BackgroundLower health literacy is a public health issue that follows a social gradient, potentially reinforcing existing health inequalities. However, levels of health literacy in particular populations can be unclear and are a key to identifying effective public health interventions. This research examined health literacy levels in Stoke‐on‐Trent, where 31.2% of the population live in areas classified amongst the 10% most deprived in England.MethodsA cross‐sectional survey using the Newest Vital Sign examined associations with demographic factors, lifestyle behaviours, Internet use and self‐rated health. The sample (n = 1046) took account of variance in levels of health literacy by age, educational attainment and deprivation. Bivariate logistic regression and multivariate logistic regression were used to estimate associations with health literacy when adjusted for other demographic factors and lifestyle behaviours.ResultsNine hundred and seventy‐two respondents completed the health literacy measure (93%): 277 (28.5%) scored low, 228 (23.5%) scored marginal and 467 (48.0%) scored adequate. Associations with higher rates of limited health literacy included older age, lower educational level, lower income, perceived poor health and lack of access to the Internet.ConclusionsGiven the complexity of factors influencing health literacy interdisciplinary approaches across health and social care and the voluntary sector are essential in identifying and developing appropriate interventions.

This paper aims to examine the socio-demographic characteristics associated with access and use of internet for health-related purposes and its relationship with health literacy. Data were drawn from a health literacy survey (N=1046) and analysed using logistic regression. Results show a strong association between health literacy, internet access and use. Socio-demographic characteristics particularly age, education, income, perceived health and social isolation also predict internet access. Thus, in addition to widening access, the movement towards digitisation of health information and services should also consider digital skills development to enable people to utilise digital technology more effectively, especially among traditionally hard-to-reach communities.Health information and services are becoming more accessible online. It has been argued that making health information and services available online can improve patient experience by enhancing shared decision making by promoting informed choice (Gann & Grant, 2013). Internet use has also been associated with health promoting behaviours (Xavier, et al, 2013), better mental health (Forsman & Nordmyr, 2015) and improved financial decision making (James, et al, 2013).Although it has its merits, concerns have been raised on how the proliferation of internet-based health information and services could reinforce existing social inequities in health (McAuley, 2014). While the internet has been used by patients to gather information, gain support and to make sense of one's health condition (Ziebland, 2004), those who are in the greatest need of health information are least likely to have access to new technologies (Aydın, Kaya, & Turan, 2015). Previous research from North America and Europe reflect a 'digital divide', whereby socio-economic and demographic factors such as age, income, education and health status were able to predict people's likelihood to access and use the internet to seek health information (Kontos, et al., 2014). In Great Britain, while the internet was accessed either every day or almost every day by 78% of adults (39.3 million) in 2015, only about 49% used it to look for health-related information (ONS, 2016). Barriers to access and internet use included financial restrictions (i.e., equipment and internet access costs are too high), medical and disabilityrelated constraints (i.e., the technology is not easily accessible for some patients), and digital complexity (i.e., accessing and navigating the internet is too complex) (Connolly & Crosby, 2014).While efforts are being made to widen the reach and accessibility of internet technology, the general population still needs to keep up with the growing amount of health-related information and services online. Just as the readability of health information needs to match the literacy skills of its users (Rowlands, et al., 2015), so does the readability of health information and services online. In England, around 11 million people lack basic digital literacy, with around 7 million having ...

Objectives When developing a clinical prediction model, penalization techniques are recommended to address overfitting, as they shrink predictor effect estimates toward the null and reduce mean-square prediction error in new individuals. However, shrinkage and penalty terms (‘tuning parameters’) are estimated with uncertainty from the development data set. We examined the magnitude of this uncertainty and the subsequent impact on prediction model performance. Study Design and Setting This study comprises applied examples and a simulation study of the following methods: uniform shrinkage (estimated via a closed-form solution or bootstrapping), ridge regression, the lasso, and elastic net. Results In a particular model development data set, penalization methods can be unreliable because tuning parameters are estimated with large uncertainty. This is of most concern when development data sets have a small effective sample size and the model's Cox-Snell is low. The problem can lead to considerable miscalibration of model predictions in new individuals. Conclusion Penalization methods are not a ‘carte blanche’; they do not guarantee a reliable prediction model is developed. They are more unreliable when needed most (i.e., when overfitting may be large). We recommend they are best applied with large effective sample sizes, as identified from recent sample size calculations that aim to minimize the potential for model overfitting and precisely estimate key parameters.

Background The objectives of this study were to estimate the population prevalence and distribution of plantar heel pain in mid-to-older age groups, examine associations with selected health status and lifestyle factors, and report the frequency of healthcare use. Methods Adults aged ≥50 years registered with four general practices were mailed a health survey ( n = 5109 responders). Plantar heel pain in the last month was defined by self-reported shading on a foot manikin, and was defined as disabling if at least one of the function items of the Manchester Foot Pain and Disability Index were also reported. Population prevalence estimates and associations between plantar heel pain and demographic characteristics, health status measures and lifestyle factors were estimated using multiple imputation and weighted logistic regression. Healthcare professional consultation was summarised as the 12-month period prevalence of foot pain-related consultation. Results The population prevalence of plantar heel pain was 9.6% (95% CI: 8.8, 10.5) and 7.9% (7.1, 8.7) for disabling plantar heel pain. Occurrence was slightly higher in females, comparable across age-groups, and significantly higher in those with intermediate/routine and manual occupations. Plantar heel pain was associated with physical and mental impairment, more anxiety and depression, being overweight, a low previous use of high-heeled footwear, and lower levels of physical activity and participation. The 12-month period prevalence of foot pain-related consultation with a general practitioner, physiotherapist or podiatrist/chiropodist was 43.0, 15.1 and 32.8%, respectively. Conclusions Plantar heel pain is a common, disabling symptom among adults aged 50 years and over. Observed patterns of association indicate that in addition to focused foot-specific management, primary care interventions should also target more general physical and psychological factors that could potentially act as barriers to treatment adherence and recovery. Electronic supplementary material The online version of this article (10.1186/s12891-019-2718-6) contains supplementary material, which is available to authorized users.