Self-Management Behaviors in Older Adults with Asthma: Associations with Health Literacy Alex D. Federman, MD, MPH,* Michael S. Wolf, PhD,† Anastasia Sofianou, MS,* Melissa Martynenko, MPH,* Rachel O’Connor, MPH,† Ethan A. Halm, MD, MPH,‡ Howard Leventhal, PhD,§ and Juan P. Wisnivesky, MD, DrPh* ¶

OBJECTIVES: To examine self-management behaviors, including medication adherence and inhaler technique, in older adults with asthma and their association with health literacy. DESIGN: Observational cohort study. SETTING: Primary care and pulmonary specialty practices in two tertiary academic medical centers and three federally qualified health centers in New York, New York, and Chicago, Illinois. PARTICIPANTS: Adults with moderate or severe persistent asthma aged 60 and older (N = 433). MEASUREMENTS: Outcomes were adherence to asthma controller medications, metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques, having a usual asthma physician, and avoidance of four common triggers. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults. RESULTS: The mean age was 67, and 36% of participants had marginal or low health literacy. Adherence was low (38%) overall and worse in individuals with low health literacy (22%) than in those with adequate literacy (47%, P < .001) and after adjusting for demographic factors and health status (odds ratio (OR) = 0.48, 95% confidence interval (CI) = 0.31–0.73). Similarly, inhaler technique was poor; only 38% and 54% had good MDI and DPI technique, respectively. Technique was worse in those with low health literacy (MDI technique:

From the *Division of General Internal Medicine, Icahn School of Medicine, Mount Sinai, New York, New York; †Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; ‡Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; §Institute of Health, Health Care Policy and Aging Research, Rutgers University, South Brunswick, New Jersey; and ¶Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine, Mount Sinai, New York, New York. Address correspondence to Alex D. Federman, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1087, New York, NY 10029. E-mail: [email protected] DOI: 10.1111/jgs.12797

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OR = 0.57, 95% CI = 0.38–0.85; DPI technique: OR = 0.42, 95% CI = 0.25–0.71). Asthma self-monitoring and avoidance of triggers occurred infrequently but were less consistently associated with low health literacy. CONCLUSION: Adherence to medications and inhaler technique are poor in older adults with asthma and worse in those with low health literacy. Clinicians should routinely assess controller medication adherence and inhaler technique and use low-literacy communication strategies to support self-management in older adults with asthma. J Am Geriatr Soc 62:872–879, 2014.

Key words: asthma; elderly; self-management; adherence; inhaler technique; health literacy

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ersistent asthma is a chronic illness often characterized by periods of inactivity punctuated by acute flares. Exacerbations may lead to use of urgent care services such as emergency department visits and hospitalization and occasionally death. Controlling asthma and preventing exacerbations requires meticulous attention to self-management,1 including avoidance of triggers, such as cigarette smoke and allergens; regular monitoring by a healthcare provider; and consistent and proper use of daily antiinflammatory controller medications. Many people fail to maintain adequate self-management behaviors. Although few studies have assessed it, asthma controller medication adherence appears to be particularly poor in older adults, with rates ranging from 9% to 21%.2 Consistent with this observation, older adults with asthma experience considerably higher rates of asthma-related urgent care use than middle-aged and younger adults with asthma and twice the mortality rate.3,4 Low health literacy may be a contributor to poor adherence and poor health outcomes in older adults. The Institute of Medicine has defined health literacy as the

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degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health and identifies it as a major contributor to poor illness self-management and poor health outcomes in general.5 Nevertheless, only a small body of literature links low health literacy to asthma outcomes,6,7 and even fewer studies have examined its effect on asthma self-management behaviors.8–10 The latter studies show small associations between health literacy and asthma inhaler technique but no association with medication adherence, and none examine the association between health literacy and asthma trigger avoidance and self-monitoring behaviors. Furthermore, the implications of the prior research is limited for older adults because the studies had small sample sizes and focused uniformly on younger adults. Because low health literacy affects up to 60% of adults age 65 and older,11–13 the current sought to examine the role of health literacy in asthma self-management behaviors in this vulnerable, understudied population. Behaviors that the third Expert Panel Report recommend for the diagnosis and management of asthma were specifically examined, including adherence to asthma controller medications, skill in the use of inhalers, asthma monitoring, and avoidance of asthma triggers.1

METHODS Participants and Settings Analyses were conducted on data from the Asthma Beliefs and Literacy in the Elderly (ABLE) study, a prospective cohort study of asthma in adults aged 60 and older. The study began recruiting elderly adults with asthma from outpatient clinics in New York, New York, and Chicago, Illinois, in December 2009. The New York practices are based at the Mount Sinai Medical Center and include the general internal medicine, geriatrics primary care, and pulmonary practices and an adult primary care practice of the Lutheran Family Health Services network of federally qualified health centers in Brooklyn, New York. The Chicago-based practices include the general internal medicine clinic of Northwestern University Hospital and the Mercy Health Clinic, a federally qualified health center. The institutional review boards of the Mount Sinai School of Medicine, Lutheran Medical Center, and the Northwestern University Feinberg School of Medicine approved the study. Potentially eligible individuals with asthma were identified in a review of the electronic clinic encounter databases at each participating site. Individuals aged 60 and older who speak English or Spanish and had uncontrolled asthma according to the National Heart, Lung, and Blood Institute’s Expert Panel on Asthma definition were enrolled.14 Individuals with a diagnosis of chronic obstructive pulmonary disease (COPD) or other chronic respiratory illness were excluded, as well as those with a smoking history of 10 pack-years or more because they are at high risk of COPD. Trained bilingual research assistants recruited participants over the telephone. After obtaining oral consent, the research assistants administered a brief screening assessment to determine final eligibility for the

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study. Eligible individuals were then invited to undergo inperson interviews in English or Spanish. Interviews were conducted at baseline and 3 and 12 months.

Outcome Measures Several measures of asthma self-management were assessed: adherence to controller medications, asthma inhaler technique, self-monitoring of asthma control, and avoidance of asthma triggers.

Medication Adherence Subjective measurement of adherence to asthma controller medications (inhaled corticosteroids (ICS) and leukotriene receptor inhibitors (LTI)) was assessed using the Medication Adherence Reporting Scale (MARS), a validated 10-item measure designed to minimize social desirability bias. It has been adapted to assess adherence to asthma medications.15 Each item is rated on a 5-point Likert scale, with higher scores indicating greater adherence. Participants with a MARS score of 4.5 or greater were classified as having good adherence to controller medications.16,17 ICS adherence was also assessed by reviewing the dose counters found on dry powder inhaler devices in participants using them. The research assistant reviewed the dry powder devices during the first 3 months of study participation for each subject and 30 days after a new prescription was obtained. Good adherence was defined as 80% or more of expected doses recorded by the device.

Inhaler Technique Participants’ ability to administer their asthma controller medication therapies was examined using a standardized checklist of steps in the proper use of a metered dose inhaler (MDI) and a dry powder inhaler (DPI). The MDI and DPI assessments addressed eight and seven steps in the use of the devices, respectively, covering the essential elements of use from preparation of the devices to their actuation and delivery of the medications.18–20 During the in-person interview, the participant was asked to demonstrate use of the placebo devices. The MDI was administered to the entire sample regardless of their current asthma medication use, whereas the DPI was administered only to those who reported having a prescription for a DPI. Trained interviewers observed the participants and documented the number of steps correctly completed. Adequate inhaler technique for both type of devices was defined as correct completion of all steps. A sensitivity analysis was also conducted in which adequate technique was defined as correct completion of six of eight steps for the MDI and five of seven steps for the DPI.

Preventive Measures and Self-Monitoring Preventive measures, other than controller medication use, included avoidance of asthma triggers and other preventive measures taken to limit the impact of allergens. These included four yes–no items: use of allergy covers, washing bed sheets in hot water, having others clean up dust and mold in the home, and whether a fur-bearing animal was kept in the home in the last 6 months. Three items

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assessed trigger avoidance as measured on a 5-point Likert scale (always, most of the time, sometimes, rarely, never): windows kept closed in spring and summer, smoking not allowed in the home, and general avoidance of fur-bearing animals.21,22 The latter three items were coded as always or most of the time versus other. Self-monitoring measures included whether participants reported having one doctor from whom they regularly received asthma care, whether they used a peak flow meter, and whether they had an asthma action plan.

Independent Variables Health literacy was measured using the Short Test of Functional Health Literacy in Adults,23 which is composed of a 36-item reading comprehension section and a four-item numeracy exercise. The reading comprehension section is presented as two timed (7-minute) clinically oriented reading passages that omit key words and phrases from sentences. The participant must select one of four response options listed under each section of missing text to complete the sentence correctly both grammatically and contextually. The numeracy section assesses the participant’s ability to read and interpret information typically encountered in a healthcare setting. Scores range from 0 to 100, with higher scores indicating greater health literacy. Health literacy was dichotomized as adequate (≥67) versus marginal or low (

Self-management behaviors in older adults with asthma: associations with health literacy.

To examine self-management behaviors, including medication adherence and inhaler technique, in older adults with asthma and their association with hea...
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