DESCRIPTION (provided by applicant): Medication Adherence, Health Literacy and Cultural Health Beliefs in a Massachusetts Community Health Center Abstract Health literacy, broadly defined as "the wide range of skills and competencies" that people use to manage their health (Zarcadoolas, et al. 2005, 196-197), is an important aspect of chronic disease self- management (Mancuso and Rincon 2006), though it has been inconsistently associated with medication adherence in multiple studies. While researchers continue to investigate the relationships among health literacy, medication adherence and health outcomes, few have successfully integrated individual-level factors such as health literacy with structural and social factors. In the proposed research, we rely on ethnographic and qualitative data, in combination with quantitative methods, to explore how medication adherence, a widespread problem in chronic disease management, is shaped by structural factors such as insurance copays, as well as by cultural health beliefs. Building on our previous research (Shaw, et al. 2012a, Shaw, et al. 2009b), the proposed study examines health literacy, health beliefs and barriers to medication adherence among patients from five ethnic groups (African-American, Hispanic, white, Vietnamese and Russian immigrant). We base this study in Massachusetts, which has recently expanded the number of people insured under publicly-funded programs while implementing cost-control measures that may limit access to prescription medications, especially for the poor. Drawing on self-report surveys, pill counts, chart review, in-depth interviews and other qualitative methods, this study will meet the following specific aims: 1. Using two different quantitative methods, to assess medication adherence among patients from 5 ethnic groups: (African-American, Hispanic, white, and Vietnamese and Russian immigrants) with chronic disease (hypertension, diabetes, or dyslipidemia); 2. Use qualitative and ethnographic methods to explore the chronic disease health beliefs that may combine with health literacy to shape medication adherence; 3. To identify factors associated with medication adherence among patients with low health literacy, including: a. beliefs about medicines; b. food insecurity; c. socioeconomic factors (e.g., type of health insurance coverage; formulary changes); and d. social support. 4. To develop recommendations for primary care providers and policymakers to improve medication adherence and mitigate formulary changes among low-income patients with chronic illness. The unique constellation of conditions in Massachusetts-of near-universal insurance coverage coupled with stringent cost control measures as the state struggles to balance its budget-offers an unmatched research opportunity and serves as a critical bellwether for coming changes facing other states with the advent of the Affordable Care Act. The diverse population of patients served by Caring Health Center, the proposed research site, provides a natural laboratory in which to explore the effects of these policy changes as they intersect with culturally variable health beliefs to shape medication adherence among urban, minority and low-income patients. Improved understanding of these complex dynamics will better prepare primary health care providers to improve adherence and help reduce stroke risk among patients with hypertension and other chronic conditions.

Medication Adherence, Health Literacy and Cultural Health Beliefs in a Massachusetts Community Health Center Project Narrative Health literacy plays a pivotal role in shaping the course of chronic disease, including health status, disease severity and patient adherence with prescribed medications. Urban, minority and low-income patients are at higher risk of nonadhererence to their chronic disease medication regimens. While much research has been done on patient literacy and readability of forms such as informed consent and patient education materials, fewer studies have explored the relationship between health literacy, structural factors, cultural health beliefs, and medication adherence. This study focuses on an inner-city population burdened by significant disparities in diabetes, heart disease, high blood pressure and obesity. Not only are Springfield residents 12- 65% more likely to be affected by these conditions than Massachusetts residents as a whole, but the city's Black and Latino residents are 20-65% more likely to be affected than their Black or Latino counterparts statewide (MDPH 2003-2007). It is well-established that regular adherence to prescribed medication can help reduce the incidence and impact of chronic disease, including stroke. Yet minority and low-income patients, in particular, face significant barriers in adhering to their medication regimens, making them less likely to benefit from available care. Study results have potential national significance, especially in the context of coming changes in the nation's health care system. As tens of millions of additional individuals gain insurance coverage, cost control measures such as formulary changes and copayment tiers will become increasingly common. The Affordable Care Act invests billions more in community health centers over the next decade, and it will become increasingly important to identify effective strategies to improve medication adherence which can be integrated into those clinics where so many of those at highest risk for obesity and chronic illness receive care.! Increasing our understanding of cultural factors, including cultural health beliefs, and their relationship to medication adherence among patients with low health literacy holds significant promise for efforts to reduce disproportionate stroke risk and mortality among minority and low- income populations.