The relationship between health literacy, patient activation, and health outcomes in breast cancer patients

The aim of this study was to evaluate the level of health literacy and patient activation in a sample of breast cancer patients as well as examine the relationships of these constructs to health outcomes. A cross-sectional study design was employed. HER-2 positive breast cancer patients receiving care at 12 oncology clinics in Texas who had scheduled office appointments between August and October 2018 were approached to participate in the study via convenience sampling. Patients who expressed willingness to participate in the study were given a 67-item survey to complete during their office visit. The survey consisted of the 6-item cancer health literacy measure (CHLT-6), the 6-item newest vital sign (NVS), the 13-item patient activation measure (PAM 13), the 27-item functional assessment of cancer therapy (FACT-G v. 4), two items measuring the quality of patient-provider communication, and single item measures for the number of ED visits/hospitalizations as well as clinical and demographic patient characteristics. All variables were analyzed descriptively (means, frequencies). Bivariate and multivariate analyses were also conducted to assess the relationships between variables and predict health outcomes. Almost 90 percent (N=146) of the 164 patients approached participated in the study. Results from the 146 study participants showed that the average age was 57.1±10.8 years. The majority were female (99%), Caucasian (72%), married or in a relationship (70%), at least had a college degree (53%), and had an annual household income over $50,000 (66%). Clinically, there was an almost equal distribution of patients from cancer stage 1 to stage 4 and most patients had been diagnosed for the first time within the last 5 years (78%). Ninety-two percent (N=134) of participants had adequate cancer health literacy while 79 percent (N= 114) had adequate general health literacy based on their CHLT-6 and NVS scores, respectively. The mean patient activation score was 65.9±15.7 (of a possible 100) with most patients (68%, N= 99) in the higher levels (level 3 or 4) of activation. The average quality of life based on an overall FACT-G score of 108 was high (82.6±16.1). Bivariate analysis showed significant positive relationships between cancer health literacy and educational level, and household income. Ethnic minorities were also found to have significantly lower patient activation scores compared to Whites. Multivariate analysis revealed that cancer health literacy, patient activation, educational level, and number of treatment types received explained 23 percent of the variation in quality of life, and all except cancer health literacy were positive and significant predictors. It is important to pay attention to modifiable factors such as patient activation that impact breast cancer patients’ quality of life in interventions aimed to improve quality of life, especially in ethnic minorities who tend to have lower patient activation levels. The high levels and homogeneity of cancer health literacy among study participants could have influenced its non-significant relationship with quality of life. Further assessments of health literacy and patient activation with quality of life as well as other health outcomes in larger and more diverse populations of breast cancer patients are warranted.