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Background: Older adults with multiple chronic conditions (MCC) and polypharmacy often face challenges with medication adherence. Nonadherence can lead to suboptimal treatment outcomes, adverse drug events, and poor quality of life., Objective: To facilitate medication adherence among older adults with MCC and polypharmacy in primary care, we are adapting a technology-enabled intervention previously implemented in a specialty clinic. The objective of this study was to obtain multilevel feedback to inform the adaptation of the proposed intervention (Phenotyping Adherence Through Technology-Enabled Reports and Navigation [PATTERN])., Methods: We conducted a formative qualitative study among patients, clinicians, and clinic administrators affiliated with a large academic health center in Chicago, Illinois. Patient eligibility included being aged 65 years or older, living with MCC, and contending with polypharmacy. Eligibility criteria for clinicians and administrators included being employed by any primary care clinic affiliated with the participating health center. Individual semistructured interviews were conducted remotely by a trained member of the study team using interview guides informed by the Exploration, Preparation, Implementation, and Sustainment Framework. Thematic analysis of interview audio recordings drew from the Rapid Identification of Themes from Audio Recordings procedures., Results: In total, we conducted 25 interviews, including 12 with clinicians and administrators, and 13 with patients. Thematic analysis revealed participants largely found the idea of technology-based medication adherence monitoring to be acceptable and appropriate for the target population in primary care, although several concerns were raised; we discuss these in detail., Conclusions: Our medication adherence monitoring intervention, adapted from specialty care, will be implemented in primary care. Formative interviews, informed by the Exploration, Preparation, Implementation, and Sustainment Framework and conducted among patients, clinicians, and administrators, have identified intervention adaptation needs. Results from this study could inform other interventions using the patient portal with older adults., (©Allison P Pack, Stacy C Bailey, Rachel O'Conor, Evelyn Velazquez, Guisselle Wismer, Fangyu Yeh, Laura M Curtis, Kenya Alcantara, Michael S Wolf. Originally published in JMIR Formative Research (https://formative.jmir.org), 17.10.2024.)

Background: Health literacy is often viewed as a static trait in longitudinal studies, which may over or underestimate an individual's ability to manage one's health., Objectives: We sought to examine health literacy over time among older adults using three widely used measures., Design: A prospective cohort study., Participants: Community-dwelling adults ages 55 to 74 at baseline with at least one follow-up visit (N = 656) recruited from one academic internal medicine clinic and six community health centers in Chicago, IL., Measures: Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA), Newest Vital Sign (NVS), and Rapid Estimate of Adult Literacy in Medicine (REALM) at baseline and up to three follow-up time points., Results: In unadjusted analyses, significant changes since baseline were found beginning at the second follow-up (mean (M) = 6.0 years, SD = 0.6) for the TOFHLA (M = - 0.9, SD = 0.95, p = 0.049) and the REALM (M = 0.3, SD = 2.5, p = 0.004) and at the last follow-up (M = 8.6 years, SD = 0.5) for the NVS (M = - 0.2, SD = 1.4, p = 0.02). There were non-linear effects of baseline age on TOFHLA and NVS scores over time (piecewise cubic spline p = 0.01 and p < 0.001, respectively) and no effect on REALM scores (B = 0.02, 95% CI - 0.01 to 0.04, p = 0.17) using multivariable mixed-effects linear regression models, controlling for race, education, income, and comorbidity., Conclusion: We found a negative relationship between age and health literacy over time as measured by the TOFHLA and NVS. Health literacy barriers appear to be more prevalent among individuals in later life, when self-care demands are similarly increasing. Clinicians might consider strategies to assess and respond to limited health literacy, particularly among patients 70 and older. REALM performance remained stable over 10 years of follow-up. This questions whether health literacy tools measure the same attribute. Prospective health literacy studies should carefully consider what measures to use, depending on their objective.

Objectives: Physical distancing precautions during the COVID-19 pandemic may challenge the provision of tangible support many middle age and older adults receive in managing their health. We examined the association between unmet tangible support needs and self-management behaviors and mental health status during the stay-at-home orders in Chicago and New York., Methods: We used data from the COVID-19 & Chronic Conditions study collected between May 1st and May 22nd, 2020. A total of 801 middle age and older adults with ≥1 chronic condition in Chicago and New York City completed the telephone interview. Adequacy of tangible social support was measured using a brief, validated scale that determined whether an individual needed assistance managing his or her health, and if yes, whether this need was met. Participants reported their level of difficulty engaging in self-management behaviors using 2 discrete items; they also self-reported medication adherence using the ASK-12 medication adherence scale. Mental health status was measured using the depression and anxiety PROMIS short-form instruments., Results: Participants' mean age was 63 years; 30% identified as Black, 26% identified as Latino, and 12% identified unmet support needs. Inadequacy of tangible support was associated with greater difficulty managing one's health and accessing medications due to COVID-19, as well as poorer medication adherence, increased anxiety and depressive symptoms, and poorer overall well-being ( P 's < .05)., Conclusions: Perceived unmet support needs during stay-at-home orders were associated with greater difficulty engaging in self-management behaviors and poorer overall well-being. Two brief items quickly identified individuals with unmet support needs.

Accurate understanding of COVID-19 safety recommendations early in the outbreak was complicated by inconsistencies in public health and media messages. We sought to characterize high-risk adults' knowledge of COVID-19 symptoms, prevention strategies, and prevention behaviors. We used data from the Chicago COVID-19 Comorbidities (C3) survey collected between March 13 thru March 20, 2020. A total of 673 predominately older adults with ≥ 1 chronic condition completed the telephone interview. Knowledge was assessed by asking participants to name three symptoms of COVID-19 and three actions to prevent infection. Participants were then asked if and how they had changed plans due to coronavirus. Most participants could identify three symptoms (71.0%) and three preventive actions (69.2%). Commonly reported symptoms included: fever (78.5%), cough (70.6%), and shortness of breath (45.2%); preventive actions included: washing hands (86.5%) and social distancing (86.2%). More than a third of participants reported social distancing themselves (38.3%), and 28.8% reported obtaining prescription medication to prepare for the outbreak. In multivariable analyses, no participant characteristics were associated with COVID-19 knowledge. Women were more likely than men, and Black adults were less likely than White adults to report practicing social distancing. Individuals with low health literacy were less likely to report obtaining medication supplies. In conclusion, though most higher-risk individuals were aware of social distancing as a prevention strategy early in the outbreak, less than half reported enacting it, and racial disparities were apparent. Consistent messaging and the provision of tangible resources may improve future adherence to safety recommendations.

Background: The US outbreak of coronavirus disease 2019 (COVID-19) accelerated rapidly over a short time to become a public health crisis., Objective: To assess how high-risk adults' COVID-19 knowledge, beliefs, behaviors, and sense of preparedness changed from the onset of the US outbreak (March 13-20, 2020) to the acceleration phase (March 27-April 7, 2020)., Design: Longitudinal, two-wave telephone survey., Participants: 588 predominately older adults with ≥ 1 chronic condition recruited from 4 active, federally funded studies in Chicago., Main Measures: Self-reported knowledge of COVID-19 symptoms and prevention, related beliefs, behaviors, and sense of preparedness., Key Results: From the onset to the acceleration phase, participants increasingly perceived COVID-19 to be a serious public health threat, reported more changes to their daily routine and plans, and reported greater preparedness. The proportion of respondents who believed they were "not at all likely" to get the virus decreased slightly (24.9 to 22.4%; p = 0.04), but there was no significant change in the proportion of those who were unable to accurately identify ways to prevent infection (29.2 to 25.7%; p 0.14). In multivariable analyses, black adults and those with lower health literacy were more likely to report less perceived susceptibility to COVID-19 (black adults: relative risk (RR) 1.62, 95% confidence interval (CI) 1.07-2.44, p = 0.02; marginal health literacy: RR 1.96, 95% CI 1.26-3.07, p < 0.01). Individuals with low health literacy remained more likely to feel unprepared for the outbreak (RR 1.80, 95% CI 1.11-2.92, p = 0.02) and to express confidence in the federal government response (RR 2.11, 95% CI 1.49-3.00, p < 0.001) CONCLUSIONS: Adults at higher risk for COVID-19 continue to lack critical knowledge about prevention. While participants reported greater changes to daily routines and plans, disparities continued to exist in perceived susceptibility to COVID-19 and in preparedness. Public health messaging to date may not be effectively reaching vulnerable communities.

Background: Limited health literacy is associated with worse physical function in cross-sectional studies. We aimed to determine if health literacy is a risk factor for decline in physical function among older adults., Methods: A longitudinal cohort of 529 community-dwelling American adults aged 55-74 years were recruited from an academic general internal medicine clinic and federally qualified health centres in 2008-2011. Health literacy (Newest Vital Sign), age, gender, race, education, chronic conditions, body mass index, alcohol consumption, smoking status and exercise frequency were included in multivariable analyses. The 10-item PROMIS (Patient-Reported Outcomes Measurement Information System) physical function scale was assessed at baseline and follow-up (mean=3.2 years, SD=0.39)., Results: Nearly half of the sample (48.2%) had either marginal (25.5%) or low health literacy (22.7%). Average physical function at baseline was 83.2 (SD=16.6) of 100, and health literacy was associated with poorer baseline physical function in multivariable analysis (p=0.004). At follow-up, physical function declined to 81.9 (SD=17.3; p=0.006) and 20.5% experienced a meaningful decline (>0.5 SD of baseline score). In multivariable analyses, participants with marginal (OR 2.62; 95%CI 1.38 to 4.95; p=0.003) and low (OR 2.57; 95%CI 1.22 to 5.44; p=0.013) health literacy were more likely to experience meaningful decline in physical function than the adequate health literacy group. Entering cognitive abilities to these models did not substantially attenuate effect sizes. Health literacy attenuated the relationship between black race and decline in physical function by 32.6%., Conclusions: Lower health literacy increases the risk of exhibiting faster physical decline over time among older adults. Strategies that reduce literacy disparities should be designed and evaluated., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To investigate how 3 measures of health literacy correlate with age and the explanatory roles of fluid and crystallised cognitive abilities in these relationships among older adults., Design: Cross-sectional baseline analysis of the 'LitCog' cohort study., Setting: 1 academic internal medicine clinic and 5 federally qualified health centres in Chicago, USA., Participants: English-speaking adults (n=828) aged 55-74 years, recruited from August 2008 through October 2011., Outcome Measures: Health literacy was measured by the Test of Functional Health Literacy in Adults (TOFHLA) and the Newest Vital Sign (NVS), both of which assess reading comprehension and numeracy in health contexts, and by the Rapid Estimate of Adult Literacy in Medicine (REALM), which assesses medical vocabulary. Fluid cognitive ability was assessed through the cognitive domains of processing speed, inductive reasoning, and working, prospective and long-term memories, and crystallised cognitive ability through the verbal ability domain., Results: TOFHLA and NVS scores were lower at ages 70-74 years compared with all other age groups (p<0.05 for both tests). The inverse association between age and TOFHLA score was attenuated from β=-0.39 (95% CI -0.55 to -0.22) to β=-0.06 (95% CI -0.20 to 0.08) for ages 70-74 vs 55-59 years when fluid cognitive ability was added to the model (85% attenuation). Similar results were seen with NVS scores (68% attenuation). REALM scores did not differ by age group (p=0.971). Crystallised cognitive ability was stable across age groups, and did not influence the relationships between age and TOFHLA or NVS performance., Conclusions: Health literacy skills show differential patterns of age-related change, which may be explained by cognitive ageing. Researchers should select health literacy tests appropriate for their purposes when assessing the health literacy of older adults. Clinicians should be aware of this issue to ensure that health self-management tasks for older patients have appropriate cognitive and literacy demands., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Current health literacy measures have been criticized for solely measuring reading and numeracy skills when a broader set of skills is necessary for making informed health decisions, especially when information is often conveyed verbally and through multimedia video. The authors devised 9 health tasks and a corresponding 190-item assessment to more comprehensively measure health literacy skills. A sample of 826 participants between the ages of 55 and 74 years who were recruited from an academic general internal medicine practice and three federally qualified health centers in Chicago, Illinois, completed the assessment. Items were reduced using hierarchical factor analysis and item response theory resulting in the 45-item Comprehensive Health Activities Scale. All 45 items loaded on 1 general latent trait, and the resulting scale demonstrated high reliability and strong construct validity using measures of health literacy and global cognitive functioning. The predictive validity of the Comprehensive Health Activities Scale using self-reported general, physical, and mental health status was comparable to or better than widely used measures of health literacy, depending on the outcome. Despite comprehensively measuring health literacy skills, items in the Comprehensive Health Activities Scale supported 1 primary construct. With similar psychometric properties, current measures may be adequate, depending on the purpose of the assessment.

Objective: To investigate whether previously noted associations between health literacy and functional health status might be explained by cognitive function., Data Sources/study Setting: Health Literacy and Cognition in Older Adults ("LitCog," prospective study funded by National Institute on Aging). Data presented are from interviews conducted among 784 adults, ages 55-74 years receiving care at an academic general medicine clinic or one of four federally qualified health centers in Chicago from 2008 to 2010., Study Design: Study participants completed structured, in-person interviews administered by trained research assistants., Data Collection: Health literacy was measured using the Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and Newest Vital Sign. Cognitive function was assessed using measures of long-term and working memory, processing speed, reasoning, and verbal ability. Functional health was assessed with SF-36 physical health summary scale and Patient Reported Outcomes Measurement Information System short form subscales for depression and anxiety., Principal Findings: All health literacy measures were significantly correlated with all cognitive domains. In multivariable analyses, inadequate health literacy was associated with worse physical health and more depressive symptoms. After adjusting for cognitive abilities, associations between health literacy, physical health, and depressive symptoms were attenuated and no longer significant., Conclusions: Cognitive function explains a significant proportion of the associations between health literacy, physical health, and depression among older adults. Interventions to reduce literacy disparities in health care should minimize the cognitive burden in behaviors patients must adopt to manage personal health., (© Health Research and Educational Trust.)

Objectives: To examine the effect of the relationship between literacy and other individual-level factors on having an advance directive (AD)., Design: Face-to-face structured interview., Setting: Participants were recruited from an academic general internal medicine clinic and one of four federally qualified health centers in Chicago., Participants: Seven hundred eighty-four adults aged 55 to 74., Measurements: Assessment of participant literacy, sociodemographic factors, and having an AD for medical care., Results: One-eighth (12.4%) of participants with low literacy, 26.6% of those with marginal literacy, and 49.5% of those with adequate literacy reported having an AD (P < .001). In multivariable analyses, literacy and race were independently associated with less likelihood of having an AD. Specifically, participants with limited literacy (risk ratio (RR) = 0.45, 95% confidence interval (CI) = 0.22-0.95) and African Americans (RR = 0.64, 95% CI = 0.47-0.88) were less likely to have an AD. Exploratory analyses showed that there was not a significant interaction between the effect of literacy and race., Conclusion: Limited literacy and African-American race were significant risk factors for not having an AD in this cohort of older adults. Literacy and race probably represent two separate but important causal pathways that need to be understood to improve how the healthcare system ascertains and protects individuals' advance care preferences., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Background: Little attention has been given to exposure to crime as a possible socioenvironmental contributor to variability in urban childhood asthma prevalence., Objective: To determine the association of violent crime, property crime, and drug abuse violations with childhood asthma prevalence in Chicago., Methods: In 2003-2005, the Chicago Initiative to Raise Asthma Health Equity conducted an asthma screening survey of children in grades K to 8 attending Chicago public and Catholic schools. Crime data were obtained from the Chicago Police Department. In addition to simple regression analysis, multilevel logistic regression analysis was performed to estimate the effect of criminal activity on neighborhood asthma variance., Results: Of the surveys returned, 45,371 (93%) were geocoded into 247 neighborhoods. Neighborhoods were divided into quartile groups by mean asthma prevalence (9%, 12%, 17%, and 22%). Criminal activity (annual incidence per 100,000 people) was significantly higher (P < .001) in neighborhoods with a high asthma prevalence, especially drug abuse violations, which increased more than 6-fold (461 vs 2,921), and violent crimes, which increased more than 3-fold (448 vs 1,566). After adjusting for community race/ethnicity, only violent crime continued to be significantly associated with the neighborhood asthma prevalence (odds ratio, 1.27; 95% confidence interval, 1.04-1.55, P < .05). When considered alongside sociodemographic and individual characteristics, violence continued to contribute significantly (P < .05), explaining 15% of neighborhood variation in childhood asthma., Conclusions: Evidence suggests an association between violent crime and childhood asthma prevalence in Chicago. A deeper understanding of the mechanisms that underlie this association may lend insight into potential interventions to address urban asthma.

Background: Prior studies have documented a high prevalence of patients who misunderstand prescription drug warning labels, placing them at risk for medication error. We evaluated whether the use of "enhanced print" drug warnings could improve patient comprehension beyond a current standard., Methods: An evaluation of enhanced print warning labels was conducted at 2 academic and 2 community health primary care clinics in Chicago, Illinois, and Shreveport, Louisiana. In total, 500 adult patients were consecutively recruited and assigned to receive (1) current standard drug warning labels on prescription containers (standard), (2) drug warnings with text rewritten in plain language (simplified text), or (3) plain language and icons developed with patient feedback (simplified text + icon). The primary outcome was correct interpretation of 9 drug warning labels as determined by a blinded panel review of patients' verbatim responses., Results: Overall rates of correct interpretation of drug warnings varied among standard, simplified text, and simplified text + icon labels (80.3%, 90.6%, and 92.1%, respectively; P < .001). Warnings with simplified text and simplified text + icons were more likely to be correctly interpreted compared with standard labels (simplified text - adjusted odds ratio [AOR] = 2.64; 95% confidence interval [CI], 2.00-3.49; simplified text + icons - AOR = 3.26; 95% CI, 2.46-4.32). Patients' ability to correctly interpret labels was not significantly different with the inclusion of icons (simplified text + icons - AOR = 1.23; 95% CI, 0.90-1.67; P = .20). Low literacy was also an independent predictor of misinterpretation (AOR, 0.65; 95% CI, 0.44-0.94). Patients with marginal and low literacy were better able to correctly interpret warning labels with simplified text + icons compared with labels with simplified text only (marginal literacy - AOR = 2.59; 95% CI, 1.24-5.44; P = .01; low literacy - AOR = 3.22; 95% CI, 1.39-7.50; P = .006)., Conclusions: Simple, explicit language on warning labels can increase patient understanding; the addition of appropriate icons is particularly useful for adults with lower literacy skills. Evidence-based standards are needed to promote patient-centered prescription labeling practices.

Rationale: The role of ethnicity and socioeconomic status in explaining variations in asthma morbidity is unclear., Objectives: To describe the magnitude of ethnic disparities in asthma morbidity in Chicago and to determine whether differences in socioeconomic status explain these disparities., Methods: We conducted a survey of 561 school-age children and 353 young adults with asthma and measured their self-reported ethnicity, socioeconomic status (using 11 variables), and asthma morbidity (symptom frequency, asthma-specific quality of life, and frequency of severe asthma exacerbations)., Measurements and Main Results: White children and adults had better asthma-specific quality of life and fewer severe asthma exacerbations compared to black and Hispanic children and adults. White children also had fewer days with asthma symptoms, but among adults there were no ethnic differences in the frequency of asthma symptoms. Socioeconomic status explained a large portion of the ethnic disparities in asthma quality of life but explained little of the disparities in other aspects of asthma morbidity., Conclusions: There are large disparities across ethnic groups in Chicago in asthma quality of life and in the frequency of severe exacerbations. Differences in socioeconomic status do not fully explain these disparities.

Background: Little is known about the level of tobacco exposure and the factors that influence exposure in children with persistent asthma., Objective: We sought to measure tobacco smoke exposure and determine factors associated with exposure in a large urban sample of asthmatic children., Methods: This cross-sectional study is based on a community-based cohort of 482 children (8-14 years old) with persistent asthma. Caregiver and household tobacco use were reported by the caregiver. Child tobacco smoke exposure was assessed by using salivary cotinine level. Multivariate linear regression of log-transformed salivary cotinine levels were used to characterize the relationship between smoke exposure and caregiver, household, and demographic characteristics. We used a multivariate logistic model to characterize associations with caregiver smoking., Results: Overall, 68.5% of children had tobacco smoke exposure. Compared with nonexposed children, those exposed to smoking by a caregiver or another household member had cotinine levels that were 1.68 (95% CI, 1.45-1.94) or 1.40 (95% CI, 1.22-1.62) times higher, respectively. Compared with Hispanic children, African American and white/other children had 1.55 (95% CI, 1.16-2.06) and 1.59 (95% CI, 1.18-2.14) times higher cotinine levels, respectively. Child exposure was also associated with caregiver depression symptoms (odds ratio, 1.01; 95% CI, 1.01-1.02), and higher household income was protective (odds ratio, 0.73; 95% CI, 0.56-0.95). Independent predictors of caregiver smoking included a protective effect of higher education (odds ratio, 0.35; 95% CI, 0.15-0.83) and a positive association with potential problematic drug/alcohol use (odds ratio, 2.30; 95% CI, 1.39-3.83)., Conclusions: Tobacco smoke exposure was high in this urban sample of asthmatic children. Caregiver smoking was strongly associated with child exposure and also was associated with lower socioeconomic status, non-Hispanic ethnicity, and depression symptoms.

Background: Many Hispanics in the United States have limited English proficiency and prefer communicating in Spanish. Language barriers are known to adversely affect health care quality and outcomes., Objective: We explored the relationship between parent language preference in a Hispanic population and the likelihood that a child with symptoms receives a diagnosis of asthma., Methods: We conducted a school-based survey in 105 Chicago public and Catholic schools. Our sample included 14,177 Hispanic children 6 to 12 years of age with a parent who completed an asthma survey. Outcomes of diagnosed asthma and possible asthma (asthma symptoms without diagnosis) were assessed by using the Brief Pediatric Asthma Screen Plus instrument., Results: Overall, 12.0% of children had diagnosed asthma, and 12.7% had possible asthma. Parents of children at risk who completed the survey in English reported higher rates of asthma diagnosis compared with parents who completed it in Spanish (55.2% vs 36.3%, P < .001). Predictors of asthma diagnosis were child sex, parental language preference, parental asthma status, and other household members with asthma., Conclusions: Parental language preference might be an important characteristic associated with childhood asthma diagnosis. Whether language itself is the key factor or the fact that language is a surrogate for other attributes of acculturation needs to be explored., Clinical Implications: Our findings suggest that estimates of asthma among Hispanic schoolchildren might be low because of underdiagnosis among children whose parents prefer communicating in Spanish.