Rachel O'Conor

Health Literacy, Cognitive Function, Proper Use, and Adherence to Inhaled Asthma Controller Medications Among Older Adults With Asthma

BACKGROUND We sought to investigate the degree to which cognitive skills explain associations between health literacy and asthma-related medication use among older adults with asthma. METHODS Patients aged ≥ 60 years receiving care at eight outpatient clinics (primary care, geriatrics, pulmonology, allergy, and immunology) in New York, New York, and Chicago, Illinois, were recruited to participate in structured, in-person interviews as part of the Asthma Beliefs and Literacy in the Elderly (ABLE) study (n = 425). Behaviors related to medication use were investigated, including adherence to prescribed regimens, metered-dose inhaler (MDI) technique, and dry powder inhaler (DPI) technique. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of fluid (working memory, processing speed, executive function) and crystallized (verbal) ability. RESULTS The mean age of participants was 68 years; 40% were Hispanic and 30% non-Hispanic black. More than one-third (38%) were adherent to their controller medication, 53% demonstrated proper DPI technique, and 38% demonstrated correct MDI technique. In multivariable analyses, limited literacy was associated with poorer adherence to controller medication (OR, 2.3; 95% CI, 1.29-4.08) and incorrect DPI (OR, 3.51; 95% CI, 1.81-6.83) and MDI (OR, 1.64; 95% CI, 1.01-2.65) techniques. Fluid and crystallized abilities were independently associated with medication behaviors. However, when fluid abilities were added to the model, literacy associations were reduced. CONCLUSIONS Among older patients with asthma, interventions to promote proper medication use should simplify tasks and patient roles to overcome cognitive load and suboptimal performance in self-care.

Low health literacy predicts decline in physical function among older adults: findings from the LitCog cohort study

Background Limited health literacy is associated with worse physical function in cross-sectional studies. We aimed to determine if health literacy is a risk factor for decline in physical function among older adults. Methods A longitudinal cohort of 529 community-dwelling American adults aged 55–74 years were recruited from an academic general internal medicine clinic and federally qualified health centres in 2008–2011. Health literacy (Newest Vital Sign), age, gender, race, education, chronic conditions, body mass index, alcohol consumption, smoking status and exercise frequency were included in multivariable analyses. The 10-item PROMIS (Patient-Reported Outcomes Measurement Information System) physical function scale was assessed at baseline and follow-up (mean=3.2 years, SD=0.39). Results Nearly half of the sample (48.2%) had either marginal (25.5%) or low health literacy (22.7%). Average physical function at baseline was 83.2 (SD=16.6) of 100, and health literacy was associated with poorer baseline physical function in multivariable analysis (p=0.004). At follow-up, physical function declined to 81.9 (SD=17.3; p=0.006) and 20.5% experienced a meaningful decline (>0.5 SD of baseline score). In multivariable analyses, participants with marginal (OR 2.62; 95%CI 1.38 to 4.95; p=0.003) and low (OR 2.57; 95%CI 1.22 to 5.44; p=0.013) health literacy were more likely to experience meaningful decline in physical function than the adequate health literacy group. Entering cognitive abilities to these models did not substantially attenuate effect sizes. Health literacy attenuated the relationship between black race and decline in physical function by 32.6%. Conclusions Lower health literacy increases the risk of exhibiting faster physical decline over time among older adults. Strategies that reduce literacy disparities should be designed and evaluated.

Asthma outcomes are poor among older adults with low health literacy.

Abstract Objective: To examine the association of health literacy (HL) with asthma outcomes among older asthmatics. Methods: The study included adults ages ≥60 with moderate to severe asthma in New York City and Chicago. We assessed asthma control with the Asthma Control Questionnaire (ACQ) and the percent predicted forced expiratory volume at 1 s (FEV1) by spirometry, hospitalizations and emergency department (ED) visits in the past 6 months, and quality of life. HL was assessed with the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multivariate logistic regression models controlled for age, sex, race, income, general health and years with asthma. Results: Among 433 individuals, 36% had low HL, 55% were over age 65, 38% were Hispanic and 22% were black. Poor asthma control was reported by 40% and 32% had FEV1 <70% of predicted; 9% had a hospital stay, 23% had an ED and 38% had poor quality of life. In multivariable analysis, individuals with low HL were more likely to have FEV1 <70% predicted (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.39–3.94, p = 0.001), hospitalizations (OR 2.53, 95% CI 1.17–5.49, p = 0.02) and ED visits for asthma (OR 1.81, 95% CI 1.05–3.10, p = 0.03). There were no differences in self-reported asthma control and quality of life. Conclusions: Low HL is associated with poor asthma control by objective measure, and greater likelihood of ED visits and hospitalization. HL is a modifiable target for interventions to improve asthma outcomes in the elderly.

Health literacy and 30-day hospital readmission after acute myocardial infarction

Objective To assess the validity of a predictive model of health literacy, and to examine the relationship between derived health literacy estimates and 30-day hospital readmissions for acute myocardial infarction (AMI). Design Retrospective cohort study. Setting and participants A National Institute of Aging (NIA) study cohort of 696 adult, English-speaking primary care patients, aged 55–74 years, was used to assess the validity of derived health literacy estimates. Claims from 7733 Medicare beneficiaries hospitalised for AMI in 2008 in North Carolina and Illinois were used to investigate the association between health literacy estimates and 30-day hospital readmissions. Measures The NIA cohort was administered 3 common health literacy assessments (Newest Vital Sign, Test of Functional Health Literacy in Adults, and Rapid Estimate of Adult Literacy in Medicine). Health literacy estimates at the census block group level were derived via a predictive model. 30-day readmissions were measured from Medicare claims data using a validated algorithm. Results Fair agreement was found between derived estimates and in-person literacy assessments (Pearson Correlation coefficients: 0.38–0.51; κ scores: 0.38–0.40). Medicare enrollees with above basic literacy according to derived health literacy estimates had an 18% lower risk of a 30-day readmission (RR=0.82, 95% CI 0.73 to 0.92) and 21% lower incidence rate of 30-day readmission (IRR=0.79, 95% CI 0.68 to 0.87) than patients with basic or below basic literacy. After adjusting for demographic and clinical characteristics, the risk of 30-day readmission was 12% lower (p=0.03), and the incidence rate 16% lower (p<0.01) for patients with above basic literacy. Conclusions Health literacy, as measured by a predictive model, was found to be a significant, independent predictor of 30-day readmissions. As a modifiable risk factor with evidence-based solutions, health literacy should be considered in readmission reduction efforts.

Literacy disparities in patient access and health-related use of Internet and mobile technologies

Age and race‐related disparities in technology use have been well documented, but less is known about how health literacy influences technology access and use.

The role of cognitive function in the relationship between age and health literacy: a cross-sectional analysis of older adults in Chicago, USA

Objectives To investigate how 3 measures of health literacy correlate with age and the explanatory roles of fluid and crystallised cognitive abilities in these relationships among older adults. Design Cross-sectional baseline analysis of the ‘LitCog’ cohort study. Setting 1 academic internal medicine clinic and 5 federally qualified health centres in Chicago, USA. Participants English-speaking adults (n=828) aged 55–74 years, recruited from August 2008 through October 2011. Outcome measures Health literacy was measured by the Test of Functional Health Literacy in Adults (TOFHLA) and the Newest Vital Sign (NVS), both of which assess reading comprehension and numeracy in health contexts, and by the Rapid Estimate of Adult Literacy in Medicine (REALM), which assesses medical vocabulary. Fluid cognitive ability was assessed through the cognitive domains of processing speed, inductive reasoning, and working, prospective and long-term memories, and crystallised cognitive ability through the verbal ability domain. Results TOFHLA and NVS scores were lower at ages 70–74 years compared with all other age groups (p<0.05 for both tests). The inverse association between age and TOFHLA score was attenuated from β=−0.39 (95% CI −0.55 to −0.22) to β=−0.06 (95% CI −0.20 to 0.08) for ages 70–74 vs 55–59 years when fluid cognitive ability was added to the model (85% attenuation). Similar results were seen with NVS scores (68% attenuation). REALM scores did not differ by age group (p=0.971). Crystallised cognitive ability was stable across age groups, and did not influence the relationships between age and TOFHLA or NVS performance. Conclusions Health literacy skills show differential patterns of age-related change, which may be explained by cognitive ageing. Researchers should select health literacy tests appropriate for their purposes when assessing the health literacy of older adults. Clinicians should be aware of this issue to ensure that health self-management tasks for older patients have appropriate cognitive and literacy demands.

Pathways linking health literacy, health beliefs, and cognition to medication adherence in older adults with asthma

Background: Limited health literacy is associated with low adherence to asthma controller medications among older adults. Objective: We sought to describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators. Methods: We recruited adults aged 60 years and older with asthma from hospital and community practices in New York, New York, and Chicago, Illinois. We measured health literacy and medication adherence using the Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale, respectively. We used validated instruments to assess asthma illness and medication beliefs. We assessed cognition using a cognitive battery. Using structural equation modeling, we modeled illness and medication beliefs as mediators of the relationship between health literacy and adherence while controlling for cognition. Results: Our study included 433 patients with a mean age of 67 ± 6.8 years. The sample had 84% women, 31% non‐Hispanic blacks, and 39% Hispanics. The 36% of patients with limited health literacy were more likely to have misconceptions about asthma (P < .001) and asthma medications (P < .001). Health literacy had a direct effect (&bgr; = 0.089; P < .001) as well as an indirect effect on adherence mediated by medications concerns (&bgr; = 0.033; P = .002). Neither medication necessity (&bgr; = 0.044; P = .138) nor illness beliefs (&bgr; = 0.007; P = .143) demonstrated a mediational role between health literacy and adherence. Conclusions: Interventions designed to improve asthma controller medication adherence in older adults may be enhanced by addressing concerns about medications in addition to using communication strategies appropriate for populations with limited health literacy and cognitive impairments.

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma.

Older adults with asthma face numerous barriers to effective self-management and asthma control, and experience worse outcomes than younger asthmatics. Yet, there have been no controlled trials of interventions specifically designed to improve their care and outcomes. Through a multi-stakeholder collaboration (patients, academia, community-based organizations, a state department of health, and an advocacy organization) we developed a multi-component asthma self-management support intervention to address the myriad psychosocial, functional, health status, and cognitive barriers to effective asthma self-management in adults ages 60 and older. We are recruiting 425 New Yorkers in Manhattan and the Bronx for a pragmatic randomized controlled trial with 3 arms: the intervention delivered in primary care settings or in their home, or usual care. In the intervention, care coaches use a novel screening tool to identify the specific barriers to asthma control and self-management they experience. Once identified, the coach and patient choose from a menu of actions to address it. The intervention emphasizes efficiency, flexibility, shared decision making and goal setting, communication strategies appropriate for individuals with limited cognition and literacy skills, and ongoing reinforcement and support. Additionally, we introduced asthma-specific enhancements to the electronic health records of all participating clinical practices, including an asthma severity assessment, clinical decision support, and a patient-tailored asthma action plan. Patients will be followed for 12months and interviewed at baseline, 3, 6, and 12months and data on emergency department visits and hospitalizations will be obtained through the New York State Statewide Planning and Research Cooperative System.

Associations Between Asthma Control and Airway Obstruction and Performance of Activities of Daily Living in Older Adults with Asthma

To determine the effect of asthma on functional limitations of older adults in the United States.

Characterizing Literacy and Cognitive Function during Pregnancy and Postpartum

Objective The objective of this study was to characterize health literacy and cognitive function in a diverse cohort of pregnant women. Methods Pregnant and postpartum women underwent in‐depth assessments of health literacy/numeracy and the cognitive domains of verbal ability, working memory, long‐term memory, processing speed, and inductive reasoning. Differences by demographic characteristics and gestational age were assessed using chi‐square tests and multivariable logistic regression. Results In this cohort of pregnant (N = 77) or postpartum (N = 24) women, 41.6% had limited health literacy/numeracy. Women were more likely to score in the lowest quartile for literacy and verbal ability if they were less educated, younger, nonwhite or had Medicaid. These factors were associated with low scores for long‐term memory, processing speed, and inductive reasoning. Although there were no differences in literacy or cognitive function by parity or gestational age, postpartum women were more likely to score in the lowest quartile for processing speed (adjusted odds ratio [aOR]: 3.79, 95% confidence interval [CI]: 1.32‐10.93) and inductive reasoning (aOR: 4.07, 95% CI: 1.21‐13.70). Conclusion Although postpartum status was associated with reduced inductive reasoning and processing speed, there were no differences in cognitive function across pregnancy. Practice Implications Postpartum maternal learning may require enhanced support. In addition, cognitive skills and health literacy may be a mediator of perinatal outcomes inequities.