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The American Journal of Managed Care September 2018
Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
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Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
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Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH
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Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH

Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
A health literacy study of older African Americans aimed to establish whether associations exist between health literacy and preventive health screening behaviors, disease control, and medication adherence.
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ABSTRACT

Objectives: To determine the health literacy (HL) of older African Americans (AAs) and establish whether associations exist between HL and preventive health screening (PHS) behaviors, disease control (DC), and medication adherence (MA).

Study Design: A prospective study using a clustered sampling of older AAs.

Methods: A total of 99 older AAs seeking care at a patient-centered medical home were given the Newest Vital Sign (NVS), Short Test of Functional Health Literacy in Adults (STOFHLA), and Morisky Medication Adherence Scale (MMAS). Sociodemographic and clinical data were obtained.

Results: The group was 75.8% female, with means of 75 years of age, 12.7 years education, and 29.5 kg/m2 body mass index and good control over disease markers: For blood pressure, 62.6% had good control; for blood glucose, 82.8%; and for total lipids/cholesterol, 63.6% (high-density lipoprotein, 81.8%; low-density lipoprotein, 73.7%). Compliance rates for primary PHS behaviors were 61.6% for influenza vaccine and 57.7% for pneumococcal vaccine. For secondary PHS behaviors, compliance rates for mammography were 97.3% among women; for colonoscopy, 84%; and for bone densitometry (BD), 62.8%. Performance differences were observed on HL scales, with 31.3% and 73.7% obtaining an adequate NVS score and STOFHLA score, respectively, but no gender differences were noted. HL scales showed positive association among themselves (= .001), patient education (NVS, P = .001; STOFHLA, P = .004), MMAS (P = .001 and P = .563, respectively), anthropometry measurements, primary PHS procedures, and 1 secondary PHS procedure (mammography), but they exhibited negative association with colonoscopy and BD. DC achieved using a PHS approach to clinical care was not associated with HL.

Conclusions: HL was positively associated with patient education, some PHS behaviors, and MA. Performance on HL scales may not enable positive identification of PHS behaviors, DC, and MA. Thus, HL may have limited efficacy as a tool to assess PHS behaviors and DC among older AAs.

Am J Manag Care. 2018;24(9):428-432
Takeaway Points

This health literacy (HL) study of older African Americans (AAs) at a patient-centered medical home (PCMH) aimed to establish whether associations exist between HL and preventive health screening (PHS) behaviors, disease control (DC), and medication adherence (MA).
  • HL was positively associated with patient education, some PHS behaviors, and MA.
  • Performance on HL scales may not enable positive identification of PHS behaviors, DC, and MA.
  • Thus, HL may have limited efficacy as a tool in assessment of older AAs’ PHS behaviors and disease management.
  • The study findings could impact PCMH management of older AAs’ preventive health screening, clinical time allocation, and economics of care.
Preventive healthcare has been the focus of human beings from time immemorial. Clichés such as “An ounce of prevention is worth a pound of cure” and “Prevention is better than cure” have been commonly used, especially in the healthcare environment.1-3 The growth of the aging US population has created an impetus for promoting newer approaches to patient care and disease management, notably, to control healthcare costs and improve health outcomes and patient quality of life.4-6 Evaluation of patient health literacy (HL) is one such approach to integrating behavioral health management into clinical care.7,8 HL is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (ie, decisions that affect healthcare use), aid understanding of health risk behaviors, and enable enhancement of health outcomes and consequent decreased cost of care.9

Older African Americans (AAs), a large segment of the US population,10 face greater health risks with poorer outcomes.11 Focusing on preventive health screening (PHS) enables detection and treatment of disease prior to progression. The US Preventive Services Task Force (USPSTF) makes recommendations for type and frequency of preventive screenings based on age and gender.12 But AAs’ relatively high distrust of their physicians affects utilization of PHS services, leading to health disparities.13 Disease prevention goes hand in hand with medication compliance. Following detection, adherence to prescribed medication regimens is essential to achieve any control of disease progression.14-16 Although the relationship between HL and preventive health has been studied in some subsets of the population,17,18 social circumstances and distrust of healthcare providers have resulted in the existence of limited information on older AAs.19-21 This study, assessing the impact of HL of AAs on PHS behaviors, medication adherence (MA), and disease control (DC), is an attempt to bridge the gap in knowledge about the group.

The study objectives were to evaluate HL and PHS behaviors among older AA patients and establish whether an association among HL, PHS behaviors, DC, and MA exists. The results of this study will provide clinicians with valuable information and enhance management of PHS service delivery and DC of geriatric AA patients.

METHODS

Study Design and Population

This prospective study was conducted using a clustered sampling of older AAs seeking care at a patient-centered medical home (PCMH) affiliated with Wayne State University (WSU) and Detroit Medical Center that provides healthcare to 4000 patients. The WSU Institutional Review Board approved the study.

Data Collection

All patients, on arrival and sign-in, were approached and provided information about the study by research personnel in the PCMH reception lounge. Patients who exhibited a desire to participate underwent a clinical examination to determine study participation suitability and were eligible if they were (1) an AA, 60 years or older, an active clinic patient for a year or more, free from terminal illness and visual impairment, and able to communicate in English and follow directions; (2) not a nursing home resident; (3) not cognitively impaired, on dialysis, on chemotherapy, on radiation therapy, or scheduled for major surgery; and (4) agreeable to participate with written informed consent.

Measures

The following data were collected from patients who met the study inclusion criteria: sociodemographic (age, gender, education, and health insurance), clinical (weight; height; body mass index [BMI]; blood pressure [BP]; fasting blood glucose [BG]; lipid profile, total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], and low-density lipoprotein cholesterol [LDL-C]); primary PHS (influenza vaccine and pneumococcal vaccine); secondary PHS (mammography, colonoscopy, and bone densitometry [BD]); and scores on HL and adherence scales (HL, Newest Vital Sign22 [NVS] and Short Test of Functional Health Literacy in Adults23 [STOFHLA]; adherence, Morisky Medication Adherence Scale24 [MMAS]).

HL assessment, using NVS and STOFHLA scales, takes longer for older patients; therefore, ample time was permitted for completion.25 The NVS scale measures HL with 6 questions designed to evaluate the patients’ understanding of current nutrition labels and includes an actual nutritional label that the patient observes. NVS scores are classified as inadequate (0-1), marginal (2-3), and adequate (4-6).22 The STOFHLA scale measures the ability to read and understand prose passages (prose literacy), appointment slips (document literacy), and prescription bottles containing numerical information (quantitative literacy). STOFHLA scores are classified as inadequate (0-16), marginal (17-22), and adequate (23-36).23

The MMAS was completed by patients to evaluate MA. The MMAS consists of 4 questions (eg, Do you ever forget to take your medicine?), each answered with a dichotomous (yes/no) response. The MMAS score was calculated by tallying the number of “no” answers to the 4 MMAS questions of nonadherence, with scores of 2 or lower classified as low adherence and 3 or higher as high adherence.24

PHS Behaviors: Control and Compliance

Patients were characterized based on PHS into controlled-risk and uncontrolled-risk categories for each health risk factor using the American College of Cardiology Practice Guidelines (Table 1).26 Compliance with primary (influenza vaccine and pneumococcal vaccine) and secondary (mammography, colonoscopy, and BD) PHS was documented consistent with the recommendations of USPSTF.12

Statistical Analysis

The data were analyzed using SPSS for Windows version 22.0 (IBM SPSS Inc; Chicago, Illinois). For this study, patients were grouped by their scores on the HL scales, NVS (inadequate [0-3] and adequate [4-6]) and STOFHLA (inadequate [0-22] and adequate [23-36]). Continuous data (eg, age) of the 2 groups were analyzed using t tests, and categorical data (eg, gender) associations were evaluated using χ2 tests. Pearson correlation coefficients were used for analysis of associations among HL, MA, and continuous data. Results are presented as mean ± SD or as n (%). Statistical significance for all tests was established at P <.05.


 
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