Pathways linking health literacy, health beliefs, and cognition to medication adherence in older adults with asthma.

BACKGROUND: Limited health literacy is associated with low adherence to asthma controller medications among older adults. OBJECTIVE: We sought to describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators. METHODS: We recruited adults aged 60 years and older with asthma from hospital and community practices in New York, New York, and Chicago, Illinois. We measured health literacy and medication adherence using the Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale, respectively. We used validated instruments to assess asthma illness and medication beliefs. We assessed cognition using a cognitive battery. Using structural equation modeling, we modeled illness and medication beliefs as mediators of the relationship between health literacy and adherence while controlling for cognition. RESULTS: Our study included 433 patients with a mean age of 67 ± 6.8 years. The sample had 84% women, 31% non-Hispanic blacks, and 39% Hispanics. The 36% of patients with limited health literacy were more likely to have misconceptions about asthma (P < .001) and asthma medications (P < .001). Health literacy had a direct effect (ß = 0.089; P < .001) as well as an indirect effect on adherence mediated by medications concerns (ß = 0.033; P = .002). Neither medication necessity (ß = 0.044; P = .138) nor illness beliefs (ß = 0.007; P = .143) demonstrated a mediational role between health literacy and adherence. CONCLUSIONS: Interventions designed to improve asthma controller medication adherence in older adults may be enhanced by addressing concerns about medications in addition to using communication strategies appropriate for populations with limited health literacy and cognitive impairments.

A qualitative investigation of the impact of asthma and self-management strategies among older adults.

OBJECTIVE: We sought feedback from elderly patients living with asthma to understand their experience with assuming self-management roles for their asthma in order to inform the design and implementation of a primary care-based strategy that could best support their asthma control. METHODS: We held six focus groups with a total of 31 English- and Spanish-speaking older adults with a current diagnosis of asthma. Focus groups addressed the effect of asthma on patients' lives and self-management strategies. Transcripts were analyzed using constant comparative techniques. RESULTS: Asthma exerted a consistent effect on patients' physical and psychological well-being. Common barriers to self-care included misuse of controller medications and uncertainty whether shortness of breath, fatigue, and cough were due to their asthma or some other chronic illness. Patients developed coping strategies to continue with daily activities even when experiencing symptoms, but did not recognize attainable asthma quality of life. CONCLUSIONS: Asthma had a distinct impact on elderly adults' quality of life; due to their longstanding history with this condition, many patients had accepted these symptoms as a "new normal." Developing strategies to reorient patients' perceptions of the possibilities for managing their illness will be critical to the success of asthma self-management support programs specific to older adults.

Assessing the association of obesity and asthma morbidity in older adults.

BACKGROUND: Obesity is a robust predictor of poor asthma control in younger adults. Given the high prevalence of asthma and obesity in older Americans, weight reduction could benefit asthma management in this population. OBJECTIVE: To assess the association between obesity and asthma outcomes among older adults. METHODS: We recruited from urban primary care clinics a prospective cohort of nonsmoking individuals with asthma who were 60 years or older without a history of other respiratory diseases. At baseline, body mass index (BMI) measurements were classified as normal (BMI, 18-25), overweight (BMI, 25-30), or obese (BMI, >30). Measures of asthma morbidity (Asthma Control Questionnaire [ACQ], and Mini Asthma Quality of Life Questionnaire [Mini-AQLQ]) and asthma-related resource utilization (inpatient or outpatient) were taken at baseline and at 3- and 12-month interviews. We used generalized estimating equation models to assess associations between obesity and asthma outcomes after controlling for potential confounders. RESULTS: Of the 437 older adults with asthma in the study, 17% had a normal BMI, 32% were overweight, and 51% were obese. Unadjusted analyses revealed that obesity was associated with lower ACQ scores (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.09-1.31) and poorer Mini-AQLQ scores (OR, 1.21; 95% CI, 1.11-1.33). Adjusted analyses revealed no significant association between obesity and ACQ (OR, 1.05; 95% CI, 0.96-1.15) and Mini-AQLQ (OR, 1.08; 95% CI, 0.99-1.19). CONCLUSION: Our study suggests that obesity is not independently associated with worse asthma outcomes in older adults, reflecting potential differences in the mechanisms that link obesity with asthma control in older vs younger populations.

Chronic Obstructive Pulmonary Disease Illness and Medication Beliefs are Associated with Medication Adherence.

Almost half of patients with COPD do not adhere to their medications. Illness and medication beliefs are important determinants of adherence in other chronic diseases. Using the framework of the Common Sense Model of Self-Regulation (CSM), we determined associations between potentially modifiable beliefs and adherence to COPD medications in a cohort of English- and Spanish-speaking adults with COPD from New York and Chicago. Medication adherence was assessed using the Medication Adherence Report Scale. Illness and medication beliefs along CSM domains were evaluated using the Brief Illness Perception Questionnaire (B-IPQ) and the Beliefs about Medications Questionnaire (BMQ). Unadjusted analysis (with Cohen's d effect sizes) and multiple logistic regression were used to assess the relationship between illness and medication beliefs with adherence. The study included 188 participants (47% Black, 13% Hispanics); 109 (58%) were non-adherent. Non-adherent participants were younger (p < 0.001), more likely to be Black or Hispanic (p = 0.001), to have reported low income (p = 0.02), and had fewer years of formal education (p = 0.002). In unadjusted comparisons, non-adherent participants reported being more concerned about their COPD (p = 0.011; Cohen's d = 0.43), more emotionally affected by the disease (p = 0.001; Cohen's d = 0.54), and had greater concerns about COPD medications (p < 0.001, Cohen's d = 0.81). In adjusted analyses, concerns about COPD medications independently predicted non-adherence (odds ratio: 0.52, 95% confidence interval: 0.36-0.75). In this cohort of urban minority adults, concerns about medications were associated with non-adherence. Future work should explore interventions to influence patient adherence by addressing concerns about the safety profile and long-term effects of COPD medications.

Strategies used by older adults with asthma for adherence to inhaled corticosteroids.

BACKGROUND: Older adults with asthma have low levels of adherence to their prescribed inhaled corticosteroids (ICS). While prior research has identified demographic and cognitive factors associated with ICS adherence among elderly asthmatics, little is known about the strategies that older adults use to achieve daily use of their medications. Identifying such strategies could provide clinicians with useful advice for patients when counseling their patients about ICS adherence. OBJECTIVE: To identify medication use strategies associated with good ICS adherence in older adults. PARTICIPANTS: English-speaking and Spanish-speaking adults ages 60 years and older with moderate or severe asthma were recruited from primary care and pulmonary practices in New York City, NY, and Chicago, IL. Patients with chronic obstructive pulmonary disease, other chronic lung diseases or a smoking history of greater than 10 pack-years were excluded. MAIN MEASURES: Medication adherence was assessed with the Medication Adherence Rating Scale (MARS). Medication use strategies were assessed via open-ended questioning. "Good adherence" was defined as a mean MARS score of 4.5 or greater. KEY RESULTS: The rate of good adherence to ICS was 37 %. We identified six general categories of medication adherence strategies: keeping the medication in a usual location (44.2 %), integrating medication use with a daily routine (32.6 %), taking the medication at a specific time (21.7 %), taking the medication with other medications (13.4 %), using the medication only when needed (13.4 %), and using other reminders (11.9 %). The good adherence rate was greater among individuals who kept their ICS medication in the bathroom (adjusted odds ration [AOR] 3.05, 95 % CI 1.03-9.02, p = 0.04) or integrated its use into a daily routine (AOR 3.77, 95 % CI: 1.62-8.77, p = 0.002). CONCLUSIONS: Keeping ICS medications in the bathroom and integrating them into daily routines are strategies associated with good ICS adherence. Clinicians concerned with adherence should consider recommending these strategies to their older asthmatic patients, although additional research is needed to determine whether such advice would improve adherence behaviors.

Asthma outcomes are poor among older adults with low health literacy.

OBJECTIVE: To examine the association of health literacy (HL) with asthma outcomes among older asthmatics. METHODS: The study included adults ages ≥60 with moderate to severe asthma in New York City and Chicago. We assessed asthma control with the Asthma Control Questionnaire (ACQ) and the percent predicted forced expiratory volume at 1 s (FEV1) by spirometry, hospitalizations and emergency department (ED) visits in the past 6 months, and quality of life. HL was assessed with the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multivariate logistic regression models controlled for age, sex, race, income, general health and years with asthma. RESULTS: Among 433 individuals, 36% had low HL, 55% were over age 65, 38% were Hispanic and 22% were black. Poor asthma control was reported by 40% and 32% had FEV1 <70% of predicted; 9% had a hospital stay, 23% had an ED and 38% had poor quality of life. In multivariable analysis, individuals with low HL were more likely to have FEV1 <70% predicted (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.39-3.94, p = 0.001), hospitalizations (OR 2.53, 95% CI 1.17-5.49, p = 0.02) and ED visits for asthma (OR 1.81, 95% CI 1.05-3.10, p = 0.03). There were no differences in self-reported asthma control and quality of life. CONCLUSIONS: Low HL is associated with poor asthma control by objective measure, and greater likelihood of ED visits and hospitalization. HL is a modifiable target for interventions to improve asthma outcomes in the elderly.

Asthma beliefs are associated with medication adherence in older asthmatics.

BACKGROUND: Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics. OBJECTIVE: To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics. DESIGN: An observational study of asthma beliefs and self-management among older adults. PARTICIPANTS: Asthmatics ages ≥ 60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago. MAIN MEASURES: Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence. KEY RESULTS: The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the "no symptoms, no asthma" belief (58.7 % vs. 31.7 %, respectively, p < 0.001), "will not always have asthma" belief (34.8 % vs. 12.5 %, p < 0.001), and the "MD can cure asthma" belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a "no symptoms, no asthma" belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment. CONCLUSIONS: Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.

Depressive symptoms, low adherence, and poor asthma outcomes in the elderly.

OBJECTIVE: To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma. METHODS: Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS). RESULTS: Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04-3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10-0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy. CONCLUSION: In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

The association between language proficiency and outcomes of elderly patients with asthma.

BACKGROUND: Asthma is a growing cause of morbidity for elderly Americans and is highly prevalent among Hispanic people in the United States. The inability to speak English poses a barrier to patient-provider communication. OBJECTIVE: To evaluate associations between limited English proficiency, asthma self-management, and outcomes in elderly Hispanic patients. METHOD: Elderly patients with asthma receiving primary care at clinics in New York City and Chicago were studied. RESULTS: Of 268 patients in the study, 68% were non-Hispanic, 18% English-proficient Hispanic, and 14% Hispanic with limited English proficiency. Unadjusted analyses showed that Hispanic persons with limited English proficiency had worse asthma control (P = .0007), increased likelihood of inpatient visits (P = .002), and poorer quality of life (P < .0001). We also found significant associations between limited English proficiency and poorer medication adherence (P = .006). Similar results were obtained in multiple regression analyses adjusting for demographics, asthma history, comorbidities, depression, and health literacy. CONCLUSION: Limited English proficiency was associated with poorer self-management and worse outcomes among elderly patients with asthma. Further understanding of mechanisms underlying this relationship is necessary to develop interventions that improve asthma outcomes in this vulnerable population.

Associations Between Asthma Control and Airway Obstruction and Performance of Activities of Daily Living in Older Adults with Asthma.

OBJECTIVES: To determine the effect of asthma on functional limitations of older adults in the United States. DESIGN: Analyses were conducted with data from the Asthma Beliefs and Literacy in the Elderly study, a prospective cohort study of people aged 60 and older with asthma. SETTING: Participants were recruited from urban primary care and pulmonary specialty practices in New York City and Chicago between 2010 and 2012. PARTICIPANTS: Individuals aged 60 and older with asthma (380 women, 72 men, mean age 67.5 ± 6.8 (range 60-98), 40% Latino, 30% black). MEASUREMENTS: Characteristics of participants with and without activity of daily living (ADL) limitations were compared using the chi-square test. Generalized estimating equations were used to model the relationships between poor asthma control (Asthma Control Questionnaire (ACQ) score >1.5) and severity of airway obstruction (forced expiratory volume in 1-second (FEV1 )) and number of ADL limitations. RESULTS: Participants with one or more ADL limitations were more likely to be female (90% vs 81%, P = .02) and Latino (58% vs 32%, P < .001), have less than a high school education (53% vs 27%, P < .001) and an income of $1,350 per month or less (79% vs 46%, P < .001), and be unmarried (78% vs 64%, P = .003). In the adjusted analysis, poorer ACQ scores (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.0-2.4; P = .05) but not severity of airway obstruction (OR = 1.1, 95% CI = 0.6-1.9) was associated with greater ADL limitations. CONCLUSION: Older adults reporting poor asthma control are more likely to have ADL limitations than those with controlled asthma, although one-time spirometry may not adequately identify those at risk of physical impairment from asthma.

Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma.

BACKGROUND: We sought to investigate the degree to which cognitive skills explain associations between health literacy and asthma-related medication use among older adults with asthma. METHODS: Patients aged ≥ 60 years receiving care at eight outpatient clinics (primary care, geriatrics, pulmonology, allergy, and immunology) in New York, New York, and Chicago, Illinois, were recruited to participate in structured, in-person interviews as part of the Asthma Beliefs and Literacy in the Elderly (ABLE) study (n = 425). Behaviors related to medication use were investigated, including adherence to prescribed regimens, metered-dose inhaler (MDI) technique, and dry powder inhaler (DPI) technique. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of fluid (working memory, processing speed, executive function) and crystallized (verbal) ability. RESULTS: The mean age of participants was 68 years; 40% were Hispanic and 30% non-Hispanic black. More than one-third (38%) were adherent to their controller medication, 53% demonstrated proper DPI technique, and 38% demonstrated correct MDI technique. In multivariable analyses, limited literacy was associated with poorer adherence to controller medication (OR, 2.3; 95% CI, 1.29-4.08) and incorrect DPI (OR, 3.51; 95% CI, 1.81-6.83) and MDI (OR, 1.64; 95% CI, 1.01-2.65) techniques. Fluid and crystallized abilities were independently associated with medication behaviors. However, when fluid abilities were added to the model, literacy associations were reduced. CONCLUSIONS: Among older patients with asthma, interventions to promote proper medication use should simplify tasks and patient roles to overcome cognitive load and suboptimal performance in self-care.

The Association of Health Literacy with Illness and Medication Beliefs among Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Low health literacy is associated with low adherence to self-management in many chronic diseases. Additionally, health beliefs are thought to be determinants of self-management behaviors. In this study we sought to determine the association, if any, of health literacy and health beliefs among elderly individuals with COPD. METHODS: We enrolled a cohort of patients with COPD from two academic urban settings in New York, NY and Chicago, IL. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Using the framework of the Self-Regulation Model, illness and medication beliefs were measured with the Brief Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ). Unadjusted analyses, with corresponding Cohen's d effect sizes, and multiple logistic regression were used to assess the relationships between HL and illness and medication beliefs. RESULTS: We enrolled 235 participants, 29% of whom had low health literacy. Patients with low health literacy were more likely to belong to a racial minority group (p<0.001), not be married (p = 0.006), and to have lower income (p<0.001) or education (p<0.001). In unadjusted analyses, patients with low health literacy were less likely to believe they will always have COPD (p = 0.003, Cohen's d = 0.42), and were more likely to be concerned about their illness ((p = 0.04, Cohen's d = 0.17). In analyses adjusted for sociodemographic factors and other health beliefs, patients with low health literacy were less likely to believe that they will always have COPD (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.65-0.94). In addition, the association of low health literacy with expressed concern about medications remained significant (OR: 1.20, 95% CI: 1.05-1.37) though the association of low health literacy with belief in the necessity of medications was no longer significant (OR: 0.92, 95% CI: 0.82-1.04). CONCLUSIONS: In this cohort of urban individuals with COPD, low health literacy was prevalent, and associated with illness beliefs that predict decreased adherence. Our results suggest that targeted strategies to address low health literacy and related illness and medications beliefs might improve COPD medication adherence and other self-management behaviors.

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma.

Older adults with asthma face numerous barriers to effective self-management and asthma control, and experience worse outcomes than younger asthmatics. Yet, there have been no controlled trials of interventions specifically designed to improve their care and outcomes. Through a multi-stakeholder collaboration (patients, academia, community-based organizations, a state department of health, and an advocacy organization) we developed a multi-component asthma self-management support intervention to address the myriad psychosocial, functional, health status, and cognitive barriers to effective asthma self-management in adults ages 60 and older. We are recruiting 425 New Yorkers in Manhattan and the Bronx for a pragmatic randomized controlled trial with 3 arms: the intervention delivered in primary care settings or in their home, or usual care. In the intervention, care coaches use a novel screening tool to identify the specific barriers to asthma control and self-management they experience. Once identified, the coach and patient choose from a menu of actions to address it. The intervention emphasizes efficiency, flexibility, shared decision making and goal setting, communication strategies appropriate for individuals with limited cognition and literacy skills, and ongoing reinforcement and support. Additionally, we introduced asthma-specific enhancements to the electronic health records of all participating clinical practices, including an asthma severity assessment, clinical decision support, and a patient-tailored asthma action plan. Patients will be followed for 12months and interviewed at baseline, 3, 6, and 12months and data on emergency department visits and hospitalizations will be obtained through the New York State Statewide Planning and Research Cooperative System.

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

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: 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.

Physician trainees' decision making and information processing: choice size and Medicare Part D.

Many patients expect their doctor to help them choose a Medicare prescription drug plan. Whether the size of the choice set affects clinicians' decision processes and strategy selection, and the quality of their choice, as it does their older patients, is an important question with serious financial consequences. Seventy medical students and internal medicine residents completed a within-subject design using Mouselab, a computer program that allows the information-acquisition process to be examined. We examined highly numerate physician trainees' decision processes, strategy, and their ability to pick the cheapest drug plan-as price was deemed the most important factor in Medicare beneficiaries' plan choice-from either 3 or 9 drug plans. Before adjustment, participants were significantly more likely to identify the lowest cost plan when facing three versus nine choices (67.3% vs. 32.8%, p<0.01) and paid significantly less in excess premiums ($60.00 vs. $128.51, p<0.01). Compared to the three-plan condition, in the nine-plan condition participants spent significantly less time acquiring information on each attribute (p<0.05) and were more likely to employ decision strategies focusing on comparing alternate plans across a single attribute (search pattern, p<0.05). After adjusting for decision process and strategy, numeracy, and amount of medical training, the odds were 10.75 times higher that trainees would choose the lowest cost Medicare Part D drug plan when facing 3 versus 9 drug plans (p<0.05). Although employing more efficient search strategies in the complex choice environment, physician trainees experienced similar difficulty in choosing the lowest cost prescription drug plans as older patients do. Our results add further evidence that simplifications to the Medicare Part D decision environment are needed and suggest physicians' role in their patients' Part D choices may be most productive when assisting seniors with forecasting their expected medication needs and then referring them to the Medicare website or helpline.

The association of health literacy with illness and medication beliefs among older adults with asthma.

OBJECTIVE: Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs. METHODS: Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n=420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models. RESULTS: Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2-2.82; OR: 2.22, 95% CI: 1.29-3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (ß=0.92, p=.05), despite recognizing their necessity (ß=-1.36, p=.01). CONCLUSIONS: Older asthmatics with low HL endorse erroneous asthma beliefs. PRACTICE IMPLICATIONS: Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.

Family composition and children's exposure to adult smokers in their homes.

OBJECTIVE: Smoking behavior is strongly influenced by the social environment. More information is needed about how the composition of households with children is associated with adult smoking behavior so that more effective interventions to reduce children's secondhand smoke exposure can be devised and implemented. METHODS: Using data from the Medical Expenditure Panel Survey 2000-2004, we conducted cross-sectional analyses to assess how adult smoking behavior is associated with household characteristics, including the number of adults and smokers present, the relationship of the child to the head of household, and relationships between adult members of the household. RESULTS: More than one third (34.4%) of children lived with > or =1 adult smoker. Almost half (49.4%) of poor children lived with a smoker, and they were more likely to live with multiple smokers compared with those who lived at >400% of the federal poverty level (21.2% vs 7.8%). Approximately 5 million children lived in households headed by an adult other than their parent, and they were significantly more likely to live with smokers: 53.4% of children who lived in their grandparents' homes and 46.2% of children in homes of other adults lived with at least 1 adult smoker, compared with 33.3% who lived in their parents' home. A total of 59.4% of all children who lived with a smoker had a smoking mother, and 56.7% of those children lived with > or =2 smokers, whereas only 17.0% of children whose mother did not smoke had smoking adults in the home. CONCLUSIONS: These findings demonstrate the significant influence of household composition on children's likelihood to live in homes with adult smokers.