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DOI 10.1378/chest.114.4.1008
1998;114;1008-1015Chest
Adam Nowlan
Mark V. Williams, David W. Baker, Eric G. Honig, Theodore M. Lee and
Knowledge and Self-Care
Inadequate Literacy Is a Barrier to Asthma
http://chestjournal.chestpubs.org/content/114/4/1008
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Copyright1998by the American College of Chest Physicians, 3300
Physicians. It has been published monthly since 1935.
is the official journal of the American College of ChestChest
1998 by the American College of Chest Physicians
by guest on July 13, 2011chestjournal.chestpubs.orgDownloaded from
Inadequate
Literacy
Is
a
Barrier
to
Asthma
Knowledge
and
Self-Care*
Mark
V.
Williams,
MD;
David
W.
Baker,
MD,
MPH;
Eric
G
Honig,
MD;
Theodore
M.
Lee,
MD;
and
Adam
Nowlan,
MPH
Study
objectives:
To
determine
the
relationship
of
literacy
to
asthma
knowledge
and
ability
to
use
a
metered-dose
inhaler
(MDI)
among
patients
with
asthma.
Design:
Cross-sectional
survey.
Setting:
Emergency
department
and
asthma
clinic
at
an
urban
public
hospital.
Patients:
Convenience
sample
of
273
patients
presenting
to
the
emergency
department
for
an
asthma
exacerbation
and
210
patients
presenting
to
a
specialized
asthma
clinic
for
routine
care.
Interventions:
Measurement
of
literacy
with
the
Rapid
Estimate
of
Adult
Literacy
in
Medicine,
asthma
knowledge
(20
question
oral
test),
and
demonstration
of
MDI
technique
(six-item
assessment).
Measurements
and
results:
Only
27%
of
patients
read
at
the
high-school
level,
although
two
thirds
reported
being
high-school
graduates;
33%
read
at
the
seventh-
to
eighth-grade
level,
27%
at
the
fourth-
to
sixth-grade
level,
and
13%
at
or
below
the
third-grade
level.
Mean
asthma
knowledge
scores
(±SD)
were
directly
related
to
reading
levels:
15.1
±
2.5,
13.9
±
2.5,
13.4
±
2.8,
11.9
±
2.5,
respectively
(p
<
0.01).
Patient
reading
level
was
the
strongest
predictor
of
asthma
knowledge
score
in
multivariate
analysis.
Poor
MDI
technique
(^3
correct
steps)
was
found
in
89%
of
patients
reading
at
less
than
the
third-grade
level
compared
with
48%
of
patients
reading
at
the
high-school
level.
In
multivariate
regression
analyses,
reading
level
was
the
strongest
predictor
of
MDI
technique.
Conclusions:
Inadequate
literacy
was
common
and
strongly
correlated
with
poorer
knowledge
of
asthma
and
improper
MDI
use.
(CHEST
1998;
114:1008-1015)
Abbreviations:
AC
=
asthma
clinic;
CI
=
confidence
interval;
ED
=
emergency
department;
MDI
=
metered-dose
inhaler;
RA
=
research
assistant;
REALM
=
rapid
estimate
of
adult
literacy
in
medicine
A
sthma
affects
at
least
14
to
15
million
adults
in
^**the
United
States1
at
an
estimated
economic
impact
of
>6
billion.2
Asthma
prevalence,
emer¬
gency
department
(ED)
visits,
hospitalizations,
and
mortality
from
asthma
have
been
rising34
and
dis¬
proportionately
affect
the
poor,
people
of
color,
and
individuals
living
in
urban,
inner-city
environ¬
ments.5-6
Socioeconomic
status
appears
to
be
a
more
important
determinant
of
asthma
morbidity
than
race.710
Less
education
(fewer
years
of
school
com¬
pleted),
less
knowledge
of
asthma,
inadequate
*From
the
Department
of
Medicine,
Divisions
of
General
Med¬
icine
(Dr.
Williams
and
Mr.
Nowlan),
Pulmonary
Medicine
(Dr.
Honig),
and
Allergy
and
Immunology
(Dr.
Lee),
Emory
Univer¬
sity
School
of
Medicine,
Atlanta,
GA,
and
the
Department
of
Medicine,
MetroHealth
Medical
Center,
Department
of
Epide¬
miology
and
Biostatistics
(Dr.
Baker),
Case
Western
Reserve
University,
Cleveland,
OH.
Manuscript
received
October
13,
1997;
revision
accepted
March
25,
1998
Correspondence
to:
Mark
V.
Williams,
MD,
Department
of
Medicine,
Emory
University
School
of
Medicine,
69
Butler
Str,
SE,
Atlanta,
GA
30303
metered-dose
inhaler
(MDI)
technique,
and
under-
treatment
have
also
been
associated
with
increased
frequency
of
ED
use.11-13
National
efforts
to
reduce
asthma
morbidity
by
reducing
ED
use
and
hospitalizations
have
focused
on
producing
guidelines
for
asthma
management
that
stress
improving
patient
education
and
self-
management.1
Asthma
education
programs
improve
knowledge
and
self-management
skills
and
decrease
morbidity.1416
However,
traditional
patient
educa¬
tion
relies
heavily
on
printed
materials
that
are
often
written
at
too
high
a
level
for low-literate
patients
to
read
and
comprehend
essential
points.1721
Although
videotapes
and
personal
demonstrations
of
MDI
use
are
more
effective
educational
techniques
than
printed
material,22
inadequate
literacy
is
probably
a
marker
for
global
problems
with
written
and
oral
communication.23-24
Thus,
asthma
education
pro¬
grams
may
not
adequately
reach
those
patients
suf¬
fering
the
greatest
morbidity
and
mortality.
This
problem
may
be
more
common
than
many
health-care
providers
realize.
Nationally,
almost
one
quarter
of
the
adult
population
(40
to
44
million
1008
Clinical
Investigations
1998 by the American College of Chest Physicians
by guest on July 13, 2011chestjournal.chestpubs.orgDownloaded from
people)
cannot
read
and
understand
very
basic
writ¬
ten
materials.25
We
previously
documented
that
35%
of
English-speaking
patients
and
62%
of
Spanish-
speaking
patients
seeking
care
at
two
inner-city
public
hospitals
lack
literacy
skills
adequate
to
func¬
tion
in
health-care
settings,
eg,
they
struggle
to
read
pill
bottles
and
appointment
slips.26
Our
previous
research
also
showed
that
low-literate
patients
with
diabetes
and
hypertension
have
poorer
disease
knowledge
than
those
with
adequate
literacy.24
If
standard
education
techniques
are
not
effective
for
asthma
patients
with
inadequate
literacy
skills,
this
may
result
in
poorer
self-management
skills
and
greater
morbidity.
To
examine
this,
we
surveyed
patients
with
asthma
presenting
to
the
ED
with
an
asthma
exacerbation
or
presenting
for
routine
care
in
a
specialized
asthma
clinic
(AC).
We
measured
the
reading
ability
of
these
patients
and
evaluated
the
relationship
of
patients'
literacy
skills
to
their
asthma
knowledge
and
MDI
skills.
Understanding
the
role
of
health
literacy
in
asthma
management
and
patient
education
should
enhance
efforts
to
improve
pa¬
tients'
knowledge
of
their
disease,
adherence
to
treatment
plans,
and
improve
self-management
skills.
Materials
and
Methods
This
study
was
conducted
in
the
ED
and
AC
at
Grady
Memorial
Hospital,
an
approximately
800-bed
urban
public
hospital
in
Atlanta,
GA.
The
vast
majority
of
its
patients
are
indigent
African-American
residents
of
Fulton
and
DeKalb
coun¬
ties.
Annually,
the
ED
is
the
site
of
>
100,000
patient
visits,
about
5%
of
which
are
for
asthma.
The
AC
has
750
active
patients
and
2,950
annual
appointment
visits.
The
study
design
and
contact
forms
were
approved
by
the
Human
Investigations
Committee.
Patients
were
enrolled
during
a
7-month
period
from
November
1995
through
May
1996.
A
convenience
sample
of
patients
was
enrolled
by
one
research
assistant
(RA)
from
the
AC
during
its
usual
scheduled
appoint¬
ments
on
Tuesday,
Wednesday,
or
Thursday
between
8
am
and
4
PM.
Patients
in
the
AC
were
recruited
while
they
waited
to
see
a
provider.
The
same
RA
enrolled
patients
who
presented
to
the
ED
after
4
PM
on
Tuesday,
Wednesday,
or
Thursday,
or
between
7
AM
and
11
PM
on
other
days.
Almost
all
patients
presenting
to
the
ED
with
a
chief
complaint
of
asthma
are
treated
in
an
"asthma
room."
Patients
in
the
ED
were
recruited
after
they
were
triaged
and
while
waiting
to
see
a
physician.
Patients
in
respira¬
tory
distress
were
recruited
after
completion
of
initial
treatment
and
stabilization
of
their
medical
condition.
To
diminish
selection
bias,
patients
were
enrolled
sequentially
from
the
medical
charts
of
patients
waiting
to
be
seen.
We
introduced
the
study
to
patients
by
explaining
that
we
wanted
to
find
out
about
the
problems
people
with
asthma
face
and
how
much
people
with
asthma
know
about
their
disease,
with
the
goal
of
helping
us
better
care
for
patients
with
asthma.
Exclusion
criteria
were
prior
enrollment
in
the
study,
age
<18
years,
<3-month
history
of
asthma,
documented
prior
diagnosis
of
COPD,
emphysema
or
chronic
bronchitis,
intoxication,
overt
psychiatric
illness,
lack
of
cooperation,
native
language
other
than
English,
too
ill
to
participate,
and
visual
acuity
worse
than
20/100.
After
obtaining
informed
consent,
we
interviewed
patients
to
collect
information
about
demographics,
medication
use,
self-
reported
health-care
utilization,
asthma
triggers,
recent
disease
severity,27-28
regular
source
of
care,
health
status,
health
history,
self-efficacy,29
attitude,29
self-perceived
understanding,
disease
knowledge,15
compliance,30
and
access
barriers.
Patients
were
then
asked
to
demonstrate
MDI
technique,
and
lastly
reading
ability
was
assessed
using
the
Rapid
Estimate
of
Adult
Literacy
in
Medicine
(REALM).31
The
REALM
is
a
rapid,
reliable
measure
of
reading
ability
in
the
health-care
setting.
It
has
high
criterion
validity,