Beyond the tip of the iceberg: Health literacy in older people.

Abstract

Global ageing brings with it an increasing need for older people to access healthcare services, health information and education to recognise and deal with health-related issues that may be associated with growing older. Ageing also carries with it an increased risk of vulnerability, which can affect quality of life and health. Nurses are commonly in the position to critically analyse vulnerability in older people from differing perspectives, including health literacy, a modifiable determinant of self-care and health behaviour. Despite increasing awareness of the importance of health literacy, it is perhaps surprising to discover that limited attention has been given to this concept in older people. Health literacy can be defined from a public health perspective as ‘linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course’ (Sørensen et al., 2012, p.3). In older people, lower health literacy in older people has been associated with sub-optimal levels of health and health outcomes, such as compliance with treatment regimes, medication adherence and capacity for self-management. Low health literacy can be directly linked with poorer health status and impairment to quality of life. Within the biomedical model, most age-related issues with low health literacy in older people have been explained in terms of differences in cognitive abilities including speed of thought processes aligned with traditional theories of ageing. From a sociological perspective, health literacy has been viewed as a potential social determinant of health that can address health inequities. To conceptualise health literacy as a social determinant of health, Nutbeam and Lloyd (2021) reported strong evidence of a social gradient in population-based studies. Health literacy is increasingly being seen as a better predictor of health than many other social determinants of health including, ethnicity, education and employment status. Indeed, if not one of the strongest predictors of health, health literacy has become the strongest social determinant of health (Ho & Smith, 2020). The importance of health literacy in older people has been illustrated by the COVID-19 global pandemic. Although all age groups are at risk of contracting the COVID-19 virus, older people are more vulnerable to mortality and morbidity associated with the viral infection (Smith et al., 2020). The emergence of the COVID-19 pandemic provided a critical test for health literacy, giving it the opportunity to highlight its importance in relation to population health and well-being. Governments and health providing agencies around the world would appear to be increasingly aware that population-based enhancement of health literacy may be equated with decreased health inequalities and improved health outcomes. To date, there is a paucity of research which specifically addresses the impact of low health literacy in older people during the global pandemic. It could be potentially rationalised through Sorensen’s integrated model of health literacy, hypothesising that lower levels of health literacy may be associated with sub-optimal levels of empowerment in health behaviour (Sørensen et al., 2012). The potential benefits of enhanced health literacy in older people are vast, perhaps now is the time to re-evaluate perspectives of health literacy research in older people. In this editorial, we will highlight the importance of the nursing role in health literacy, consider challenges in nurse education, critique approaches towards health literacy assessment and highlight the potential links that may exist between health literacy empowerment and resilience. Regardless of caring environment, hospital or community-based, nursing staff are key providers of patient education and health-related information. Therefore, it is somewhat surprising that although the nursing profession shoulders most of the responsibility for the delivery of health-related patient education, limited global attention has been given to nursing awareness, knowledge and application of health literacy, especially in the care of older people. Despite this, the provision of shame-free health literacy support for older people has been associated with greater levels of empowerment, engagement, activation and optimal health-related outcomes (Loan et al., 2018). Regardless of nursing specialty, health literacy is an essential skill that enhances effective communication and aids in the provision of person-centred care for older people, potentially reflected by increased patient satisfaction of care. High-quality research is essential, to ensure effective evidence-based health literacy practice. Whilst fully appreciating the need to explore the role of illness and cognition in the health literacy of older, more emphasis could be placed on the determinants and correlates of health literacy. We view the importance of clearly defined terms and the use of valid measurement tools as the basic requirements in any research that aims to understand the role of health literacy in older people. Healthy and successful ageing is important, perhaps more attention could be given towards the assessment of issues that may be more meaningful to the older person, such as physical activity and diet, these may enhance the quality of life of the older person and ensure that they are in a better position to make and act health-related preferences and decisions upon these day-to-day activities. There is clearly scope for more nursing research to help to identify barriers and facilitators for the delivery of appropriate and effective health literacy practices. Now may also be an opportune time to develop important longitudinal studies that explore the relationship between health literacy and health-related outcomes in older people. Over a decade ago, writing in the Journal of Clinical Nursing, Scheckel et al. (2010) highlighted the importance of health literacy education. They specifically advocated for novel approaches towards the instruction of health literacy in the nursing profession, stressing that dedicated teaching in the practice of health literacy would expand students’ existing skills and knowledge in preparation for their professional practice. To date, despite its importance, not all nursing educational institutes would appear to subscribe to this educational approach. The inclusion of health literacy-related questions in all formats of nursing assessment may provide a good starting point. Students could be encouraged to ask open-ended questions and using ‘teach-back’ methods when providing health-related information to older people. Using the ‘teach-back’ approach helps to validate that the nurse has provided information in an understandable format, patient understanding can be verified when they can restate the information in their own words. The value of the ‘teach-back’ approach is that it can empower nurses to authenticate understanding and correct erroneous information with older people. Despite the development of several promising nursing health literacy initiatives since Scheckel’s work, providing innovative solutions and strategies, it is thought that many of these have been grossly under-utilised by the profession (Loan et al., 2018). With a global ageing population, now is the time to give more attention to the education-related health literacy research for older people in society. Developing educational approaches in health literacy for all undergraduate nursing students, based upon sound evidence, may be the best way forward to ameliorate and allay against problems and provide a path towards promoting a healthier ageing process. From a post-registration perspective, the establishment of strategic competency-based health literacy education may enhance the health literacy professionalism of nurses. Due to the fast-changing and dynamic nature of health literacy, these initiatives for older people are required as a matter of urgency. Getting older is not in itself a barrier to being able to source the Internet or other forms of computer-based technology, like telemedicine services. Increasingly, older people are accessing vast amount of health-related information is available, although carefulness needs to be taken in relation to the reliability and dependability of some of this information. Digital health literacy is increasingly playing an important role. To enhance the ability of older people to use the Internet, age-related changes in vision and cognition health-related websites need to be considered when specifically designing material for older people. Failure to do so may affect the accessibility of Internet for older people due to potential limitations of working memory, perceptual speed, text comprehension and spatial memory. All forms of health-related information could be made more user-friendly by using an appropriate typeface, writing style, navigational composition and accessibility. Around the world, nurses should not only be aware of the potential problems associated with health illiteracy in older people, but they should also be able to actively try to remedy the situation. Unlike socio-demographic characteristics, like age and ethnicity, which are non-modifiable, there is reasonable evidence to suggest that levels of health literacy can be modified and enhanced in older people. Health literacy interventions could be designed to directly tackle the cognitive difficulties, which may limit older people’s ability to access and understand health-related information. To date, most e-interventions for improving levels of health literacy in older people have focused on reducing the cognitive demands, usually involving increasing the readability of materials or to ensure that assistance is being provided by an appropriate member of healthcare staff. Nurses working with older people should have an awareness of the potential benefits of relatively straightforward approaches that can be taken to address health literacy deficits, including using plain language and non-jargonistic terms when delivering health-related information. Attending to these basic prerequisites may be effective to facilitate the understanding of older people, potentially enhancing empowerment and resilience. Patient-centred approaches to health literacy place a focus on identifying an individual’s knowledge, motivation and skills to gain, comprehend and apply health-related information. In general, this approach to communication is encouraged, especially when dealing with health literacy issues in older people. Developing health literacy interventions is one aspect of the research process, however, measurement of health literacy is also required, and this has been known to be a demanding process. Identifying low levels of health literacy is clearly important in older people; however, there is some debate around the best way to capture this complex and dynamic concept. Historically, researchers have applied objective measures, like the Rapid Estimate of Adult Literacy in Medicine (REALM), within older people research. Since then, more comprehensive subjective measurement tools have emerged. One of these, the HLS-EU, originally developed and validated in Europe is now used widely around the world. The European Health Literacy Survey Questionnaire (HLS-EU) provides the researcher with a scale which is focused on task-specific competencies, such as illness prevention and health promotion, potentially important in capturing vital aspects of active ageing in the assessment of health literacy in older adult. More recently, other measures have surfaced which capture important aspects of age-specific conditions, like dementia literacy. The World Health Organization has promoted the importance of the role of health literacy in the development of empowerment and resilience in older people (WHO, 2013). Empowerment is seen as a process through which people gain more control over their lives, their health and its determinants. Through empowerment, health literacy programmes contribute to democratising the healthcare system and to achieving a stronger commitment to health and well-being in communities and in society at large. Resilience is viewed as a form of adaptation, recovery and ‘bouncing back’ in the face of adversity. In relation to both traits, health literacy is viewed as an asset for individuals and communities, as such, any investment that is made to strengthen health literacy in older people may yield a substantial return in enhanced health and well-being. In conjunction with appropriate social resources, health literacy can become an valuable asset that will help to support older people to become more empowered and resilient for active ageing. Presently, we believe that there are significant research gaps in the area of health literacy in older people, including scope for up to date systematic reviews, examining the relationship between health literacy, resilience and empowerment in older people. It was the aim of this editorial to capture the most relevant nursing aspects of health literacy in older people. As stated, we believe the health literacy has become one of the most important determinants of health in older people, which can be considered as a modifiable element of socioeconomic inequalities in health. Increasingly, evidence suggests that health literacy mediates the relationship between socioeconomic standing and health inequalities. Therefore, health literacy has the potential to improve health outcomes and may prove to be decisive in the development of resilience and empowerment in the world’s older population. Nurses should be instrumental in enhancing levels of health literacy in older people and greater attention needs to be given to age-specific aspects of health literacy in older adults in nurse education. As the title of this editorial indicates, we speculate that the issue of health literacy in older people may be likened to that of the iceberg model, only part of the problem is readily seen, perhaps those with age-related disorders, the majority remain hidden beneath the surface. We believe that nurses are in an ideal position to play a vital role in identifying and tackling the health literacy-related issues of those in the latter group. None.