Health Literacy, Cognition & Asthma Self-Management. Rachel O Conor, MPH October 29, 2013

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1 Health Literacy, Cognition & Asthma Self-Management Rachel O Conor, MPH October 29, 2013

2 Acknowledgements Alex Federman, MD MPH Michael Wolf, PhD MPH Juan Wisnivesky, MD DrPH MPH Melissa Martynenko, MPH MPA Anastasia Sofianou, MS

medications Proper use of inhaler devices Poor self

3 Asthma Chronic lung disease affecting ~25 million Americans Requires routine self-management Adherence to controller medications Proper use of inhaler devices Poor self management = worse clinical outcomes CDC, 2012 Vital and Health Statistics

4 Rosas-Salzar et al. J Allergy Clin Immunol Federman et al. J Asthma, 2010 Federman et al. J Asthma. In press; Federman et al. JAGS, under review Asthma and Health Literacy Medication Adherence Health Literacy Asthma Knowledge & Beliefs Worse Asthma Outcomes Inhaler Technique

association with health tasks explained by cognitive function

5 Health Literacy and Cognitive Function Prior research found HLcognitive function associations Wolf, et al (2012) found HL association with health tasks explained by cognitive function Minimal research has examined HL, cognitive function and self-care behaviors

6 Objective Investigate the degree to which cognitive function explains the association between health literacy and asthma self-management tasks among elderly asthmatics.

7 Study Design Asthma Beliefs Literacy in the Elderly (ABLE) Longitudinal cohort study New York City and Chicago Cohort: 452 elderly asthmatics In-person interview

8 Study Design Inclusion Criteria: Mild, moderate, or severe persistent asthma Age 60 years English- or Spanish-speaking < 10 pack year history of cigarette smoking

Adherence Report Scale 10-item, self report

9 Measures: Outcomes Outcome Measure Description Medication Adherence Medication Adherence Report Scale 10-item, self report Adapted for asthma medication Score 4.5 = good adherence Diskus Technique Demonstration 7 step checklist, observation >75% steps correct Meter Dose Inhaler Technique Demonstration 8 step checklist, observation >75% steps correct

10 Measures: Independent Variables Independent Variable Measure Description Health Literacy STOFHLA Reading and Numeracy sections Score 67 adequate Score < 67 limited Crystallized Animal Naming Name as many animals of any kind in one minute Fluid - Processing Speed - Executive Function - Long Term Memory - Working Memory - Global Function Factor Score - Pattern Comparison - Trails A & B - WMS II Story A - WMS Letter Number Sequencing - MMSE Series of validated cognitive tests

11 Analysis Plan Pearson correlations cognitive and literacy scores Independent multivariable logistic regression models Stepwise multivariable logistic regression models Step 1: Health Literacy Step 2: Health Literacy and Crystallized Step 3: Health Literacy and Fluid Covariates: age, sex, race/ethnicity, chronic conditions, years with asthma

12 Sample Characteristics n=443 Mean Age 68 years 84% female 40% Hispanic 30% NH Black 36% limited literacy 79% daily controller medication use Mean years with asthma 31 years

13 Correlations of Cognitive Measures with STOFHLA Cognitive Test Correlation Coefficient Crystallized Animal Naming 0.52 Fluid Factor score 0.81 Processing Speed Pattern Comparison 0.70 Executive Function Trails A & B 0.75 Working Memory Letter Number 0.70 Working Memory WMS immediate 0.56 Long Term Memory WMS delayed 0.57 Global Function MMSE 0.77

14 Independent Associations Health Literacy independently associated with all outcomes Fluid independently associated with all outcomes Crystallized independently associated with diskus technique

15 Adherence to Asthma Controller HL OR HL + CA OR HL + FA OR Adequate Literacy 2.53* ( ) 2.35* ( ) 1.50 ( ) Crystallized 1.02 ( ) Fluid 1.63* ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

16 Correct Diskus Technique HL OR HL + CA OR HL + FA OR Adequate Literacy 3.25* ( ) 2.50* ( ) 2.01 ( ) Crystallized 1.09* ( ) Fluid 1.76 ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

17 Correct Inhaler Technique HL OR HL + CA OR HL + FA OR Adequate Literacy 1.71* ( ) 1.67* ( ) 1.09 ( ) Crystallized 1.00 ( ) Fluid 1.48 ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

18 Conclusion Fluid and crystallized abilities predictive of asthma self-management behaviors Fluid abilities explain relationship between STOFHLA and asthma self-care behaviors

19 Limitations Elderly asthmatics 2 large urban academic medical centers Cross-sectional analyses Self-reported medication adherence

20 Implications Cognitive function is important Incorporate cognitive strategies into patient communication interventions Goal: reduce cognitive demands of health tasks

21 Thank You! Sponsored by National Heart, Lung, And Blood Institute (Grant No. R01HL096612) Contact Information Rachel O Conor, MPH Research Project Manager Division of General Internal Medicine Northwestern University 750 N. Lakeshore Drive, 10 th Floor Chicago, IL r-oconor@northwestern.edu

24 Non-Adherent to Asthma Controller Limited Literacy 2.41* ( ) Global Cognitive Function Model 1 Model 2 Model 3 Model * ( ) Crystalized 0.95* ( ) Fluid 0.64* ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

25 Correct Diskus Technique Model 1 Model 2 Model 3 Model 4 Limited Literacy 3.25 * Global Cognitive Function Crystalized Verbal Fluid Cognitive ( ) 0.81 * ( ) 0.87 * ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions * ( )

26 Incorrect Diskus Technique Model 5 Model 6 Model 7 Model 8 Limited Literacy 2.02 ( ) Global Cognitive 0.86 * Function ( ) 2.31* ( ) 2.29* ( ) 2.11 ( ) 0.87* ( ) Crystalized Verbal 0.89 * ( ) 0.89 * ( ) Fluid Cognitive 0.68 ( ) 1.40 ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

27 Incorrect MDI Technique Model 1 Model 2 Model 3 Model 4 Limited Literacy 1.63* ( ) Global Cognitive Function Crystalized Verbal 0.88 * ( ) 0.97 ( ) Fluid Cognitive * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions * ( )

28 Incorrect MDI Technique Model 5 Model 6 Model 7 Model 8 Limited Literacy 1.07 ( ) Global Cognitive 0.88 * Function ( ) 1.55 ( ) 1.25 ( ) 1.05 ( ) 0.89* ( ) Crystalized Verbal 0.99 ( ) 1.01 ( ) Fluid Cognitive 0.76 ( ) 0.95 ( ) * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

29 Non-Adherent to Asthma Controller Model 1 Model 2 Model 3 Model 4 Health Literacy 2.41 ( ) Global Cognitive Function 0.81 ( ) Crystalized Verbal 0.95* ( ) Fluid Cognitive 0.64* ( ) p<0.001, p<0.01, * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

30 Non-Adherent to Asthma Controller Medicine Model 5 Model 6 Model 7 Model 8 Health Literacy 1.30 ( ) Global Cognitive 0.81 Function ( ) 2.15* ( ) 1.85 ( ) 1.43 ( ) 0.80 ( ) Crystalized Verbal 0.97 ( ) 0.99 ( ) Fluid Cognitive 0.76 ( ) 1.20 ( ) p<0.001, p<0.01, * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

31 Improper Diskus Technique Model 1 Model 2 Model 3 Model 4 Health Literacy 3.25 Global Cognitive Function Crystalized Verbal ( ) 0.81 ( ) 0.87 ( ) Fluid Cognitive 0.46 ( ) p<0.001, p<0.01, * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

32 Improper Diskus Technique Model 5 Model 6 Model 7 Model 8 Health Literacy 2.02 ( ) Global Cognitive 0.86 Function ( ) 2.31* ( ) 2.29* ( ) 2.11 ( ) 0.87* ( ) Crystalized Verbal 0.89 ( ) 0.89 ( ) Fluid Cognitive 0.68 ( ) 1.40 ( ) p<0.001, p<0.01, * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

33 Improper MDI Technique Model 1 Model 2 Model 3 Model 4 Health Literacy 1.63* ( ) Global Cognitive Function Crystalized Verbal 0.88 ( ) 0.97 ( ) Fluid Cognitive 0.67 ( ) p<0.001, p<0.01, * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

34 Improper MDI Technique Model 5 Model 6 Model 7 Model 8 Health Literacy 1.07 ( ) Global Cognitive 0.88 Function ( ) 1.55 ( ) 1.25 ( ) 1.05 ( ) 0.89* ( ) Crystalized Verbal 0.99 ( ) 1.01 ( ) Fluid Cognitive 0.76 ( ) 0.95 ( ) p<0.001, p<0.01, * p<0.05 All models adjusted for age, sex, race, years with asthma, and total number of chronic conditions.

Structural Equation Modeling of Health Literacy and Medication Adherence by Older Asthmatics

Structural Equation Modeling of Health Literacy and Medication Adherence by Older Asthmatics Alex Federman, MD, MPH Division of General Internal Medicine Icahn School of Medicine at Mount Sinai New York,