Education, literacy, and health: Mediating effects on hypertension knowledge and control

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Abstract

Objective

To determine whether literacy mediates the association between education, hypertension knowledge and control.

Methods

In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control.

Results

In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1–8: β = −0.30, 95% CI = −1.44–0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10–2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54–4.70).

Conclusion

Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure.

Practice implications

Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.

Introduction

Over the past several decades, studies have repeatedly highlighted the strong association between lower educational attainment and poor health outcomes, including mortality [1], [2], [3], [4], [5]. These relationships have remained significant even after adjusting for relevant socioeconomic indicators. While there have been many plausible explanations proposed to understand this association, the causal pathways between education and health are still not entirely clear.

Recent investigations have examined the role of adult literacy skills as a mediating factor to the education–health relationship [6], [7], [8]. Literacy is a multifaceted concept that includes many of the cognitive and social skills learned through formal education processes; reading and numeracy are just a few of the fundamental components [9]. A significant body of research has consistently documented a strong, graded relationship between both education and literacy skills with health knowledge [10], [11], [12]. Fewer studies to date have evaluated the relationship between literacy and health outcomes, including mortality; those documenting positive associations found literacy to be the more dominant predictor compared to years of education [6], [7], [8].

In this study, we sought to examine whether literacy mediated the association between education, hypertension knowledge and control among a sample of adults receiving care at safety net clinics in diverse areas of the United States. We hypothesized that educational attainment would be significantly related to a patient's understanding of disease and treatment, and that this relationship would be strongly mediated by literacy skills. The associations between education, literacy, and hypertension control were thought to be more complex, as acquisition of knowledge often does not translate to behavior.

Section snippets

Setting and participants

We recruited consecutive patients with diagnosed hypertension and scheduled appointments from six primary care safety net clinics in Grand Rapids, MI, Chicago, IL, and Shreveport, LA. Clinics in Grand Rapids (n = 2) and Chicago (n = 2) were all affiliated with federally qualified health centers. One clinic in Shreveport was a community health center and the other a public hospital ambulatory care clinic. The institutional review boards at each location approved the study procedures. Eligible

Results

Table 1 provides both an overall statistical description of the study population and stratifications by educational attainment and health literacy level. The mean age of patients was 53.6 years (SD = 12.0); 67.9 percent were female, and 78.5 percent were African American. A third of subjects were recruited from each of the study sites, 30.6 percent from Chicago, 36.1 percent from Grand Rapids, and 33.3 percent from Shreveport. Most participants (65.8%) were unemployed, and 43.9 percent did not

Discussion

Few studies to date have attempted to examine in detail the link between education, literacy, and health [8], [17]. In this multi-site study among medically underserved patient populations, approximately half of adults with diagnoses of hypertension were uncontrolled. Those who reported fewer years of schooling possessed less knowledge of the disease and its treatment and were at greater risk for not having their hypertension under control. Limited literacy skills mediated the relationship

Acknowledgements

Funding for this study was provided in part by a research grant awarded to Cherry Street Health Services by the Michigan Department of Community Health. Dr. Tang is a National Research Service Award postdoctoral fellow at the Institute for Healthcare Studies, which is supported under an institutional award from the Agency for Healthcare Research and Quality, T-32 HS 000078. Dr. Persell is supported by career development award 1 K08 HS015647-01 from the Agency for Healthcare Research and Quality.

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