Health Literacy in the Elderly
More than half of the United States’ elderly population is unable to meet their own health care demands. This includes preventative services, reading prescription bottles, communicating effectively with health care providers, and having positive health outcomes in the face of chronic disease. The failure to meet these needs is related to low health literacy, or the lack of social and cognitive skill sets to understand information provided to them or seek out new services.
Low health literacy places an unfortunate health risk on the patient and a financial risk on the health care system. Nursing is obligated as a health care provider to identify patients with limited health literacy and provide unique communication of education. As a profession, nursing should also be empowered to reduce cost to health care and adjust change to nursing curricula to include health literacy concepts. Health Literacy of the Elderly Health literacy has varied definitions that are dependent on the organization or discipline for which the discourse is occurring.
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A collaboration of definitions of health literacy is the ability to employ reading and math skills to function in health related activities, the social and cognitive capacity to obtain and understand the health information as it is provided to them, the ability to seek out medical services, and the sense to maintain good health (Speros, 2005, p. 635). There is not one agreed upon definition of this concept by any one agency or discipline. This serves to affirm what Speros (2005, pp. 33-634) acclaimed to be true: since health literacy is a new concept over the last two decades, the clear definition of it and ownership with subsequent accountability should belong to nursing.
This is again confirmed as nursing is held accountable as healthcare providers lacking in proficiently teaching their patients as assessed via The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group survey (Weidmer, Brach, & Hays, 2012, p. 3). McCleary-Jones (2012, p. 14) also espouses the goals of Healthy People 2020 in relation to health literacy and that promotion of educational curricula of nursing will help to reach those benchmarks while fulfilling the core values and focus of nursing in general of communication, patient education, and advocacy (Ferguson & Pawlak, 2011, p. 123). Medical schools are already mandated to teach and assess that curriculum for communication skills of new physicians and are beginning to incorporate health literacy practices (Harper, Cook, & Makoul, 2007, p. 113).
As a topic that could be intimately defined and uniquely addressed by nursing, it is imperative that nursing education programs rise to the occasion to prepare future generations of nurses identify those at high risk of inadequate health literacy and how to appropriately intervene on their behalf. Background The US Department of Education performed an assessment of a sample population of 19,000 adults over the age of 16 in 2003 with the goal of understanding better the state of literacy as it pertained to their ability to use the written word to function productively in society (Jones, 2007, p. 51). Approximately half of the sample population was not proficient at a level that would be required to actively participate in health care activities with confidence in health literacy (Jones, 2007, p. 951). The same US Department of Education assessment included a health literacy section specifically separate from the general literacy portion and the findings were consistent; 53% of the sample population had intermediate health literacy (Jones, 2007, p. 953).
At the time of the study, this meant that 75 million adults in the United States were unable to participate confidently in their own health care decisions and care as necessary and defined by health literacy (Jones, 2007, p. 953). 59% of the sample population were white, over the age of 65, and had basic or below basic health literacy (Jones, 2007, p. 954). Patients with lower health literacy are at risk for higher rates of hospitalization, poor health outcomes, and increased rates of mortality (Barrow, 2012, p. 20).
These increased risks are not because these aggregates do not seek care, but merely that they may seek care later or that they do not seek preventative services such as those notably sought by their health literate counterparts (Barrow, 2012, p. 20). Lack of preventative services may lead patients to seek care at emergency facilities instead of primary care practices, causing an increase to rising health care costs and congestion to already crowded emergency departments (Scudder, 2006, p. 32). Health literacy skills can be attributed to higher levels of preventative care and healthier outcomes (Barrow, 2012, p. 20).
A common misconception could be that increased number of school years leads to increased knowledge and literacy. Previous studies have shown, too, that the number of years in school is directly inversely proportional to the overall mortality of the individual (Baker, Parker, Williams, Clark, & Nurss, 1997, p. 1027). A more important indicator, however, is the literacy attainment while in formal education, not the number of years of schooling (Baker et al. , 1997, p. 1027). How long someone spends within an institution is chronology whereas literacy level is a better barometer of future ability to adjust to future health demands (Baker et al. 1997, p. 1030). In example, someone in their 70’s completed high school more than fifty years earlier, with different educational and social standards, different health care needs and technology, and without chronic health changes. What is more likely to be an accurate reflection on that individual’s ability to cope with their health care demands is more dependent on what has helped them to learn and grow during the 50 years that has elapsed since graduation than the 4 years leading up to it (Baker et al. , 2002, p. 1282).
As people age their reading abilities decline and their cognitive impairments increase (Scudder, 2006, p. 31). This, unfortunately, occurs at a time when the complexity of their medical disease courses are increasing and their therapies are continuing to become more intricate (Scudder, 2006, p. 31). Poor health literacy of the elderly population demonstrates that they have a lack of understanding about their disease processes and that it is important that educational interventions are tailored to their unique needs (Eckman et al. , 2012, p. 149).
Adults over the age of 65 are also the population with the most prevalent needs for chronic disease management (Baker, et al. , 2002, p. 1278). As mentioned before 59% of this age demographic is unable to participate at a functional health literacy level for the sake of its own health care. As also discussed previously, the lower reading ability is probably attributable to age-related changes and not a lack of education. Baker et al. , (2002, p. 1278) also explains that the elderly’s prevalence for chronic diseases and poor health literacy are not directly related to poor mental health or dementia.
Problem Statement Limited health literacy of adults age 65 and older leads to an increased risk for poor health outcomes and increased rates of hospitalizations, which translates to rises in health care expenditures. Nurses have a professional responsibility to ensure that patients understand their health-related information as it is provided to them. Significance Approximately 40 million Americans over the age of 65 have a below average level of health literacy and are unable to perform basic health care functions (Jones, 2007, p. 954).
This is unfortunate as this population demographic is the one more likely to require chronic disease management, prescription bottle interpretation, appointment management, self-care instructions, preventative maintenance, health education, and home health aid (Baker, et al. , 2002, p. 1278). The discrepancy between health literacy and health care needs may have important cost implications. As the elderly do not utilize preventative services from failure to accurately comprehend their treatment regimen, they may seek emergency services and primary care options (Baker, et al. , 2022, p. 1278).
A 2005 study of Medicare recipients concluded that those that demonstrated low levels of health literacy were more likely to employ an inefficient mix of emergency services and less preventative care, thus costing more health care dollars (Scudder, 2006, p. 32). Hospitalization rates are twice as high (52%) for patients with lower health literacy capabilities (Baker, et al. , 2002, p. 1282). Regardless of socioeconomic background, educational achievement, or self-reported health status, health literacy remained an independent variable that affects admission rates and, ultimately, health care expenditures (Baker, et al. 2002, p. 1278). Preventative services, also underutilized by lower literacy individuals, raise the cost of health care when hospitalization or emergency care is sought for treatment (Scudder, 2006, p. 31).
In 2003, the Agency for Healthcare Research and Quality (AHRQ) reviewed the relationship between health literacy and health outcomes. The findings of that report mandated that the use of preventative services correlated with higher levels of health literacy (Scudder, 2006, p. 31). The AHRQ also confirmed that lower health literacy leads to poorer health outcomes (Scudder, 2006, p. 31). Summary Ferguson and Pawlak (2011, p. 26) develop the term “medicalization” in reference to reimbursement for services rendered to patients based on diagnoses and procedures and a lack of incentive to spend time on education because of a lack of fiscal incentive for providers. Nurses can therefore play an even more instrumental role in advocating health literacy on behalf of their patients, especially the largest demographic, the elderly. With the relative new development and lack of clear definition of health literacy across all disciplines, nursing could play a more integral role in education and advocacy for this aggregate population.
Nursing curricula should begin to incorporate health literacy concepts (McCleary-Jones, 2012, p. 214). As new nurses enter the workforce, they will be trained to identify patients with lower levels of health literacy, enhance communication with those individuals, offer alternative educational materials to decrease the risk of poor health outcomes and comorbidities, and those new nurses will have a higher appreciation for continuing education as it pertains to health literacy (McCleary-Jones, 2012, p. 214).
Exposing student nurses to health literacy concepts will also allow them to recognize different screening tools available to formally measure health literacy (McCleary-Jones, 2012, p. 214). Training future nurses in health literacy is also in keeping with the goals of Healthy People 2020, whereas there is an objective to increase the health literacy skills of practitioners (McCleary-Jones, 2012, p. 214). Providing nursing to the elderly population in order to improve health literacy will require specific and unique education interventions tailored to the individual.
Assessment must occur that incorporates the person’s literacy level, cultural consideration, and without fear of embarrassment (Speros, 2005, p. 638). Comprehension might be increased with the use of plain language, pictures, audio-visual cues, information limiting per visit, teach backs, and speaking slowly (Speros, 2005, p. 638). The most important aspect of education for the patient is shame-free support that is tailored to their literacy level (Speros, 2005, p. 638). This communication is the responsibility of the provider, in this case, the nurse (Ferguson & Pawlak, 2011, p. 25). An improvement in communication, education, and health literacy will improve the health outcome for the patient, reduce morbidity, hospitalizations, increase preventative care, and reduce health care costs.
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