Lower Neurocognitive Functioning Disrupts the Effective Use of Internet-Based Health Resources in HIV Disease: The Mediating Effects of General Health Literacy Capacity

Health literacy mediates the association between cognition and healthcare provider interactions among gay and bisexual men with HIV disease

Introduction: Gay and bisexual men (GBM) account for the highest rates of incident infection with HIV in the U.S., and experience social, systemic barriers to accessing and engaging in healthcare services. Interacting with healthcare providers can be a complex process for some GBM with HIV disease. The current study examined the contributions of cognition and health literacy to perceived interactions with healthcare providers among GBM with HIV disease. Methods: The sample included 100 adults with HIV disease (ages 24-75) who identified as GBM. All participants completed the Dealing with Health Professionals subscale of the Beliefs Related to Medication Adherence survey, as well as the Cogstate neuropsychological battery, self-report measures of cognitive symptoms, and well-validated measures of health literacy. Results: Worse performance-based cognition and subjective cognitive symptoms were both associated with perceived difficulties dealing with healthcare providers, but these associations were fully mediated by lower health literacy. Conclusion: Health literacy may play a role in the association between poorer cognitive functioning and difficulties navigating healthcare interactions among GBM with HIV disease. Further studies are needed to determine whether cognitive approaches to enhancing the access, understanding, and use of health information in GBM with HIV disease improves healthcare interactions and outcomes.

Computer use: a protective factor for cognition in aging and HIV disease?

BACKGROUND

Modifiable lifestyle factors such as engagement with technology may be beneficial to cognition in older adults, but we know little about these relationships in older persons with chronic medical conditions.

AIMS

The current study examined the association between computer use frequency and cognition in younger and older adults with and without HIV disease.

METHODS

Participants included 110 older persons with HIV (pwHIV; age ≥ 50 years), 84 younger pwHIV (age ≤ 40 years), 76 older HIV-, and 66 younger HIV- adults who completed a comprehensive medical, psychiatric, and cognitive research assessment. Demographically adjusted scores were derived from a well-validated clinical battery of performance-based neuropsychological tests. Participants also completed self-reported measures of cognitive symptoms in daily life and the Brief Computer Use and Anxiety Questionnaire (BCUAQ).

RESULTS

Older age was associated with less frequent computer use among persons with and without HIV disease. More frequent computer use was strongly and independently related to better cognitive performance, particularly in higher order domains (e.g., episodic memory and executive functions) and among the older seronegative adults. A small, univariable correlation between more frequent computer use and fewer cognitive symptoms in daily life was observed in the full sample, but that relationship was better explained by computer-related anxiety and HIV/age study group.

DISCUSSION

These findings add to the existing literature that suggests regular engagement with digital technologies may have a beneficial impact on cognitive functioning, consistent with the technological reserve hypothesis.

Health literacy mediates the effects of educational attainment on online pharmacy navigation skills in older adults with HIV disease

ObjectiveThe Internet serves an increasingly critical role in health behaviors for older adults with chronic medical conditions. Guided by theories of health behaviors and literacy, this study examined whether the relationship between educational attainment and online pharmacy skills in older persons with HIV disease (PWH) is mediated by health literacy. Design: Participants included 98 PWH age 50 and older who completed the Test of Online Pharmacy Skills (TOPS), which required them to navigate an experimenter-controlled online pharmacy to perform several naturalistic tasks (e.g., refill an existing prescription). Participants also completed the Medication-Management Test-Revised (MMT-R). Results: Mediation analyses revealed a significant indirect effect of education on both online pharmacy accuracy and MMT-R, which was fully mediated by health literacy. In contrast, there was no direct or indirect effect of education on online pharmacy speed when health literacy was included as a mediator. Conclusion: Health literacy plays an important role in the relationship between years of education attained and the ability of older PWH to successfully navigate online pharmacy tasks and manage their medications. Future studies might examine whether interventions to improve electronic health literacy among older PWH who have lower educational attainment have beneficial effects on online health behaviors.

e-Health Literacy Skills in People with Chronic Diseases and What Do the Measurements Tell Us: A Scoping Review

Background: Use of electronic health (e-Health) technologies has increased in the past decade and inadequate e-Health literacy may lead to health-related social inequality. This is especially true for patients living with chronic diseases who are often involved in self-care. However, the measurement of e-Health literacy represents several challenges. Among available instruments, the e-Health Literacy Scale (eHEALS) is the only instrument with available psychometric properties. Aim: To identify studies measuring e-Health literacy in adults living with chronic disease and its relationship to health-related behaviors and other perceptions such as quality of life, self-efficacy, or specific disease biomarkers, and studies analyzing the impact of educational intervention on e-Health literacy. Methods: The authors searched MEDLINE, the Cochrane Library, and Web of Science databases to identify studies published in English language until April 2022. Results: Seventeen studies involving 4,877 participants were included. A majority of the studies were cross-sectional with a lack of appropriate controls. Five of the included studies were experimental, involving 758 participants. All of them reported positive effects of educational interventions on the improvements in self-reported e-Health literacy skills. However, most studies were at risk of bias. Conclusion: Despite these limitations, the findings of this review indicate the positive relationship between e-Health literacy and various health care processes in adults with chronic diseases and highlights a need for prospective controlled studies. Promoting e-Health literacy might give better opportunities for the active involvement of people with chronic diseases in self-care and for the implementation of online interventions into existing system of care.

Preliminary Validity of a Telephone-Based Neuropsychological Battery in a Consecutive Series of Persons with HIV Disease Referred for Clinical Evaluation

OBJECTIVE

The COVID-19 pandemic necessitated use of remote assessments by clinical neuropsychologists. Telehealth was particularly important for vulnerable groups, including persons living with HIV (PLWH); however, limited internet access can be a serious barrier to care. This study examined the preliminary validity of a telephone-based neuropsychological assessment in a clinical sample of PLWH.

METHOD

A consecutive series of 59 PLWH were assessed via telephone at an HIV clinic in the southern U.S. between April 2020 and July 2022. The battery included auditory-verbal neuropsychological tests of memory, attention, and executive functions, and questionnaires assessing self-reported mood and activities of daily living (ADL).

RESULTS

Study measures demonstrated acceptable internal consistency. PLWH demonstrated worse neuropsychological performance compared with expectations derived from the normal curve and an HIV-seronegative adult sample (N = 44). PLWH assessed via telephone demonstrated similar impairment rates to that of a consecutive series of PLWH (N = 41) assessed in-person immediately prior to the pandemic. Higher telephone-based global neuropsychological scores were related to younger age, more education, better fund of knowledge, White race/ethnicity, fewer medical conditions, and fewer depression symptoms. Global neuropsychological impairment was strongly and independently associated with greater dependence in ADL domains, particularly for instrumental activities.

CONCLUSIONS

Although telephone-based approaches to neuropsychological assessment are not ideal, these data provide support for the feasibility, internal consistency, and preliminary validity of this method in a consecutive clinical series of PLWH. The direct comparability of telephone-based and in-person neuropsychological assessments remains to be determined by prospective, counterbalanced study designs examining both PLWH and seronegative individuals.

Neurocognitive performance differences between black and white individuals with HIV disease are mediated by health literacy

Objective:Health disparities are evident for Black Americans with HIV disease, who are disproportionally affected by the epidemic in the United States. The current study investigated whether the higher rates of neurocognitive impairment in Black Americans with HIV disease may be at least partly attributable to health literacy, which is a potentially modifiable factor. Method: Participants were 61 White and 25 Black participants (ages 27-70) with HIV disease who were enrolled in studies at an urban academic center in Southern California. Neurocognitive function was assessed by an age-adjusted global score from the Cogstate battery. Health literacy was measured by a composite score derived from the Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign, and 3-Brief. Results: Bootstrap confidence interval mediation analyses showed that health literacy was a significant mediator of the relationship between race and neurocognition; that is, there were no direct ethnoracial differences in neurocognition after accounting for health literacy. A follow-up model to confirm the directionality of this association demonstrated that neurocognition was not a significant mediator of the relationship between race and health literacy. Conclusions: Low health literacy may contribute to the higher rates of neurocognitive impairment for Black Americans with HIV disease. Future studies might examine the possible mechanism of this mediating relationship (e.g., access to health information, health behaviors, socioeconomics) and determine whether culturally tailored interventions that improve health literacy also confer broader brain health benefits for Black Americans with HIV disease.

How did individual differences in neurocognition and health literacy influence the initial uptake and use of health-related information about COVID-19?

Introduction: The rapid development of coronavirus disease 2019 (COVID-19) into a pandemic required people to quickly acquire, evaluate, and apply novel complex health-related information about the virus and transmission risks. This study examined the potentially unique and synergistic roles of individual differences in neurocognition and health literacy in the early uptake and use of COVID-19 public health information.Method: Data were collected between April 23 and 21 May 2020, a period during which 42 out of 50 states were under a stay-at-home order. Participants were 217 healthy adults who completed a telephone-based battery that included standard tests of neurocognition, health literacy, verbal IQ, personality, and anxiety. Participants also completed measures of COVID-19 information-seeking skills, knowledge, prevention intentions, and prevention behaviors.Results: A series of hierarchical multiple regressions with data-driven covariates showed that neurocognition (viz, episodic verbal memory and executive functions) was independently related to COVID-19 knowledge (e.g. symptoms, risks) at a medium effect size, but not to information-seeking skills, prevention intentions, or prevention behaviors. Health literacy was independently related to all measured aspects of COVID-19 health information and did not interact with neurocognition in any COVID-19 health domain.Conclusions: Individual differences in neurocognition and health literacy played independent and meaningful roles in the initial acquisition of knowledge related to COVID-19, which is a novel human health condition. Future studies might examine whether neurocognitive supports (e.g. spaced retrieval practice, elaboration) can improve COVID-19-related knowledge and health behaviors in vulnerable populations.

Group differences in health literacy are ameliorated in ehealth literacy

BACKGROUND

Heath literacy and eHealth literacy are skills that enable individuals to seek, understand and use information in ways which promote and maintain health. The present study examined group differences (ethnicity, immigration) in both literacies and whether there exists an association between the literacies and potential outcomes/gains in health behaviors, health care utilization, perceived health and perceived outcomes of Internet search.

METHODS

Participants included 819 Israeli men and women who responded to a nationally representative random-digital-dial (RDD) telephone survey. Respondents were veteran Jews, immigrants from the Former Soviet Union, and Palestinian Citizens of Israel.

RESULTS

Significant differences between the groups were found in health literacy, especially in higher ordered skills, so that the immigrant group was the lowest, after accounting for demographic variables. No significant group differences were found in eHealth literacy. Health literacy was found to be significantly associated with healthcare utilization, perceived health and perceived outcomes of Internet search while eHealth literacy was associated with perceived health and perceived outcomes of Internet search. No interaction was found between group and literacies in the prediction of the outcomes.

CONCLUSIONS

Immigration hampers health literacy but differences are ameliorated in eHealth literacy. Finding on association between literacies and outcomes replicated previous ones and the absence of moderation by group attests to the robustness of the models on health literacies.

Misattributions of the source of health-related information in HIV disease

Introduction: Growing access to both legitimate and dubious sources of health information makes accurate source memory increasingly important, yet it may be negatively impacted by conditions that impair prefrontal functioning, including HIV. This study hypothesized that instructions supporting source encoding on a health-related memory task would disproportionately benefit source memory of people with HIV (PWH), and to examine the pattern of source memory errors that are observed.Method: 102 individuals (61 HIV+, 41 HIV-) completed comprehensive neurobehavioral (including health literacy) and neuromedical evaluations, and were randomly assigned to one of two conditions for a health-related memory task: Attend to Source Instructions explicitly participants to attend to the source of health statements presented to them, which were either health professionals or lay-persons, whereas no such instruction was provided in a Control Instructions condition.Results: There was no significant interaction of HIV status by condition or main effect of HIV (ps>.05). There was a main effect of condition whereby those who received Attend to Source Instructions performed better on item-corrected source memory than those in the Control Instructions condition (p =.04). Those who received Control Instructions were more likely to misattribute the source of the health information to a health professional when the correct source was a lay-person (Cohen's d = -0.53), which was correlated with poorer overall cognitive performance (p =.008) and performance-based measures of health literacy (ps<.05).Conclusions: Given that people are rarely reminded to attend to the source of new health information in the real world, the risk for misattributing health information to a qualified health professional in the absence of such instructions raises the concern that people may readily incorporate questionable health recommendations into their health regimen, particularly among persons with poorer cognitive functioning and lower levels of health literacy. This may have significant downstream health consequences such as drug interactions, side effects, and inefficacy.

Neurocognitive Functioning is Associated with Self-Reported and Performance-Based Treatment Management Abilities in People Living with HIV with Low Health Literacy

OBJECTIVE

People living with HIV (PLWH) are at higher risk for poorer neurocognitive functioning and health literacy than uninfected persons, which are associated with worse medical outcomes. Aging research suggests that the effect of neurocognitive functioning on health outcomes may be more pronounced in those with low health literacy. We aimed to determine whether low health literacy might amplify the adverse effects of neurocognitive functioning on treatment management outcomes in 171 PLWH aged 40+.

METHOD

In this cross-sectional, observational study, participants completed a well-validated battery of neurocognitive, health literacy, and treatment management measures. A binary health literacy variable (low vs. adequate) was determined via established cut points on the well-validated health literacy tests. Treatment management outcomes included biomarkers of HIV (i.e., CD4 counts and viral load), self-management of HIV disease (i.e., self-reported medication adherence and self-efficacy for HIV disease management), and performance-based health-related decision-making.

RESULTS

Forty-seven percent of the sample met the criteria for low health literacy. Multivariable regressions adjusting for clinicodemographic (e.g., race, socioeconomic status) covariates revealed significant interactions for self-efficacy for HIV disease management and health-related decision-making, such that neurocognitive functioning was associated with these outcomes among those with low, but not adequate health literacy.

CONCLUSIONS

Findings suggest that low health literacy may increase the vulnerability of PLWH to the adverse effects of neurocognitive impairment on health outcomes, or conversely that adequate health literacy may provide a buffer against the health risks associated neurocognitive impairment. Interventions targeting health literacy in PLWH may mitigate the effects of neurocognitive impairment on health outcomes.

Online pharmacy navigation skills are associated with prospective memory in HIV disease

OBJECTIVE

The increased use of online pharmacy services in the midst of the COVID-19 pandemic provides an important backdrop against which to examine the role of neurocognitive functions in health-related Internet navigation skills among persons with chronic medical conditions, such as HIV disease. Prospective memory (PM) is reliably impaired in HIV disease and is related to laboratory-based measures of medication management capacity in other populations. This study examined whether PM shows veridicality in relationship to online pharmacy navigation skills in persons with HIV disease.

METHOD

Participants included 98 persons with HIV disease age 50 and older who completed the Cambridge Prospective Memory Test (CAMPROMPT) and the Medication-Management Test-Revised (MMT-R) as part of a neuropsychological study. Participants also completed the Test of Online Pharmacy Skills (TOPS), which required them to navigate a simulated, experimenter-controlled online pharmacy to perform several naturalistic tasks (e.g., refill an existing prescription).

RESULTS

Lower PM had medium associations with poorer MMT-R and TOPS accuracy scores that were not better explained by other neurocognitive functions. The association between PM and TOPS accuracy was driven by errors of omission and did not vary meaningfully based on whether the intention was cued by time or an event.

CONCLUSIONS

These data suggest that PM cue detection processes show veridicality with online pharmacy navigation skills. Future studies might examine the benefits of PM-based strategies (e.g., salient prompts) in supporting online health navigation skills in populations that experience clinically impactful PM failures.

An Empirical Mediation Analysis of Mechanisms Underlying HIV-1-Associated Neurocognitive Disorders

HIV-1-associated neurocognitive disorders (HAND), characterized by alterations in the core components of cognitive function and age-related disease progression, persist in the post-cART era. However, the neurobehavioral mechanisms that mediate alterations in the core components of cognitive function and the progression of neurocognitive impairments have yet to be systematically evaluated. To address this knowledge gap, statistical mediation analysis was assessed, providing a critical opportunity to empirically evaluate putative neurobehavioral mechanisms underlying HAND. Neurocognitive assessments, conducted in HIV-1 transgenic (Tg) and control animals across the functional lifespan (i.e., Postnatal Day (PD) 30 to PD 600), tapped multiple cognitive domains including preattentive processes, learning, sustained attention, and long-term episodic memory. Three longitudinal mediation models were utilized to assess whether deficits in preattentive processes mediate alterations in learning, sustained attention and/or long-term episodic memory over time. Preattentive processes partially mediated the relationship between genotype and learning, genotype and sustained attention, and genotype and long-term episodic memory across the functional lifespan, explaining between 44% and 58% of the HIV-1 transgene effect. Understanding the neurobehavioral mechanisms mediating alterations in HAND may provide key targets for the development of a diagnostic biomarker, novel therapeutics, and cure/restoration strategies.