Literacy and race as risk factors for low rates of advance directives in older adults

Objectives: To examine the effect of the relationship between literacy and other individual-level factors on having an advance directive (AD).

Design: Face-to-face structured interview.

Setting: Participants were recruited from an academic general internal medicine clinic and one of four federally qualified health centers in Chicago.

Participants: Seven hundred eighty-four adults aged 55 to 74.

Measurements: Assessment of participant literacy, sociodemographic factors, and having an AD for medical care.

Results: One-eighth (12.4%) of participants with low literacy, 26.6% of those with marginal literacy, and 49.5% of those with adequate literacy reported having an AD (P < .001). In multivariable analyses, literacy and race were independently associated with less likelihood of having an AD. Specifically, participants with limited literacy (risk ratio (RR) = 0.45, 95% confidence interval (CI) = 0.22-0.95) and African Americans (RR = 0.64, 95% CI = 0.47-0.88) were less likely to have an AD. Exploratory analyses showed that there was not a significant interaction between the effect of literacy and race.

Conclusion: Limited literacy and African-American race were significant risk factors for not having an AD in this cohort of older adults. Literacy and race probably represent two separate but important causal pathways that need to be understood to improve how the healthcare system ascertains and protects individuals' advance care preferences.