Background Low health literacy is associated with poor outcomes in asthma and other diseases but the mechanisms governing this relationship are not well-defined. Objective To assess whether literacy is related to subsequent asthma self-management, measured as adherence to inhaled steroids, and asthma outcomes. Methods In a prospective longitudinal cohort study, numeric (Asthma Numeracy Questionnaire (ANQ)) and print literacy (Short Test of Functional Health Literacy in Adults (S-TOFHLA)) were assessed at baseline in adults with moderate or severe asthma for their impact on subsequent electronically monitored adherence and asthma outcomes (asthma control, asthma-related quality of life, and FEV1) over 26 weeks, using mixed-effects linear regression models. Results 284 adults participated: 48±14 years, 71% female, 70% African American, 6% Latino, mean FEV1 66% ± 19%, 86 (30%) with hospitalizations and 148 (52%) with ED visits for asthma in the prior year. Mean ANQ score (range 0–4) was 2.3 ± 1.2; mean S-TOFHLA score 31 ± 8 (range 0–36). In unadjusted analyses numeric and print literacy were associated with better adherence (p=0.01, p=0.08), asthma control (p=0.005, p <0.001), and quality of life (p<0.001, p<0.001). After controlling for age, sex, and race/ethnicity, the associations diminished and only quality of life (numeric: p=0.03, print p=0.006) and asthma control (print p=0.005) remained significantly associated with literacy. Race/ethnicity, income, and educational attainment were correlated (p<0.001). Conclusion While the relationship between literacy and health is complex, interventions which account for and address the literacy needs of patients may improve asthma outcomes. Clinical Implications/Key Summary In adults with moderate or severe asthma, higher health literacy scores were associated with better subsequent quality of life and asthma control.

Background Improving inhaled corticosteroid (ICS) adherence should improve asthma outcomes. Objective In a randomized controlled trial we tested whether an individualized problem-solving intervention improves ICS adherence and asthma outcomes. Methods Adults with moderate or severe asthma from clinics serving inner-city neighborhoods were randomized to problem-solving (PS) (defining specific barriers to adherence, proposing/ weighing solutions, trying the best, assessing, and revising) or standard asthma education (AE) for 3 months, then observed for 3 months. Adherence was monitored electronically. Outcomes included: asthma control, FEV1, asthma-related quality of life, emergency department (ED) visits, and hospitalizations. In an intention-to-treat-analysis, longitudinal models using random effects and regression were employed. Results 333 adults were randomized: 49±14 years, 72% female, 68% African American, 7% Latino, mean FEV1 66%±19%, 103(31%) with hospitalizations and 172(52%) with ED visits for asthma in the prior year. There was no difference between groups in overall change in any outcome (p>0.20). Mean adherence (61%±27%) declined significantly (p=0.0004) over time by 14% and 10% in the AE and PS groups, respectively. Asthma control improved overall by 15% (p=0.002). In both groups, FEV1 and quality of life improved: 6% (p=0.01) and 18% (p<0.0001), respectively. However, the improvement in FEV1 only occurred during monitoring but not subsequently after randomization. Rates of ED visits and hospitalizations did not significantly decrease over the study period. Conclusion Problem-solving was not better than asthma education in improving adherence or asthma outcomes. However, monitoring ICS use with provision of medications and attention, imposed on both groups, was associated with improvement in FEV1 and asthma control. Clinical Trials registration ClinicalTrials.gov number NCT00115323.

Background Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers. Objective To conduct a pilot study to assess feasibility, acceptability, and preliminary evidence of effectiveness. Methods A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a nonprofessional, modeled preparations for a medical visit, attended the visit, and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage, and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid adherence, asthma control, quality of life, FEV1, ED visits, and hospitalizations. Mixed-effects models guided an intention-to-treat analysis. Results 100 adults participated: age 47±14 years, 75% female, 71% African American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p= 0.001) but not significantly in the PA group (p=.30). Both PA and MI groups demonstrated improved asthma control (p=0.01 in both) and quality of life (p=0.001, p=0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups. Conclusion The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life.

Background-Patients with moderate or severe asthma, particularly those who are minority or poor, often encounter significant personal, clinical practice, and health system barriers to accessing care.