Black Women With Limited Health Literacy Identified as Vulnerable to Systemic Lupus Erythematosus Impact

Mithunan Maheswaranathan, MD

Credit: Duke

New research found that in Black women with systemic lupus erythematosus (SLE), those with limited health literacy had worse clinical outcomes and experience disparate health outcomes.¹

“Limited health literacy is associated with worse clinical outcomes including increased hospitalizations and readmissions, greater use of emergency care services, and higher disease activity. Recent studies have demonstrated limited health literacy and numeracy are associated with worse patient-reported outcomes and higher disease activity in individuals with systemic lupus erythematosus (SLE).² However, the exact mechanisms by which limited health literacy may contribute to worse outcomes in patients with SLE have not been entirely elucidated,” lead investigator Mithunan Maheswaranathan, MD, assistant professor of medicine, rheumatology and immunology, rheumatology fellowship, Duke University School of Medicine, and colleagues wrote.¹

The investigators analyzed data from 267 Black women with SLE that were enrolled in the Peer Approaches to Lupus Self-Management (PALS) program. These data included baseline surveys and assessments obtained at the start of the PALS study and clinical data on disease activity and lupus damage. Other outcomes assessed included patient activation, self-efficacy, physician/patient communication, and quality of life. The investigators dichotomized participants that reported in the “limited” range on any item using the 3-item Chew Health Literacy Screening with outcomes compared via generalized linear models.¹

Maheswaranathan and colleagues identified 88 participants (33%) with limited health literacy. After covariate-adjusted analyses for age, education, and income, these participants were more likely to have lower patient activation (Patient Activation Measure; P < 0.0001) and specifically limited confidence to figure out solutions when new problems arose with their health (P = 0.041). They had lower self-efficacy (Lupus Self-Efficacy; P < 0.0001) and worse patient-centered care scores (P = 0.0002).¹

Specifically under patient-centered care scores, patients with limited health literacy were significantly more likely than those with adequate health literacy to report problems getting answers that were understandable (52.3% vs 31.5%; P = 0.0002) and reported issues with their physician taking enough time to answer their questions (39.1% vs 21.8%; P = 0.0037). They were more likely to report being “very dissatisfied” on care received from their primary care provider over the past 12 months compared to those with adequate health literacy (16.5% vs 6.3%, P = 0.0117). These differences remained significant after covariate adjustments.¹

Maheswaranathan also found that these participants with limited health literacy were more likely to experience higher lupus damage (self-administered Brief Index of Lupus Damage; P = .016) and higher disease activity (Systemic Lupus Activity Questionnaire symptom severity; P = 0.006) compared to those with adequate health literacy before and after adjusted analyses.¹

Before and after adjusted analyses, those with limited health literacy reported worse lupus quality of life (P = 0.0004), had greater levels of stress (Perceived Stress Scale-4; P < 0.0001) and were 2.4 times more likely to have probable major depression (Patient Health Questionnaire Depression Scale-8 of ≥10; P = 0.004) and probable anxiety disorder (General Anxiety Disorder-7 of ≥10; P = 0.007) compared to those with adequate health literacy.¹

“... providing education in the clinic visit using plain language and clear communication could help with improving understanding of medication intent and may lead to improved downstream clinical outcomes, such as a higher adherence to receiving medication. This study offers unique and novel insights into associations of limited health literacy with patient-reported and clinical outcomes, as well as potential mediators that may explain how limited health literacy contributes to more distal adverse health-related outcomes,” Maheswaranathan and colleagues concluded.¹

REFERENCES

1. Maheswaranathan M, Boan AD, Ramakrishnan V, et al. Association of Limited Health Literacy With Clinical and Patient-Reported Outcomes in Individuals With Systemic Lupus Erythematosus. ACR Open Rheumatol. August 18, 2024. Doi.org/10.1002/acr2.11719
2. Katz P, Dall'Era M, Trupin L, et al. Impact of limited health literacy on patient-reported outcomes in systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2021; 73(1): 110–119.