Health literacy and its relationship with process and outcome in advanced kidney disease

Abstract

Introduction: Management of Chronic Kidney Disease (CKD) aims to reduce the risk of kidney failure and cardiovascular disease and, if appropriate, prepare patients for renal replacement therapy: dialysis or kidney transplantation. Kidney transplantation is superior to dialysis in terms of survival and quality of life, but donor organs are a limited resource. CKD care pathways are complex, and shared decision-making and self-care activities are promoted. Health literacy is an attribute facilitating access, understanding, appraisal and use of health-related information. Socioeconomic disparities exist in CKD care and outcomes. Low health literacy is associated with both low socioeconomic status (SES) and poorer health outcomes, so is hypothesised to mediate pathways which promote health inequity.

Aims/Methods: This thesis investigates:
• The prevalence of limited health literacy at different treatment stages of CKD, and associations with demographics and SES (systematic review and meta-analysis).
• Associations between low health literacy and CKD outcomes (systematic review)
• The prevalence and associations of limited health literacy in UK patients with advanced CKD in the Access to Transplant and Transplant Outcome Measures (ATTOM) study
• Associations between limited health literacy and clinical outcomes, including deceasedand living-donor kidney transplantation, using prospective data from the ATTOM study.
• Health literacy as a mediator in the relationship between low educational level and time to transplant wait-listing and deceased- or living-donor kidney transplantation

Results: The pooled prevalence of limited health literacy among people with CKD was 25%. Prevalence was lower among transplanted patients compared to those with non-dialysis or dialysis CKD. Limited health literacy was consistently, independently associated with low SES and non-white ethnicity. Current evidence from peer-reviewed literature for associations between low health literacy and clinical outcomes was limited. In the ATTOM study, limited health literacy was independently associated with low socioeconomic status and increased comorbidity. Prevalence of limited health literacy was significantly lower among transplant recipients compared to dialysis or wait-listed patients, after adjustment for comorbidity. Limited health literacy was associated with reduced chance of transplant wait-listing, living-donor transplant or transplantation from any donor at 2 years from dialysis start. In mediation analysis, health literacy mediated 25-30% of the total effect of low educational level on increased time to deceased-donor transplant wait-listing, living-donor transplantation or transplantation from any donor type.

Conclusions: A quarter or more of patients with CKD have limited health literacy, so are unlikely to be able to fully understand or appraise health-related information or navigate care pathways if standard communication methods are used. By mediating the relationship between low socioeconomic status and access to transplantation, health literacy differences may promote inequity. Interventions which successfully reduce these effects could improve patients’ understanding, reduce inequity and improve outcomes.

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Identifiers

ORCID for Paul Roderick: orcid.org/0000-0001-9475-6850

ORCID for Simon Fraser: orcid.org/0000-0002-4172-4406

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