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. 2020 Jun;68(6):1279-1285.
doi: 10.1111/jgs.16381. Epub 2020 Feb 24.

Literacy Mediates Racial Differences in Financial and Healthcare Decision Making in Older Adults

S Duke Han  1   2   3   4   5   6   7 , Lisa L Barnes  5   6   7 , Sue Leurgans  6   7 , Lei Yu  6   7 , David A Bennett  6   7 , Patricia A Boyle  5   6
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Free PMC article

Literacy Mediates Racial Differences in Financial and Healthcare Decision Making in Older Adults

S Duke Han et al. J Am Geriatr Soc. 2020 Jun.
Free PMC article

Abstract

Background/objectives: Decision making in financial and healthcare matters is of critical importance for well-being in old age. Preliminary work suggests racial differences in decision making; however, the factors that drive racial differences in decision making remain unclear. We hypothesized literacy, particularly financial and health literacy, mediates racial differences in decision making.

Design: Community-based epidemiologic cohort study.

Setting: Communities in northeastern Illinois.

Participants: Nondemented Black participants (N = 138) of the Rush Alzheimer's Disease Center Minority Aging Research Study and the Rush Memory and Aging Project who completed decision-making and literacy measures were matched to White participants (N = 138) according to age, education, sex, and global cognition using Mahalanobis distance (total N = 276).

Measurements: All participants completed clinical assessments, a decision-making measure that resembles real-world materials relevant to finance and healthcare, and a financial and health literacy measure. Regression models were used to examine racial differences in decision making and test the hypothesis that literacy mediates this association. In secondary analyses, we examined the impact of literacy in specific domains of decision making (financial and healthcare).

Results: In models adjusted for age, education, sex, and global cognition, older Black adults performed lower than older White adults on literacy (β = -8.20; SE = 1.34; 95% CI = -10.82 to -5.57; P < .01) and separately on decision making (β = -.80; SE = .23; 95% CI = -1.25 to -.34; P < .01). However, when decision making was regressed on both race and literacy, the association of race was attenuated and became nonsignificant (β = -.45; SE = .24; 95% CI = -.93 to .02; P = .06), but literacy remained significantly associated with decision making (β = .04; SE = .01; 95% CI = .02-.06; P < .01). In secondary models, a similar pattern was observed for both financial and healthcare decision making.

Conclusions: Racial differences in decision making are largely mediated by literacy. These findings suggest that efforts to improve literacy may help reduce racial differences in decision making and improve health and well-being for diverse populations. J Am Geriatr Soc 68:1279-1285, 2020.

Keywords: decision making; disparities; financial; health; literacy; race.

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Conflict of interest statement

Conflict of Interest Disclosures: No conflicts of interest

Figures

Figure 1.
Figure 1.. Mediation of Race Association with Total Decision Making by Literacy.
Standardized regression coefficients for the association between race and literacy (−8.20) and literacy and total decision making (0.04), after multiplication, estimate the indirect effect of race on total decision making through literacy. The direct effect of race on total decision making is estimated by standardized regression coefficient for the association between race and total decision making after controlling for literacy (−0.45). Regression models were adjusted for age, education, sex, and global cognition. *p<0.05
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