Health literacy and asthma

doi:10.1016/j.jaci.2012.01.040

Journal of Allergy and Clinical Immunology

Volume 129, Issue 4, April 2012, Pages 935-942

https://doi.org/10.1016/j.jaci.2012.01.040 Get rights and content

The report “Healthy people” from the US Department of Health and Human Services defines health literacy (HL) as follows: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” The same report identifies asthma as a public health problem of high priority. Unfortunately, impaired HL is prevalent in our society, and patients with low HL and asthma face multiple challenges as they attempt to manage their disease. Indeed, the National Asthma Education and Prevention Program's current guidelines require patients to have considerable HL and self-management skills. Numerous studies have linked inadequate literacy with poor health outcomes. Unlike many sociodemographic variables, HL can potentially be addressed in the health care setting. The purpose of this review is to raise awareness of the problem, summarize the current evidence linking HL and asthma, and offer strategies to strengthen the communication between patients and health care providers to decrease asthma health disparities. In addition, we discuss potential future directions for research in this field.

Section snippets

HL and health outcomes

The economic effect of low HL can be significant. In 1998, the National Academy on an Aging Society estimated that the additional health care expenditures (eg, longer hospital stays) caused by low HL (functional illiteracy and marginal literacy vs adequate literacy) were approximately $73 billion.¹¹

In 2 consecutive systematic reviews of the literature encompassing pediatric and adult observational studies from 1980 to 2011 (examining a total of 155 articles), low literacy was generally

HL and asthma

Approximately 34 million persons in the United States have been given a diagnosis of asthma during their lifetimes.¹⁵ Asthma increases health care expenditures, reduces productivity, increases school and work absenteeism, and decreases the quality of life of affected persons and their families.¹⁶

Asthma and asthma morbidity result from incompletely understood interactions among heredity, environment, and lifestyle.¹⁷ In the United States both limited HL and asthma are significant problems in

Challenges in assessing HL

Identification of patients with low HL is challenging.⁸ In a small study of children with asthma, Wittich et al³¹ found only moderate agreement between the health provider's perception of the HL of the child's caregiver and the measured HL of the child's caregiver. Simply asking patients whether they can read is not a sufficient assessment of their literacy skills, nor is it sufficient to ask patients about their education attainment. In fact, the highest grade of education completed is often

Addressing low HL

Patient education is necessary for asthma self-management and the foundation of many asthma interventions. Patient education has been associated with improved lung function and reduced frequency of asthma symptoms.35, 40 Unfortunately, educational programs do not always explicitly address HL and might thus not reach those patients with the greatest morbidity.18, 23 Tailored education assuming low literacy in all subjects might be key in improving asthma outcomes in this group.

In a prospective

Conclusions

Although our understanding of HL and asthma has markedly improved, much work remains to be done. Current evidence from studies of children and adults suggests that poor HL is an important key barrier to asthma knowledge. However, the relationship between low HL and other asthma outcomes is incompletely understood. Large longitudinal studies that include objective markers (eg, lung function measures) and the development of instruments that measure specific literacy skills should significantly

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The US Department of Health and Human Services has defined health literacy (HL) 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. Structural and social determinants of health lead to low HL in approximately 36% of adults in the United States, where this condition is most prevalent in racial and ethnic minorities, economically disadvantaged communities, and immigrants with limited English proficiency. In turn, low HL can worsen asthma outcomes through direct effects (eg, nonadherence to or incorrect use of medications) and indirect effects (eg, an unhealthy diet leading to obesity, a risk factor for asthma morbidity). The purpose of this update is to examine evidence from studies on low HL and health and asthma outcomes published in the last 12 years, identify approaches to improve HL and reduce health disparities in asthma, and discuss future directions for research in this area under the conceptual framework of a socioecological model that illustrates the multifactorial and interconnected complexity of this public health issue at different levels.
Low parental numeracy and severe asthma exacerbations in a prospective study of Puerto Rican youth
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Numeracy is the mathematical knowledge required to understand and act on instructions from health care providers. Whether persistently low parental numeracy is linked to childhood asthma exacerbations is unknown.
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Prospective study of 225 youth with asthma in San Juan (PR) who participated in 2 visits approximately 5.3 years apart, with the first at ages 6 to 14 years and the second at ages 9 to 20 years. Parental numeracy was assessed with a modified version of the Asthma Numeracy Questionnaire (score range = 0-3 points), and persistently low parental numeracy was defined as a score less than or equal to 1 point at both visits. Asthma exacerbation outcomes included more than or equal to 1 emergency department (ED) visit, more than or equal to 1 hospitalization, and more than or equal to 1 severe exacerbation (≥1 ED visit or ≥1 hospitalization) for asthma in the year before the second visit. Spirometry was conducted using an EasyOne spirometer (NDD Medical Technologies, Andover, Massachusetts).
In an analysis adjusting for age, sex, parental education, use of inhaled corticosteroids, and the time between study visits, persistently low parental numeracy was associated with more than or equal to 1 ED visit for asthma (odds ratio [ORs], 2.17; 95% confidence interval [CI], 1.10-4.26), more than or equal to 1 hospitalization for asthma (OR, 3.92; 95% CI, 1.42-10.84), and more than or equal to 1 severe asthma exacerbation (OR, 1.99; 95% CI, 1.01-3.87) in the year before the follow-up visit. Persistently low parental numeracy was not significantly associated with change in lung function measures.
Persistently low parental numeracy is associated with asthma exacerbation outcomes in Puerto Rican youth.
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The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.
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À l’occasion de rencontres entre pneumo-pédiatres et pneumologues d’adultes, nous avons revu la littérature concernant l’évolution de l’observance médicamenteuse dans l’asthme selon la classe d’âge des patients. Cette observance – acceptable chez les nourrissons – décroit avec l’âge, notamment à partir de l’adolescence. Certaines études montrent que les adultes sont également très inobservants. Les médicaments inhalés sont les moins bien pris. Plusieurs éléments expliquent la mauvaise observance : complexité des traitements, difficultés à utiliser les systèmes d’inhalation, mauvaise compréhension ou perception de leurs bénéfices, crainte des effets secondaires, image de pathologie chronique… Pourtant une mauvaise observance est associée à des risques d’escalade thérapeutique inutile et d’aggravation de l’asthme, avec d’avantage d’exacerbations, augmentation de l’absentéisme scolaire, dégradation de la qualité de vie, voire excès de mortalité. Le traitement de l’inobservance repose sur une bonne relation entre soignants et asthmatiques, une meilleure formation des soignants, une meilleure information des patients. Il doit être personnalisé. L’évolution des technologies, notamment informatiques, ouvre de nouvelles possibilités d’informations sur la maladie (réseaux, applications dédiées) qui peuvent aider à limiter les oublis (inhalateurs connecté) et contribuer à la recherche clinique. L’analyse de la littérature est compliquée par des définitions et des moyens de mesure de l’observance différents.
While asthma patients’ treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.
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Citation Excerpt :
HCPs are often unable to identify patients who have limited literacy during clinical interactions,38 and health literacy may be dynamic during periods of high emotional stress. Although quick assessments of literacy have been developed for the outpatient setting,39,40 most experts do not recommend the use of health literacy screening29 for several reasons: (1) many patients with low health literacy are ashamed to ask for assistance or do not want their HCP to know about their difficulties with health literacy,41 (2) health literacy screeners are often time-consuming42 and do not provide direct guidance for communication, and (3) no evidence supports that literacy screening improves the delivery of health care or health outcomes.43-45 Finally, although adherence and health literacy are individually important factors impacting difficult-to-control asthma, evidence suggests that they are also connected.
Medication nonadherence and health literacy are key factors that influence the management of difficult-to-control asthma. Adherence, or the extent to which a patient follows a treatment plan, extends beyond asthma medication use and includes an appropriate inhaler technique. Assessment of adherence is critical before making a diagnosis of severe asthma and stepping up asthma therapy but is challenging in the clinical context. Health literacy, or the degree to which individuals can obtain, process, and understand health information and services needed to make health care decisions, is additionally important for asthma management and has been shown to impact medication adherence. Initiatives aiming to improve difficult-to-control asthma should address medication adherence and health literacy. Universal health literacy precautions are recommended while communicating with patients, in addition to the creation of low health literacy asthma action plans. To improve adherence, a comprehensive assessment of adherence should be conducted. Additional evidence-based interventions aiming to improve adherence focus on appropriate inhaler use, improved access to medications, the use of digital platforms, school-based asthma interventions, and the implementation of culturally tailored interventions. Data are limited regarding the use of these initiatives in patients with severe or difficult-to-control asthma.

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: Disclosure of potential conflict of interest: A. J. Apter receives research support from the National Institutes of Health/National Heart, Lung, and Blood Institute. J. C. Celedón is on the advisory board for Genentech and receives research support from the National Institutes of Health/National Heart, Lung, and Blood Institute. The rest of the authors declare that they have no relevant conflicts of interest.

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Reviews and feature articleHealth literacy and asthma

Section snippets

HL and health outcomes

HL and asthma

Challenges in assessing HL

Addressing low HL

Conclusions

J Natl Med Assoc

J Allergy Clin Immunol

Chest

Patient Educ Couns

Patient Educ Couns

J Allergy Clin Immunol

Ambul Pediatr

Patient Educ Couns

J Pediatr Nurs

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

J Allergy Clin Immunol

Patient Educ Couns

Literacy and health outcomes

Health literacy: a prescription to end confusion

Healthy people 2010

Health literacy: a manual for clinicians

Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association

JAMA

National Assessment of Adult Literacy (NAAL): a first look at the literacy of America's adults in the 21st century

Low health literacy and health outcomes: an updated systematic review

Ann Intern Med

Health literacy in primary care: A clinician's guide

Insurance expansion and health literacy

JAMA

Health literacy implications for health care reform: a workshop summary

Reviews and feature article
Health literacy and asthma