Health literacy among Medicare enrollees in a managed care organization

Beliefs about generic drugs among elderly adults in hospital-based primary care practices

OBJECTIVE

This study aimed to characterize seniors' beliefs about generic drugs, and examine potential correlates of these beliefs, including socioeconomic and health status variables, health literacy, and physician communication skills.

METHODS

Older adults (> or = 65 years) were interviewed in two primary care practices of an inner-city, tertiary care hospital (n = 311). Beliefs about generics were measured using a scale that compared generic and brand name drugs across four domains. Beliefs were modeled with multivariable linear regression.

RESULTS

Negative beliefs about generics were associated with non-white race (p < 0.0001), lower education (p = 0.008) and income (p = 0.001), and having Medicaid coverage (p = 0.001). Individuals with low health literacy and who reported that their physicians had poor communication skills were more likely to hold negative views (p < 0.0001 and p = 0.003, respectively). In multivariable analysis, black race (beta = -2.30, p = 0.006) and inadequate health literacy (beta = -2.17, p = 0.0004) remained strongly associated with negative views about generic drugs. Poor physician communication skills also predicted negative beliefs about generics but the association was not significant for all levels of communication skill.

CONCLUSION

Many low-income seniors mistrust generic medications, especially African-Americans and seniors with low health literacy.

PRACTICE IMPLICATIONS

Educational efforts to promote generic medications should account for patients' health literacy and cultural backgrounds.

Social determinants of Black-White disparities in breast cancer mortality: a review

Despite the recent decline in breast cancer mortality, African American women continue to die from breast cancer at higher rates than do White women. Beyond the fact that breast cancer tends to be a more biologically aggressive disease in African American than in White women, this disparity in breast cancer mortality also reflects social barriers that disproportionately affect African American women. These barriers hinder cancer prevention and control efforts and modify the biological expression of disease. The present review focuses on delineating social, economic, and cultural factors that are potentially responsible for Black-White disparities in breast cancer mortality. This review was guided by the social determinants of health disparities model, a model that identifies barriers associated with poverty, culture, and social injustice as major causes of health disparities. These barriers, in concert with genetic, biological, and environmental factors, can promote differential outcomes for African American and White women along the entire breast cancer continuum, from screening and early detection to treatment and survival. Barriers related to poverty include lack of a primary care physician, inadequate health insurance, and poor access to health care. Barriers related to culture include perceived invulnerability, folk beliefs, and a general mistrust of the health care system. Barriers related to social injustice include racial profiling and discrimination. Many of these barriers are potentially modifiable. Thus, in addition to biomedical advancements, future efforts to reduce disparities in breast cancer mortality should address social barriers that perpetuate disparities among African American and White women in the United States.

Literacy and blood pressure--do healthcare systems influence this relationship? A cross-sectional study

BACKGROUND

Limited literacy is common among patients with chronic conditions and is associated with poor health outcomes. We sought to determine the association between literacy and blood pressure in primary care patients with hypertension and to determine if this relationship was consistent across distinct systems of healthcare delivery.

METHODS

We conducted a cross-sectional study of 1224 patients with hypertension utilizing baseline data from two separate, but similar randomized controlled trials. Patients were enrolled from primary care clinics in the Veterans Affairs healthcare system (VAHS) and a university healthcare system (UHS) in Durham, North Carolina. We compared the association between literacy and the primary outcome systolic blood pressure (SBP) and secondary outcomes of diastolic blood pressure (DBP) and blood pressure (BP) control across the two different healthcare systems.

RESULTS

Patients who read below a 9th grade level comprised 38.4% of patients in the VAHS and 27.5% of the patients in the UHS. There was a significant interaction between literacy and healthcare system for SBP. In adjusted analyses, SBP for patients with limited literacy was 1.2 mmHg lower than patients with adequate literacy in the VAHS (95% CI, -4.8 to 2.3), but 6.1 mmHg higher than patients with adequate literacy in the UHS (95% CI, 2.1 to 10.1); (p = 0.003 for test of interaction). This literacy by healthcare system interaction was not statistically significant for DBP or BP control.

CONCLUSION

The relationship between patient literacy and systolic blood pressure varied significantly across different models of healthcare delivery. The attributes of the healthcare delivery system may influence the relationship between literacy and health outcomes.

The Demographic Assessment for Health Literacy (DAHL): a new tool for estimating associations between health literacy and outcomes in national surveys

OBJECTIVE

To impute limited health literacy from commonly measured socio-demographic data and to compare it to the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) for estimating the influence of limited health literacy on health status in the elderly.

METHODS

The Prudential Medicare Study assesses the S-TOFHLA score, leading to a "reference standard" classification of 25% of people with inadequate literacy; the National Health Interview Survey has no such assessment. We estimated a regression of S-TOFHLA on sex, age, years of schooling, and race/ethnicity in The Prudential Medicare Study data to derive a Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. Using regression, we then examined associations between several health status measures (including hypertension, diabetes, physical and mental SF-12) and inadequate literacy (imputed or test-based).

RESULTS

Estimates of association using imputed inadequate literacy closely approximate those obtained using S-TOFHLA-based inadequate literacy for most outcomes examined.

CONCLUSIONS

As few population surveys measure health literacy, the DAHL, a readily calculated health literacy proxy score, may be useful for expanding the scope of health literacy research in national survey data.

Assessing and Improving Research Participants' Understanding of Risk: Potential Lessons from the Literature on Physician-Patient Risk Communication

Evidence that lay people frequently misinterpret risk raises concerns for the ethical conduct of human research, which requires adequate disclosure, understanding, and appreciation of risk information. Review of the risk communication research literature suggests new directions for empirical research on human research ethics: Investigation is needed on how to best assess and improve potential and enrolled subjects' understanding of risk information. Preferences regarding the presentation of risk information and the effects of alternative presentation formats and decision aids on knowledge, trust, satisfaction, risk/benefit analysis, and perceptions of respectful treatment should be studied. Research is also needed on the effects of payment for research participation, the order in which study information is presented, and having one's own physician present risk information.

Health Literacy and Health Actions: A Review and a Framework From Health Psychology

The association between performance on health literacy measures and health outcomes is well established. The next step is to understand the processes through which health literacy affects health. This review introduces a framework drawing on ideas from health psychology and proposing that associations between health literacy and health outcomes could be mediated by a range of health actions involving access and use of health care, patient—provider interactions, and the management of health and illness. The framework outlines routes through which health literacy might affect either health actions themselves or the motivational and volitional determinants that have been identified in social cognition models. The implications of the framework for future research and intervention strategies are discussed.

Cognition and health literacy in patients with hypertension

BACKGROUND

Approximately half of the US population has marginal or inadequate health literacy, a measure highly associated with health outcomes. This measure is often linked to age and education, but recent evidence from patients with chronic heart failure suggests that much of age-related variability in health literacy can be explained by cognitive abilities (e.g., working memory, processing speed).

OBJECTIVE

We examined the role of cognitive and sensory abilities as mediators of age and education in determining functional health literacy among patients with hypertension.

PARTICIPANTS

Four hundred ninety two community-dwelling adults diagnosed with hypertension (aged 21 to 92 years) participated. They were primarily female (73%), African-American (68%), and reported taking on average 7.8 prescribed medications.

MEASUREMENTS

Before participation in a medication adherence intervention study, participants completed a battery of health literacy-related tasks. They completed tests that measured health literacy [Short Test of Functional Health Literacy in Adults (STOFHLA)], cognitive abilities (working memory, processing speed), sensory abilities (visual acuity and hearing), and physical health.

RESULTS

Regression analyses showed that health literacy was related to age, education, and race (accounting for 24.4% of variance in STOFHLA scores). Cognitive ability accounted for an additional 24% of variance and greatly reduced the influence of age, education, and race (by 75%, 40%, and 48%, respectively).

CONCLUSIONS

When controlling for cognitive and sensory variables, the association of age and education with STOFHLA scores was dramatically reduced. Thus, future interventions aimed at improving self-care for patients with low health literacy should aim to reduce demands on patients' cognitive abilities.

Functional health literacy and health-promoting behaviour in a national sample of British adults

OBJECTIVES

To measure the prevalence of limited functional health literacy in the UK, and examine associations with health behaviours and self-rated health.

DESIGN

Psychometric testing using a British version of the Test of Functional Health Literacy in Adults (TOFHLA) in a population sample of adults.

SETTING

UK-wide interview survey (excluding Northern Ireland and the Scottish Isles).

PARTICIPANTS

759 adults (439 women, 320 men) aged 18-90 years (mean age _ 47.6 years) selected using random location sampling.

MAIN OUTCOME MEASURES

Functional health literacy, self-rated health, fruit and vegetable consumption, physical exercise and smoking.

RESULTS

We found that 11.4% of participants had either marginal or inadequate health literacy. Multivariable logistic regression analysis indicated that the risk of having limitations in health literacy increased with age (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06), being male (odds ratio _ 2.04; 95% confidence interval 1.16 to 3.55), low educational attainment (odds ratio _ 7.46; 95% confidence interval 3.35 to 16.58) and low income (odds ratio _ 5.94; 95% confidence interval 1.87 to 18.89). In a second multivariable logistic regression analysis, every point higher on the health literacy scale increased the likelihood of eating at least five portions of fruit and vegetables a day (odds ratio _ 1.02; 95% confidence interval 1.003 to 1.03), being a non-smoker (odds ratio _ 1.02; 95% confidence interval 1.0003 to 1.03) and having good self-rated health (odds ratio _ 1.02; 95% confidence interval 1.01 to 1.04), independently of age, education, gender, ethnicity and income.

CONCLUSIONS

The results encourage efforts to monitor health literacy in the British population and examine associations with engagement with preventative health behaviours.

Health literacy, cognitive abilities, and mortality among elderly persons

BACKGROUND

Low health literacy and low cognitive abilities both predict mortality, but no study has jointly examined these relationships.

METHODS

We conducted a prospective cohort study of 3,260 community-dwelling adults age 65 and older. Participants were interviewed in 1997 and administered the Short Test of Functional Health Literacy in Adults and the Mini Mental Status Examination. Mortality was determined using the National Death Index through 2003.

MEASUREMENTS AND MAIN RESULTS

In multivariate models with only literacy (not cognition), the adjusted hazard ratio was 1.50 (95% confidence of interval [CI] 1.24-1.81) for inadequate versus adequate literacy. In multivariate models without literacy, delayed recall of 3 items and the ability to serial subtract numbers were associated with higher mortality (e.g., adjusted hazard ratios [AHR] 1.74 [95% CI 1.30-2.34] for recall of zero versus 3 items, and 1.32 [95% CI 1.09-1.60] for 0-2 vs 5 correct subtractions). In multivariate analysis with both literacy and cognition, the AHRs for the cognition items were similar, but the AHR for inadequate literacy decreased to 1.27 (95% CI 1.03 - 1.57).

CONCLUSIONS

Both health literacy and cognitive abilities independently predict mortality. Interventions to improve patient knowledge and self-management skills should consider both the reading level and cognitive demands of the materials.

Perceptions of quality-of-life effects of treatments for diabetes mellitus in vulnerable and nonvulnerable older patients

OBJECTIVES

To assess whether patient perceptions of treatments for diabetes mellitus differ according to clinical criteria such as limited life expectancy and functional decline (i.e., vulnerability).

DESIGN

Cross-sectional survey.

SETTING

Clinics affiliated with two Chicago-area hospitals.

PARTICIPANTS

Patients aged 65 and older living with type 2 diabetes mellitus (N=332).

MEASUREMENTS

Utilities (quantitative measures of preference on a scale from 0 to 1, with 0 representing a state equivalent to death and 1 representing life in perfect health) were assessed for nine hypothetical treatment states using time trade-off questions, and patients were queried about specific concerns regarding medications. Vulnerability was defined according to the Vulnerable Elders Scale.

RESULTS

Thirty-six percent of patients were vulnerable. Vulnerable patients were older (77 vs 73) and had diabetes mellitus longer (13 vs 10 years; P<.05). Vulnerable patients reported lower utilities than nonvulnerable patients for most individual treatment states (e.g., intensive glucose control, mean 0.61 vs 0.72, P<.01), but within group variation was large for both groups (e.g., standard deviations >0.25). Although mean individual state utilities differed across groups, no significant differences were found in how vulnerable and nonvulnerable patients compared intensive and conventional treatment states (e.g., intensive vs conventional glucose control). In multivariable analyses, the association between vulnerability and individual treatment state utilities became nonsignificant except for the cholesterol pill.

CONCLUSION

Older patients' preferences for intensity of treatment for diabetes mellitus vary widely and are not closely associated with vulnerability. This observation underscores the importance of involving older patients in decisions about treatment for diabetes mellitus, irrespective of clinical status.

Functional health literacy and understanding of medications at discharge

The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 or more new medications. Between 4 and 18 days after discharge, patients were contacted by telephone and asked about the name, number, dosages, schedule, purpose, and adverse effects of the new medication(s) and whether they could name their medical contact person. We recorded the number of correct answers, patient age, and years of education. Of the survey respondents, 86% were aware that they had been prescribed new medications, but fewer could identify the name (64%) or number (74%) of new medications or their dosages (56%), schedule (68%), or purpose (64%). Only 11% could recall being told of any adverse effects, and only 22% could name at least 1 adverse effect. Older patients tended to answer fewer questions correctly (P=.02). We observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and survey (P=.17), or number of new medications (P=.65). Overall, we found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.

Designing for older adult users of handheld technology

There are few interface design guidelines for handheld devices used by adults sixty years and older. Yet, this growing user group would benefit from the portability offered by such technology in promoting health management and social interaction. In this paper, we describe a usability framework for conducting studies on the use of a PocketPC by older adult caregivers. The usability framework provides a basis for conducting studies taking into account the user profile of an older adult, environment factors, usability quality factors, and technology objectives.

Unmet needs for mental health services for latino older adults: perspectives from consumers, family members, advocates, and service providers

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.

The contributing role of health-care communication to health disparities for minority patients with asthma

Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.

Emotion, Affect, and Risk Communication with Older Adults: Challenges and Opportunities

Recent research suggests that emotion, affect, and cognition play important roles in risk perception and that their roles in judgment and decision-making processes may change over the lifespan. This paper discusses how emotion and affect might help or hinder risk communication with older adults. Currently, there are few guidelines for developing effective risk messages for the world's aging population, despite the array of complex risk decisions that come with increasing age and the importance of maintaining good decision making in later life. Age-related declines in cognitive abilities such as memory and processing speed, increased reliance on automatic processes, and adaptive motivational shifts toward focusing more on affective (especially positive) information mean that older and younger adults may respond differently to risk messages. Implications for specific risk information formats (probabilities, frequencies, visual displays, and narratives) are discussed and directions for future research are highlighted.

Optimal recall period and response task for self-reported HIV medication adherence

Self-reported measures of antiretroviral adherence vary greatly in recall time periods and response tasks. To determine which time frame is most accurate, we compared 3-, 7-day, and 1-month self-reports with data from medication event monitoring system (MEMS). To determine which response task is most accurate we compared three different 1-month self-report tasks (frequency, percent, and rating) to MEMS. We analyzed 643 study visits made by 156 participants. Over-reporting (self-report minus MEMS) was significantly less for the 1-month recall period (9%) than for the 3 (17%) or 7-day (14%) periods. Over-reporting was significantly less for the 1-month rating task (3%) than for the 1-month frequency and percent tasks (both 12%). We conclude that 1-month recall periods may be more accurate than 3- or 7-day periods, and that items that ask respondents to rate their adherence may be more accurate than those that ask about frequencies or percents.

A health literacy assessment of the National Epilepsy Foundation Web site

Health literacy is defined as the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions. Based on the 2003 US National Assessment of Adult Literacy (NAAL), more than 90 million people have literacy levels rated as "basic" or "below basic." The Institute of Medicine recommends that health-related information be written at a sixth grade level or below. As Web-based health information is being accessed by more than 50 million people, a reading level assessment of the National Epilepsy Foundation of America Web site was undertaken. Two online programs were used to assess the reading level of each Web page in two main areas, "Understanding Epilepsy" and "Living with Epilepsy," using established readability formulas. One hundred seventy-six Web links were evaluated in English and 43 in Spanish. Based on the Flesch Reading Ease and Huerta Reading Ease assessments, 5.7% of National Epilepsy Foundation Web pages in English and 31-46% in Spanish had a sixth grade or lower reading level. Similar results have been reported in previous reviews of other health education Web sites in cancer, pediatrics, and asthma. The National Epilepsy Foundation Web site, a well-respected resource for patients and their families, contains a significant amount of health education content that is not appropriate for those with marginal health literacy. Editorial changes are needed to bring the information to suggested levels. Suggestions for developing appropriate materials are provided.

Knowledge of phosphorus compared with other nutrients in maintenance dialysis patients

OBJECTIVE

This study's objective was to assess knowledge of phosphorus compared with other nutrients in patients undergoing maintenance dialysis (MD).

DESIGN

We compared knowledge of phosphorus vs. other nutrients important to the MD diet (potassium, sodium, and protein) in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD). We further measured gender, age, education level, and functional health literacy to assess correlations in patient nutrient knowledge. Nutrient knowledge was measured using a 25-item Chronic Kidney Disease Knowledge Assessment Tool for Nutrition (CKDKAT-N), and functional health literacy was measured using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA).

SETTING AND PATIENTS

Patients received maintenance outpatient PD or HD at Wisconsin Dialysis, Inc. (Madison, WI).

MAIN OUTCOME MEASURE

The main outcome measure was knowledge of phosphorus vs. knowledge of potassium, sodium, and protein.

RESULTS

Forty-seven MD patients participated in the study (29 undergoing HD, 18 undergoing PD, 30 males, 17 females, average age of 58.6 (SD, 13.8) years, and average grade level of 1.4 (SD, 2.6) years of post-secondary education). Thirty-five participants had adequate health literacy, 4 had marginal health literacy, and 8 had inadequate health literacy. The CKDKAT-N scores ranged from 6-21 for 25 items, with a mean score of 13 (SD, 2.91). Knowledge of phosphorus compared with knowledge of other nutrients was poor (0.38 vs. 0.72, P = .003). In a comparison of HD vs. PD patient knowledge, both phosphorus (0.37 vs. 0.42, P = .231) and other nutrients (0.69 vs. 0.80, P = .115) were the same.

CONCLUSION

Despite regular dietary instruction, patients undergoing MD have a poor knowledge of dietary phosphorus content, compared with knowledge of other nutrients important in chronic kidney disease. Interestingly, there was no difference in nutrition knowledge when comparing PD and HD patients, despite differences in education level and health literacy between groups.

Investigating Hispanic/Latino perceptions about colorectal cancer screening: a community-based approach to effective message design

OBJECTIVE

The Hispanic/Latino population has been documented as having the lowest colorectal cancer (CRC) screening rates in the United States, putting this group at-risk for late-stage presentation of disease. We assessed knowledge, attitudes, and behavior regarding CRC screening to inform the development of messages that promote screening among Hispanic/Latino patients.

METHODS

In-person structured interviews with Spanish-speaking adults age 50-80 at two clinics and a senior center in a Hispanic/Latino community (N=234).

RESULTS

Most (67.1%) participants had no more than an eighth-grade education and 63.3% reported their reading ability as less than "very good." Only 18.4% of participants correctly identified the colon on a diagram; 19.2% correctly described at least one aspect of a polyp. Less than half of the participants perceived themselves as at-risk for CRC, and less than one-third knew about any of the standard screening tests. After hearing descriptions of the screening tests, participants perceived stool cards as easier, safer, less painful, less embarrassing, and less scary than endoscopy (p<.001). Approximately two-thirds of unscreened patients said that screening had never been mentioned or suggested to them; about one-quarter said they did not get screened because they felt fine or were not worried. Over 96% of participants said they would get screened if a doctor suggested it.

CONCLUSION

Assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach for developing effective targeted health messages.

PRACTICE IMPLICATIONS

Messages to increase CRC screening knowledge and behavior in the Hispanic/Latino community should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and clearly describe options.

The Drug Facts Box: Providing Consumers with Simple Tabular Data on Drug Benefit and Harm

Context. Direct-to-consumer drug ads have been criticized for providing inadequate and misleading information. Requiring ads to include a table with data on drug benefits and side effects (derived from clinical trials) could help, provided that consumers understand such tabular information. Objective. To determine if people could understand and use a 9-row × 2-column ``study findings table'' presenting expected outcomes (both beneficial and harmful) with and without a drug. Subjects.A convenience sample of 274 participants: 186 recruited from alumni of Dartmouth's ``Community Medical School'' public lecture series and Dartmouth Hitchcock's Center for Shared Decision Making and 88 veterans and their families recruited from waiting rooms in the Veterans Affairs outpatient clinic, White River Junction, Vermont. Design. Cross-sectional survey. Participants were tested on their comprehension of the study findings table about the drug tamoxifen used for the primary prevention of breast cancer—with no instructions on how to use the table. Main outcome measure. Five comprehension questions testing how well participants could read and use the table with drug benefits and side effects data. Results. On average, participants correctly answered 4 of the 5 table comprehension questions: 89% correctly used the table to determine the percentage of womengiventamoxifenwhogotabloodclotintheirlegsor lungs, and 71% were able to use data in the table to calculate the absolute difference in the proportion of women who got breast cancer in the tamoxifen v. the placebo group. Most participants were also able to use the table to make comparisons. Conclusion. Most participants—even those with lower formal educational attainment—were able to understand and use the tabular data.

Assessing and Addressing Low Health Literacy Among Surgical Outpatients

Patients with low health literacy do not have the ability to read, understand, and use health information to make appropriate health decisions. There is a high incidence of low health literacy in the United States, and health care practitioners in outpatient surgical centers need to be aware of this problem and take steps toward addressing it. Tools for assessing health literacy are available, and health care practitioners should use these tools to incorporate an assessment of health literacy into their preoperative patient assessments.

Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework

Health literacy deficits affect half the American patient population and are linked to poor health, ineffective disease management and high rates of hospitalization. Restricted literacy has also been linked with less satisfying medical visits and communication difficulties, particularly in terms of the interpersonal and informational aspects of care. Despite growing attention to these issues by researchers and policy makers, few studies have attempted to conceptualize and assess those aspects of dialogue that challenge persons with low literacy skills, i.e., the oral literacy demand within medical encounters. The current study uses videotapes and transcripts of 152 prenatal and cancer pretest genetic counseling sessions recorded with simulated clients to develop a conceptual framework to explore oral literacy demand and its consequences for medical interaction and related outcomes. Ninety-six prenatal and 81 cancer genetic counselors-broadly representative of the US National Society of Genetic Counselors-participated in the study. Key elements of the conceptual framework used to define oral literacy demand include: (1) use of unfamiliar technical terms; (2) general language complexity, reflected in the application of Microsoft Word grammar summary statistics to session transcripts; and, (3) structural characteristics of dialogue, including pacing, density, and interactivity. Genetic counselor outcomes include self-ratings of session satisfaction, informativeness, and development of rapport. The simulated clients rated their satisfaction with session communication, the counselor's effective use of nonverbal skills, and the counselor's affective demeanor during the session. Sessions with greater overall technical term use were longer and used more complex language reflected in readability indices and multi-syllabic vocabulary (measures averaging p<.05). Sessions with a high proportionate use of technical terms were characterized by shorter visits, high readability demand, slow speech speed, fewer and more dense counselor speaking turns and low interactivity (p<.05). The higher the use of technical terms, and the more dense and less interactive the dialogue, the less satisfied the simulated clients were and the lower their ratings were of counselors' nonverbal effectiveness and affective demeanor (all relationships p<.05). Counselors' self-ratings of informativeness were also inversely related to use of technical terms (p<.05). Just as print material can be made more reader-friendly and effective following established guidelines, the medical dialogue may also be made more patient-centered and meaningful by having providers monitor their vocabulary and language, as well as the structural characteristics of interaction, thereby lowering the literacy demand of routine medical dialogue. These consequences are important for all patients but may be even more so for patients with restricted literacy.

Relationship of literacy and heart failure in adults with diabetes

Background

Although reading ability may impact educational strategies and management of heart failure (HF), the prevalence of limited literacy in patients with HF is unknown.

Methods

Subjects were drawn from the Vermont Diabetes Information System Field Survey, a cross-sectional study of adults with diabetes in primary care. Participants' self-reported characteristics were subjected to logistic regression to estimate the association of heart failure and literacy while controlling for social and economic factors. The Short Test of Functional Health Literacy was used to measure literacy.

Results

Of 172 subjects with HF and diabetes, 27% had limited literacy compared to 15% of 826 subjects without HF (OR 2.05; 95% CI 1.39, 3.02; P < 0.001). Adjusting for age, sex, race, income, marital status and health insurance, HF continued to be significantly associated with limited literacy (OR 1.55, 95% CI 1.00, 2.41, P = .05).

After adjusting for education, however, HF was no longer independently associated with literacy (OR 1.31; 95% CI 0.82 – 2.08; P = 0.26).

Conclusion

Over one quarter of diabetic adults with HF have limited literacy. Although this association is no longer statistically significant when adjusted for education, clinicians should be aware that many of their patients have important limitations in dealing with written materials.

An exploratory study of older adults' comprehension of printed cancer information: is readability a key factor?

Printed cancer information often is written at or beyond high school reading levels, despite lower average literacy abilities of the public. The objectives of this exploratory study were twofold: (1) to evaluate older adults' comprehension of breast (BC), prostate (PC), and colorectal (CC) cancer information; and (2) to determine if comprehension of BC, PC, and CC information varies according to text readability. Comprehension of printed cancer resources was evaluated with 44 community-dwelling older adults using the Cloze procedure and recall questions. Participants' comprehension scores were compared with Simple Measure of Gobbledegook (SMOG) readability scores (<grade 13 vs. grade 13+). Overall, older adults had satisfactory comprehension of cancer information as measured by Cloze (.86 +/- .01) and recall (.71 +/- .02). For CC information written at grade 13, however, a significant negative correlation between readability and Cloze comprehension was found (r(s) = -.44, SE = .17, p = .019), indicating poorer participant comprehension at higher readability levels. Comprehension of BC or PC information did not vary by readability level. Though readability plays a role in older adults' understanding of cancer information, cancer type and content are also important factors that influence comprehension. Use of plain language is recommended for CC resources.

Correlates of health literacy in patients with chronic heart failure

PURPOSE

Many older adults have inadequate health-related literacy, which is associated with poor health outcomes. Thus, it is important to identify determinants of health literacy. We investigated relationships between health literacy and general cognitive and sensory abilities, as well as education, health, and demographic variables, in a community sample of middle-aged and older adults.

DESIGN AND METHODS

Participants were 314 community-dwelling adults (67% female, 48% African American) diagnosed with chronic heart failure recruited for a pharmacist-based intervention study to improve adherence to chronic heart failure medications. We adminstered demographic, health, education, cognitive (e.g., processing speed, working memory), and sensory measures, and the Short Test of Functional Health Literacy in Adults (STOFHLA), as part of the baseline condition of this study.

RESULTS

STOFHLA scores were lower for participants who were older, less educated, male, African American, had more comorbidities, or scored lower on all cognitive ability measures. Hierarchical linear regression analyses showed that education and cognitive ability were independently associated with the STOFHLA measure and explained age differences in health literacy.

IMPLICATIONS

The association of cognitive abilities and literacy has important implications for health literacy models and for interventions to reduce the impact of low health literacy on health outcomes. For example, medication instructions should be designed to reduce comprehension demands on general cognitive abilities as well as literacy skills.

Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans

PURPOSE

To understand factors that influence African-Americans' attitude toward eye examinations.

METHODS

Ten focus groups were conducted with 86 African-Americans. Four focus groups were conducted with people 65 years of age and older who had not received a dilated fundus examination (DFE) in the past 2 years, two groups were held with people 65 years of age and older who had had a recent DFE, and two groups each were held with people 40 to 64 years of age, with and without recent DFEs. Focus group interviews were conducted by using a moderator guide to address perceived benefits of and barriers to getting an eye examination; motivators for getting DFEs; and knowledge of eye examinations, glaucoma, and diabetic retinopathy. Participants also completed a questionnaire that provided demographic information. Quantitative and qualitative analyses were conducted.

RESULTS

Cost or lack of sufficient insurance was identified as the most important barrier to getting a DFE. Also frequently mentioned was not having any symptoms and being too busy. The most frequently cited benefit of getting a DFE was to help prevent eye disease, whereas the most frequently reported motivating factor was experiencing a vision problem. Regarding knowledge, many people did not know the risk factors for glaucoma, but seemed to have a better understanding of how to reduce the effects of diabetes on their eyes.

CONCLUSIONS

Study findings identified important links between financial resources and experiencing a vision problem and the adoption of preventive eye care in an urban African-American population.

Development of an illustrated medication schedule as a low-literacy patient education tool

OBJECTIVE

Patients with low health literacy have difficulty understanding prescription drug labels and other medication instructions. This article describes the development, implementation, and preliminary evaluation of an illustrated medication schedule (a "pill card") that depicts a patient's daily medication regimen using pill images and icons.

METHODS

Participants in a randomized controlled trial who were assigned to receive the pill card intervention described their use of the card and its perceived effectiveness. Responses were analyzed by level of patient literacy and other characteristics.

RESULTS

Among the 209 respondents, 173 (83%) reported using the pill card when they initially received it, though use declined to 60% approximately 3 months later. Patients with inadequate or marginal literacy skills, less than high school education, or cognitive impairment were most likely to refer to the card on a regular basis initially and at 3 months (p<0.05). Most pill card users (92%) rated the tool as very easy to understand, and 94% found it helpful for remembering important medication information, such as the name, purpose, or time of administration.

CONCLUSION

Nearly all patients considered an illustrated medication schedule to be a useful and easily understood tool to assist with medication management. Patients with limited literacy skills, educational attainment, or cognitive function referred to the aid with greater frequency.

PRACTICE IMPLICATIONS

Picture-based instructions promote better understanding of prescription medications, particularly among patients with limited literacy skills or cognitive impairment, and should be used more widely in practice.

Educating Patients About Their Medications: The Potential And Limitations Of Written Drug Information

Drug information on labels and inserts is a major source of knowledge for patients as they attempt to balance the risks and benefits of drugs and administer them safely. Yet this information is often inconsistent, incomplete, and difficult for patients to read and understand. We reviewed the numerous sources of written prescription drug information, the regulations that govern their content and format and the lack of oversight in the process, and the history that led to this system. We suggest that oversight and standards are needed so that written drug information can serve as a coherent and organized system to educate patients.

Medication beliefs as mediators of the health literacy-antiretroviral adherence relationship in HIV-infected individuals

Identifying modifiable barriers to antiretroviral adherence remains an important aim. We hypothesized that mistaken beliefs regarding taking HIV medications mediated the relation between low literacy and poor adherence. We studied 87 HIV-infected individuals on standard antiretroviral regimens for >or= 3 months. Adherence was assessed using pharmacy refill records. Medication beliefs, including an individual's norm for acceptable adherence, were measured using questions developed by expert panel. Literacy was associated with >or=95% adherence (64% for >or=9th grade level vs. 40% for <9th grade level). Participants with <95% adherence had a lower threshold of acceptable adherence than those with >or=95% adherence [80% adherence (interquartile range 70-90%) vs. 90% adherence (interquartile range 80-90%)]. However, the effect was independent of literacy. No other beliefs assessed were associated with adherence. Although the beliefs assessed do not mediate the relation between literacy and adherence, we identified low adherence norms as a potentially modifiable belief associated with adherence.

The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study

Background

An estimated one-half of Americans have limited health literacy skills. Low literacy has been associated with less receipt of preventive services, but its impact on colorectal cancer (CRC) screening is unclear. We sought to determine whether low literacy affects patients' knowledge or receipt of CRC screening.

Methods

Pilot survey study of patients aged 50 years and older at a large, university-affiliated internal medicine practice. We assessed patients' knowledge and receipt of CRC screening, basic sociodemographic information, and health literacy level. We defined limited literacy as reading below the ninth grade level as determined by the Rapid Estimate of Adult Literacy in Medicine. Bivariate analyses and exact logistic regression were used to determine the association of limited health literacy with knowledge and receipt of CRC screening.

Results

We approached 105 patients to yield our target sample of 50 completing the survey (recruitment rate 48%). Most subjects were female (72%), African-American (58%), and had household incomes less than $25,000 (87%). Overall, 48% of patients had limited literacy skills (95% CI 35% to 61%). Limited literacy patients were less likely than adequate literacy patients to be able to name or describe any CRC screening test (50% vs. 96%, p < 0.01). In the multivariable model, limited literacy patients were 44% less likely to be knowledgeable of CRC screening (RR 0.56, p < 0.01). Self-reported screening rates were similar (54% vs. 58%, p = 0.88).

Conclusion

Patients with limited literacy skills are less likely to be knowledgeable of CRC screening compared to adequate literacy patients. Primary care providers should ensure patients' understanding of CRC screening when discussing screening options. Further research is needed to determine if educating low literacy patients about CRC screening can increase screening rates.

Crafting a melanoma educational campaign to reach middle-aged and older men

BACKGROUND

From 1973 through 2002, melanoma mortality rates have risen steeply in middle-aged and older men. Men's higher mortality rate from melanoma is hardly an isolated example of the ways in which men's health lags behind women's health. Given the significantly higher melanoma mortality rates of men compared with women, there is now a need for a melanoma education program targeted to middle-aged and older men and their closest contacts, including spouses, significant others, and health care professionals.

OBJECTIVES

In this article, we discuss the theoretical and practical foundations for such a program. Then, taking into account factors such as socioeconomic status, health literacy, and residence, we present suggestions for creating such a campaign.

CONCLUSIONS

Planners for a new educational campaign must understand the target audience's motivations for and perceived barriers to behavioral change. Future studies should examine what motivates certain men to conduct skin self-examinations, ask their physicians about melanoma, and attend melanoma screenings, whereas other men with similar risk factors are less prevention conscious. Issues of health literacy and understandability of our messages must be further explored.

Brief cognitive battery in the diagnosis of mild Alzheimer's disease in subjects with medium and high levels of education

There has been an increasing trend to utilize short cognitive batteries for the diagnosis of dementia. Most of these batteries have been designed in countries with high standards of education and are less suitable for populations with low levels of education.We developed a battery that has been previously shown to be highly accurate in the diagnosis of dementia in individuals with low levels of education. The accuracy of this battery for patients with higher levels of education is unknown.

Myelomeningocele Information on the Internet is Accessible and of Variable Quality, and Requires a High Reading Level

PURPOSE

We assessed the accessibility, readability and quality of myelomeningocele information on the Internet.

MATERIALS AND METHODS

We entered the term "spina bifida" into the Google, Yahoo! and Microsoft Network search engines, and stored the first 100 links from each Web site. A total of 164 unique Web sites remained for analysis, of which 159 were classified as relevant. Relevant Web sites were considered to have relevant content if more than 50% of the text was directly relevant to the disease, and to have relevant educational content if more than 50% of the text was aimed at relaying educational information. Readability was assessed using the Flesch-Kincaid Grade Level scale. The quality of the 159 Web sites with relevant content was assessed using American Public Health Association Criteria for Assessing Health Information on the Internet. Six criteria were assessed, namely credibility, content, links, design, interactivity and caveats. Web sites were analyzed by 2 separate medical doctors, with each reviewer blinded to the findings of the other. A weighted kappa statistic was used to calculate interrater reliability.

RESULTS

Of 159 relevant sites 146 (91.8%) had relevant content and 122 (76.7%) had relevant educational content. The average Flesch-Kincaid reading level was 10.9 (range 6 to 12). Quality was assessed on a 3-point scale, with 1 denoting poor quality, 2 fair and 3 good. Average scores were 1.92 for credibility, 1.88 for content, 2.29 for links, 2.53 for design, 1.99 for interactivity and 2.90 for caveats. The weighted kappa statistic for interrater reliability was 0.83.

CONCLUSIONS

Myelomeningocele information on the Internet is relatively accessible, requires a high reading level for comprehension and is of variable quality.

Identifying elderly at greatest risk of inadequate health literacy: A predictive model for population-health decision makers

BACKGROUND

Despite concern that inadequate functional health literacy (FHL) is a widely prevalent problem and is associated with a variety of adverse health consequences, there is an absence of tools that population-health decision makers can use to efficiently identify those at risk of inadequate FHL.

OBJECTIVES

The objective of this study was to develop and validate a predictive model for estimating FHL in the elderly, generate a national estimate of FHL, and assess the construct validity of the national estimate.

METHODS

Using data from the largest study of FHL in the elderly, a multiple regression model to estimate FHL was developed and validated using common demographic predictors. Subsequently, the model was used to estimate FHL in the 65-year or older subgroup of the 1992 National Adult Literacy Survey (NALS). Construct validity of the FHL estimate was assessed by evaluating the direction, magnitude, and significance of association with reported general functional literacy (GFL) proficiency in the 1992 NALS.

RESULTS

A 20-variable model was derived (R2 = 0.365). The model correctly classified 73.2% of the sample into the appropriate FHL category. National prevalence of inadequate and marginal FHL was estimated to be 39.2% and 5.2%, respectively. FHL was significantly correlated with prose, document, and quantitative dimensions of GFL at r = 0.58 or higher (P<.0001).

CONCLUSIONS

This study was the first to quantitatively model and substantiate the high national prevalence of inadequate FHL in the elderly. The proposed quantitative model can be used in subsequent research to efficiently risk-stratify individuals by FHL level in large data sets to assess the relationships between FHL and health status, utilization, expenditures, and satisfaction. Furthermore, the model can be used to identify individuals at high risk of inadequate FHL, which will enable targeting of educational interventions that address FHL deficiencies.

Communicating with special populations: children and older adults

Veterinary professionals must meet the growing expectations of a diverse range of clients to sustain success in veterinary medicine. Few veterinarians, however, receive comprehensive skills training for communicating effectively with clients, particularly among special populations, such as children and older adults. An increasing number of veterinary professionals have recognized a need to master requisite skills for effectively interacting with pet-owning families. This article highlights the importance of the human-animal bond for children and older adults, addresses issues of pet loss, and provides suggestions for meeting the communication needs of both populations.

Development of a reliable and construct valid measure of nutritional literacy in adults

BACKGROUND

Research into the relation of literacy to health status has not included measures of nutritional literacy. This may be a critical area in the study of chronic conditions such as hypertension and diabetes, which can both relate to obesity and nutrition. This paper details the development and psychometric characteristics of the Nutritional Literacy Scale (NLS), offered as a measure of adults' ability to comprehend nutritional information.

METHODS

In order to assess the internal consistency and construct validity of the NLS, demographic data, readability statistics, NLS scores and scores on the Reading Comprehension Section of the Short Test of Functional Health Literacy in Adults (S-TOFHLA) were collected in a cross-sectional study of 341 patients from two primary care practices.

RESULTS

The NLS score showed acceptable internal consistency of 0.84 by Cronbach's alpha coefficient. The Pearson correlation between the NLS and the S-TOFHLA was 0.61, supporting evidence for construct validity.

CONCLUSION

Given the importance of proper weight and nutrition in the health of the public, as well as the absence of research on literacy skills as related to nutritional concepts, the NLS has the potential to add to the national research agenda in these areas.

The Case for Development of a New Test of Health Literacy

PURPOSE/OBJECTIVES

To review the need for reading assessments for patients with cancer, review existing reading assessment tools, and make a case for a new tool specific to patients with cancer.

DATA SOURCES

Published articles, experiences, and discussions with published authors in the field of literacy.

DATA SYNTHESIS

Valid and reliable tools that assess word recognition and comprehension exist for general use in health care. Word-recognition tests do not always predict comprehension, and a commonly used comprehension test has sections assessing only very low, second year of high school, and graduate-level skills.

CONCLUSIONS

A new tool, developed specifically for patients with cancer, may better capture reading ability and comprehension. It is being evaluated for use in a clinical setting.

IMPLICATIONS FOR NURSING

If nurses know their patients' reading levels, they can plan more effectively for teaching self-care and discussing decision making. Outcomes related to health and satisfaction may improve if poor readers are given materials they can understand.

Health Literacy in Geriatric Patients

The concept of health literacy is a recent addition to healthcare literature, appearing in the early to mid 1990s. Health literacy refers to individuals' ability to understand their healthcare issues and effectively care for themselves in the healthcare system. Individuals' health literacy abilities vary greatly and can be viewed on a continuum ranging from adequate to marginal to inadequate. Repeated research has demonstrated that older individuals, the geriatric patient population, are at risk of inadequate or marginal health literacy. This risk impacts health outcomes and cost for caring for the older people in our society who are the consumers of a large quantity of healthcare services. The demographic data from the research show that multiple factors influence an individual's health literacy. Besides age, individuals with less education, lower income, "blue collar" jobs, and poor health status (mental and physical) can be at risk of marginal or inadequate health literacy. Providing care to low health literacy patients is complicated by commercially prepared healthcare materials and presentations that are often written well above the average national literacy level. Studies in this review examine various approaches to healthcare education and provide viable options for educating those with low health literacy. This review stresses the importance of healthcare professionals identifying older individuals with marginal or inadequate health literacy and being able to provide education in an effective manner to this segment of the population.

Health literacy and health risk behaviors among older adults

BACKGROUND

Limited health literacy is associated with poorer physical and mental health, although the causal pathways are not entirely clear. In this study, the association between health literacy and the prevalence of health risk behaviors was examined among older adults.

METHODS

A cross-sectional survey of 2923 new Medicare, managed-care enrollees was conducted in four U.S. metropolitan areas (Cleveland OH; Houston TX; Tampa FL; Fort Lauderdale-Miami FL). Health literacy was measured using the short form of the Test of Functional Health Literacy in Adults. Behaviors investigated included self-reported cigarette smoking, alcohol consumption, physical activity, body mass index, and seat belt use.

RESULTS

Individuals with inadequate health literacy were more likely to have never smoked (46.7% vs. 38.6, p =0.01); to completely abstain from alcohol (75.6% vs. 57.9, p <0.001); and to report a sedentary lifestyle (38.2% vs. 21.6%, p <0.001) compared to those with adequate health literacy. No significant differences were noted by mean body mass index or seat belt use. In multinomial logistic regression models that adjusted for relevant covariates, inadequate health literacy was not found to be significantly associated with any of the health risk behaviors investigated.

CONCLUSIONS

Among community-dwelling elderly, limited health literacy was not independently associated with health risk behaviors after controlling for relevant covariates.

Caregiver health literacy and the use of child health services

OBJECTIVES

Eighty million US adults have low health literacy, a risk factor for increased health care use among adults. The purpose of this work was to assess the association between caregiver health literacy and the use and cost of child health services.

METHODS

We conducted a cross-sectional study of caregiver-child dyads from a sample of children aged 12 months to 12 years presenting to the pediatric emergency department of an urban, public hospital. Caregiver health literacy was measured by the Short Test of Functional Health Literacy in their preferred language (English or Spanish). Child health care use was measured by a 12-month retrospective review of the public hospital system's electronic database and of state Medicaid billing records for 4 types of visits: preventive care, urgent care, emergency care, and hospital care. Cost of child health care use was provided by Medicaid billing records. Multivariate analysis included caregiver education, age, and language proficiency, as well as child age, special health care needs, ethnicity, and health-insurance coverage.

RESULTS

A total of 290 dyads were enrolled in the study. Twenty-two percent of caregivers had low (inadequate or marginal) health literacy. Caregivers with low health literacy were more likely to have less than a high school education, to have limited English proficiency, and to have been born outside the United States. There were no differences in health care use or cost between children of caregivers with low health literacy and children of caregivers with adequate health literacy. Three caregiver characteristics were associated with increased use of child health care services: born outside the United States, age at child's birth <24 years, and limited English proficiency.

CONCLUSIONS

One in 5 caregivers of young children has low health literacy. Caregiver health literacy, however, was not associated with disparities in the use of child health services in this inner-city, ethnic minority population.

Distinguishing characteristics of patients who seek more information or request a prescription in response to direct-to-consumer advertisements

OBJECTIVE

The objective of this study was to examine demographic and psychographic profiles of individuals who sought additional information or requested a prescription drug based on a direct-to-consumer advertisement.

METHODS

A cross-sectional descriptive survey was used for collecting data from a random sample of 200 Minnesotans during Fall 2002. Chi-square and Mann-Whitney U tests were used as nonparametric tests for assessing differences in distributions between our categories of study subjects.

RESULTS

Out of 177 deliverable surveys, 81 (46%) were returned. Of these, 80 surveys were usable for analysis. The results showed that the distinguishing characteristics of individuals who sought additional information based on an advertisement were associated with demographic variables such as number of drugs taken daily and monthly out-of-pocket expenditures for prescription drugs. In contrast, distinguishing characteristics of individuals who requested prescription drugs (in addition to seeking information) based on an advertisement were psychographic in nature such as (1) viewing themselves as having greater influence on their physician, (2) having a stronger relationship with their physician, (3) expressing greater satisfaction with their current therapy, (4) viewing prescriptions as less of a burden, and (5) having higher outcome expectations for prescription drugs compared to the respondents who did not ask for a prescription drug based on a direct-to-consumer advertisement.

CONCLUSIONS

Distinguishing characteristics of information seekers were demographic in nature, whereas those characteristics of prescription requesters were psychographic in nature.

What an informed patient means for the future of healthcare

Professionalism is the basis of medicine's contract with society, and the principle of patient autonomy is a fundamental value of our profession. Physicians must respect patient autonomy by being honest and empowering patients to make informed decisions about their health. What information do patients need to understand in order to be able to take care of their health? How do we make sure that information is adequately communicated so that everyone who needs it can access and understand it? Health literacy is increasingly recognised as essential for successful access, navigation, self-care and management of health and wellness in America. Unfortunately, there is a large gap between the literacy demands of the health system and the health literacy skills of most Americans. A recent Institute of Medicine report concludes that nearly half of American adults have difficulty understanding and acting upon health information. Low health literacy is associated with less knowledge of diseases and self-care, worse self-management skills, lower medication compliance rates, higher rates of hospitalisation and worse health outcomes. Health literacy problems are magnified as patients are increasingly asked to take more responsibility for their health in a healthcare system that is increasingly complex, specialised and technologically sophisticated. Most would agree that is it hard to be a patient these days; health literacy is needed for navigating and understanding what you need to do. Improving health literacy is essential for improving quality, reducing disparities and reducing costs.

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy

BACKGROUND

The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence.

OBJECTIVES

To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions.

RESEARCH DESIGN

Prospective cohort study.

SUBJECTS

New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549).

MEASURES

Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%.

RESULTS

Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64).

CONCLUSIONS

The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.

The role of medication use and health on the decision to quit drinking among older adults

OBJECTIVE

To determine the extent to which changes in medication use and health influence the decision to quit drinking among older adults.

METHOD

The sample consisted of 8,883 elderly enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PA-PACE) program who completed surveys in 2000 and 2002. Survey data were linked with prescription claims to examine medication and health factors associated with drinking cessation between baseline and follow-up.

RESULTS

Overall, 3.9% of those using alcohol at baseline quit drinking during the study period. Logistic regression results showed that individuals who initiated antipsychotic (OR = 2.92) and antineoplastic therapies (OR = 2.67) were the most likely to quit drinking.

DISCUSSION

These findings support the hypothesis that elderly quit drinking in response to ill health. Results have implications for alcohol interventions in older adults and underscore the importance of separating former drinkers from lifetime abstainers in the study of alcohol-health relationships.