Health Literacy Peer Reviewed Articles for Older Adults

Gerontol Geriatr Med. 2016 Jan-Dec; 2: 2333721416630492.

Health Literacy and Older Adults

A Systematic Review

Amy K. Chesser

^oneWichita State Academy, KS, U.s.a.

Nikki Keene Forest

¹Wichita State Academy, KS, USA

Kyle Smothers

²Medical School, Dublin, Republic of ireland

Nicole Rogers

¹Wichita State University, KS, U.s.

Received 2015 Apr 2; Revised 2015 Dec 17; Accepted 2015 Dec 30.

Abstract

Objective: The objective of this review was to assess published literature relating to wellness literacy and older adults. Method: The current review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Results: Eight articles met inclusion criteria. All studies were conducted in urban settings in the Usa. Report sample size ranged from 33 to 3,000 participants. Two studies evaluated health-related outcomes and reported significant associations between low health literacy and poorer health outcomes. Two other studies investigated the impact of health literacy on medication management, reporting mixed findings. Discussion: The findings of this review highlight the importance of working to improve health care strategies for older adults with low health literacy and highlight the need for a standardized and validated clinical health literacy screening tool for older adults.

Keywords: older adults, aging, health literacy, health outcomes, medication adherence, cognition, health disparities

Introduction

Wellness literacy is an important topic in today'southward wellness care environs (Cutilli, 2007). Ratzan and Parker (2000) define health literacy as "the caste to which individuals have the capacity to obtain, process, and understand basic health data and services needed to brand appropriate wellness decisions." (p. 4) Studies suggest that low health literacy levels are predictors of disparaging health outcomes. Patients with low health literacy use emergency services more frequently (Baker et al., 2002), take college health care costs (Weiss & Palmer, 2004), utilize preventive services such as vaccinations and mammograms less oft (Scott, Gazmararian, Williams, & Bakery, 2002), and are associated with higher mortality rates (Baker et al., 2007). Socioeconomic status, age, race, cognition, and instruction level are considered contributing factors of health literacy levels, with age as one of the highest correlates of low health literacy (Cutilli, 2007).

Older adults (age 65 and older) are currently the fastest growing population in the United States. It is estimated that older adults will account for 20% of the population by 2030 (Federal Interagency Forum on Aging-Related Statistics, 2008). The 2003 National Assessment of adult literacy estimated merely 3% of older adults, 65 and older, were skilful with wellness literacy skills (Kutner, Greenburg, Jin, & Paulsen, 2006). There are several different age-related changes that could contribute to the subtract in health literacy in older adults. Although the rate and severity of these age-related changes vary amidst individuals, these should exist considered when assessing an older adult'due south wellness literacy. A decline in an older adult's cognitive ability could contribute to an older adult's ability to embrace and/or recall new topics (Craik & Byrd, 1982; Cornett, 2006; Kintsch, 1998). Physical impairments such as hearing and vision loss may too contribute to a decreased ability to process health information (Cornett, 2006; Speros, 2009). Psychosocial factors such as socioeconomic status and coping may negatively influence agreement health information (Cornett, 2006). Regrettably, as the gap in physical and cerebral power betwixt younger generations and older adults widen, it can atomic number 82 to a sense of shame and embarrassment which reduces effective communication conduits and further complicates older developed health literacy (Cornett, 2006; Speros, 2009).

In an attempt to further understand health literacy in the older population, a systematic literature review was conducted. The current review includes studies specifically designed to measure the older adult population (65 years of age and older) and wellness literacy, related wellness outcomes, and interventions. Due to the limited number of articles published in this research expanse, the authors elected to include publications older than v years. Eight articles investigating older adults and wellness literacy met the inclusion criteria. Simply one review specifically addressed health literacy and older adults; however, this review was published in 2007 (Cutilli, 2007). The remaining reviews addressed a concept assay of the term health literacy in older adults, low wellness literacy and wellness outcomes, and health literacy among older cancer patients (Amalraj, Starkweather, Nguyen, & Naeim, 2009; Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; Oldfield & Dreher, 2010). The well-nigh recent of these reviews, Berkman et al. (2011), comprehensively addressed a wide population (young and one-time) and a diversity of measures related to health literacy. With respect to older adults, the authors identified and discussed five studies specifically addressing older adults. Based on review of these 5 studies, Berkman concluded that inside these samples, older adults with depression wellness literacy also exhibited poorer health. Given the importance for responsible health intendance stewardship, it is necessary for those involved in the care of older adults to empathise the touch on of health literacy, and the unique factors that affect older adults. Equally such, an updated systematic review regarding the health literacy of older adults is warranted to institute what is known and what can be done to aid set older adults to make the all-time health care decisions.

Method

The electric current review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA; Fink et al., 2010; Moher, Liberati, Tetzlaff, Altman, & Grp, 2009). Medline was used to identify peer-reviewed literature that included a combination of free-text and thesaurus terms for concepts including "health literacy, elderly, geriatrics, older adult, and low wellness literacy," combined with a qualitative and quantitative methods filter, respectively. Detailed search terms have been listed past database in Table 2. Searches were limited to January 1, 2010, through Dec 31, 2014, including merely publications written in English language and conducted within the United States. Our study overlapped the Berkman et al. (2011) review by several months to ensure no published studies were omitted. This strategy was adapted for other databases every bit required. A complete listing of the database search structure is constitute in Table 1. To place the relevant literature for this review, 5 electronic databases were searched: MEDLINE®, the Cumulative Alphabetize to Nursing and Centrolineal Health Literature (CINAHL), the Cochrane Library, PsychINFO, and the Educational Resources Information Middle (ERIC). Citations were imported into EndNote® data management software, when possible. Indistinguishable studies were identified and removed. Older adults were defined equally age 65 years onetime and older every bit commonly divers in industrialized countries and clinically within the United states (Hinrichsen & Molinari, 1998).

Table 1.

Database Search Construction.

Search	Search term construction	Articles located
1. PubMed (MEDLINE)	"The states"[Mesh] AND (elderly OR geriatric*) AND "wellness literacy" Filter: 2010/01/01 to 2015/12/31	260
2. CINAHL	"wellness literacy" AND (elderly OR geriatric*)	97
**Variant search	(("health literacy" AND (elderly OR geriatric)) AND United States US as keyword addition*	22
3. ERIC	health literacy AND (elderly OR geriatric*)	35
**Variant search	health literacy AND (elderly OR geriatric) AND U.s.a. US equally keyword improver	v
iv. Cochrane Library	MeSH descriptor: [Us] combined with wellness literacy AND (elderly OR geriatric*)	36
**Variant search	MeSH descriptor: [United States] combined with "health literacy"	238
5. PsycINFO	"health literacy" AND (elderly OR geriatric*) AND lo.Exact("US")	61
**Variant search	wellness literacy AND (elderly OR geriatric*) AND lo.Exact("US")	86

Table 2.

Summary of Health Literacy Studies.

Reference	Sample and setting	Health literacy measurement	Methodology	Central findings: Health literacy	Associated factors
Wolf, Feinglass, Thompson, and Bakery (2010)	due north = 2,956; 65+ years Medicare enrollees English speaking Multisite: Cleveland, Houston, Tampa and Fort Lauderdale/Miami	S-TOFHLA (divided into 7 categories instead of typical 3)	Cross-exclusive questionnaire Interviewer-administered survey (1 60 minutes in-home) Compared HL to self-rated physical function, mental wellness, and mortality rates	Depression HL associated with older age, non-White, lower income, less pedagogy, abstinence from booze consumption, less frequent PA and underweight Depression HLs reported more activeness limitations and worse baseline physical operation and mental health Literacy could be causally related to physical performance; decrease cognitive skills may lead to progressively lower agreement of how to stay salubrious, when to seek medical attention, and how to properly follow medical regimens to recover from acute and care for chronic health conditions	Graded relationship between literacy scores and baseline physical operation (lowest iii HL scores poorer physical part compared with highest HL category) Human relationship to mental health was a threshold rather than continuous (Categories one and 2 worse mental health compared with Category 7) All-cause mortality rate greater for those with lowest HL
Gerber, Cho, Arozullah, and Lee (2010)	n = 450; 65+ years African American M = 78.ii years Caucasian Yard = 76.viii years Medicare recipients Chicago, IL	Due south-TOFHLA	Cross-sectional questionnaire, interviewer-administered survey (in-dwelling house or medical center) Compared medication adherence past African American and Caucasian older adults	More African Americans reported a history of hypertension (70.7% vs. 57.one%; p = .003) or diabetes (26.3% vs. 14.7%; p = .003), worse health status, lower health literacy, worse depression scores, and less social back up compared with Caucasians (all, p < .001). African Americans were more likely to written report running out of medications before refilling them and not e'er following physician instructions on how to take medications. No difference between races was observed in forgetting to have medications.	Fifty-fifty later adjusting for differences in demographics, wellness literacy, depression, and social back up, older African Americans reported following medication directions less oft than older Caucasians.
Ganzer, Insel, and Ritter (2012)	n = 56; 65+ years M = 80.four years English speaking Community abode NYC metro area	S-TOFHLA	Cantankerous-sectional survey Descriptive pilot report Relationship between working retentivity, HL, and recollect of v signs of stroke	Over fifty% of the sample had loftier health literacy Signs of stroke recalled M = 2.9 ± i.33 Stroke sign call up was associated with working memory (r = .38, p < .01), health literacy (r = .44, p < .01), pedagogy (r = .36, p < .01), and dementia (r = .54, p < .01). Working memory was positively associated with educational activity (r =.58, p < .01), income that meets expenses (r = −.34, p < .05), health literacy (r = .57, p < .01), and age (r = −.33, p < .05). Health literacy was significantly related to education (r = .46, p < .01). Using regression, health literacy was the best predictor of stroke recall (β = .56, p < .01).	With additional regression analysis considering working memory, health literacy and dementia together, both health literacy (β = .28, p < .05) and dementia (β = .44, p < .01) were significantly associated with remember of signs of stroke. Results demonstrate that working retention and health literacy were significantly associated with recall of the signs of stroke. Only health literacy remained a significant predictor of the retrieve of the warning signs of stroke When MMSE (dementia) was included in regression, health literacy remained a significant predictor of recall, simply dementia was more strongly associated with recall.
McDougall, Mackert, and Becker (2012)	n = 45; 65+ years Chiliad = 77.11 years Community-residing older adults Central Texas metro expanse	REALM	Pilot study Cantankerous-sectional Relationship between health literacy, retentivity performance, and performance-based functional ability	Health literacy non related to education (.19) or age (−.fifteen) Education and cognition (.30) were associated significantly. Wellness literacy was associated with RBMT memory functioning groups (normal vs. poor; .25) and DAFS-Eastward scores (.50).	Pedagogy was not related to wellness literacy
Patel (2010); Detroit, MI	n = 62; 65+ years K = 73.2 years African American Principal care setting	S-TOFHLA, NVS	Evaluated utility of NVS and S-TOFHLA	No meaning differences in NVS and Due south-TOFHLA scores between men and women. L per centum of participants were deemed sufficiently literate using S-TOFHLA in comparison with 42% using NVS. Mean time to consummate NVS was 11.7 min. Previous enquiry in younger population reports completion time to be 2.9 min.	Patient's educational level and age were better predictors than NVS score for assessing health literacy in this population.
Mosher, Lund, Kripalani, and Kaboli (2012)	n = 310, 65+ years Yard = 74 years Veterans from a primary care clinic English speaking Iowa City, VA Eye	REALM	Cross-exclusive Confront-to-face interview Examined clan of health literacy with medication knowledge, adherence, and adverse drug events	Lower health literacy was associated with less knowledge of medication names and purposes. Patients with low health literacy knew 32.2% of medications by proper name, as compared with 54.half-dozen% of medication names for patients with marginal health literacy, and 60.8% for patients with adequate health literacy (p < .001). Lower literacy group knew the purpose of 61.8% of their medications, compared with 77.four% and 81.4% in the marginal and adequate literacy groups, respectively (p < .001).	Health literacy was not associated with self-reported medication adherence or agin drug events Health literacy was not associated with number of prescribed medications
Cordasco, 2011	north = 160, historic period 65+ years 1000 = 72.0 years Spanish speaking Diagnosed with diabetes for at least one twelvemonth Clinics associated with a big safety-net hospital LA Canton, CA	Castilian REALM, South-TOFHLA, and SILS	Cross-sectional 1-on-one interview Evaluated accuracy of SILS in detecting IHL in monolingual Spanish speakers; investigates best predictor SILS or instruction level	S-TOFHLA indicated 84% had IHL All-time performing SILS question, "How confident are you filling out medical forms past yourself?" AUROC curve of 0.82; loftier sensitivity (fewer than 1 out of 10 with IHL will be missed), low specificity (7 out of 10 with IHL will exist misclassified) Remaining two SILS questions had AUROC curves less than 0.50. Educational accomplishment AUROC bend was 0.88; education cutoff of 6 years or less had a specificity to 0.81 and sensitivity of 0.83	Utilise unmarried items every bit screen for IHL in older U.S. monolingual Spanish speakers Should either apply the "confidence with forms" SILS, existence aware of its specificity limitations, or a single question assessing educational accomplishment
Bickmore et al. (2010)	northward = 33; 65+ years English speaking Boston Medical Center	TOFHLA	Two-armed intervention trial; evaluated the use of reckoner blithe characters as vehicles for health pedagogy and behavioral change counseling	Participants with inadequate health literacy had lower levels of reckoner literacy compared with participants with adequate health literacy, although this difference was only trending toward significance, likely due to the smaller sample size	Overall, there were very few differences in measures of acceptance and usability betwixt patients with acceptable and inadequate wellness literacy, suggesting that ECAs are approachable and usable by patients regardless of wellness literacy level. In the few measures in which there were meaning or most-significant differences on health literacy, these were mostly in favor of patients with inadequate health literacy.

Key Questions

The key questions nosotros answer in this article are as follows: For studies published regarding health literacy with participants' age 65 years old and older, what is the testify regarding:

how health literacy is assessed,
the demographics of study participants,
what wellness outcomes have been measured,
levels of medication adherence,
whether cognitive role and health literacy interventions were developed or tested.

A applied screen of the literature where a broad range of potentially useable articles that could be obtained in a timely manner was conducted (Fink et al., 2010). The authors conducted the initial screen using titles and abstracts. When information was not available within the abstract, each full-text article was located and screened for the initial inclusion criteria. Inclusion criteria included the following: (a) measure out of wellness literacy, (b) older adult population (age 65 and older), (c) empirically based research methodology, and (d) a published time period of 2010-2014. The exclusion criteria included the following: (a) review/discussion articles; (b) case studies, tool development, and medical education studies; (c) manufactures published prior to the Berman (2011) review; and (d) oral, financial, and mental health literacy. The methodological screen (used to appraise quality of manufactures and selection of the best available studies) included empirical methodology to ensure the search was exhaustive and included a review of the reference sections in each of the retrieved manufactures, a checked of relevant articles confronting an index of retrieved articles, and a hand search of journals with published systematic reviews on health literacy. Two reviewers independently assessed all articles confronting the inclusion criteria. Whatsoever disagreements were discussed and resolved by a tertiary reviewer. Due to the lack of evidence (only one article met our final criteria), the authors deemed information technology irrelevant to rate the quality of the studies, per the PRISMA guidelines. A period diagram of the article option process is detailed in Figure 1. Health literacy measures, characteristics of the target populations, data collection, and data results were extracted by iv review authors. Articles were non excluded based on methodological quality criteria as this review was intended to review all empirical research in the discipline area. No meta-analysis was conducted.

An external file that holds a picture, illustration, etc. Object name is 10.1177_2333721416630492-fig1.jpg

Flow diagram article selection procedure.

Results

Study Selection

A total of 384 articles were identified for review using the primary inclusion and exclusion criteria (Effigy 1). Three hundred forty-ii articles were excluded due to written report time period, lack of health literacy measure, population age, beingness a review, discussion article, example study, tool development (testing of health literacy measures, validation of health literacy measures, or comparison of new health literacy measures against older assessment tools in the general population), or medical didactics report. Of the 42 remaining articles, six remained afterwards total-text evaluation of the inclusion of a health literacy measure and an older adult population. Two additional studies were included after a hand search of published systematic reviews resulting in eight total reviewed manufactures for the systematic review. Study setting, sample size, population, data collection method, health literacy measure out, and central findings were noted for each of these studies (Table 2).

Study Characteristics

All studies discussed in the current review were conducted in urban settings. 3 of the eight studies (38%) were multi-site investigations (Gerber, Cho, Arozullah, & Lee, 2010; McDougall, Mackert, & Becker, 2012; Wolf, Feinglass, Thompson, & Baker, 2010). Although all studies were conducted in the United States, the study settings were geographically diverse, including the due east coast (Wolf et al., 2010), Midwest (Gerber et al., 2010; Mosher, Lund, Kripalani, & Kaboli, 2012; Patel et al., 2011), Northeast (Bickmore et al., 2010; Ganzer, Insel, & Ritter, 2012), and South (McDougall et al., 2012; Wolf et al., 2010). Half of the studies were conducted in principal care settings (northward = iv; Bickmore et al., 2010; Cordasco, Homeier, Franco, Wang, & Sarkisian, 2012; Mosher et al., 2012; Patel et al., 2011), two in community settings (n = 2; Ganzer et al., 2012; McDougall et al., 2012), and two conducted in-dwelling interviews with Medicare enrollees (due north = ii; Gerber et al., 2010; Wolf et al., 2010).

Study sample size ranged from 33 to iii,000 participants. Half of the studies had a sample size of 62 or fewer participants (Bickmore et al., 2010; Ganzer et al., 2012; McDougall et al., 2012; Patel et al., 2011). Three studies had a sample size between 160 and 450 participants (Cordasco et al., 2012; Gerber et al., 2010; Mosher et al., 2012), and ane study had sample size of iii,000 participants (Wolf et al., 2010). 7 of the eight studies (88%) were cantankerous-exclusive, while one was a ii-arm intervention (Bickmore et al., 2010). All study populations included adults aged 65 years or older. Specific populations included Veteran Diplomacy (VA) patients (Mosher et al., 2012), older adults who'southward chief language was Spanish (Cordasco et al., 2012), Medicare enrollees (Gerber et al., 2010; Wolf et al., 2010), customs habitation urbanites (Bickmore et al., 2010; Ganzer et al., 2012; McDougall et al., 2012), and African Americans (Cho et al., 2010; Gerber et al., 2010; Patel et al., 2011).

With respect to wellness literacy research, the most common assessment tools used to mensurate wellness literacy include the following: The Wide Range Achievement Test–Revised (WRAT-R), Rapid Gauge of Adult Literacy in Medicine (REALM; Davis et al., 1993), the Test of Functional Wellness Literacy in Adults (TOFHLA; Parker, Bakery, Williams, & Nurss, 1995), and the Newest Vital Sign (NVS; Weiss et al., 2005). Table 3 provides a comprehensive description of these measures. A number of these measures were represented in literature currently reviewed. The S-TOFHLA was the measure out of pick in one-half of the studies (Ganzer et al., 2012; Gerber et al., 2010; Patel et al., 2011; Wolf et al., 2010), while an additional study used the Spanish version of the S-TOFHLA (Cordasco et al., 2012). 3 studies (38%) used the REALM (Cordasco et al., 2012; McDougall et al., 2012; Mosher et al., 2012). 1 study used the NVS (Patel et al., 2011), one used the three-particular Single Item Literacy Screening (SILS; Cordasco et al., 2012), and one used the TOFHLA (Bickmore et al., 2010). Wellness literacy was evaluated with respect to demographics (age, teaching, race, and income), self-rated and functional health, medication adherence, mortality, memory and cognitive health, and calculator literacy.

Tabular array 3.

Health Literacy Cess Tools.

	REALM	TOFHLA S-TOFHLA	(SILS)	SAHLSA	NVS	METER	FHLTs	HLSI	Wellness LiTT
Constructs measured	Word recognition and pronunciation of medical terms	Reading comprehension and numeracy skills	Reading and verbal comprehension, need for help, and confidence	Word recognition of medical terms	Reading and comprehension of a nutrition label	Word recognition of medical terms	Reading comprehension	Prose, document, quantitative, oral, and Internet-based information seeking skills	Prose, document, quantitative
Year Published	1991/1993	1995/1999	2004/2006/2008/2009	2006/2010	2007	2009	2009	2010/2012	2011
Assistants fourth dimension (min)	3-7 long 1 brusk	22 long 7 brusque	one-2	3-vi long 2-3 brusk	iii-4	two-3	Median 3	>10 long v-10 short	xviii
Number of items	7/66 items	17/l items or 4/36 items	4 items	l items or 18 items	6 items	lxx items	21 items	25 items or 10 items	30 items
Performance-based	X	Ten		X	10	X	10	X	Ten
Cocky-administration			X			X		Ten	X
Available in Spanish		X	Not validated	X	X				Ten
Phone, mail, reckoner administration			Ten			X		10	With touch screen
Communication (pronunciation, verbalization)	10			Ten		X
Comprehension		X	X		X		Ten	X	10
Quantitative		10			Ten			10	X
Wellness data seeking								X
Function			X		Ten		X	Ten	X
Decision making/critical thinking		X			X			10	X
Self-efficacy			10
Need for help			X
Navigation								X

Health Literacy in Older Adults—Key Findings

Demographics

The most common demographic variables assessed in the reviewed articles include education, race, income, and age. The relationship between these measures and health literacy was mixed. Health literacy was not related to education every bit measured by McDougall et al. (2012). Still, Wolf et al. (2010), Ganzer et al. (2012), and Cordasco (2012) all written report a relationship between health literacy and education. Moreover, Cordasco et al. conclude that a unmarried question assessing education is as constructive as the best performing SILS question. Mosher et al. (2012) detect health literacy and pedagogy interacted with their agin drug upshot among low literacy participants, only the multivariable analysis findings were not pregnant. Patel et al. (2011) report that participant education level and historic period were better predictors than the NVS score for assessing health literacy in ane population. Gerber et al. (2010) and Bickmore et al. (2010) did non accost education. In the only study to address gender differences, Patel (2011) reports no difference between men and women when comparison the NVS and S-TOFHLA. With respect to race, Gerber and colleagues (2010) study African Americans had a lower level of health literacy compared with Caucasian participants (all, p < .001). Although African American participants had significantly lower wellness literacy, low scores, and social back up than did Whites, race remained an important cistron in a multivariate model (Gerber et al., 2010). Wolf et al. (2010) report that individuals with lower wellness literacy were older, more likely to exist non-White, and accept a lower household income. Patel et al. (2011) study an African American population, while Cordasco (2011) focuses on monolingual Spanish speakers, 87% of Bickmore's participants were African American and 20% were Hispanic; however, these authors did not consider race in their analysis. With respect to age, Wolf et al. (2010) report that their lower literate participants were more probable to be older, and this relationship was notably linear and graded. As reported to a higher place, Patel et al. (2011) discover education level and age to be better predictors than the NVS score for assessing wellness literacy. Ganzer et al. (2012) report a relationship between age and working memory, simply not between historic period and health literacy. McDougall et al. (2012) report no relationship between historic period and health literacy. Although the full general literature reports a human relationship between income level and health literacy, just iii authors specifically investigating older adults collected this information. Wolf et al. (2010) report that individuals with lower health literacy were too more likely to accept a lower income. In Gerber et al.'s (2010) multivariate analysis of forgetting to accept medications, income was significant. As with similar demographic results, Ganzer et al. (2012) written report a relationship between income and working retention, but non with health literacy.

Health outcomes

It seems reasonable that health literacy would be important when considering an older individuals' health. The lack of health-related knowledge and/or skills may serve as a barrier to the date in good for you behaviors, preventative services, and acute every bit well as chronic disease management. Ii studies evaluated health-related outcomes: One examined self-reported physical health while the other evaluated instrumental activities of daily living. Wolf et al. (2010), while controlling for demographic and socioeconomic factors, health behaviors, and number of chronic weather, reported a causal clan between lower wellness literacy levels and self-reported concrete functioning, including a graded relationship betwixt literacy scores and baseline concrete operation (Wolf et al., 2010). The authors suggest that insufficient health literacy resulting in a decrease in cerebral skills and reading fluency "may atomic number 82 to progressively lower understanding of how to stay healthy, when to seek medical attention, and how to properly follow medical regimens to recover from acute and care for chronic wellness conditions." They further suggest that over an extended menstruation, these insufficiencies could compound and issue in a continual decline in baseline physical operation. In addition, a multivariate analysis controlling for demographics, socioeconomic status, and baseline health (number of chronic conditions, physical functioning, activeness limitations, mental health) indicated that the all-cause mortality charge per unit was greater for those with everyman health literacy levels (Wolf et al., 2010). McDougall et al. (2012) investigate the relationship between health literacy, memory performance, and instrumental activities of daily living. Similar to Wolf et al.'southward (2010) findings, health literacy showroom the strongest relationship with participants' instrumental activities of daily living (0.fifty) and was also related to cerebral damage (0.30), retentiveness (0.25), and age (−0.15).

Medication adherence

Medication management is an of import factor in an older adult'southward overall health condition. Poor medication adherence is associated with increases in morbidity, mortality, and wellness care costs (Gazmararian et al., 2006; Keller, Wright, & Pace, 2008). 2 recent studies investigated the impact of health literacy on medication direction. Mosher et al. (2012) assess the relationship between wellness literacy and medication knowledge, adherence, and adverse drug events. Lower health literacy was associated with less noesis of medication names and purposes. Patients with low health literacy knew the fewest (32.ii%) medications past name, as compared with 54.6% and 60.8% for participants with marginal and adequate wellness literacy, respectively (p < .001). Similarly, the lower literacy group knew the purpose of 61.8% of their medications, compared with 77.4% and 81.4% in the marginal and acceptable literacy groups, respectively (p < .001). Health literacy was not associated with self-reported medication adherence or agin drug events (Mosher et al., 2012).

Cognitive health

The affect of cognitive health on an private'south health literacy should non exist overlooked. This variable is especially of import in an older adult population where age-related cognitive turn down is the norm (Spirduso, Francis, & MacRae, 2005). Health literate individuals most certainly rely on cognitive functions to recall and process health data. Three studies addressed this topic. Wolf et al. (2010) compare health literacy with self-rated physical function, mental wellness status measured by the SF-36, and bloodshed rates. He reports a causal relationship between health literacy and cognitive health. Wolf et al.'s (2010) results propose the human relationship between health literacy and mental health is a threshold relationship not continuous or linear (Wolf et al., 2010). Lower levels of mental wellness were associated with lower wellness literacy scores, simply the relationship was not continuous in nature. Participants in the two lower literacy categories exhibited poorer mental health compared with those in highest wellness literacy category. McDougall et al. (2012) investigate the relationship between health literacy, retentivity performance, noesis, and performance-based functional ability. Health literacy scores were high in this sample, with 76% of the sample scoring a perfect 66/66 on the REALM. Wellness literacy was associated with memory functioning and performance-based functional ability, but was non associated with teaching or age. Education and cognition were significantly related to health literacy. Similar to McDougall (2012), more than 50% of Ganzer et al.'s (2012) sample exhibited high health literacy (a median score of 33/36 on the S-TOFHLA). Ganzer et al. were interested in the relationship between working memory, health literacy, and the recall of 5 signs of stroke. Approximately 1 hr later on reading nigh the signs of stroke, participants recalled 2.ix ± i.33 of the v signs of stroke. Stroke sign recall was associated with working memory, health literacy, education, and dementia. Working memory was later associated with education, income that meets expenses, wellness literacy, and historic period. Health literacy was related to education. Using regression, health literacy was the best predictor of stroke call up (β = .56, p < .01).

Interventions

Bickmore et al. (2010) address health literacy and its connection to health information technology. In an effort to reduce disparities betwixt insufficient and sufficient health literate older adults with respect to estimator/health information technology access, the authors developed a computer interface to mimic face-to-confront advice (Embodied Conversational Agents), face-to face beingness one of the all-time methods to communicate health information. Within their study, the authors evaluated health literacy and figurer apply. Results indicate that participants with inadequate health literacy reported poorer levels of cocky-reported estimator literacy compared with participants with adequate health literacy. With respect to use of the Embodied Conversational Agent, participants with inadequate health literacy completed fewer home-based conversations compared with participants with adequate health literacy. Beyond this measure, at that place were few differences in measures of acceptance and usability between patients with adequate and inadequate health literacy. The authors suggest that these Embodied Conversational Agents were approachable and usable past patients regardless of health literacy level (Bickmore et al., 2010).

New measures

Two authors evaluated the use of newly developed wellness literacy measures. Patel et al. (2011) compare a new health literacy mensurate, NVS, with the S-TOFHLA in an older developed African American sample. The NVS has been evaluated in a younger population and was shown to be quickly administered, taking younger participants only 2.9 min to complete. Gender comparisons revealed no differences for both the NVS and Due south-TOFHLA. With respect to wellness literacy, fifty% of participants were deemed sufficiently literate using S-TOFHLA in comparing with 42% using NVS. Patient's educational level and age were ameliorate predictors than the NVS score for assessing health literacy in this population. Mean time to complete NVS was 11.seven min rendering impractical as a quick assessment of health literacy. Cordasco et al. (2012) evaluate the accuracy of SILS in detecting inadequate wellness literacy in monolingual Spanish speakers. The comparison mensurate, the Due south-TOFHLA, identified inadequate wellness literacy in 84% of the sample. The best performing SILS question was "How confident are y'all filling out medical forms by yourself?" Using stringent cutoffs for this question, the sensitivity was high, meaning the use of this single question to place inadequate health literacy would miss fewer than 1 out of 10 participants. Conversely, the use of this question has low specificity, significant 7 out of 10 participants with inadequate health literacy would be misclassified. Using this single SILS question yielded no meliorate results than using a uncomplicated measure of educational attainment to identify a participant at run a risk for inadequate wellness literacy. The authors conclude that the unmarried SILS question is useful as a screening tool, being aware of the specificity limitations. Conversely, i could attain like results screening past assessing educational accomplishment.

Give-and-take

Efforts to fully empathize the variables that influence health literacy are hampered by investigators utilize of diverse health literacy measures. The authors reviewed each tool validation study to assess if the authors were testing a health literacy measure in the older adult population. However, no study nosotros reviewed in the main search reported the validation of health literacy tools for use in an older developed population. These critical missteps probable resulted in many of the mixed findings. The validation and standardization of tools has important clinical implications as the telephone call for an integrated health literacy screening tool in primary care settings increases (Hart, Chesser, Wipperman, Wilson, & Kellerman, 2011).

The five demographic variables evaluated in the manufactures selected for review were education, race, gender, age, and income. The relationship of health literacy to these measures was mixed, and unfortunately not all studies evaluated the impact of these measures. The nigh consistently collected demographic variable was teaching. Data were collected in half dozen of the eight studies, and an association between health literacy and educational activity was noted in v of half-dozen. The results of Cordasco (2013) and Patel et al. (2011), where teaching was the strongest predictor of low wellness literacy, clearly demonstrate the significance and importance of education in shaping an individual'due south health literacy. Age was examined in four of the 8 studies; results were split. Wolf et al. (2010) and Patel et al. (2011) find age to be an important contributor to their participant'south health literacy; conversely, Ganzer et al. (2012) and McDougall et al. (2012) did not. The discrepancy betwixt these studies, as well as with the larger body of health literacy research, could be in part due to age differences besides as the restricted age range in these studies. The mean ages of Wolf and Patel were approximately 73 years with standard deviations betwixt 6.0 and 8 years, respectively. Ganzer's (80.4 ± seven.95 years) and McDougall's (77.11 years) samples were older. Furthermore, when considering the importance of age in the broader health literacy inquiry, these studies were restricted to adults anile 65+ years; whereas the general health literacy research includes adults of all ages. Discrepancies may also be due in part to the big difference in sample sizes of the reviewed studies. The Gerber et al. (2010) and Wolf et al. (2010) studies both had large sample sizes while the others eight studies were quite minor in comparison. The smaller studies may take been underpowered and subsequently provide a reminder to future researchers of the need for stronger evidence. Race was considered in two of the eight studies, and in both studies, race was a determining gene in low health literacy. The role of income on an private's health literacy was examined in three studies; two reported a relationship. Earlier studies take reported mixed findings with some indicating an association betwixt participant'southward gender and literacy (von Wagner, Knight, Steptoe, & Wardle, 2007) and others not finding an association (Paasche-Orlow, Parker, Gazmararian, Nielsen-Bohlman, & Rudd, 2005). Only i commodity reports that gender of participants did non play a role in their participants' health literacy (Patel et al., 2012).

Adults with poor health literacy are more likely to report their health as poor (42%) and are more likely to lack health insurance (28%) than adults are with skillful wellness literacy (Berkman et al., 2011). These individuals are also less probable to obtain important preventive wellness activities such as mammograms, pap smears, and flu shots. They also brand greater employ of services designed to treat the complications of disease and utilize fewer services designed to prevent complications. These aforementioned individuals besides tend to enter the health care system when they are sicker, consequently increasing the length of handling and reducing positive wellness outcomes (Berkman et al., 2011). The 2 studies included in this review that evaluated wellness outcomes both support the assertion that wellness literacy affects health: Wolf et al. (2010) through measures of physical office and McDougall et al. (2012) through measures of instrumental activities of daily living. Wolf et al. (2010) were interested in determining whether the relationship betwixt health literacy and health outcomes is continuous and graded, or threshold in nature. Results propose a causal association betwixt lower health literacy levels and self-reported physical operation, including a continuous, graded relationship between literacy scores and baseline physical functioning (Wolf et al., 2010). The authors propose that a decrease in cognitive skills and reading fluency negatively affect health literacy and "may lead to progressively lower understanding of how to stay good for you, when to seek medical attention, and how to properly follow medical regimens to recover from acute and treat chronic health weather." They farther advise that over an extended period, these insufficiencies could compound and outcome in a continual decline in baseline concrete functioning. It is increasingly apparent that health literacy researchers need to investigate if information technology is possible to improve older developed's health literacy. If possible, it may so also be possible that empowered older adults could engage in good for you behaviors, embrace preventative services, and better manage their astute and as chronic diseases.

Similar to the health barriers experienced by low literate older adults, the literature suggests that these same individuals are less likely to properly have medications, adhere to the directions, and often do not correctly interpret medication labels or standard health messages (Berkman et al., 2011). The currently reviewed older adult wellness literacy research did non present strong support for these assertions. Moser'south 2012 commodity reports that older adults with lower wellness literacy knew fewer medication names and their purpose. However, health literacy was not associated with medication adherence or adverse drug effects. Moreover, Gerber et al., (2011) research suggests wellness literacy was not a factor in his participants following medication instructions in their sample. These inconsistent results highlight the complex and persistently undefined part of health literacy in medication adherence and patient rubber.

Health literacy is associated with cognitive function across multiple domains in older adults. Unfortunately, older adults may face up additional retention and cognitive challenges that can farther limit their health literacy. It is normally accustomed that both working memory (Salthouse, 2010) and wellness literacy decline (Baker, Gazmararian, Sudano, & Patterson, 2000) with advancing historic period. The results of Wolf et al. (2010), McDougall (2011), and Ganzer et al. (2012) all ostend the relationship between noesis and health literacy in older adults. The purpose of a study by Ganzer et al. (2012) was to investigate working memory and health literacy, factors that have the potential to influence the think of the signs of stroke in older adults. The successful recall of the signs of stroke could initiate prompt action to seek care and prevent the deleterious furnishings of stroke. The results of the study demonstrated that working retentiveness and health literacy were significantly associated with recall of the signs of stroke. In fact, multiple regression analysis denoted health literacy as the all-time predictor of stroke call up. Wolf et al. (2010) report a threshold at which noesis affects wellness literacy and hypothesizes that a lifetime of continual cerebral refuse may atomic number 82 to inadequate wellness literacy. Declining cerebral function may lead to increasing difficulty in the ability to brand appropriate health choices, determine when to seek out medical care, and how to properly follow medical treatments.

Cordasco (2011) and Bickmore et al. (2010) offer ii important findings that could affect clinical and perhaps community-based settings: the use of a single detail health literacy screener and the use of an embodied conversational agent as an approachable and usable vehicle to nowadays health care data by all consumers regardless of health literacy levels (Bickmore et al., 2010; Cordasco et al., 2012). These findings could be implemented across settings (e.k., customs, medical, and social service settings) to improve both identification of older adults with depression health literacy levels likewise the delivery of health data.

Finally, the use of specific wellness literacy measures for different populations is still under argue (Powers, Trinh, & Bosworth, 2010). The REALM and Due south-TOFHLA are the 2 most often used measures of health literacy (Chin et al., 2011). Previous research has examined processing capacity and knowledge related to health literacy measures among older adults to better sympathise the relationship betwixt knowledge, mental capacity, and health literacy scores (Mentum et al., 2011). In addition, the utilize of health literacy measures have not been successfully validated amongst the older adult population suggesting the apply of some tools to exist inappropriate due to historic period-related reasons (Saldana, 2012).

Limitations

The findings of this systematic review are not without limitations. As with all systematic reviews, there is a possibility for research bias. To minimize potential biases, scientific methodology was used and reported to identify studies and synthesize findings (Moher et al., 2009). Although some work has advanced the field, boosted research is warranted. With more than lxx,000 peer-reviewed studies investigating health literacy (nosotros located 76,806 academic publications through a broad search) from 2010 to 2014, few studies isolated the older developed population. Limited information are bachelor from country, regional, national, or international representation samples. A standardized definition was used for the systematic review; however, information technology is not uncommon for other historic period definitions to be used when defining older adults (eastward.g., 55 and older, or 60 and older; Federman et al., 2013; Federman et al., 2014; Hinrichsen & Molinari, 1998). The lack of clinical heterogeneity (similar participant characteristics) and the lack of statistical heterogeneity (findings beyond studies) limit the generalizability of findings (Crowther & Cook, 2007).

Conclusion

The findings of this review highlight the few number of studies specifically examining health literacy in older adults and the importance of working to meliorate the health literacy of older adults. In the older adult population, teaching clearly affects wellness literacy. The impact of age and income was significantly related to wellness literacy in the studies with a large sample size. Although only examined by two investigators, race was an of import factor in both studies. Gender, while only examined in 1 report, was non related to literacy levels in older adults. It appears that individuals with depression health literacy oftentimes feel poor physical and/or cognitive health. However, the office of health literacy in medication direction needs further clarification. It appears wellness literacy screening in clinical intendance settings would be a beneficial tool in the care of older adults. The advantages of improving wellness literacy include improved health care decisions, communication, compliance to treatment directions, and improved health status, all of which should outcome in cost savings to the health care system and improved patient–provider satisfaction.

Footnotes

Declaration of Alien Interests: The authors alleged no potential conflicts of interest with respect to the research, authorship, and/or publication of this commodity.

Funding: The authors received no financial back up for the enquiry, authorship, and/or publication of this article.

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