Research article
Health Literacy: An Overlooked Factor in Understanding HIV Health Disparities

https://doi.org/10.1016/j.amepre.2007.07.022Get rights and content

Background

Limited health literacy may be a contributing factor to racial disparities in health care. This study examined the mediating effect of limited health literacy on the relationship between race and HIV-medication adherence.

Methods

A total of 204 patients infected with HIV were recruited from two clinics in 2001. Structured in-person interviews were conducted to obtain information on patient demographics, medication adherence, and health literacy. Multivariate regression models were run in 2006 to examine the associations among race, literacy, and HIV-medication adherence after adjusting for relevant covariates.

Results

In an adjusted analysis that excluded literacy, African Americans were 2.40 times more likely to be nonadherent to their HIV-medication regimen than whites (95% confidence interval [CI]=1.14–5.08). When literacy was included in the final model, the effect estimates of race diminished 25% to nonsignificance. Literacy remained a significant independent predictor of nonadherence (adjusted odds ratio [AOR]=2.12, 95% CI=1.93–2.32).

Conclusions

In this study, limited health literacy mediated the relationship between race and HIV-medication adherence. Investigators need to consider the potential utility of responding to literacy and communication barriers in health care as part of interventions to reduce racial disparities.

Introduction

Recent studies have suggested that limited literacy in adults may contribute to racial disparities in health.1, 2, 3 This is important, as reducing disparities in health care is one of the two primary federal goals for public health in the United States.4, 5 According to the Institute of Medicine (IOM), 90 million people in the U.S. lack the literacy proficiency needed to properly understand and act on health information.6 This has often been referred to as health literacy, a reflection of both a patient’s ability and the literacy prerequisites of the healthcare system.7 Although limited health literacy has been associated with poorer health outcomes, and also has been shown to be more prevalent among African Americans than whites,1, 2, 3, 8, 9 it is unclear whether racial differences in health literacy explain the presence of health disparities.

In the context of HIV, individuals with low literacy skills have been more likely to possess a poor working knowledge of their disease and its treatment.10, 11, 12, 13, 14, 15 Kalichman et al. 10, 11 found that infected patients with limited literacy had less general knowledge of the disease and their own treatment compared to patients with adequate literacy, and that they were less likely to have an undetectable viral load. While Paasche-Orlow et al.16 found no association between health literacy and HIV-medication adherence or viral load suppression, Wolf et al.15 found that patients with low literacy were more than three times as likely to be nonadherent to their anti-retroviral regimens than those with adequate literacy.

The HIV literature also documents substantial racial disparities in health outcomes. Most noteworthy, African Americans with HIV infection are at greater risk for a faster progression to AIDS and shorter survival in comparison to whites.17, 18 Racial differences in medication usage contribute to disparities in health outcomes.19, 20, 21 Possible explanatory factors have been offered, including variability in access to medication22, 23 and adherence practices.6, 24 Although health literacy and race are independently associated with medication adherence,25 it is unclear to what extent health literacy might be an underlying mechanism that promulgates racial differences in HIV-medication adherence.

Recent studies have suggested that health literacy is a more powerful predictor of health status than race.1, 2, 3 What has yet to be presented are mediating analyses exploring health literacy as a determinant of racial differences in the performance of health-promoting behaviors, such as medication adherence. As such, the objective of this study was to examine the mediating effect of health literacy on the relationship between race and HIV medication adherence.

Section snippets

Sample

The study sample and methods have been described previously in detail.13 From June to September 2001, a total of 204 consecutive HIV-infected patients on one or more antiretroviral medications were recruited from outpatient infectious disease clinics at the Northwestern Memorial Hospital (Chicago site) and the Louisiana State University Health Sciences Center at Shreveport (LSUHSC). Patients who had been on their current regimen for less than 2 weeks were excluded from participation, as were

Results

Respondents had a mean age of 40.1 years (SD=9.2 years), 79.9% were male and 45.1% were African American. More than half (55.9%) of respondents were unemployed, 39.7% had an annual household income less than $10,000, and 52.9% were either covered by Medicaid or did not carry any health insurance. Over 60% reported at least some college education. Approximately one third had either low or marginal literacy skills; 11.3% were reading at or below a 6th-grade level (low literacy), and 20.1% were

Discussion

Understanding the reason for pervasive health disparities across race and ethnicity is a major research, practice, and policy goal in the U.S.33, 34 To provide new insights into the pathways that lead to health disparities, patients were recruited from two U.S. regions to examine whether health literacy mediates race disparities in HIV-medication adherence. It was found that African-American patients had a twofold greater likelihood of being nonadherent to their anti-retroviral regimens. Yet

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