Journal of Gerontological Nursing

CNE Article 

Examining the Association of Health Literacy and Health Behaviors in African American Older Adults: Does Health Literacy Affect Adherence to Antihypertensive Regimens?

Racquel Richardson Ingram, PhD, RN; L. Louise Ivanov, PhD, RN

Abstract

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Read the article, “Examining the Association of Health Literacy and Health Behaviors in African American Older Adults: Does Health Literacy Affect Adherence to Antihypertensive Regimens?” found on pages 22–32, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until February 28, 2015.

Contact Hours

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Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objective

Review the findings of a research study that examines health literacy and adherence to antihypertensive regimens among African American older adults.

Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand the health information needed to make appropriate health decisions. The health behaviors of African American adults with inadequate health literacy skills affect their health outcomes. This study examined the association of health literacy and adherence behaviors in African American older adults (N = 121) with hypertension using a descriptive correlational design. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine survey, and adherence was measured using the Hill-Bone Compliance Scale. Most of the participants were functioning with inadequate health literacy. No statistically significant association was found between health literacy and adherence, but regression analysis showed that age and health status significantly predicted adherence: Those who were younger and reported poor or fair health status were less likely to adhere to treatment.

Abstract

How To Obtain Contact Hours By Reading This Article
Instructions

1.1 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Examining the Association of Health Literacy and Health Behaviors in African American Older Adults: Does Health Literacy Affect Adherence to Antihypertensive Regimens?” found on pages 22–32, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until February 28, 2015.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objective

Review the findings of a research study that examines health literacy and adherence to antihypertensive regimens among African American older adults.

Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand the health information needed to make appropriate health decisions. The health behaviors of African American adults with inadequate health literacy skills affect their health outcomes. This study examined the association of health literacy and adherence behaviors in African American older adults (N = 121) with hypertension using a descriptive correlational design. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine survey, and adherence was measured using the Hill-Bone Compliance Scale. Most of the participants were functioning with inadequate health literacy. No statistically significant association was found between health literacy and adherence, but regression analysis showed that age and health status significantly predicted adherence: Those who were younger and reported poor or fair health status were less likely to adhere to treatment.

Nationwide, African American individuals are disproportionately affected by hypertension, and the complications of this condition are also more severe in this population (Douglas, Ferdinand, Bakris, & Sowers, 2002; Hajjar, Kotchen, & Kotchen, 2006; Hekler et al., 2008; Peters, 2004; U.S. Department of Health and Human Services [USDHHS], 2000). Health behaviors of African American adults older than 50 with hypertension have been extensively explored, yet high levels of nonadherence to antihypertensive regimens continuously occur in this population (Krousel-Wood, Thomas, Munter, & Morisky, 2004; Schneider et al., 2001). Factors found to be associated with adherence to antihypertensive regimens include demographic characteristics; knowledge, awareness, beliefs, and attitudes about their antihypertensive regime; depression, side effects associated with medication(s); the complexities of medication regimens; quality of life; and health care system issues (Krousel-Wood et al., 2004). Low levels of education among African Americans (American Heart Association [AHA], 2010; Douglas et al., 2002; USDHHS, 2000), which lead to low health literacy levels, may be equally important in their poor adherence to antihypertensive regimens. According to Cutilli (2005), African Americans have lower levels of health literacy than Caucasians, as well as higher rates of nonadhering health behaviors and health disparities (Safeer & Keenan, 2005; Wolf, Gazmararian, & Baker, 2007).

The National Association of Adult Literacy has reported that adults with low levels of literacy are older; they tend to have low levels of education, low-paying jobs, and low socioeconomic status; and they are often ethnic or racial minorities (National Center for Education Statistics (2000). Adherence to prescribed medical regimens may be affected by patients’ poor understanding of their condition (Byrd, Fletcher, & Menifield, 2007). Indeed, according to the Agency for Healthcare Research and Quality (AHRQ, 2007), individuals with low health literacy levels are 12 to 18 times more likely than others to lack the ability to adhere to their health care regimens. The problem is far greater in poor older adult minorities (AHRQ, 2007) and may be partially responsible for the health care disparities observed in these groups. Thus, research is needed to address the effects that health literacy may have on health behaviors that affect adherence in African American adults with hypertension. Predisposing, reinforcing, and enabling factors are determinants of health behaviors in adult populations (Ahmed, Fort, Elzey, & Bailey, 2004; Glanz, Rimer, & Viswanath, 2008; Green & Kreuter, 2005); therefore, these factors were used in this study to examine the associations of health literacy and adherence.

Method

Design

A descriptive correlational design was used to examine the associations of health literacy to the health behaviors of African American older adults with hypertension. Because health behaviors are influenced by predisposing, reinforcing, and enabling factors, these factors were explored as determinants affecting health literacy and adherence. Predisposing factors were age, educational level, and understanding of health information and were considered factors that manipulate health behaviors. Reinforcing factors were defined as the self-determination of an individual’s overall health status. Enabling factors are operationally defined as factors that support individuals’ ability to maintain their health, such as income level, access to health care, comorbidities, and the frequency with which health information is read.

Setting and Sample

Institutional Review Board approval was obtained by the participating university to recruit African American residents of housing communities and those who attended two predominantly African American churches in Forsyth County, North Carolina. The convenience sample included African American adults older than 50 who had been diagnosed with hypertension and had been prescribed an antihypertensive medication or were under dietary restrictions. To be eligible, they had to be able to follow written and verbal directions. Those with visual and hearing impairments were excluded because they could not complete the study instruments.

Data Collection

Participants were recruited by posting and passing out flyers in four subsidized housing communities with mainly African American residents—with permission of the housing authority—and in two churches with predominantly African American congregations—with permission of church leaders. Prior to posting and mailing flyers, the first author (R.R.I.) provided an overview of the study to the leaders of the housing developments and church leaders. The flyers contained the dates for participant recruitment sessions at the housing developments and churches. Recruitment sessions took place in meeting rooms or in conference rooms that were conveniently accessible and provided privacy.

A 5- to 10-minute overview provided a description of the research and allowed interested and qualified participants the opportunity to ask questions. Consent forms were signed, and eligible participants were given the research instruments (described below) to complete. After the participants completed their sessions, they were given a $10 gift card for a discount retail store for their time.

Data were collected using a demographic questionnaire, the Hill-Bone Compliance Scale (HBCS), and the Rapid Estimate of Adult Literacy in Medicine (REALM) survey. The REALM was administered first, and then participants self-administered the HBCS and the demographic questionnaire. If participants had difficulty reading, the questions from the HBCS and the demographic questionnaire were read aloud to them. Participants who could not read were allowed to continue with the study and were given a score of 0 on the REALM.

Instruments

The REALM measures health literacy in adults (Doak, Doak, & Root, 1996; Greenberg, 2001; Pawlak, 2005) and is considered the most reliable and most frequently used assessment tool for determining health literacy (Bass, Wilson, & Griffith, 2003; Davis et al., 2006; Golbeck, Ahlers-Schmidt, & Paschal, 2005; Monachos, 2007; Osborn et al., 2007; Paasche-Orlow, Parker, Gazmararian, Nielsen-Bohlman, & Rudd, 2005). The REALM can be administered in approximately 5 to 10 minutes (Greenberg, 2001). Individuals are given a copy of the REALM assessment and are asked to read aloud 22 medical terms that are listed in three separate columns, one column at a time. The terms included in the REALM are based on a psychometric analysis of item difficulty and discrimination, and the frequency of word usage in written patient materials. The terms are arranged in order of difficulty (Barragán et al., 2005; Bass et al., 2003; Davis et al., 1991, 1993; Osborn et al., 2007). According to psychometric analysis, the first three words of the REALM were chosen for their simplicity and ability to boost confidence and decrease anxiety during administration (Davis et al., 1991). The terms included in the REALM are all medically related and should be easily recognized by adults. Specifically, the words are associated with body parts and illnesses that are commonly used in written materials and on health care forms (Davis et al., 1991, 1993).

Correct pronunciation of these words, based on dictionary pronunciation, is the scoring standard for the REALM. The REALM thus produces a literacy score that is associated with health care knowledge and reading grade level (Davis et al., 1991, 1993). The maximum total score is 66. Scores are transferred to grade equivalencies and used to indicate health literacy levels. REALM scores of 0 to 18 are equivalent to not being able to read at a third-grade level, scores of 19 to 44 are equivalent to fourth- to sixth-grade reading levels, scores of 45 to 60 are equivalent to seventh- to eighth-grade reading levels, and scores above 60 are equivalent to a high school reading level (Davis et al., 1991, 1993). Scores from the REALM can be used to identify individuals who cannot read, as well as those who may need simplified instructions (Davis et al., 1991, 1993).

The HBCS is used to assess adherence to antihypertensive regimens. The measure assesses behaviors in three subscale domains: decreased sodium intake, taking medications or medication adherence, and keeping related appointments (Kim, Hill, Bone, & Levine, 2000). According to Kim et al. (2000), these subscales were theoretically derived.

The HBCS takes approximately 5 to 8 minutes to complete. Scores are based on 14 questions that contain information related to antihypertensive regimen adherence, using a Likert scale format: all of the time (4), most of the time (3), some of the time (2), and none of the time (1) (Kim et al., 2000). Scores range from 14 to 56, with higher scores indicating less adherence based on self-reports of frequent sodium intake, nonadherence to prescribed medication regimens, and not keeping hypertension management appointments.

In a previous study by Kim et al. (2000), the HBCS was tested for reliability using two different samples of African American participants. A Cronbach’s alpha coefficient of 0.74 was obtained in the first sample, and 0.84 in the second sample, confirming reliability. Content validity of the HBCS was determined by a panel of three physicians and five nurses who were specialists in hypertensive research and practice; 100% agreement was achieved on the 14 items. Subsequently, two literacy experts analyzed the questions for difficulty and deemed the questions to be written at a fifth-grade level (Kim et al., 2000). Both Kim et al. (2000) and Krousel-Wood, Munter, Jannu, Desalvo, and Re (2005) concluded that the HBCS is reliable in settings involving African American older adults with hypertension. Psychometric testing of the HBCS has suggested that only the medication compliance subscale measure is stable. Nevertheless, the total HBCS score was used in this analysis. The Cronbach’s alpha co-efficient was 0.73 with the sample in this study, indicating satisfactory reliability.

The demographic questionnaire was created by the authors. Questions were designed based on issues identified as potential contributors to adherence to a hypertensive regimen. The demographic questionnaire contained 16 questions on income, educational background, and other information needed to capture predisposing, reinforcing, and enabling factors. Questions were phrased simply to enhance understanding and facilitate participant completion of the questionnaire.

Results

Characteristics of the Sample

Originally 125 African Americans agreed to participate. However, 3 of the participants were younger than 50 and thus did not meet eligibility requirements for the study. One participant withdrew from the study after completing the consent form and responding to a few questions on one of the measures. This participant did not offer an explanation for the decision to withdraw. The final sample thus consisted of 121 African American participants, 61 men and 60 women.

Participants’ ages ranged from 50 to 87 (mean = 59.75; SD = 7.94). Seventy percent reported educational levels below the 12th grade; others had some post-high school education such as a technical trade, community college, or a degree from a university or college. The majority (82%) of participants lived alone in subsidized housing. A little more than half (59%) were unemployed, and the majority (88%) had incomes less than $20,000 per year. Approximately 35% of the participants were uninsured, and 56% received health care services from facilities that did not require up-front copayments. More than half had had hypertension for 5 or more years and reported taking antihypertensive medications for 5 or fewer years. Eighty-one percent reported at least one comorbidity in addition to high blood pressure, with high cholesterol and diabetes being the most common. Participant demographic characteristics are listed in Table 1.

Demographic Characteristics of the Sample (N = 121)

Table 1: Demographic Characteristics of the Sample (N = 121)

Adherence to antihypertensive regimens was measured by the HBCS. The overall mean score was 24, and 51% of the participants had HBCS scores of 24 or higher. Thus, almost half of the participants were not adhering to their antihypertensive regimens. The mean total REALM score on health literacy was 46, with scores ranging from 0 (indicating that the participant was not able to read health care-related written material) to 66 (a perfect REALM score). Approximately 13% of the participants had REALM scores at the third-grade level or below, indicating low literacy levels and difficulty reading health information. Approximately 55% had REALM scores in the fourth- to eighth-grade range, indicating moderate literacy levels; only 32% had REALM scores in the high school range. According to Davis et al. (1991), participants in the moderate range or below may struggle to read health care materials and will do better if the materials are written at a lower reading level. Thus, the scores found here indicated that the majority (68%) of the participants were not able to adequately read and understand written health care information and were functioning with inadequate health literacy.

Spearman rho analyses were used to examine predisposing (age, education, understanding health/prescription information), reinforcing (health status), and enabling (income, health care receipt, comorbidities) factors that might influence health literacy levels and adherence behaviors to antihypertensive regimens in African American older adults (Table 2). Participants who were older than 60 were more likely to receive private health care (r = 0.414, p < 0.01), and they had higher incomes (r = 0.190, p < 0.05). Those with higher educational levels were more likely to report excellent or good health (r = 0.232, p < 0.05), have higher incomes (r = 0.391, p < 0.01), and have higher literacy scores (r = 0.505, p < 0.01). Those with higher income levels were more likely to report excellent or good health (r = 0.186, p < 0.05), receive private health care (r = 0.334, p < 0.01), and have higher literacy scores (r = 0.236, p < 0.01). Finally, those who had more than one co-morbidity were more likely to receive private health care (r = 0.235, p < 0.01).

Spearman Rho Correlations of Predisposing, Reinforcing, and Enabling Factors With HBCS And Realm

Table 2: Spearman Rho Correlations of Predisposing, Reinforcing, and Enabling Factors With HBCS And Realm

In the first standard multiple regression model (Table 3), adherence (HBCS) was regressed on the variables representing predisposing, reinforcing, and enabling factors. Health literacy (REALM) was included as an additional enabling factor in this model. All factors were entered as one block to assess the effect of all possible predictors within the factors. Regression analysis indicated that the overall model significantly predicted adherence to antihypertensive regimens (R2 = 0.164; F[8, 112] = 2.738; p < 0.01). However, the variables within the factors only explained 16% of the variance in adherence. Only age (ß = −0.247, p < 0.01) and health status (ß = −0.180, p < 0.05) were significant predictors of adherence to the antihypertensive regimen.

Multiple Regression Analysis of Predisposing, Reinforcing, and Enabling Factors With Adherence (HBCS Score) as Outcome

Table 3: Multiple Regression Analysis of Predisposing, Reinforcing, and Enabling Factors With Adherence (HBCS Score) as Outcome

Significant correlations were found between adherence and age (r = −0.249, p < 0.01); younger participants tended to be less adherent to their antihypertensive regimen (Table 2). Less educated participants were also less adherent (r = −0.200, p < 0.05), as were those with poor health (r = −0.267, p < 0.01). No significant correlations, however, were found between health literacy and adherence.

In the second standard multiple regression model (Table 4), health literacy (REALM) was regressed on the predisposing, reinforcing, and enabling factors. All factors were entered as one block to assess the effect of all possible predictors within the factors. Regression analysis results indicated that the overall model significantly predicted health literacy (R2 = 0.269; F[7, 113]= 5.594; p < 0.01) but explained only 27% of the variance. Only education (ß = 0.446, p < 0.001) was significantly associated with health literacy; as would be expected, those who were more highly educated were more health literate.

Multiple Regression Analysis of Predisposing, Reinforcing, and Enabling Factors With Health Literacy (REALM) as Outcome

Table 4: Multiple Regression Analysis of Predisposing, Reinforcing, and Enabling Factors With Health Literacy (REALM) as Outcome

Discussion

Approximately half of these participants were nonadherent to their antihypertensive regimens. This is similar to the finding of Gatti, Jacobson, Gazmararian, Schmotzer, and Krapalani (2009) that 53% of African American older women did not adhere to prescribed general medications. In this study, high nonadherence rates were more common among the male participants; their rates were 7% higher than female participants. Bosworth et al. (2008) also found a 50% nonadherence rate for African American participants. Hekler et al. (2008) found that among African Americans, believing diet, age, and weight were related to hypertension was associated with lower systolic blood pressure and greater adherence to a medical regimen for hypertension. These findings suggest that health beliefs related to hypertension have an effect on adherence to hypertensive regimens, highlighting the need for further study in this area.

Approximately 13% of the participants in this study had total REALM scores in the low literacy range, and more than half had REALM scores in the moderate literacy range. Only 32% had literacy levels in the high school range. This may have reflected the socioeconomic status of participants, most of whom lived in subsidized housing and had limited incomes. This is consistent with Bosworth et al. (2008), who found that 45% of African American participants in their study had less than 12th-grade health literacy levels based on REALM scores, and with Arozullah et al. (2006), who found that more than half of their participants had literacy levels at the eighth-grade level or less. All of these studies indicate that overall, African Americans’ literacy levels are low, which makes it difficult for them to understand the prescription and antihypertensive regimen information given to them by health care providers.

In this study, participants between the ages of 50 and 60 tended to be less adherent to their antihypertensive regimen than those participants older than 60. One issue in dealing with hypertension is lack of symptoms. Perhaps younger participants (those ages 50 to 60) were less adherent because they did not understand the seriousness of their illness; it is also possible that they did not understand what was expected of them in dealing with their hypertension. Gatti et al. (2009) also found that younger participants were less adherent than older participants, as did Banta et al. (2009). Although 50 to 60 is the age when a person is typically first diagnosed with diseases such as diabetes, hypertension, and high cholesterol, at this “young” age, it may be difficult to accept this because of not feeling or appearing sick. However, this suggests the importance of targeting interventions to those who are younger and have not been diagnosed for a long period.

Those who reported poor or fair health status were also significantly less likely to adhere to their anti-hypertensive regimen than those in good health. Similarly, Banta et al. (2009) found a significant relationship between poor adherence and poor health status among hypertensive participants. People who report poor health may not understand the correlation between adherence to a hypertensive regimen and their poor health, highlighting a need for interventions to inform them about these correlations. Providers should inquire about specific issues that interfere with individuals’ ability to adhere to their regimens and on that basis, develop strategies to address these issues. Further, because this study suggested that affordability issues affect adherence, a plan to explore ways to allow antihypertensive medications to be purchased at minimal cost is needed.

Although many treatments are available for hypertension and accompanying disease states, nonadherence is a major factor in prolonging the disease (USDHHS, 2000). In this study, participants with lower educational levels were less likely than those with higher levels of education to adhere to their antihypertensive regimen. Similarly, Banta et al. (2009) found that participants who were nonadherent had less education than their adherent counterparts, and the AHRQ (2007) reported that participants with low health literacy levels were 12 to 18 times less likely to adhere to their health care regimens. In the current study, no significant association was found between health literacy and adherence. However, this may be explained in part by the fact that most of the participants had been diagnosed with hypertension for at least 5 years, allowing them time to adjust to their diagnosis, develop some understanding of their anti-hypertensive regimen, and learn to adhere to the regimen. In particular, the older participants had had multiple opportunities to learn about and improve adherence. Also, it is possible that some participants in the study indicated low adherence in the hope that they would receive assistance with their medical regimen from the researchers. Patients need to be adequately educated and adequately monitored to achieve the desired therapeutic response to their regimens. Finally, it is worth noting that the REALM score is based on ability to pronounce medical terms, and that may be a misleading criterion for those without considerable education. Nonetheless, the lack of a significant association between health literacy and adherence means that unanswered questions remain that need further study. In particular, research is needed to identify the determinants of adherence to ensure that patients stay with their prescribed hypertensive regimen.

Education significantly explained health literacy with this study. Participants who had higher levels of education were more health literate, and not surprisingly, those who were more health literate could better understand health information. These findings suggest that interventions to improve comprehension of health information need to focus on individuals who lack a high school education. In the current study, 68% of participants had literacy levels at the eighth-grade level or lower.

Sudore et al. (2006) found that low literacy rates were associated with poor health, with illnesses such as diabetes and depression, and with poor access to health care. In the current study, no significant relationship was found between health literacy and health status. This was possibly due to self-reporting of health status, which may have reflected some bias. That is, participants may have had differing perceptions of “poor” health status as no definition of this was provided.

Older participants were more likely than younger participants to understand health information and to receive private health care. Although age and education were not correlated, those with higher educational levels were also more likely to report stable health status, have higher income levels, and have higher literacy scores.

Nevertheless, income levels in this study were generally low, with most participants having an annual income less than $20,000. This low income level may prevent spending money on seeing a physician or buying medications. In addition to their low income levels, most of the participants had government-assisted type insurance (i.e., Medicaid or Medicare) with medication coverage limitations, lived alone in subsidized housing, and were unemployed. Thus, they tended to focus more on overcoming economic difficulties than on spending money on health care. Typically, individuals in similar situations may choose not to fill prescriptions, may initiate a medical regimen only to abandon it after a few weeks or months, or may adhere to only parts of the prescribed medical regimen.

Limitations

The HBCS and demographic questionnaire in this study were self-reports, and measures obtained by self-report do not always produce the most accurate responses (Osterberg & Blaschke, 2005). Further, false reports of adherence on the HBCS by participants may have been made in an effort to please or impress the researchers, possibly contributing to the lack of a significant association between the two variables. Participants with low literacy levels received assistance with completing the demographic questionnaire and the HBCS. They received a score of 0 if they could not read. This assistance affects the generalizability of the findings.

Approximately 5% to 8% of participants were lost because of the time it took each individual participant to complete the HBCS. Also, the number of participants who needed assistance in completing the questionnaires was not documented, although this information might have been helpful in explaining some of the lost data. Finally, the sample was a convenience sample and was biased toward those with low incomes. This bias could have affected the relationship between health literacy and adherence. Thus, it is crucial to expand the study to a broader sample.

Despite these limitations, this study provides useful insights into the health care deficits that African American older adults with low levels of health literacy experience (Greenberg, 2001). In-depth research is needed to explore barriers to adherence associated with lower health literacy in African American populations. Researchers should also explore other factors that influence adherence, such as access to health care information, and provide appropriate interventions to improve health outcomes.

Implications for Geriatric Nurses

Nurses who work in various settings, including hospitals, skilled nursing facilities, and community clinics, need to be aware that health literacy may be an issue for many of their patients. It is imperative for nurses to communicate with patients on a comprehensible level and provide health care information at a sixth- to eighth-grade level to ensure comprehension. They should include a health literacy assessment in admission procedures to ensure that patients can understand their treatment regimen and, in particular, their medication and medication schedule. For those with low literacy, nurses should offer alternative ways to present information about keeping up with medicines, such as using large letters, color codes, and other aids. Nurses should also follow up with new patients to ensure they understand their medicines and are following treatment guidelines.

Some pharmaceutical companies have patient assistance programs and a discounted medication list that allows patients to purchase a 30- to 90-day supply of their prescribed antihypertensive medications at an affordable rate, when compared to their insurance copayment. These programs may be available through health care facilities, community programs, or faith-based organizations. A list of these pharmaceutical companies and the specific patient eligibility criterion should be developed and consistently updated. When appropriate, a facility-specific process identifying eligible patients should be established.

Patients older than 50 but who have not reached the qualifying age for Medicare may meet the criterion to receive assistance from one of the pharmaceutical programs. Patients who do qualify for Medicare are yet faced with controversial and complex decisions related to their health care plans. Nurses should be advocates for this geriatric population by becoming familiar with the terminology and conditions surrounding Medicare policies to assist this population with adherence to their health care regimens.

All health care providers should be patient advocates and encourage pharmaceutical companies to print prescription information at lower literacy levels to ensure comprehension of the information. Patients may choose not to fill prescriptions, may initiate a medical regimen only to abandon it after a few weeks or months, or may adhere to only parts of the prescribed medial regimen. Providers can play a vital role in determining whether patients are adequately informed about their prescribed regimens and adequately monitored to achieve the desired therapeutic response. The development of appropriately leveled health care materials can lead to measurable improvements in adherence to health care regimens (USDHHS, 2000).

Finally, nurses should strive to be a part of committees and organizations that advocate for comprehensible and affordable health care. More specifically, a policy that mandates standardization of medication cost varying only by geographical location related to cost-of-living expenses would be ideal. In addition, the declining economy significantly impacts health care cost and typically causes patients with low incomes to have to inappropriately choose between health care and traditional living expenses (e.g., housing, food). Assisting patients with adherence to their antihypertensive regimens promotes life sustainability and should be a priority nursing intervention.

Conclusion

Further research on health literacy and adherence behaviors in African American older adults with hypertension is needed. Although a statistically significant association was not found between health literacy and adherence, regression analysis showed that age and health status significantly predicted adherence. Patients of all ages will benefit from adequate health literacy, but special attention should be given toward older adults with hypertension since their health care regimens are typically complex and multifaceted. In addition, nurses should advocate for patients with low health literacy. Specific nursing interventions include incorporating patient health literacy assessments into care, increasing access to health care information, encouraging pharmaceutical companies to produce health care information at a lower literacy level, informing patients about their prescribed regimens and evaluating their comprehension of the information, and frequent monitoring of adherence behaviors toward antihypertension regimens.

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Demographic Characteristics of the Sample (N = 121)

Variable Mean (SD, Range)
Age (years) 59.75 (7.94, 50 to 87)
%
Gender
  Men 50
  Women 50
Educational level
  Less than 12th grade 70
  High school graduate/college/equivalent 30
Marital status
  Single (includes divorced, widowed, separated) 84
  Married 16
Employment status
  Unemployed (including retired) 59
  Full time 25
  Part time 16
Income range (per year)
  $0 to $19,999 88
  $20,000 or more 12
Health status
  Fair or poor 60
  Excellent or good 40
Type of health insurance
  Government assisted (i.e., Medicaid or Medicare) 49
  None 35
  Private or other 16
Access to health care
  Facilities not requiring up-front payment (e.g., free clinics, public health, emergency department) 56
  Private office, veteran’s hospital, other 44
Years diagnosed with hypertension
  5 or more 51
  4 or less 49
Likelihood to read/understand written health information 59
Comorbidities (at least one in addition to hypertension) 81

Spearman Rho Correlations of Predisposing, Reinforcing, and Enabling Factors With HBCS And Realm

Variable 1 2 3 4 5 6 7 8 9 10
HBCS total score 1.00 −0.249** −0.200* −0.141 −0.102 −0.267** −0.101 −0.082 0.042 −0.101
Agea 1.00 0.025 0.237** 0.180* 0.083 0.190* 0.414** 0.168 −0.049
Educational levela 1.00 0.112 0.204* 0.232* 0.391** 0.119 0.099 0.505**
Understanding of health/prescription informationa 1.00 0.532** 0.081 0.044 0.196* 0.192* 0.242**
Ability to read prescription informationb 1.00 −0.027 0.110 0.221* 0.130 0.424**
Health statusc 1.00 0.186* 0.085 0.065 0.003
Annual incomeb 1.00 0.334** 0.117 0.236**
Access to health careb 1.00 0.235** 0.051
Comorbiditiesb 1.00 0.052
REALM score 1.00

Multiple Regression Analysis of Predisposing, Reinforcing, and Enabling Factors With Adherence (HBCS Score) as Outcome

Variable β t Value p Value
Agea −0.247 −2.485 0.014*
Educational levela −0.086 −0.833 0.407
Understanding of health/prescription informationa −0.091 −0.978 0.330
Health statusb −0.180 −2.003 0.048*
Annual incomec −0.013 −0.138 0.891
Access to health carec 0.091 0.885 0.378
Comorbiditiesc 0.149 1.642 0.103
REALM scorec −0.162 −1.602 0.112

Multiple Regression Analysis of Predisposing, Reinforcing, and Enabling Factors With Health Literacy (REALM) as Outcome

Variable β t Value p Value
Agea −0.054 −0.584 0.560
Educational levela 0.446 5.178 0.000***
Understanding of health/prescription informationa 0.228 2.728 0.007**
Health statusb −0.050 −0.595 0.553
Annual incomec 0.079 0.905 0.367
Access to health carec −0.076 −0.794 0.429
Comorbiditiesc −0.005 −0.054 0.957

Keypoints

Ingram, R.R. & Ivanov, L.L. (2013). Examining the Association of Health Literacy and Health Behaviors in African American Older Adults: Does Health Literacy Affect Adherence to Antihypertensive Regimens?Journal of Gerontological Nursing, 39(3), 22–32.

  1. African Americans in the United States are disproportionately affected by hypertension, and the complications of hypertension are also more severe in this population.

  2. Research is needed to address the effects that health literacy (the degree to which individuals have the capacity to obtain, process, and understand the health information needed to make appropriate health decisions) may have on health behaviors that affect adherence in African Americans with hypertension.

  3. Regression analysis showed that age and health status significantly predicted adherence in this study and most of the participants were functioning with inadequate health literacy.

  4. Nurses caring for geriatric patients with low health literacy should aim to communicate with patients on a comprehensible level and provide health care information at a sixth- to eighth-grade level to ensure comprehension and to ensure patients understand their medicines and are following treatment guidelines.

Authors

Dr. Ingram is Associate Professor of Nursing, Winston-Salem State University, Winston-Salem, and Dr. Ivanov is Associate Professor of Nursing, University of North Carolina at Greensboro, Greensboro, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was partially funded by a Sigma Theta Tau International Honor Society of Nursing—Gamma Zeta Chapter, Ruth P. Council Research Grant.

Address correspondence to Racquel Richardson Ingram, PhD, RN, Associate Professor of Nursing, Winston-Salem State University, 601 Martin Luther King Jr. Drive, F.L. Atkins Building, Winston-Salem, NC 27110; e-mail: ingramr@wssu.edu.

Received: May 20, 2012
Accepted: September 19, 2012
Posted Online: February 11, 2013

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