reading level, preferably including pictures and illustrations.14
It is also important to provide instruction in the language in which the patient is most fluent. For example, compared to those with adequate and marginal health literacy, women with inadequate functional health literacy in Spanish were significantly less likely to have ever had a Papanicolaou (Pap) test.21 Of course, having assessment tools translated into the original language does not solve health literacy problems. In Turkey, risk factors for the lowest levels of health literacy include being female educated at the primary school level, in poor economic conditions, and older.22 In California, Cordasco, et al.23 compared by age levels of health literacy, educational attainment, English comprehension, and language use in inpatients. They found that the prevalence of inadequate health literacy increased significantly with increasing age. The correlation between older age and lower health literacy persisted when controlling for educational achievement, race, ethnicity, gender, and immigration status. Additionally, older adults were more likely to have never learned to read, have no formal education, have limited English comprehension, and speak a non‐English language at home. This suggests that providers should develop and use low‐literacy educational materials, programmes, and services to meet the chronic disease needs of an older, multiethnic population and ameliorate the negative health effects of associated low literacy.23
Differences in mental health literacy across the adult lifespan suggest that more specific, age‐appropriate messages about mental health are required for different age groups.19 Care must be taken to tailor material to the audience to optimise understanding. This means providers should ensure that the material does not exceed the users’ literacy level and that any translated materials are sensitive to the culture of the target population.24
Educational strategies to improve health literacy
Fortunately, proper educational techniques (Table 8.3) can make a difference in health care for people with low health literacy.12 Of 111 patients with poorly controlled diabetes, 55% had literacy levels at the sixth‐grade level or below. Over the six‐month study period, patients with low and high literacy had similar improvements in A1C when they received one‐to‐one education and medication management using techniques that did not require high literacy from clinic‐based pharmacists. Among community‐dwelling Korean older adults, limited health literacy was associated independently with higher rates of chronic medical conditions and lower subjective health status. Nurses were found to be key to providing health education to these older adults25 to help them maintain their independence. The greatest potential barrier to addressing health literacy is that most patients are often unwilling to admit that they have literacy problems.14 Indeed, Weiss, et al. found that 97% of their research subjects, regardless of literacy level, reported that television was their primary source of information.20
Table 8.3 Educational techniques to improve health literacy.
Source: Based on Rothman, et al.12.
| Written materialIs age appropriateUses simple wordsIs at a sixth‐grade levelIn the primary language of the patientIncludes pictures and illustrationsPresents a small amount of information Auditory materialDelivered slowlyIs delivered one‐on‐oneIs delivered by a trusted providerIs in the patient’s primary language |
Table 8.4 Cultural factors that affect health care.
| AgeGenderEthnicityAssimilationGeneration cohortThe ever‐changing nature of culture |
Cultural sensitivity in geriatrics
The need for cultural sensitivity
Developing strategies to increase awareness of cultural differences and address them appropriately in the context of providing good health care is difficult because of the various influences on culture (Table 8.4). Reaching this goal is further complicated by the fact that culture is fluid and constantly changing. These changes compound misunderstandings between members of different cultural groups. A further complication is the fact that there are cultural differences between different generations26 who share the same cultural background. Also, cultural differences often seem to be insurmountable between men and women of the same cultural background. Gender differences across cultures can be even more complicated. These differences highlight the complicated and constantly changing nature of culture. Providing geriatrics care often requires that health care providers interact with multiple generations of the same family. Therefore, any strategies employed to address cultural differences in the clinical setting need to be general and flexible in approach.
When cultures clash
Culture surrounds and defines everyone. Both providers and patients have their own national and ethnic cultures. These include their culture of origin and the cultural values, beliefs, language, and local culture (acculturation) skills they have adopted. The patients’ cultures will influence when they seek treatment, their expectation of care, and whether they will comply with the providers’ recommendations.27 Health care providers have the culture of biomedicine and their specific profession (e.g. medicine, nursing, and pharmacy) and speciality (e.g. surgery, geriatrics, and rheumatology). In addition, both providers and patients have cultural ideas and values that relate to their social culture28‐30 age,31,32 gender,33,34 and gender identity.35,36 Finally, health care providers for older adults are almost always younger than their patients. This age difference also has ramifications for compliance based on trust and respect.37
Finding a way to communicate effectively is critical to good patient care. Patient satisfaction and the likelihood of compliance with medical instructions38,39 are linked to patient–provider communication. If cultural differences are not addressed, then poor health outcomes and limited quality of medical decision‐making may result.40 Patient satisfaction with health care is affected by age, race, and literacy level. In low‐income populations, communication satisfaction may be lower for groups that are traditionally active in doctor–patient interactions (e.g. younger patients, patients with higher literacy skills). Health care providers should be aware that older, non‐white, optimistic, and literacy‐deficient patients report greater communication satisfaction than their younger, white, pessimistic, and functionally literate peers. Furthermore, they are more likely to cope with their illnesses by withdrawing rather than by actively pushing for a higher standard of care.41 Therefore, health care providers should continuously seek ways to facilitate dialogue with patients who are older and non‐white and have poor literacy skills. Thus, cultural sensitivity can help providers improve health care delivery in the clinical encounter. It can lead to better provider–patient communication, more accurate diagnoses, more effective treatment, higher patient satisfaction/compliance, and efficient use of medical resources.
For most adults who are not health care providers themselves, navigating the culture of biomedicine is challenging. These challenges are even greater for older adults who are handicapped with physical, mental, and/or social limitations. Most older adults have chronic diseases in addition to acute diseases. Health care providers often underappreciate the physical burdens of these chronic diseases. For example, community‐dwelling Korean older adults with low health literacy often have been reported to have significantly higher rates of arthritis and hypertension. After adjusting for age, education, and income, older individuals with low health literacy had more significant
