care providers’ ultimate goal is to provide the best medical care possible to all older adults. This goal is made difficult when these older adults do not possess adequate health literacy – that is, the ability to understand and manage their own health care. Good communication is critical to improving health literacy. When the cultural characteristics of both patients and providers are so different that communication is compromised, poor health literacy is likely to make it difficult for patients to receive good health care. This chapter presents ideas on how cultural context affects the provision of health care to an ageing, multiethnic population. Collaboration between providers and older adults and their caregivers4 is crucial. This chapter addresses barriers to accomplishing the goal of providing good health care resulting from cultural differences and provides suggestions to minimise cultural differences in clinical encounters. Because there is so much cultural diversity worldwide, this chapter serves as a reminder that the problem must be addressed rather than provide a laundry list of solutions. A list of resources at the end of the chapter will help guide practitioners in developing their own strategies to develop and maintain cultural sensitivity to improve health care to their multicultural patient base.
The importance of health literacy in health care
Health literacy refers to individuals’ ability to understand and manage their personal health care issues. Individuals with limited health literacy have less health knowledge, worse self‐management skills, and lower use of preventive services – especially those aged 65 years and older5 – and higher self‐reported health disparities associated with race/ethnicity and educational attainment.6 Older age has been strongly associated with having limited health literacy in studies that assessed health literacy as reading comprehension, reasoning, and numeracy skills.7 Increasingly, the ability to communicate and to use electronic media are becoming factors in health literacy.8
Factors that influence health literacy
Multiple factors influence health literacy9 (Table 8.1). Factors such as increasing age, less education, lower income, ‘blue collar’ jobs, and poor health status (both mental and physical) can put people at risk for marginal or inadequate health literacy.10 This risk impacts health outcomes and therefore the cost of caring for older adults. Limited health literacy is associated with low socioeconomic status, comorbidities, and poor access to health care, suggesting that it may be an independent risk factor for health disparities in older people.11 Lower literacy was more common among older adults and adults who required medication assistance.12 Poor health literacy has dire consequences (Table 8.2). Among community‐dwelling older adults who had recently enrolled in Medicare, inadequate health literacy was independently associated with poorer physical and mental health.13 Older adults are particularly affected by health literacy issues because their reading and comprehension abilities are influenced by their cognition and vision and hearing status. Inadequate health literacy can lead to difficulties in accessing health care, following a health care provider’s instructions, and taking medication properly. People with inadequate health literacy are more likely to be hospitalised than 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
