Research article
Health Literacy and Health Risk Behaviors Among Older Adults

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Background

Limited health literacy is associated with poorer physical and mental health, although the causal pathways are not entirely clear. In this study, the association between health literacy and the prevalence of health risk behaviors was examined among older adults.

Methods

A cross-sectional survey of 2923 new Medicare, managed-care enrollees was conducted in four U.S. metropolitan areas (Cleveland OH; Houston TX; Tampa FL; Fort Lauderdale–Miami FL). Health literacy was measured using the short form of the Test of Functional Health Literacy in Adults. Behaviors investigated included self-reported cigarette smoking, alcohol consumption, physical activity, body mass index, and seat belt use.

Results

Individuals with inadequate health literacy were more likely to have never smoked (46.7% vs. 38.6, p =0.01); to completely abstain from alcohol (75.6% vs. 57.9, p <0.001); and to report a sedentary lifestyle (38.2% vs. 21.6%, p <0.001) compared to those with adequate health literacy. No significant differences were noted by mean body mass index or seat belt use. In multinomial logistic regression models that adjusted for relevant covariates, inadequate health literacy was not found to be significantly associated with any of the health risk behaviors investigated.

Conclusions

Among community-dwelling elderly, limited health literacy was not independently associated with health risk behaviors after controlling for relevant covariates.

Introduction

An increasing body of evidence has shown that an individual’s capacity to obtain, process, and understand basic information and services needed to make appropriate health decisions, known as health literacy, significantly affects various domains of health.1 In particular, limited health literacy has been associated with problems with the use of preventive services,2 delayed diagnoses,3 understanding of one’s medical condition,4, 5 adherence to medical instructions,6 self-management skills,7 and ultimately health outcomes.7, 8, 9 The economic consequences of limited health literacy have also been documented, finding lower literate individuals to incur higher medical costs and to be more inefficient in their health services use.10

Limited health literacy is highly prevalent in the United States. The Institute of Medicine determined that an estimated 48% of the adult population lack the reading and numeracy skills required to fully understand and act on health information.1, 11, 12 Those who are socioeconomically disadvantaged, elderly, immigrants, or who belong to racial/ethnic minority groups or live in rural areas of the country may be disproportionately hindered by such literacy barriers.1

To optimize effective public health responses, the nature of the relationship between literacy and health outcomes requires further clarification. In 2004, the Agency for Healthcare Research and Quality released a systematic review of the literature on health literacy and its relationship to healthcare use and outcomes.13 This report issued a call for further research to document more consistently the causal pathways through which health literacy affects individual health. One particular mechanism that has been previously proposed is through various health risk behaviors known to be linked to health status and outcomes, despite the lack of empirical evidence to support such a pathway.14, 15 Although prior studies have documented an association between lower educational attainment and higher prevalence of health risk behaviors (i.e., cigarette smoking, alcohol consumption, physical activity, and body mass index [BMI]),16, 17, 18 the relationship between health literacy and health risk behaviors has not been thoroughly investigated to date.

The overall objective of this analysis was to examine whether inadequate health literacy was associated with various behavioral risks, including cigarette smoking, alcohol consumption, physical activity, overweight and obesity, and seat belt use among a cohort of newly enrolled Medicare managed-care enrollees.

Section snippets

Methods

In 1997, a multisite, cross-sectional survey was conducted among new Medicare enrollees in health plans of a national managed-care organization in four U.S. metropolitan areas (Cleveland OH, Houston TX, Tampa FL, Fort Lauderdale–Miami FL). The recruitment plan has been previously described in detail.9, 19 Individuals were excluded from the study if it was determined that they were not comfortable speaking either English or Spanish; were blind or had a severe vision problem not correctable with

Data and Procedure

Consenting individuals completed a 1-hour, in-person interview in their home that assessed self-reported physical and mental health, prevalence of chronic conditions, functional status, use of preventive health services, health-risk behaviors, and health literacy. Survey items also included: demographics (age, gender, race/ethnicity, language [Spanish or English], annual income, occupation [based on patient self-report of occupation and classifications made by the U.S. Census), and educational

Outcome Measures

The main outcome measures investigated were five of the leading health indicators identified by Healthy People 2010.21 These included self-report of current and past cigarette smoking status, current alcohol use and problem drinking (as measured by the CAGE questionnaire [a four-question screen for alcohol dependence])22; height (converted to meters) and weight (converted to kilograms) for BMI calculations; physical activity (20 minutes or longer; <1 time per week, 1–2 times per week, 3 times

Literacy Assessment

The short version of the Test of Functional Health Literacy in Adults (S–TOFHLA) was used as a measure of health literacy for this study.23 The S–TOFHLA includes (1) a reading comprehension section, which has items that measure the ability to read and understand prose passages (prose literacy), appointment slips (document literacy); and (2) a numeracy section with items assessing the ability to interpret prescription bottles containing numerical information (quantitative literacy). Each item in

Statistical Analysis

Chi-square tests were calculated to examine bivariate associations between health literacy (adequate, marginal, inadequate), sociodemographic variables, and the five health risk behaviors. The following categories were used for the outcome variables: smoking habit (never, former, current); alcohol use (none, light to moderate, heavy); physical activity (<1 time per week, 1–2 times per week, 3 times per week, ≥4 times per week); BMI (mean and categories: <18.5 kg/m2, 18.5–24.9 kg/m2, 25–29.9 kg/m

Results

Approximately one third of respondents had marginal (11.3%) or inadequate (22.2%) health literacy skills. Respondents with marginal or inadequate health literacy were more likely to be older, African American or Hispanic (Spanish or English speaking), have a lower annual income, and fewer years of education (Table 1).

Prevalence of Health Risk Behaviors

Among all respondents, 12.2% were current cigarette smokers and 46.8% had formerly smoked. Less than 4% (3.3%) were identified as being heavy alcohol drinkers, 34.2% were moderate drinkers, and 62.5% abstained from alcohol. More than one quarter (26.2%) of respondents were physically active ≥4 times per week, while 43.5% were physically inactive (<1 20-minute session per week). The mean BMI of respondents was 26.6 kg/m2(SD=4.7), with 26.3% classified as overweight (BMI=25.0–29.9 kg/m2), and

Discussion

Among a sample of Medicare managed-care enrollees, inadequate health literacy was not significantly associated with any of the behavioral health risks investigated after controlling for relevant covariates. This is the first study to examine the relationship between health literacy and alcohol consumption, physical activity, overweight and obesity, and seat belt use. It is also the first population-based study to evaluate the association between health literacy and cigarette smoking status in

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