Patient Education and Counseling 65 (2007) 253–260

www.elsevier.com/locate/pateducou

Literacy, self-efficacy, and HIV medication adherence

Michael S. Wolf a,b,*, Terry C. Davis c, Chandra Y. Osborn a, Silvia Skripkauskas a,b,
Charles L. Bennett d, Gregory Makoul b
a
Health Literacy and Learning Program (HeLP), Institute for Healthcare Studies, Feinberg School of Medicine,
Northwestern University, United States
b
Center for Communication and Medicine, Feinberg School of Medicine, Northwestern University, United States
c
Louisiana State University Health Sciences Center at Shreveport, United States
d
Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, United States
Received 3 March 2006; received in revised form 25 July 2006; accepted 13 August 2006

Abstract

Objective: We examined the relationship between patient literacy level and self-reported HIV medication adherence, while estimating the
mediating roles of treatment knowledge and self-efficacy on this relationship.
Methods: Structured patient interviews with a literacy assessment, supplemented by medical chart review, were conducted among 204
consecutive patients receiving care at infectious disease clinics in Shreveport, Louisiana and Chicago, Illinois. Literacy was measured using
the Rapid Estimate of Adult Literacy in Medicine (REALM), while the Patient Medication Adherence Questionnaire (PMAQ) was used to
assess medication self-efficacy and adherence to antiretroviral regimens in the past 4 days.
Results: Approximately one-third of patients (30.4%) were less than 100% adherent to their regimen, and 31.4% had marginal to low literacy
skills. In multivariate analyses, low literate patients were 3.3 times more likely to be non-adherent to their antiretroviral regimen ( p < 0.001).
Patients’ self-efficacy, but not knowledge, mediated the impact of low literacy on medication adherence (AOR 7.4, 95% CI 2.7–12.5).
Conclusion: While low literacy was a significant risk factor for improper adherence to HIV medication regimens in our study, self-efficacy
mediated this relationship.
Practice implications: Comprehensive intervention strategies that go beyond knowledge transfer may be needed to address self-efficacy
among patients across all literacy levels to be successful in the management of difficult medication schedules.
# 2006 Published by Elsevier Ireland Ltd.

Keywords: Literacy; Health literacy; Self-efficacy; Knowledge; HIV; Medication adherence

1. Introduction million people in the United States lack the literacy

The prevalence and consequences of poor HIV medication
adherence have been repeatedly documented in the literature,
and adherence has been linked to specific patient and regimen
characteristics [1–4]. Literacy may play a role; previous
studies have shown that persons with low literacy skills are
more likely to possess a poor working knowledge of HIV and
its treatment [5–9]. According to the Institute of Medicine, 90
* Corresponding author at: Institute for Healthcare Studies, Northwestern
University, 676 N. St. Clair Street, Suite 200, Chicago, IL 60611,
United States.
E-mail address: mswolf@northwestern.edu (M.S. Wolf).
proficiency needed to properly understand and act on health
information [10]. This has often been referred to as health
literacy; a reflection of both a patient’s ability and the literacy
prerequisites of the healthcare system. Low-income indivi-
duals, ethnic minorities, and persons in rural areas are
disproportionately hindered by literacy barriers and therefore
face significant health literacy barriers as well [11].
The direct relationship between patient literacy and HIV
medication adherence behavior has received limited
attention. Kalichman et al. found that infected patients
with limited literacy had less general knowledge of the
disease and their own treatment compared to patients with
adequate literacy skills, and were less likely to have an

0738-3991/$ – see front matter # 2006 Published by Elsevier Ireland Ltd.

doi:10.1016/j.pec.2006.08.006
254 M.S. Wolf et al. / Patient Education and Counseling 65 (2007) 253–260
undetectable viral load [5,6]. Yet other studies reporting an
association between literacy and treatment knowledge have
either failed to report or did not find a significant association
between low literacy and improper adherence to medication
regimens [7,8].
1.1. Literacy and self-efficacy
Self-efficacy related to managing medications may help
explain why many lower literate patients may not adhere to
their antiretroviral regimen. Self-efficacy refers to an
individual’s own perceived ability to perform a specified
behavior or set of behaviors. This is a construct central to
Social Cognitive Theory, which proposes that behaviors are
determined not solely by knowledge, but rather by the
outcome and efficacy expectations related to performing
them [12,13]. Outcome expectations refer to an individual’s
perceptions about whether behaviors will lead to certain
outcomes, while efficacy expectations (self-efficacy) refer to
the individual’s beliefs about whether he or she can
successfully enact the behavior in question. Self-efficacy
has been previously investigated in a variety of contexts and
settings; it has been repeatedly shown to predict the
likelihood of initiating communication [14], adjusting to
illness and treatment [15–17], and engaging in recom-
mended health behaviors [18,19]. Self-efficacy has also been
proposed as a mediating factor between educational
attainment and health behaviors [20,21].
1.2. Purpose of study
We have previously reported low literacy to be a
significant independent predictor of HIV treatment knowl-
edge and correct identification of medications in one’s
current regimen among a diverse cohort of patients in
Chicago, Illinois and Shreveport, Louisiana. For the present
study, we sought to investigate among this same cohort of
patients: (1) the relationship between limited literacy and
HIV medication adherence; and (2) whether HIV treatment
knowledge, self-efficacy, or both mediated the literacy-
adherence relationship.
Based on prior studies examining the relationship
between literacy and health outcomes [22], and common
proposed pathways for how literacy might impact HIV
medication adherence [23], we hypothesized that limited
literacy would directly influence both patients’ knowledge
of their treatment regimen and self-efficacy to properly
manage medication schedules. Combined, knowledge and
self-efficacy are likely to empower individuals to engage in
the recommended health behaviors associated with proper
administration and adherence to prescribed antiretroviral
regimens [24]. While other variables (e.g., culture, socio-
economic resources) may factor into literacy, self-efficacy,
and treatment knowledge, we specifically sought to
examine the proximal relationships between these variables
in this study.
2. Methods
2.1. Sample
The study sample and methods have been previously
described in detail [9]. From June to September 2001, we
enrolled a total of 204 consecutive HIV-infected patients
receiving medical care who were prescribed one or more
antiretroviral medications and received medical care through
outpatient infectious disease clinics at the Northwestern
Memorial Hospital (Chicago site) and the Louisiana State
University Health Sciences Center at Shreveport (LSUHSC).
Patients who had been on their current regimen for less than 2
weeks were excluded from participation, as were those with
one or more of the following conditions, as noted in the
medical record: (1) dementia; (2) blindness or severely
impaired vision not correctable with eyeglasses; (3) deafness
or hearing problems uncorrectable with hearing aid; (4) too ill
to participate in the survey. Approval for human subjects
research was obtained from institutional review boards at both
study sites prior to consenting patients to the study.
2.2. Data and procedure
Trained research assistants received referrals of inter-
ested and eligible patients from clinic health providers, then
engaged in an informed consent process and conducted a
structured interview with recruited patients. All interviews
were conducted in a private room at each respective clinic
immediately prior to patients’ scheduled physician visits.
Information gathered pertained to patient demographic
information, treatment knowledge, self-efficacy for medica-
tion management, literacy level, and regimen adherence.
Demographic questions specifically included patient age,
gender, race/ethnicity, level of educational attainment,
employment status, monthly income, and health insurance
coverage.
2.2.1. Medication adherence
Patients self-reported any recent missed doses using
pages that contained names and color photographs of
common HIV medications included in a revised version of
the Patient Medication Adherence Questionnaire (PMAQ)
[25,26]. Revisions to the PMAQ included question items that
were simplified to be more easily understood by lower
literate patients, and the visual cues to aid in regimen
identification. Patient antiretroviral agents, as well as co-
morbidities and non-HIV prescriptions, were obtained
through medical chart reviews.
The PMAQ requires patients to identify their medication
and then report on a missed dose in the past 4 days for each
antiretroviral agent in their HAART regimen. Specifically,
four questions were asked regarding whether the patient had
missed taking a dose yesterday, the day before yesterday, 3
days ago, and over the past weekend. Patients were rated as
having proper adherence if they self-reported no missed
 M.S. Wolf et al. / Patient Education and Counseling 65 (2007) 253–260
doses in this time period, while those acknowledging one or
more missed doses were considered non-adherent.
2.2.2. Treatment knowledge
An HIV treatment knowledge score was derived through a
series of five open-ended questions that asked patients to (1)
provide a working definition for CD4 lymphocyte count, (2) a
working definition for viral load, (3) demonstrate an under-
standing of a CD4 lymphocyte count by stating whether the
value should go up or down, (4) demonstrate an understanding
of viral load by stating whether the value should go up or down,
and (5) correctly identify all medications in their current
regimen using pages containing names and color photographs
of all common HIV medications. A Board certified Infectious
Disease physician blinded to patient characteristics and other
questionnaire results classified CD4 count and viral load
knowledge as correct if the patient could provide a relevant
description of the terms and the desired goals of treatment.
Patient knowledge of HIV medications was coded as correct if
they identified all medications, or incorrect if they identified
the wrong medications or did not report all medications in their
HAART regimen. For this study, patients were scored as
having high knowledge if they responded to all five items
correctly, moderate knowledge if they answered correctly to
three to four items, and low knowledge if they appropriately
responded to fewer than three of the five items.
2.2.3. Self-efficacy
Patients’ self-efficacy to properly take and manage their
HIV medications was measured using a 25-item scale
included in the PMAQ [25]. Items included statements
related to perceived difficulties associated with adhering to
HAART regimens, including pharmacy access, social stigma,
employment, social support, attitude, provider communica-
tion, dietary restrictions, adverse medication reactions, recall,
and regimen complexity. Patients were asked to respond to
each statement by endorsing the item on a 3-point scale
(agree, not sure, disagree). In the current study, this measure
showed good internal consistency (alpha = 0.80). A total
medication self-efficacy score was calculated (range 25–75);
with participants categorized as having either low (<40),
moderate (40–50), or high (>50) self-efficacy.
2.2.4. Literacy
Patient literacy was assessed using the Rapid Estimate of
Adult Literacy in Medicine (REALM), a health word
recognition test that is the most common measure of adult
literacy in medical settings [27]. Patients are asked to read
aloud 66 medical terms. Scores are determined based on the
total number of words pronounced correctly, with dictionary
pronunciation being the scoring standard. Raw scores are
then converted into one of four reading grade levels: 3rd
grade or less (0–18), 4th–6th grade (19–44), 7th–8th grade
(45–60), and 9th grade and above (61–66). In health care
studies where patients need only be categorized as low
(scores 0–44), marginal (scores 45–60) or adequate (scores
255
61–66) readers, the information provided by the REALM is
generally sufficient. The REALM is highly correlated with
standardized reading tests and the Test of Functional Health
Literacy in Adults (TOFHLA) [28,29].
2.3. Statistical analysis
Chi-square and student’s t-tests were used to evaluate the
association between patient literacy, demographic (age,
gender, race, insurance coverage, employment, monthly
income, site) and clinical (number of HIV and non-HIV
medications currently taken, comorbidity, treatment in past
6 months for mental illness or illicit drug use) character-
istics, treatment knowledge, medication self-efficacy, and
self-reported adherence to HAART regimens (100%
adherence versus <100% adherence, past 4 days). Patient
literacy was classified either as low (6th grade and below),
marginal (7th–8th grade) or adequate (9th grade and higher).
Multivariate logistic regression models were used to
estimate the independent relationship between low literacy
and the outcomes of HIV treatment knowledge, medication
self-efficacy, and medication adherence while controlling
for potential confounding variables (age, gender, race, site)
and risk factors (number of HIV medications in regimen,
other medications taken, comorbidity, history of mental
illness and/or illicit drug use).
2.3.1. Mediational analysis
We used a method for using regression analysis to
analyze the pathways linking literacy and HIV medication
adherence is mediational analysis [30]. Mediating variables
are those thought to lie in a causal pathway between the main
predictor variable and the outcome. First, the independent
relationship between literacy and medication adherence was
established after adjusting for all exogenous covariates and
potential interaction effects (baseline model). Second, the
relationship between literacy and HIV treatment knowledge
and medication self-efficacy were then examined. Finally,
both knowledge and self-efficacy were added to the baseline
model as mediators, and changes in odds ratios for patient
literacy analyzed. This approach has been used by others to
study the degree to which health behaviors mediate the effect
of socioeconomic status on health [31]. Model calibration
and discrimination was estimated using the Hosmer–
Lemeshow goodness-of-fit chi-square test and the c-statistic
from receiver operating characteristic (ROC) curves. All
statistical analyses were performed using STATA, version
8.0 (College Station, TX).
3. Results
3.1. Sample characteristics
The mean age of respondents was 40.1 years (S.D. = 9.2
years), 45.1% of the patients were African-American and
256 M.S. Wolf et al. / Patient Education and Counseling 65 (2007) 253–260

79.9% were male. More than half of respondents (55.9%)
were unemployed, 39.7% had a household income less than
$800/month, and 27.5% did not carry any health insurance.
Over 60% of patients reported at least some college
education. Approximately one-third of patients had limited
literacy skills; 11.3% were reading at or below a 6th grade
level (low literacy) and 20.1% were reading at a 7th–8th
grade level (marginal literacy). More than half (52.5%) of all
patients were also receiving treatment for a non-HIV related
chronic illness. Nearly one-third reported receiving mental
health services and 9.3% received treatment for alcohol or
illicit drug use in the past 6 months. Significant differences
in demographic and clinical characteristics were noted
across literacy levels, and are shown in Table 1. In particular,
respondents with limited literacy were more likely to be
African-American, male, lower educated, employed but
uninsured, and to be from the Shreveport site.
3.2. Self-efficacy, knowledge, and adherence
Over 70% of the patients were taking 3 or more
antiretroviral medications in addition to a mean of 3

Table 1
Characteristics of sample, stratified by literacy level
Variable Literacy level p-Value
Adequate (n = 140) Marginal (n = 41) Low (n = 23)
Age 0.91
<40 57.9 63.4 56.5
40–50 29.3 26.8 26.1
>50 12.8 9.8 17.4
Gender 0.03
Male 78.3 65.9 84.3
Race <0.001
African-American 31.4 68.3 86.9
Education <0.001
<High school 5.7 22.0 34.8
High school graduate 17.9 43.9 43.5
>High school 76.4 34.1 21.7
Monthly income 0.06
<$800 33.6 43.9 69.6
$800–999 24.3 24.4 13.0
$1000–1500 11.4 9.8 0.0
>$1500 30.7 21.9 17.4
Employment <0.001
Unemployed 73.9 56.1 52.9
Employed, part-time 13.0 17.1 15.0
Employed, full-time 13.1 26.8 32.1
Insurance <0.001
Private 33.6 21.9 0.0
Medicare 20.0 22.0 13.0
Medicaid/free care 46.4 56.1 87.0
Site 0.02
Shreveport 50.7 43.9 78.3
Chicago 49.3 56.1 21.7
HIV Treatment Knowledge Score <0.001
Low 17.1 48.8 78.3
Moderate 33.6 34.1 8.7
High 49.3 17.1 13.0
HIV Medication Self-efficacy Score <0.001
Low 24.3 19.5 60.9
Moderate 43.6 39.0 30.4
High 32.1 41.5 8.7
Number of HIV medications in regimen 0.17
1–2 25.9 35.5 45.0
3 or more 74.1 64.5 55.0
Medication adherence, past 4 days 0.01
100% adherence 70.0 80.5 47.8
 M.S. Wolf et al. / Patient Education and Counseling 65 (2007) 253–260 257

Table 2
Adjusted Odds Ratios (OR) for low HIV treatment knowledge and medication self-efficacy by literacy levela
Outcome Literacy level
Adequate (n = 140) Marginal (n = 41) Low (n = 23)
Low HIV treatment knowledge (%) 17.1 48.8 78.3
Crude OR (95% CI) 1.0 1.7 (0.5–6.3) 2.3 (1.1–5.6)
Adjusted OR (95% CI) 1.0 1.5 (0.4–7.0) 2.4 (2.2–2.6)
Low HIV medication self-efficacy (%) 24.3 19.5 60.9
Crude OR (95% CI) 1.0 0.8 (0.6–1.0) 4.8 (3.8–6.1)
Adjusted OR (95% CI) 1.0 1.6 (0.3–3.2) 5.8 (2.0–15.7)
Poor HIV medication adherence (%) 70.0 80.5 47.8
Crude OR (95% CI) 1.0 0.5 (0.2–1.2) 2.9 (1.3–6.5)
Adjusted OR (95% CI) 1.0 2.1 (0.8–5.5) 3.3 (1.3–8.7)
CI, confidence interval.
a
Odds ratios adjusted made for age, insurance coverage, employment status, number of medications in HIV regimen, number of non-HIV prescription
medications currently taken, presence of a comorbid chronic condition, treatment for a mental health condition in past 6 months, and treatment for alcohol or
drug use in past 6 months.

(S.D. = 2.9) non-HIV prescription medications. Patients Odds Ratio (AOR) 2.4, 95% confidence interval (CI) 2.2–2.6),
with low literacy had the highest rate of non-adherence low medication self-efficacy (AOR 5.8, 95% CI 2.0–15.7),
(52.2%), while individuals with marginal literacy skills were and medication non-adherence in the past 4 days (AOR 3.3,
least likely to self-report missing any doses of antiretroviral 95% CI 1.3–8.7).
medications (19.5%). Lower literate patients were more
likely to possess poorer knowledge of their HIV treatment, 3.3. Mediational analyses
and report lower self-efficacy for taking their medications as
prescribed. The multivariate model for medication non-adherence in
Multiple logistic regression models that included HIV the past 4 days was repeated in mediational analyses,
treatment knowledge, medication self-efficacy, and medica- including the hypothesized potential mediating factors of
tion adherence as dependent variables were analyzed using HIV treatment knowledge and medication self-efficacy
generalized estimating equations (GEE) for binomial data (Table 3). When both of these variables were entered into the
(Table 2). Low literacy (6th grade) was a significant model, the relationship between literacy and medication
independent predictor of low treatment knowledge (Adjusted adherence attenuated to a point of non-significance (AOR
2.0, 95% CI 0.8–5.3). Low medication self-efficacy, but not
low HIV treatment knowledge, was a significant indepen-
Table 3
Adjusted Odds Ratios (AOR) for non-adherence to HIV medication regi-
dent predictor of medication non-adherence in the final
men, past 4 days model (AOR 7.4, 95% CI 2.7–12.5).
Variable Model 1 Model 2a
Other independent predictors of medication non-adher-
b
ence were older age (>50; AOR 1.6, 95% CI 1.2–2.2) and
AOR 95% CI AORb 95% CI
three or more antiretroviral agents in one’s HIV regimen
Literacy level (AOR 1.2, 95% CI 1.1–1.3). Interactions with literacy,
9th grade (adequate) 1.0 (Referent) 1.0 (Referent)
7th–8th grade (marginal) 2.1 0.8–5.5 1.6 0.6–4.7
knowledge, and medication self-efficacy were entered into
6th grade (low) 3.3 1.3–8.7 2.0 0.8–5.3 the model; none were statistically significant.
HIV treatment knowledge
High 1.0 (Referent)
Moderate 0.8 0.5–1.2 4. Discussion and conclusion
Low 1.1 0.7–1.6
HIV medication self-efficacy 4.1. Discussion
High 1.0 (Referent)
Moderate 3.1 1.4–6.9 We recruited patients from two regions of the United
Low 7.4 2.7–12.5 States to examine the relationship between literacy and
CI, confidence interval. adherence to HIV antiretroviral medications. Nearly one-
a
Model diagnostics: Hosmer–Lemeshow chi-square p = 0.57; c = 0.74. third of patients in our sample were less than 100% adherent
b
Adjustments made for age, insurance coverage, employment status,
to their HAART regimen, and patient literacy level was
number of medications in HIV regimen, number of non-HIV prescription
medications currently taken, presence of a comorbid chronic condition, associated with more than a three-fold greater likelihood of
treatment for a mental health condition in past 6 months, and treatment for missed doses. This provides general support for previous
alcohol or drug use in past 6 months. findings that documented the association between limited
258 M.S. Wolf et al. / Patient Education and Counseling 65 (2007) 253–260
literacy and improper adherence to antiretroviral regimens.
Yet in mediational analyses, the effect of literacy on
adherence was reduced by 40% after knowledge and self-
efficacy were included in the model. Self-efficacy to manage
medications, but not treatment knowledge, was a significant
mediating factor that independently predicted missed doses
in a patient’s antiretroviral regimen. To our knowledge, this
is the first study that documents the association between
limited literacy, self-efficacy, and medication adherence in
the context of HIV.
This finding is important, given that many low literacy
intervention strategies have focused on more superficial
pathways between literacy and health behaviors, such as
simplifying health education materials to improve patient
knowledge of disease and treatment [32–35]. Knowledge,
alone, may not sufficiently explain the barrier faced by
individuals with limited literacy skills. Yet this should not be
surprising, as this notion is supported by previous studies
that found significant associations between low literacy and
inadequate health knowledge, but were not able to make the
next link between literacy and the health outcome under
investigation [8,36,37].
Our research also supports previous speculations that the
relationship between literacy and health outcomes, includ-
ing medication adherence, is not linear [37–40]. Rather,
there may be a threshold effect where low literacy, at the 6th
grade level and below, poses a substantial problem on
adherence to antiretroviral regimens. It is also possible that
the REALM, while considered to be the most practical
literacy assessment for healthcare settings currently avail-
able to researchers, lacks the precision needed for a detailed
analysis of the literacy–medication adherence relationship
[28].
4.1.1. Limitations
Additional study limitations should be mentioned. We
assessed adherence via self-report rather than more objective
measures, such as random pill counts, MEMS caps, or
pharmacokinetic laboratory assessments. Although we
utilized an existing, validated assessment tool to measure
HIV medication adherence, patients may under-report
missed doses through questionnaires [25,26]. However,
several recent studies have concluded that brief self-report
measures, such as the PMAQ, are viable and accurate means
to measure adherence behaviors [3,41,42]. Our data is also
derived from a cohort of HIV-infected patients interviewed 5
years ago, and may not directly reflect the experience of
those currently on HAART regimens. While more recent
advances offer the potential for simplified and less restrictive
dosing schedules, adherence still remains a significant
challenge for patients with the disease [43,44]. Therefore,
we believe our findings to still be relevant in the present day.
Yet even with the reduction in pill burden, seemingly simple
medication schedules and instructions may prove difficult to
patients with limited literacy [45,46]. In addition, other
studies have shown that limited literacy impacts the ability
of individuals to perform the constellation of skills needed to
manage chronic disease, such as long-term medication use,
translating to worse health outcomes [47]. Finally, we were
unable to control for other possible contributing variables
such as social support in our model. Social support has
previously been described as a mediating factor in the
relationship between health literacy and outcomes, and is
likely to have a similar role in the literacy and self-efficacy
relationship [48].
4.2. Conclusion
The responsibility for the successful management of
chronic disease should not solely reside with the patient,
especially for those with limited literacy skills. The Institute
of Medicine has highlighted the important role of the health
system in shaping a more health literate environment [10].
Future research should further explore direct and indirect
pathways, including knowledge and self-efficacy, through
which literacy affects health outcomes among patients with
HIV and other chronic conditions. Research should also
continue to be aimed at further developing and evaluating
the effectiveness of novel low literacy interventions with
respect to health outcomes and costs. These strategies should
also be tested in diverse clinical settings, including
community health centers that have government mandates
to serve low-income, minority patients at greater risk for
literacy barriers and who face more challenging social
environments.
4.3. Practice implications
Interventions are needed that extend beyond the many
‘plain language’ programs developed over the past decade
that have been a hallmark professional response to the
health literacy epidemic. These methods have resulted in
only minimal improvements in knowledge outcomes
among individuals with low literacy skills, and usually
do not lead to improvements in health behaviors [32–34].
Instead, comprehensive interventions are needed that
target both patient understanding and self-efficacy through
empowering approaches to care. Lorig and colleagues
have extensively documented the effectiveness of a
general chronic disease self-management program at
improving self-efficacy and health outcomes [49–51].
However, their program requires further testing for use
among lower literate and socioeconomically disadvan-
taged adults.
Patients’ literacy and self-efficacy to manage their
medications can be addressed by improving the commu-
nication skills of healthcare providers. This would include
avoiding technical jargon, encouraging questions, and using
the ‘teach back’ technique to confirm patient understanding.
Providers might also consider discussing the specific
implementation of the medication schedule within the
patient’s current lifestyle and daily routine [52]. This allows
 M.S. Wolf et al. / Patient Education and Counseling 65 (2007) 253–260
for preventive problem-solving around potentially difficult
scenarios that might lead to missed doses. Existing tools are
in place to guide provider communication skills training and
evaluation [53].
Beyond the physician and patient encounter, interven-
tions should address the need for minimizing the complexity
of demands placed on the patient by the health system.
Schillinger and Davis offer examples for doing this,
including reallocating resources to support multidisciplinary
teams, outreach activities and the ongoing monitoring of
patients under chronic care [54]. New advances in multi-
media technology could be used to better disseminate patient
education and to provide follow-up reminders to patients as
well as providers. Recently, new low literacy chronic disease
management strategies were developed and tested that
included care coordination and intensive education and
follow-up for patients with diabetes and heart failure [55].
These methods appear to be highly effective and could be
translated for the management of HIV. Both literacy and
self-efficacy should be measured in the evaluation of similar
HIV intervention strategies to ensure the identified
disparities are addressed.
Acknowledgement
Dr. Wolf is supported by a Centers for Disease Control and
Prevention Career Development Award (K01 EH000067-01).
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