people with adequate skills.14 Lower health literacy was associated with increased risk of death after hospitalisation for acute heart failure.15
Table 8.1 Common factors affecting health literacy.
Source: Based on Healthy People 20209.
| Factor | Impact |
|---|---|
| Age | Functional literacy declines with age. |
| Education | Ability to communicate with providers Ability to read written health instructions Ability to accurately interpret written health‐related information Ability to use electronic technology |
| Cognitive status | Poor mental health status Affects recognition of need for healthcare Affects ability to access necessary healthcare Affects ability to follow healthcare instructions |
| Income | Insurance status Living in poverty Job insecurity Immigration status |
| Race/Ethnicity | Differing cultural beliefs Lack of proficiency in the local language Lower education levels |
| Health status | Hearing loss Level of pain Level of disability Limitations of daily activities Poor physical functioning Vision loss |
Table 8.2 Consequences of low health literacy.
| Poorer physical healthPoorer mental healthDifficulty accessing health careDifficulty following instructions from a health care providerDifficulty taking medications properlyIncreased hospitalisationsPremature mortality |
Functional literacy declines with age.16 Home interviews conducted with community‐dwelling older adults (n = 2774) found that a significant decrease in health literacy was associated with every year increase in age, even following adjustments for gender, race, ethnicity, cognitive status, and education. Differences in newspaper reading frequency, visual acuity, chronic medical conditions, and health status did not explain older participants’ lower literacy. Both health literacy and cognitive abilities independently predict mortality.
Interventions to improve patient knowledge and self‐management skills should consider both the reading level and cognitive demands of the materials.17 Memory and verbal fluency are strongly associated with health literacy, independent of education and health status, even in those with subtle cognitive dysfunction. Reducing the cognitive burden of health information might mitigate the detrimental effects of limited health literacy in older adults.18 In addition, there are age differences in knowledge, as shown by Farrer, et al.19 in a study on mental health literacy. In Australia, this study showed that a community’s knowledge and beliefs about mental health problems, risk factors, treatments, and sources of help varied as a function of age. Older adults (70+ years) were poorer than younger age groups at correctly recognising depression and schizophrenia. Older respondents were more likely to believe that schizophrenia could be caused by character weakness.19
The role of education in health literacy
Education plays a key role in overcoming the effects of poor health literacy. If health information is shared via spoken instruction, it is best to remember that older adults understand medical information better when they are spoken to slowly, simple words are used, and a restricted amount of information is presented. Often, health literacy is addressed using written materials. However, in the United States, many older adults read at an eighth‐grade level, and 20% of the population reads at or below a fifth‐grade level. A study of 177 low‐income, community‐dwelling older adults (with no cognitive or visual impairments) was carried out to determine whether they had difficulty understanding written information provided by clinicians. The subjects’ mean reading skills were at a fifth‐grade level, below those of the general American population. One‐quarter of subjects reported difficulty in understanding written information from clinicians.20 However, most health care materials are written at a tenth‐grade level.10 Healthcare providers must identify older adults with marginal or inadequate health literacy and adjust their health care education strategies to meet these literacy needs. For optimal comprehension and compliance, patient education material should be written at a sixth‐grade or lower reading level, preferably including pictures and illustrations.14
It is also important to provide instruction in the language in which the patient is most fluent. For example, compared to those with adequate and marginal health literacy, women with inadequate functional health literacy in Spanish were significantly less likely to have ever had a Papanicolaou (Pap) test.21 Of course, having assessment tools translated into the original language does not solve health literacy problems. In Turkey, risk factors for the lowest levels of health literacy include being female educated at the primary school level, in poor economic conditions, and older.22 In California, Cordasco, et al.23 compared by age levels of health literacy, educational attainment, English comprehension, and language use in inpatients. They found that the prevalence of inadequate health literacy increased significantly with increasing age. The correlation between older age and lower health literacy persisted when controlling for educational achievement, race, ethnicity, gender, and immigration status. Additionally, older adults were more likely to have never learned to read, have no formal education, have limited English comprehension, and speak a non‐English language at home. This suggests that providers should develop and use low‐literacy educational materials, programmes, and services to meet the chronic disease needs of an older, multiethnic population and ameliorate the negative health effects of associated low literacy.23
Differences in mental health literacy across the adult lifespan suggest that more specific, age‐appropriate messages about mental health are required for different age groups.19 Care must be taken to tailor material to the audience to optimise understanding. This means providers should ensure that the material does not exceed the users’ literacy level and that any translated materials are sensitive to the culture of the target population.24
Educational strategies to improve health literacy
Fortunately, proper educational techniques (Table 8.3) can make a difference in health care for people with low health literacy.12 Of 111 patients with poorly controlled diabetes, 55% had literacy levels at the sixth‐grade level or below. Over the six‐month study period, patients with low and high literacy had similar improvements in A1C when they received one‐to‐one education and medication management using techniques that did not require high literacy from clinic‐based pharmacists. Among community‐dwelling Korean older adults, limited health literacy was associated independently with higher rates of chronic medical conditions and lower subjective health status. Nurses were found to be key to providing health education to these older adults25 to help them maintain their independence. The greatest potential barrier to addressing health literacy is that most patients are often unwilling to admit that they have literacy problems.14 Indeed, Weiss, et al. found that 97% of their research subjects, regardless of literacy level, reported that television was their primary source of information.20
Table 8.3 Educational techniques to improve health literacy.
Source: Based on Rothman, et al.12.
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Written materialIs age appropriateUses
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