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The American Journal of Managed Care September 2018
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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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A total of 150 older AA patients were identified for the study. Among them, 32 did not meet the study criteria and 19 refused to participate, most often citing time constraints and lack of interest as reasons. Table 2 summarizes the characteristics of the 99 AA patients partitioned by NVS and STOFHLA scores.

The group was 75.8% female; had means of 75 years of age, 12.7 years of education, and 29.5 kg/m2 BMI; was devoid of current smokers; and possessed public/private health insurance. Screening for chronic diseases, such as obesity, hypertension, diabetes, and hyperlipidemia, showed that most participants had good control over disease markers (BP [62.6%], BG [82.8%], and lipids [TC, 63.6%; HDL-C, 81.8%; LDL-C, 73.7%]). Among the primary and secondary PHS measures, influenza vaccine was obtained by 61.6%, pneumococcal vaccine by 57.7%, mammography by 97.3% of women, colonoscopy by 84%, and BD by 62.8%.

The overall performance of the group on NVS and STOFHLA was quite different, with a minority (31.3%) obtaining an adequate score on NVS but the majority (73.7%) performing well on STOFHLA. However, no gender differences in HL scale performance were observed. The HL scales, NVS and STOFHLA, showed a strong positive association among themselves (P = .001) and also with patient education (NVS, P = .001; STOFHLA, P = .004). Anthropometry measurements (weight, height, and BMI) correlated positively with HL scales; nevertheless, NVS had a stronger positive association with weight (P = .025) and BMI (P = .050) than did STOFHLA. Primary PHS procedures displayed a positive association with HL scales; however, the association of influenza vaccine (P = .048) and pneumococcal vaccine (P = .051) was much stronger with STOFHLA than with NVS. Even though a positive association was evident between HL scales and 1 secondary PHS procedure (mammography), the others, colonoscopy and BD, exhibited a negative association, which was notably stronger between NVS and BD (P = .007).

Disease control achieved using a PHS approach to clinical care, as measured by BP, BG, and lipids (TC, HDL-C, and LDL-C), was not associated with performance on HL scales. The MMAS, a measure of MA, was positively associated with both HL scales; however, there was a stronger association with STOFHLA (P = .001) compared with NVS (P = .563).


The principal aims of this study were to evaluate the PHS behaviors among an older AA patient population and establish whether there exists an association of HL—measured by NVS and STOFHLA, each using a different approach for measurement—with PHS behaviors, DC, and MA. Our PCMH patient sample of elderly AAs had a higher number of women, which is consistent with the geriatric population, wherein females are healthier, have a longer life span, and make up the majority.27 Also, there was a total lack of gender-distinguishing characteristics exhibited by both of the HL scales, a noteworthy observation that needs further verification. The strong negative association of patient age with education and HL, documented earlier, was another characteristic of this older group similar to previous reports.28,29 Overall, with no strong trends, our research offers weak support for using HL scales to positively identify PHS behaviors, DC, and MA. More research to confirm these inferences is necessary.

The preventive health and chronic disease management focus of our PCMH was validated by the high PHS and DC rates.30 Furthermore, although the disease markers for hypertension, diabetes, and hyperlipidemia (ie, BP, BG, and lipids) were not distinguishable by HL level measured using 2 HL scales, weight and, consequently, BMI showed a significant positive association with NVS but not STOFHLA. This is interesting on 2 fronts; primarily, NVS uses an understanding of a nutrition label to measure HL,22 and BMI measuring obesity is, in a way, a measure of food consumption or eating behaviors. Secondly, those who scored adequately on NVS were more overweight or obese than those who scored inadequately. Although this seems contradictory and may not bode well for NVS, verification of these findings may enable use of the scale in identification of obesity and eating disorders, especially among older AAs.

Primary and secondary PHS compliance are important components of USPSTF-recommended annual screening guidelines for older adults.12 An adequate score on STOFHLA and NVS was associated with higher compliance with both influenza and pneumococcal vaccines, the primary PHS indicators studied, with compliance rates matching recent US surveillance reports.10 However, STOFHLA exhibited stronger compliance-distinguishing characteristics. This aspect of STOFHLA, which uses the ability to read and understand prose passages and appointment slips to measure HL,23 may find application in identifying primary PHS compliance among an older AA population subset. Nonetheless, BD, a nutrition-related indicator of bone health and a secondary PHS procedure, displayed a strong negative association with NVS, pointing once again to the nutritional health identification abilities of NVS. Among other secondary PHS tests, mammography and colonoscopy both recorded high compliance rates. Even though in this study HL scales were unable to distinguish between PHS compliance rates of patients, findings of another study associated adequate self-reported HL with mammography, health-promoting behaviors, and health-related beliefs.31 However, whereas occupational status was found to be a compliance predictor for colonoscopy, being fearful and having an uncomfortable feeling during the procedure were cited as compliance barriers with mammography in another study.32

MA, as measured by MMAS, had a strong positive association with the patient’s education level and STOFHLA but a weak relationship with NVS. Additionally, as confirmed by other studies, the HL scales in this research, NVS and STOFHLA, were significantly associated with the patient’s education level but simultaneously had a very limited ability for positive identification of PHS behaviors, DC, and MA, thereby providing insufficient justification for their use among the elderly.28,33-38 In a healthcare environment, where cost containment and delivery of quality healthcare in a cost-effective manner are the needs of the hour—often preached at all levels of healthcare management—employing scales to measure HL may not be an efficient use of clinical time, especially when older patients need far greater time for screening, evaluation, and delivery of healthcare. Thus, HL may have limited efficacy as a tool in the arsenal of geriatric healthcare.

Strengths and Limitations

Although results of this study could significantly affect PCMH management of older AA patients, especially in PHS, clinical time allocation, and economics of care, the study does have limitations. The sample was selected from among voluntary participants, making it impossible to determine the characteristics of nonparticipants and the potential impact on study findings. Also, this study was carried out at an urban PCMH where care is provided by university-based clinical personnel with a focus on preventive care and therefore may not represent the care generally available. Thus, although the AA participant sociodemographics are representative of an older minority population seeking care at an urban university PCMH, it may not be possible to generalize the results. Nevertheless, the findings are unique, bear importance, have not been reported earlier, and warrant further investigation.


The study shows that HL had strong positive associations with patient education level, some PHS behaviors, and MA; nevertheless, performance on the scales may not enable positive identification of PHS behaviors, DC, and MA. Consequently, HL may have limited efficacy as a tool in assessment of PHS behaviors and disease management among older AAs.

This article has been corrected in Am J Manag Care. 2019;25(5):256.

Author Affiliations: Departments of Medical Education/Diversity & Inclusion and Internal Medicine/Geriatrics, Wayne State University School of Medicine (ANFA, PJP), Detroit, MI.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ANFA, PJP); acquisition of data (PJP); analysis and interpretation of data (ANFA, PJP); drafting of the manuscript (ANFA); critical revision of the manuscript for important intellectual content (ANFA); statistical analysis (ANFA); administrative, technical, or logistic support (PJP); and supervision (ANFA, PJP).

Address Correspondence to: Anil N.F. Aranha, PhD, 9D - Wayne State University Health Center, 4201 Saint Antoine Dr, Detroit, MI 48201-2153. Email:

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