blacks (OR = 1.45; p = .04) had greater interest in discussing genomic information with a doctor than Whites. Blacks (β = -0.41; p < .001) and Hispanics (β = -0.25; p = 033) intended to change fewer health habits than Whites; health literacy was negatively associated with number of health habits participants intended to change. Conclusions: Findings suggest that race/ethnicity may affect responses to genomic risk information. Additional research could examine how cognitive representations of this information differ across racial/ethnic groups. Health literacy is also critical to consider in developing approaches to communicating genomic information.
Improving breast cancer services for African-American women living in St. LouisNoel, L., Connors, S.K., Goodman, M., & Gehlert, S.
Journal titleBreast Cancer Research and Treatment
A mixed methods, community-based research study was conducted to understand how provider-level factors contribute to the African-American and white disparity in breast cancer mortality in a lower socioeconomic status area of North St. Louis. This study used mixed methods including: (1) secondary analysis of Missouri Cancer Registry data on all 885 African-American women diagnosed with breast cancer from 2000 to 2008 while living in the geographic area of focus; (2) qualitative interviews with a subset of these women; (3) analysis of data from electronic medical records of the women interviewed; and (4) focus group interviews with community residents, patient navigators, and other health care professionals. 565 women diagnosed with breast cancer from 2000 to 2008 in the geographic area were alive at the time of secondary data analysis; we interviewed (n = 96; 17 %) of these women. Provider-level obstacles to completion of prescribed treatment included fragmented navigation (separate navigators at Federally Qualified Health Centers, surgical oncology, and medical oncology, and no navigation services in surgical oncology). Perhaps related to the latter, women described radiation as optional, often in the same words as they described breast reconstruction. Discontinuous and fragmented patient navigation leads to failure to associate radiation therapy with vital treatment recommendations. Better integrated navigation that continues throughout treatment will increase treatment completion with the potential to improve outcomes in African Americans and decrease the disparity in mortality.
Increasing research literacy: The community research fellows training programCoats, J.V., Stafford, J.D., Thompson, V.S., Javois, B.J., & Goodman, M.
Journal titleJournal of Empirical Research on Human Research Ethics
The Community Research Fellows Training (CRFT) Program promotes the role of underserved populations in research by enhancing the capacity for community-based participatory research (CBPR). CRFT consists of 12 didactic training sessions and 3 experiential workshops intended to train community members in research methods and evidence-based public health. The training (a) promotes partnerships between community members and academic researchers, (b) enhances community knowledge of public health research, and (c) trains community members to become critical consumers of research. Fifty community members participated in training sessions taught by multidisciplinary faculty. Forty-five (90%) participants completed the program. Findings demonstrate that the training increased awareness of health disparities, research knowledge, and the capacity to use CBPR as a tool to address disparities.
Mammograms on-the-go - Predictors of repeat visits to mobile mammography vans in St Louis, Missouri, USA: A case-control studyDrake, B.F., Abadin, S.S., Lyons, S., Chang, S.H., Steward, L.T., Kraenzle, S., & Goodman, M.
Journal titleBMJ Open
Objectives: Among women, breast cancer is the most common non-cutaneous cancer and second most common cause of cancer-related death. The purpose of this study was to determine the extent to which women use mobile mammography vans for breast cancer screening and what factors are associated with repeat visits to these vans. Design: A case-control study. Cases are women who had a repeat visit to the mammography van. (n=2134). Participants: Women who received a mammogram as part of Siteman Cancer Center's Breast Health Outreach Program responded to surveys and provided access to their clinical records (N=8450). Only visits from 2006 to 2014 to the mammography van were included. Outcome measures: The main outcome is having a repeat visit to the mammography van. Among the participants, 25.3% (N=2134) had multiple visits to the mobile mammography van. Data were analysed using χ2 tests, logistic regression and negative binomial regression. Results: Women who were aged 50-65, uninsured, or African-American had higher odds of a repeat visit to the mobile mammography van compared with women who were aged 40-50, insured, or Caucasian (OR=1.135, 95% CI 1.013 to 1.271; OR=1.302, 95% CI 1.146 to 1.479; OR=1.281, 95% CI 1.125 to 1.457), respectively. However, the odds of having a repeat visit to the van were lower among women who reported a rural ZIP code or were unemployed compared with women who provided a suburban ZIP code or were employed (OR=0.503, 95% CI 0.411 to 0.616; OR=.868, 95% CI 0.774 to 0.972), respectively. Conclusion: This study has identified key characteristics of women who are either more or less likely to use mobile mammography vans as their primary source of medical care for breast cancer screening and have repeat visits.
Quantitative evaluation of the community research fellows training programMcGowan, L.D., Stafford, J.D., Thompson, V.L., Johnson-Javois, B., & Goodman, M.
Journal titleFrontiers in Public Health
Context: The community research fellows training (CRFT) programis a community-based participatory research (CBPR) initiative for the St. Louis area. This 15-week program, based on a Master in Public Health curriculum, was implemented by the Division of Public Health Sciences at Washington University School of Medicine and the Siteman Cancer Center. Objectives: We measure the knowledge gained by participants and evaluate participant and faculty satisfaction of the CRFT program both in terms of meeting learning objectives and actively engaging the community in the research process. Participants: We conducted analyses on 44 community members who participated in the CRFT program and completed the baseline and follow-up knowledge assessments. Main outcome measures: Knowledge gain is measured by a baseline and follow-up assessment given at the first and final session. Additionally, preand post-tests are given after the first 12 sessions. To measure satisfaction, program evaluations are completed by both the participants and faculty after each topic. Mid-way through the program, a mid-term evaluation was administered to assess the program's community engagement. We analyzed the results from the assessments, preand post-tests, and evaluations. Results: The CRFT participants' knowledge increased at follow-up as compared with baseline on average by a 16.5 point difference (p>0.0001). Post-test scores were higher than pre-test scores for 11 of the 12 sessions. Both participants and faculty enjoyed the training and rated all session well. Conclusion: The CRFT program was successful in increasing community knowledge, participant satisfaction, and faculty satisfaction. This success has enhanced the infrastructure for CBPR as well as led to CBPR pilot projects that address health disparities in the St. Louis Greater Metropolitan Area.
Race, law, and health: Examination of 'Stand Your Ground' and defendant convictions in FloridaAckermann, N., Goodman, M., Gilbert, K., Arroyo-Johnson, C., & Pagano, M.
Journal titleSocial Science and Medicine
Previous analyses of Stand Your Ground (SYG) cases have been primarily descriptive. We examine the relationship between race of the victim and conviction of the defendant in SYG cases in Florida from 2005 to 2013. Using a regression analytic approach, we allow for simultaneous examination of multiple factors to better understand existing interrelationships. Data was obtained from the Tampa Bay Times SYG database (237 cases) which was supplemented with available online court documents and/or news reports. After excluding cases which were, still pending as of January 2015; had multiple outcomes (because of multiple suspects); and missing information on race of victim and weapon of victim, our final analytic sample has 204 cases. We chose whether the case resulted in a conviction as the outcome. We develop logistic regression models using significant bivariate predictors as candidates. These include race of the victim (White, non-White), whether the defendant could have retreated from the situation, whether the defendant pursued the victim, if the victim was unarmed, and who was the initiator of the confrontation. We find race of the victim to be a significant predictor of case outcome in this data set. After controlling for other variables, the defendant is two times (OR = 2.1, 95% CI [1.07, 4.10]) more likely to be convicted in a case that involves White victims compared to those involving non-White victims. Our results depict a disturbing message: SYG legislation in Florida has a quantifiable racial bias that reveals a leniency in convictions if the victim is non-White, which provides evidence towards unequal treatment under the law. Rather than attempting to hide the outcomes of these laws, as was done in Florida, other states with SYG laws should carry out similar analyses to see if their manifestations are the same as those in Florida, and all should remediate any injustices found.
Racial composition over the life course: Examining separate and unequal environments and the risk for heart disease for African American menGilbert, K.L., Elder, K., Lyons, S., Kaphingst, K., Blanchard, M., & Goodman, M.
Journal titleEthnicity and Disease
Purpose: Studies have demonstrated the effects of segregated social and physical environments on the development of chronic diseases for African Americans. Studies have not delineated the effects of segregated environments specifically on the health of African American men over their lifetime. This study examines the relationship between life course measures of racial composition of social environments and diagnosis of hypertension among African American men. Design: We analyzed cross-sectional data from a convenience sample of African American men seeking health care services in an outpatient primary care clinic serving a medically underserved patient population (N=118). Multivariable logistic regression analyses were used to examine associations between racial composition of multiple environments across the life course (eg, junior high school, high school, neighborhood growing up, current neighborhood, place of employment, place of worship) and hypertension diagnosis. Results: The majority (86%) of participants were not currently in the workforce (retired, unemployed, or disabled) and more than half (54%) reported an annual household income of <$9,999; median age was 53. Results suggest that African American men who grew up in mostly Black neighborhoods (OR=4.3; P=.008), and worked in mostly Black environments (OR=3.1; P=.041) were more likely to be diagnosed with hypertension than those who did not. Conclusion: We found associations between mostly Black residential and workplace settings and hypertension diagnoses among African American men. Findings suggest exposure to segregated environments during childhood and later adulthood may impact hypertension risk among African American men over the life course.
Racism at the Intersections: Gender and Socioeconomic Differences in the Experience of Racism Among African AmericansKwate, N.O.A., & Goodman, M.
Journal titleAmerican Journal of Orthopsychiatry
Several studies investigating the health effects of racism have reported gender and socioeconomic differences in exposures to racism, with women typically reporting lower frequencies, and individuals with greater resources reporting higher frequencies. This study used diverse measures of socioeconomic position and multiple measures and methods to assess experienced racism. Socioeconomic position included education and financial and employment status. Quantitative racism measures assessed individual experiences with day-to-day and with major lifetime incidents and perceptions of the extent to which African Americans as a group experience racism. A brief qualitative question asked respondents to describe a racist incident that stood out in recent memory. Participants comprised a probability sample of N ± 144 African American adults aged 19 to 87 residing in New York City. Results suggested that women reported fewer lifetime incidents but did not differ from men on everyday racism. These differences appear to be partly because of scale content. Socioeconomic position as measured by years of education was positively associated with reported racism in the total sample but differently patterned across gender; subjective social status showed a negative association. Qualitative responses describing memorable incidents fell into 5 key categories: resources/opportunity structures, criminal profiling, racial aggression/assault, interpersonal incivilities, and stereotyping. In these narratives, men were more likely to offer accounts involving criminal profiling, and women encountered incivilities more often. The findings highlight the need for closer attention to the intersection of gender and socioeconomic factors in investigations of the health effects of racism.
The impact of teach-back on comprehension of discharge instructions and satisfaction among emergency patients with limited health literacy: A randomized, controlled studyGriffey, R.T., Shin, N., Jones, S., Aginam, N., Gross, M., Kinsella, Y., … Kaphingst, K.A.
Journal titleJournal of Communication in Healthcare
Objective: Recommended as a ‘universal precaution’ for improving provider–patient communication, teach-back has a limited evidence base. Discharge from the emergency department (ED) to home is an important high-risk transition of care with potential for miscommunication of critical information. We examined whether teach-back improves: comprehension and perceived comprehension of discharge instructions and satisfaction among patients with limited health literacy (LHL) in the ED. Methods: We performed a randomized, controlled study among adult patients with LHL, randomized to teach-back or standard discharge instructions. Patients completed an audio-recorded structured interview evaluating comprehension and perceived comprehension of (1) diagnosis, (2) ED course, (3) post-ED care, and (4) reasons to return and satisfaction using four Consumer Assessment of Healthcare Providers and Systems questions. Concordance with the medical record was rated using a five-level scale. We analyzed differences between groups using multivariable ordinal logistic regression. Results: Patients randomized to receive teach-back had higher comprehension of post-ED care areas: post-ED medication (P < 0.02), self-care (P < 0.03), and follow-up instructions (P < 0.0001), but no change in patient satisfaction or perceived comprehension. Conclusion: Teach-back appears to improve comprehension of post-ED care instructions but not satisfaction or perceived comprehension. Our data from a randomized, controlled study support the effectiveness of teach-back in a busy clinical setting. Further research is needed to test the utility and feasibility of teach-back for routine use including its impacts on distal outcomes.
An empirical analysis of White privilege, social position and healthKwate, N.O.A., & Goodman, M.
Journal titleSocial Science and Medicine
Accumulated evidence has demonstrated that social position matters for health. Those with greater socioeconomic resources and greater perceived standing in the social hierarchy have better health than those with fewer resources and lower perceived standing. Race is another salient axis by which health is stratified in the U.S., but few studies have examined the benefit of White privilege. In this paper, we investigated how perceptions of inequality and subjective and objective social status affected the health and well-being of N=630 White residents in three Boston neighborhoods lying on a social gradient differentiated by race, ethnicity, income and prestige. Outcomes were self-rated health, dental health, and happiness. Results suggested that: neighborhood residence was not associated with health after controlling for individual level factors (e.g., positive ratings of the neighborhood, education level); objective measures of socioeconomic status were associated with better self-reported and dental health, but subjective assessments of social position were more strongly associated; and White residents living in the two wealthiest neighborhoods, and who perceived Black families as welcome in their neighborhoods enjoyed better health than those who believed them to be less welcome. However, those who lived in the least wealthy and most diverse neighborhood fared worse when reporting Black families to be welcome. These results suggest that White privilege and relative social position interact to shape health outcomes.
Analysis of ordinal outcomes with longitudinal covariates subject to missingnessGoodman, M., Li, Y., Stoddard, A.M., & Sorensen, G.
Journal titleJournal of Applied Statistics
We propose a mixture model for data with an ordinal outcome and a longitudinal covariate that is subject to missingness. Data from a tailored telephone delivered, smoking cessation intervention for construction laborers are used to illustrate the method, which considers as an outcome a categorical measure of smoking cessation, and evaluates the effectiveness of the motivational telephone interviews on this outcome. We propose two model structures for the longitudinal covariate, for the case when the missing data are missing at random, and when the missing data mechanism is non-ignorable. A generalized EM algorithm is used to obtain maximum likelihood estimates.
Brentwood community health care assessmentGoodman, M., Gonzalez, M., Gil, S., Si, X., Pashoukos, J.L., Stafford, J.D., … Pashoukos, D.A.
Journal titleProgress in Community Health Partnerships: Research, Education, and Action
Brentwood community health care assessmentGoodman, M., Gonzalez, M., Gil, S., Si, X., Pashoukos, J.L., Stafford, J.D., … Pashoukos, D.A.
Journal titleProgress in Community Health Partnerships: Research, Education, and Action
Background: The Community Alliance for Research Empowering Social Change (CARES) is an academic-community research partnership designed to train community members on research methods and develop the infrastructure for community-based participatory research (CBPR) to examine and address racial/ethnic health disparities. The Brentwood Community Health Assessment (BCHA) was developed through a CBPR pilot project grant from CARES. Objectives: The purpose of the BCHA is to assess health care utilization and identify existing barriers to health care access among a multi-ethnic community in the Hamlet of Brentwood, New York. Methods: Using CBPR approaches, the community-academic research partnership develop the study design and survey instrument. Trained Bilingual (English/Spanish) data collectors verbally administered surveys door-to-door to residents of Brentwood from October 2010 to May 2011. Inclusion criteria required participants to be at least 18 years of age and speak either English or Spanish. Results: Overall, 232 residents completed the BCHA; 49% were male, 66% Hispanic, 13% non-Hispanic White, 13% non-Hispanic Black, 29% had less than a high school education, and 33% were born in United States. The assessment results revealed that most residents are able to access health care when needed and the most significant barriers to health care access are insurance and cost. Conclusions: We describe the community-academic partnered process used to develop and implement the BCHA and report assessment findings; the community-partnered approach improved data collection and allowed access into one of Suffolk County's most vulnerable communities.
Does numeracy correlate with measures of health literacy in the emergency department?Griffey, R.T., Melson, A.T., Lin, M.J., Carpenter, C.R., Goodman, M., & Kaphingst, K.A.
Journal titleAcademic Emergency Medicine
Objectives The objective was to quantify the correlation between general numeracy and health literacy in an emergency department (ED) setting. Methods This was a prospective cross-sectional convenience sample study of adult patients in an urban, academic ED with 97,000 annual visits. General numeracy was evaluated using four validated questions and health literacy using three commonly used validated screening tools (Short Test of Functional Health Literacy in Adults [S-TOFHLA], Rapid Estimate of Adult Literacy in Medicine-Revised [REALM-R], and the Newest Vital Sign [NVS]). Scores were dichotomized for health literacy tests to limited (low or marginal) versus adequate health literacy, and the proportion of patients answering all numeracy questions correctly was calculated with the mean proportion of correct responses in these groups. The correlation between numeracy scores and scores on the health literacy screening tools was evaluated using Spearman's correlation. Results A total of 446 patients were enrolled. Performance on questions evaluating general numeracy was universally poor. Only 18 patients (4%) answered all numeracy questions correctly, 88 patients (20%) answered zero questions correctly, and overall the median number of correct answers was one (interquartile range [IQR] = 1 to 2). Among patients with limited health literacy (LHL) by any of the three screening tools used, the mean number of correct numeracy answers was approximately half that of patients with adequate health literacy. However, even among those with adequate health literacy, the average number of correct answers to numeracy questions ranged from 1.6 to 2.4 depending on the screening test used. When dichotomized into those who answered ≤50% versus >50% of numeracy questions correctly, there was a significant difference between those with LHL and those who scored ≤50% on numeracy. Health literacy screening results were correlated with general numeracy in the low to moderate range: S-TOFHLA rs = 0.428 (p < 0.0001); REALM, rs = 0.400 (p < 0.0001); and NVS, rs = 0.498 (p < 0.0001). Conclusions Correlations between measures of general numeracy and measures of health literacy are in the low to moderate range. Performance on numeracy testing was nearly universally poor, even among patients performing well on health literacy screens, with a substantial proportion of the latter patients unable to answer half of the numeracy items correctly. Insofar as numeracy is considered a subset of health literacy, these results suggest that commonly used health literacy screening tools in ED-based studies inadequately evaluate and overestimate numeracy. This suggests the potential need for separate numeracy screening when these skills are important for health outcomes of interest. Providers should be sensitive to potential numeracy deficits among those who may otherwise have normal health literacy.
Effect of cognitive dysfunction on the relationship between age and health literacyKaphingst, K.A., Goodman, M., MacMillan, W.D., Carpenter, C.R., & Griffey, R.T.
Journal titlePatient Education and Counseling
Objective: Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood. Methods: We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction. Results: Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r= -0.16, p= 0.001 vs. r= -0.35, p< 0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups. Conclusion: Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults. Practice implications: Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.
Feasibility and diagnostic accuracy of brief health literacy and numeracy screening instruments in an urban emergency departmentCarpenter, C.R., Kaphingst, K.A., Goodman, M., Lin, M.J., Melson, A.T., & Griffey, R.T.
Journal titleAcademic Emergency Medicine
Objectives The objective was to evaluate the diagnostic accuracy of five health literacy screening instruments in emergency department (ED) patients: the Rapid Evaluation of Adult Literacy in Medicine-Revised (REALM-R), the Newest Vital Sign (NVS), Single Item Literacy Screens (SILS), health numeracy, and physician gestalt. A secondary objective was to evaluate the feasibility of these instruments as measured by administration time, time on task, and interruptions during test administration. Methods This was a prospective observational cross-sectional study of a convenience sampling of adult patients presenting during March 2011 and February 2012 to one urban university- affiliated ED. Subjects were consenting non-critically ill, English-speaking patients over the age of 18 years without aphasia, dementia, mental retardation, or inability to communicate. The diagnostic test characteristics of the REALM-R, NVS, SILS, health numeracy, and physician gestalt were quantitatively assessed by using the short Test of Functional Health Literacy in Adults (S-TOFHLA). A score of 22 or less was the criterion standard for limited health literacy (LHL). Results A total of 435 participants were enrolled, with a mean (±SD) age of 45 (±15.7) years, and 18% had less than a high school education. As defined by an S-TOFHLA score of 22 or less, the prevalence of LHL was 23.9%. In contrast, the NVS, REALM-R, and physician gestalt identified 64.8, 48.5, and 35% of participants as LHL, respectively. A normal NVS screen was the most useful test to exclude LHL, with a negative likelihood ratio of 0.04 (95% confidence interval [CI] = 0.01 to 0.17). When abnormal, none of the screening instruments, including physician gestalt, significantly increased the posttest probability of LHL. The NVS and REALM-R require 3 and 5 minutes less time to administer than the S-TOFHLA. Administration of the REALM-R is associated with fewer test interruptions. Conclusions One-quarter of these ED patients had marginal or inadequate health literacy. Among the brief screening instruments evaluated, a normal NVS result accurately reduced the probability of LHL, although it will identify two-thirds of ED patients as high risk for LHL. None of the brief screening instruments significantly increases the probability of LHL when abnormal.
Is low health literacy associated with increased emergency department utilization and recidivism?Griffey, R.T., Kennedy, S.K., McGownan, L., Goodman, M., & Kaphingst, K.A.
Journal titleAcademic Emergency Medicine
Objectives: The objective was to determine whether patients with low health literacy have higher emergency department (ED) utilization and higher ED recidivism than patients with adequate health literacy. Methods: The study was conducted at an urban academic ED with more than 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross-sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (S-TOFHLA) and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis and retaining those significant at an alpha of 0.05 in the final model. Results: Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. Conclusions: In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days.
Perceived barriers to mammography among underserved women in a Breast Health Center Outreach ProgramFayanju, O.M., Kraenzle, S., Drake, B.F., Oka, M., & Goodman, M.
Journal titleAmerican Journal of Surgery
Background To investigate perceived barriers to mammography among underserved women, we asked participants in the Siteman Cancer Center Mammography Outreach Registry-developed in 2006 to evaluate mobile mammography's effectiveness among the underserved-why they believed women did not get mammograms. Methods The responses of approximately 9,000 registrants were analyzed using multivariable logistic regression. We report adjusted odds ratios (OR) and 95% confidence intervals (CI) significant at 2-tailed P values less than.05. Results Fears of cost (40%), mammogram-related pain (13%), and bad news (13%) were the most commonly reported barriers. Having insurance was associated with not perceiving cost as a barrier (OR.44, 95% CI.40 to.49), but with perceiving fear of both mammogram-related pain (OR 1.39, 95% CI 1.21 to 1.60) and receiving bad news (OR 1.38, 95% CI 1.19 to 1.60) as barriers. Conclusion Despite free services, underserved women continue to report experiential and psychological obstacles to mammography, suggesting the need for more targeted education and outreach in this population.
Racial disparities in risk of second breast tumors after ductal carcinoma in situLiu, Y., Colditz, G.A., Gehlert, S., & Goodman, M.
Journal titleBreast Cancer Research and Treatment
The purpose of the study was to examine the impact of race/ethnicity on second breast tumors among women with ductal carcinoma in situ (DCIS). We identified 102,489 women diagnosed with primary DCIS between 1988 and 2009 from the 18 NCI-SEER Registries. Cox proportional hazard regression was used to estimate race/ethnicity-associated relative risks (RRs) and their 95 % confidence intervals (CI) of ipsilateral breast tumors (IBT; defined as DCIS or invasive carcinoma in the ipsilateral breast) and contralateral breast tumors (CBT; defined as DCIS or invasive carcinoma in the contralateral breast). Overall, 2,925 women had IBT and 3,723 had CBT. Compared with white women, black (RR 1.46; 95 % CI 1.29–1.65), and Hispanic (RR 1.18; 95 % CI 1.03–1.36) women had higher IBT risk, which was similar for invasive IBT and ipsilateral DCIS. A significant increase in IBT risk among black women persisted, regardless of age at diagnosis, treatment, tumor grade, tumor size, and histology. The CBT risk was significantly increased among black (RR 1.21; 95 % CI 1.08–1.36) and Asian/PI (RR 1.16; 95 % CI 1.02–1.31) women compared with white women. The association was stronger for invasive CBT among black women and for contralateral DCIS among Asian/PI women (Pheterogeneity < 0.0001). The black race-associated CBT risk was more pronounced among women ≥50 years at diagnosis and those with comedo DCIS; in contrast, a significant increase in risk among Asian/PI women was restricted to those <50 years and those with noncomedo DCIS. Racial/ethnic differences in risks of second breast tumors after DCIS could not be explained by pathologic features and treatment.
Responses to genomic information by race/ethnicity in a medically underserved populationKaphingst, K.A., Stafford, J.D., D'Agostino-McGowan, L., Seo, J., Lachance, C., & Goodman, M.
Journal titleHealth Psychology
Screening for colorectal cancer: Using data to set prevention prioritiesColditz, G.A., McGowan, L.D.A., James, A.S., Bohlke, K., & Goodman, M.
Journal titleCancer Causes and Control
Introduction: Adherence to colorectal cancer screening recommendations is known to vary by state, but less information is available about within-state variability. In the current study, we assess county-level screening rates for Missouri, with the goal of better targeting public health efforts to increase screening. Methods: Prevalence of colorectal cancer screening among Missouri adults between the ages of 50 and 74 was obtained from 2008 and 2010 Behavioral Risk Factor Surveillance System data. We used multilevel logistic regression to generate county-specific estimates. After excluding 77 counties with fewer than 30 respondents, information was available about 3,739 individuals in 37 counties, representing 78.5 % of the state population. Results: Across counties, the prevalence of being up-to-date with recommended colorectal cancer screening ranged from 25 to 70 %. Conclusion: State-level information about colorectal cancer screening masks substantial within-state variability. Assessing and monitoring county-level disparities in screening can guide public health efforts to increase screening and reduce colorectal cancer mortality. More complete population survey data will make such analysis possible.