Original Article

Cardiovascular Diseases Health Literacy among Patients, Health Professionals, and Community-Based Stakeholders in a Predominantly Medically Underserved Rural Environment

Authors: Hadii M. Mamudu, PhD, MPA, Liang Wang, DrPH, MD, Amy M. Poole, MS, Cynthia J. Blair, BA, Mary Ann Littleton, PhD, Rob Gregory, BA, Lynn Frierson, BA, Carl Voigt, BA, Timir K. Paul, MD, PhD


Objective: The central Appalachian region of the United States is disproportionately burdened with cardiovascular disease (CVD); however, the level of literacy about CVD among residents has not been well studied. This study aimed to examine the prevalence and factors of CVD health literacy (HL) among a sample of patients/caregivers, providers/professionals, and community stakeholders.

Methods: In 2018, data were collected from central Appalachian residents in six states: Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. CVD HL status was determined by assessing correct responses to five interrelated questions about basic knowledge of CVD. Multiple logistic regression analyses were used to examine the associations between potential factors and CVD HL status.

Results: Of the total respondents (N = 82), <50% correctly answered all 5 CVD HL questions. Multiple logistic regression analyses showed that compared with respondents with advanced college degrees, those with a college degree or less were more likely to have low HL for “typical symptom of CVD,” “physical exercise and CVD,” “blood pressure and CVD,” and “stress and CVD.” In addition, compared with respondents younger than 50 years, those 50 years and older were 3.79 times more likely to have low HL for “physical exercise and CVD.”

Conclusions: These results suggest the incorporation of CVD HL into CVD care and that educational attainments should be part of CVD policies and programs in the region.
Posted in: Cardiovascular Disease34

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1. Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, et al, eds. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Publ. No. CBM 2000–2001. Bethesda, MD: National Institutes of Health, US Department of Health and Human Services; 2000. 2. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med 2005;165:1946–1952. 3. Baumann KE, Phillips AL, Arya M. Overlap of HIV and low health literacy in the southern USA. Lancet HIV 2015;2:e269–e270. 4. Rebeiro PF, McPherson TD, Goggins KM, et al. Health literacy and demographic disparities in HIV care continuum outcomes. AIDS Behav 2018;22:2604–2614. 5. Powell CK, Hill EG, Clancy DE. The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ 2007;33:144–151. 6. Rothman R, Malone R, Bryant B, et al. The relationship between literacy and glycemic control in a diabetes disease-management program. Diabetes Educ 2004;30:263–273. 7. Sharif I, Blank AE. Relationship between child health literacy and body mass index in overweight children. Patient Educ Couns 2010;79:43–48. 8. Scott TL, Gazmararian JA, Williams MV, et al. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40:395–404. 9. Lindau ST, Basu A, Leitsch SA. Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study. J Gen Intern Med2006;21:829–834. 10. Golboni F, Nadrian H, Najafi S, et al. Urban-rural differences in health literacy and its determinants in Iran: a community-based study. Aust J Rural Health 2018;26:98–105. 11. Quisenberry AJ, Scott AE, Shoben AB, et al. Health literacy and attention to cigarette health warning labels among rural smokers. Tob Regul Sci 2018;4:38–46. 12. Mamudu HM, Jones A, Paul T, et al. Geographic and individual correlates of subclinical atherosclerosis in an asymptomatic rural Appalachian population. Am J Med Sci 2018;355:140–148. 13. Lima de Melo Ghisi G, da Silva Chaves GS, Rodrigues Britto R, et al. Health literacy and coronary artery disease: a systematic review. Patient Educ Couns 2018;101:177–184. 14. Kripalani S, Goggins K, Nwosu S, et al. Medication nonadherence before hospitalization for acute cardiac events. J Health Commun 2015;20(suppl 2):34–42. 15. Martin LT, Schonlau M, Haas A, et al. Literacy skills and calculated 10-year risk of coronary heart disease. J Gen Intern Med 2011;26:45–50. 16. Mayberry LS, Schildcrout JS, Wallston KA, et al. Health literacy and 1-year mortality: mechanisms of association in adults hospitalized for cardiovascular disease. Mayo Clin Proc 2018;93:1728–1738. 17. van Schaik TM, Jorstad HT, Twickler TB, et al. Cardiovascular disease risk and secondary prevention of cardiovascular disease among patients with low health literacy. Neth Heart J 2017;25:446–454. 18. Musich S, Ozminkowski RJ, Bottone FGJ, et al. Barriers to managing coronary artery disease among older women. J Women Aging 2014;26:146–159. 19. Rymer JA, Kaltenbach LA, Anstrom KJ, et al. Hospital evaluation of health literacy and associated outcomes in patients after acute myocardial infarction.Am Heart J 2018;198:97–107. 20. Gazmararian JA, Kripalani S, Miller MJ, et al. Factors associated with medication refill adherence in cardiovascular-related diseases: a focus onhealth literacy. J Gen Intern Med 2006;21:1215–1221. 21. Lu M, Ma J, Lin Y, et al. Relationship between patient’s health literacy and adherence to coronary heart disease secondary prevention measures. J Clin Nurs 2019;28:2833–2843. 22. Oscalices MIL, Okuno MFP, Lopes MCBT, et al. Health literacy and adherence to treatment of patients with heart failure. Rev Esc Enferm USP 2019;53:e03447. 23. Savitz ST, Dobler CC, Shah ND, et al. Patient-clinician decision making forstable angina: the role of health literacy. EGEMS (Wash DC) 2019;7:42. 24. Zullig LL, McCant F, Melnyk SD, et al. A health literacy pilot intervention to improve medication adherence using Meducation(R) technology. Patient Educ Couns 2014;95:288–291. 25. Elbashir M, Awaisu A, El Hajj MS, et al. Measurement of health literacy in patients with cardiovascular diseases: a systematic review. Res Social Adm Pharm 2019;15:1395–1405. 26. Ibrahim SY, Reid F, Shaw A, et al. Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease. J Public Health (Oxf ) 2008;30449–455. 27. Lane NM, Lutz AY, Baker K, et al. Health care costs and access disparities in Appalachia. http://www.arc.gov/assets/research_reports/HealthCareCostsandAccessDisparitiesinAppalachia.pdf. Published 2012. Accessed September 13, 2016. 28. Wallston KA, Cawthon C, McNaughton CD, et al. Psychometric properties of the brief health literacy screen in clinical practice. J Gen Intern Med 2014;29:119–126. 29. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med 2004;36:588–594. 30. Lindahl B, Norberg M, Johansson H, et al. Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk. Eur J Prev Cardiol 2020;27:209–215. 31. Braun RT, Hanoch Y, Barnes AJ. Tobacco use and health insurance literacy among vulnerable populations: implications for health reform. BMC Health Serv Res 2017;17:729. 32. Scott J, Dardas L, Sloane R, et al. Understanding social determinants of cardiometabolic disease risk in rural women. J Community Health 2020;45:1–9. 33. Appalachian Regional Commission. Census population change, 2000–2010. https://www.arc.gov/reports/custom_report.asp?REPORT_ID=41. Accessed September 13, 2016. 34. Berkman ND, Dewalt DA, Pignone MP, et al. AHRQ Evidence Report Summaries, 87. Literacy and health outcomes: summary. https://www.ncbi.nlm.nih.gov/books/NBK11942. Published 2004. Accessed August 14, 2020. 35. Cutler D. Education and Health: National Poverty Center Policy Brief #9. Ann Arbor: University of Michigan: ERIC; 2007.