Mr C, a 72-year-old patient with type 2 diabetes, is brought to the emergency department comatose with a blood sugar of 29 mg/dL. When seen in his primary care provider’s office the previous day, his blood sugar was 456 mg/dL; he was prescribed fast-acting insulin with meals in addition to an increase in his insulin glargine.
Every day, low health literacy results in patients’ misunderstanding the instructions of their clinicians, sometimes with very serious consequences. Mr C did not understand his clinician’s verbal and written instructions and took too much fast-acting insulin at breakfast.
An estimated 90 million people in the United States have low basic literacy skills, with the average adult reading at an eighth-grade level.1 Almost 20% of American adults cannot read and almost 30% do not read well, for a combined level of approximately 50% who have some difficulty reading at even a fifth-grade level. This group of Americans with limited reading skills comprises several demographic groups, including older adults, Latinos, African Americans, American Indians, and Alaskan natives.1
This low basic literacy is combined with widespread illiteracy associated with health information. Health literacy is multifaceted and includes printed literature, oral communication, and numeracy. Printed literature requires reading and writing ability, while oral literacy requires the ability to listen and speak. Many older adults have vision and/or hearing loss that represent additional obstacles to health literacy. Numeracy — the ability to understand and use numbers — is especially important with respect to medication dosages.
Even people with high basic literacy skills can have low health literacy, and medical jargon can seem like a foreign language to many people. The most widely used definition for health literacy is “the ability to obtain, process, and understand basic health information and services needed to make appropriate healthcare decisions and follow instructions for treatment.”2
Poor health literacy among Americans has been an area of focus for several federal agencies for more than a decade. The Institute of Medicine first described the problem in a 2004 report titled, “Health Literacy: A Prescription to End Confusion.”3 The Joint Commission addressed the issue in a 2007 white paper titled, “What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety.”4 In 2010, the United States Department of Health and Human Services suggested solutions in its “National Action Plan to Improve Health Literacy” and included a health literacy goal to improve communication in the Healthy People 2010 10-year national health objectives.5,6 The objective has also been included in the Healthy People 2020 agenda for improving health among Americans.7 Despite publication of ample literature on health literacy since Ratzen and Parker2 first defined the issue, health literacy remains a widespread problem among older adults.
Why Does It Matter?
The Agency for Healthcare Research and Quality (AHRQ) reported that low health literacy is associated with more emergency department visits and hospital readmissions, less preventive care, and poor medication administration skills.8 Older adults with poor health literacy were found to have overall poorer health status and higher mortality than those who possessed adequate health literacy skills.8 In addition to poor patient outcomes, low health literacy is a financial burden on our healthcare system with costs reaching to $92 billion annually in the United States.9 A Veterans Health Administration study indicated that low health literacy was a significant factor in higher healthcare costs.10 Hitting closer to home, many payers are penalizing healthcare practitioners who have poor patient outcomes.
Older Adult Learning Theory
Before we can address best practices to overcome low health literacy, we need to understand how older adults learn and factors that could impede older adult learning. Geragogy involves the principles of older adult learning theory. Factors affecting learning can be physical functions such as vision, hearing, and mobility.11,12 Increasing age can be associated with a decrease in vision and hearing, as well as slower psychomotor abilities. Adjustments in teaching will need to be made when educating these patients. Cognitive factors need to be considered. Older adults may have decreased short-term memory and a tendency to be distracted.11 Repetition is a key element in teaching the older adult.
Elliot identified the following principles of older adult learning11:
- “Approach the older adult in a way that communicates respect, acceptance, and support. Create a learning environment in which the patient can feel comfortable when expressing what is and is not understood.”
- “Schedule teaching session in mid-morning when energy levels are usually highest for the older adult. Conduct several brief sessions over different days rather than one long session, which may cause fatigue.”
- “Provide more time for the older adult to process new information.”
- “Link new knowledge to past experiences. Reminiscing helps the older adult reconnect with lived experiences.”
- “Keep the content practical and relevant to the older adult’s daily activities, social structure, and physical function. Older adults tend to be more motivated when the information is perceived as a way to address a current problem.”
- “Minimize distractions.”
- “Speak slowly, but not so slowly that the patient becomes bored or distracted.”
- “Use terminology that is familiar to the older adult.”
- “Give older adults written material that reinforces the major points of teaching. Use a large font.”
- “Use visuals that portray older adults in a positive manner.”
- “Encourage patients to keep written information easily accessible such as near a phone, bed table, or on the refrigerator.”
- “Use concrete terms and avoid abstract terminology.”
- “Encourage older adults to be actively involved in their teaching.”
- “Encourage family members to actively participate in the educational sessions.”
Many of the principles of geragogy are also recommendations for low health literacy, which are discussed later in this article.