Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: https://www.tandfonline.com/loi/wshc20
Low Health Literacy and Older Adults: Meanings,
Problems, and Recommendations for Social Work
Aaron Findley
To cite this article: Aaron Findley (2015) Low Health Literacy and Older Adults: Meanings,
Problems, and Recommendations for Social Work, Social Work in Health Care, 54:1, 65-81, DOI:
10.1080/00981389.2014.966882
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Social Work in Health Care, 54:65–81, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0098-1389 print/1541-034X online
DOI: 10.1080/00981389.2014.966882
Low Health Literacy and Older Adults:
Meanings, Problems, and Recommendations
for Social Work
AARON FINDLEY, LSW, MDiv
Countryside, Illinois, USA
Many older adults struggle to manage their health care problems.
Low health literacy exacerbates such struggles and contributes to a
variety of adverse health behaviors and outcomes. Addressing how
health literacy impinges on the lives of older adults is a neglected
area of social work practice and knowledge. This article explores
seven areas: defining health literacy, the problem and prevalence
of low health literacy among older adults, health inequalities and
health literacy, a brief literature review, neglected issues in the
literature, suggestions for macro and micro social work interventions to improve health literacy for older adult populations, and
conclusion.
KEYWORDS functional health literacy, literacy, well-being of
older adults, geriatric social work, health education, health
inequalities, communication with health care providers, social
work interventions
INTRODUCTION
Health literacy and its various effects on the well-being of older adults is a
crucial yet often underexamined area of social work discourse and practice.
By the age of 85, over half of older adults struggle to manage health care
problems and require some assistance with one or more activities of daily living, and low health literacy can exacerbate such struggles (McInnis-Dittrich,
2009; Sorrell, 2006). Erroneous, partial, and low health literacy contributes
Received September 11, 2014; accepted September 15, 2014.
Address correspondence to Aaron Findley, LSW, MDiv. E-mail: afindley@luc.edu
65
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to numerous and varied negative health behaviors and outcomes (Zamora &
Clingerman, 2011). Since geriatric social workers enhance the well-being of
older adults, addressing how health literacy impinges on their lives from a
wholistic standpoint is a critical area of social work practice and knowledge.
DEFINING HEALTH LITERACY
Functional health literacy (FHL) is defined as the ability to understand
health-related information, and functional literacy is the ability to read and
write to function in society; health literacy and functional literacy—although
overlapping—are not interchangeable terms (Liechty, 2011). Properly managing one’s health requires more than functional literacy; it requires health
literacy that necessitates skills in acquiring, processing, and acting on accurate information developed through formal education and through informal
personal experiences (Mitty & Flores, 2008; Nutbeam, 2008).
Healthy People 2010, a noteworthy federal health initiative, defines
health literacy as: “the degree to which individuals have the capacity
to obtain, process, and understand basic health information and services
needed to make appropriate health decisions” (Cagle & Kovacs, 2009, p. 22).
The World Health Organization (WHO) broadens the definition as involving:
the achievement of a level of knowledge, personal skills and confidence
to take action to improve personal and community health by changing
personal lifestyles and living conditions. Thus, health literacy means more
than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it
effectively, health literacy is critical to empowerment. (Nutbeam, 2008,
p. 2074)
Health literacy can also be pithily understood as “understanding health
information and then acting on it,” and the basic skills involve reading, writing, and numeracy such as calculating the next time a medication dose is
needed (Mitty & Flores, 2008, p. 230). Strategies to promote health literacy
will unavoidably remain tied to broader strategies to enhance general literacy, numeracy, English language skills, and oral communication. Acquiring,
communicating, and processing health information is indispensable in making informed health decisions. General literacy skills are needed for health
literacy, but health literacy per se also necessitates supplementary healthrelated knowledge and skills such as basic medical vocabulary, familiarity
with how the health care system functions, and knowledge of how health
affects biopsychosocial well-being (Liechty, 2011; Nutbeam, 2008).
Simply put, health literacy can be a risk or protective factor and both
models are needed for a more nuanced conceptualization of health literacy
Low Health Literacy and Older Adults
67
(Nutbeam, 2008). Health literacy has been measured based on the ability to
complete health-related information and processing tasks, and these healthrelated activities can be categorized into three areas: (1) “clinical tasks” such
as correctly apprehending instructions such as taking a pain reliever at recommended times or knowing how to use portable oxygen therapy tanks,
(2) “preventive tasks” such as understanding recommendations related to
preventive services like annual breast cancer screenings and prostate exams,
and (3) “health care system navigation,” which entails understanding the vast
world of health insurance as well as the eligibility requirements for benefit
programs like Medicaid, interpreting a medical bill, or identifying legitimate
websites for accurate health information (Liechty, 2011, p. 100).
THE PROBLEM AND PREVALENCE OF LOW HEALTH LITERACY
AMONG OLDER ADULTS
The link between poor literacy skills and health has been recognized by
many studies and the concept of “functional health literacy” has received
much critical scholarly attention from clinical public health, nursing, and
social work; however, the health literacy of older adults has not received
the sustained attention from social workers that the subject merits (Nutbeam,
2008; Chinn, 2011; Bergsma, 2004, Hickey et al., 2014).
Research indicates that health information today is presented in ways
that most adults find inaccessible (Kutner, Greenberg, Jin, & Paulsen 2006).
Among adult age groups, those aged 65 or older have the smallest percentage of people with proficient health literacy skills and the largest percentage
with below basic health literacy skills (Kutner et al. 2006). Nearly one-fifth
of the American public is “functionally illiterate” (Cagle & Kovacs, 2009,
p. 22). Older adults with diabetes, high cholesterol, and hypertension are
nearly two times as likely to have low health literacy (Hickey et al., 2013).
Approximately one-third of all Medicare enrollees had inadequate levels of
health literacy (Keifer, 2001). One review of 85 studies found that the prevalence of low and marginal health literacy among older American adults was
estimated around 20% (McDougall, Mackert, & Becker, 2012). The oldest
adults, those with lower education and income, and those with poorer health
had lower levels of health insurance literacy (McCormack, Bann, Uhrig,
Berkman, & Rudd, 2009). Health literacy is especially critical for managing
medication, since adults over age 65 years use over 30% of all prescription
medications (McDougall et al., 2012, p. 71).
Low literacy in any given population is associated both directly and
indirectly with a wide variety of poor health outcomes (Nutbeam, 2008). The
absence of plain language guidelines alone is associated with health care disparities, medical errors, chronic illness management, and failure to engage
in healthy lifestyles like weight management (Mitty & Flores, 2008). Those
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with low literacy levels use health information and services less and experience poorer self-management of disease (DeWalt, Berkman, Sheridan, Lohr,
& Pignone, 2004). Low literacy is frequently associated with poor socioeconomic conditions, and this, in turn, is linked with negative health effects
(Nutbeam, 2008). Few studies have explored the association between subjective happiness and health literacy, but one study revealed that health literacy
was positively correlated with happiness, and the lowest-quartile happiness
was associated with poverty, unfavorable self-rated health, and lower health
literacy (Angner, Miller, Ray, Saag, & Allison, 2010).
General literacy has been associated in studies with higher education,
better income, and improved likelihood of employment (Kutner et al., 2007).
Mental health, visual acuity, and frequency of reading the newspaper were
all positively associated with higher health literacy (Baker, Gazmararian,
Sudano, & Patterson, 2000). Whether general or health literacy, literacy is
associated with a sense of personal control that has, in turn, been correlated
with perceived happiness (Angner et al., 2010). Health literacy is associated with “cognitive function across multiple domains” among older adults
(McDougall et al., 2012, p. 70). Health care costs can be up to four times
higher for older adults with low general and health literacy skills (McDougall
et al., 2012).
Older adults have documented health literacy problems. Four levels
of health literacy exist (proficient, intermediate, basic, and below basic);
basic and below basic health literacy levels are inadequate to manage health
care needs (Liechty, 2011). The 2003 National Assessment of Adult Literacy
(NAAL) survey found that “more than one-third of adults” fell into either
the basic or below basic levels of health literacy, while only 52% of adults
functioned at the “intermediate level” and 12% were deemed “proficient”
(Kutner et al., 2006; Liechty, 2011, p. 100). According to one 2003 National
Assessment of Adult Literacy or NAAL (the first-ever national assessment of
health literacy), only an abysmal 3% of the older adults who were surveyed
were measured as proficient in health literacy (SOPHE, 2011). The estimated
cost of low health literacy ranges from $106 to $238 billion yearly in the
United States (Liechty, 2011). Two documented challenges for older adults
with low health literacy are accessing health information on the Internet and
using basic math (SOPHE, 2011).
The 1992 National Adult Literacy Survey (NALS) estimated that approximately 90 million adult Americans performed at the two lowest levels of
functional literacy; at these lower levels, individuals were not able to complete a Social Security card application or perform rudimentary math (Kirsch,
Jungeblut, Jenkins, & Kolstad, 1993). Individuals in this survey who scored at
the lowest levels included older adults as well as the economically insecure,
racial minorities, and those with lower levels of education (Angner et al.,
2010).
Low Health Literacy and Older Adults
69
Among older adults difficulties with health literacy can exacerbate
already challenging or life-threatening problems. Health literacy has been
demonstrated in many studies to correlate significantly with chronic disease–
specific knowledge and outcomes as well as increased resource use and
costs (Cordasco, Asch, Franco, & Mangione, 2009). Up to 80% of older
Americans have at least one chronic health condition, and the higher the comorbidity rate, the more they need to navigate health care information and
systems effectively (SOPHE, 2011). One study revealed that 40% of patients
with pacemakers and defibrillators had minimal or inadequate understanding
about their cardiac health (Hickey et al., 2014).
Health literacy scores decline with advancing age, and reading skills are
worse among older age groups (Baker et al., 2000). The higher prevalence of
dementia and cognitive impairment among older individuals may explain, in
part, much of their lower reading scores (Baker et al., 2000). One large study
using the Short Test of Functional Health Literacy in Adults (S-TOFHLA, range
0-100) and the Mini Mental State Examination (MMSE) found that African
Americans and Hispanics had lower mean S-TOFHLA scores than Caucasians,
but no statistically significant difference was found between men and women
(Baker et al., 2000).
The high prevalence of limited English comprehension in older patients
in the United States (especially among patients in safety-net hospitals) is
troubling (Cordasco et al., 2009). The use of safety-net hospitals—hospitals
with large numbers of the uninsured and Medicaid recipients—is rising, and,
in light of current demographics, more older individuals with limited English
comprehension will likely continue to increase in future decades (DeLia,
2006; Cordasco et al., 2009).
Assessing older adults’ health literacy may be a challenge also, because
of multiple variables such as hearing or visual impairment, language barriers, ineffective physician–patient communication, the possibility of cognitive
impairment, the early socialization among some older adults of accepting
medical authority without raising questions or disagreements, psychological
barriers such as anxiety or lower self-esteem, or they may be embarrassed
about their struggles with literacy and may try to hide their ignorance (Sorrell,
2006).
HEALTH INEQUALITIES AND HEALTH LITERACY
Health literacy mirrors other health inequalities. It is not simply a personal
matter but is influenced by a variety of educational, class, cultural, racial,
social, financial, and health services variables (Chang et al., 2004). Health
literacy has been seen as one catalyst of health and other social disparities
(Liechty, 2011). Health literacy declines with age, and data highlight other
demographic attributes as health risk factors including lack of Internet access,
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lack of health insurance, having less than a 12th grade education, having one
or more physical disabilities, and Hispanic ethnicity (Liechty, 2011).
Those with low health literacy are at risk for many potentially adverse
health outcomes: higher systolic blood pressure, lower treatment adherence,
“poorer glycemic control,” poorer self-reported health, requiring more help
and guidance in their health care, lower patient satisfaction, insufficient
knowledge of treatment plans at discharge, higher rates of hospitalization,
longer hospital stays, less likely to seek preventive care, more likely to use
emergency rooms and ambulance transport, more likely to not obtain an
annual flu shot, less knowledgeable about chronic disease management, and
present themselves for medical treatment in a graver state of illness compared with those with higher health literacy (Kutner et al., 2006; Liechty,
2011, p. 101; Mitty & Flores, 2008). One cross-sectional survey of communitydwelling Korean-American older adults found that individuals with low
health literacy had significantly higher rates of arthritis, hypertension, higher
limitations in activity, higher rates of pain, and lower subjective sense of
health and happiness (Kim, 2009).
Patients with limited English comprehension are at a higher risk for the
following challenges: misapprehending medical instructions, less knowledge
about their illnesses, reduced levels of treatment adherence, experience more
adverse health outcomes, and billed for more health care costs (Cordasco
et al., 2009; Crane, 1997; Manson, 1988; Perez-Stable, Napoles-Springer, &
Miramontes, 1997; Brach, 2005).
Health care providers often report that serving populations with low
health literacy is exasperating and challenging, which undermines patient–
provider rapport and communication and unintentionally aggravates preexisting health inequalities (Liechty, 2011). One observational study revealed
that 81% of outpatient physician encounters with patients with low health
literacy were filled with unexplained medical jargon (Castro, Wilson, Wang,
& Schillinger, 2007). Unparsed medical jargon affords health social workers, nurses, and gerontologists the chance to translate medical terms into lay
terms or else explain the basics of medical terms for the benefit of older
adult patients.
Regarding the use of online health information among older adults and
younger adults, a substantial digital inequality continues to characterize computer and Internet use in America (especially among older, lower-income
African Americans); however, these disparities can be rectified through teaching older adults how to navigate informational websites such as the National
Institutes on Health’s SeniorHealth.gov website (Brodie et al., 2000). There
is some evidence that psychological barriers such as perceived relevance,
fear, and lower self-esteem may motivate maladaptive attitudes about computers and Internet use in underserved and older populations, yet most older
adults who do not know how to use a computer say they are willing to learn
(Bertera, Bertera, Morgan, Wuertz, & Attey, 2007).
Low Health Literacy and Older Adults
71
BRIEF LITERATURE REVIEW
The concept of health literacy has been underused in social work scholarship, but in recent decades a steady flow of research about health literacy
continues to be done (Liechty, 2011). A tenfold increase in the number of
journal articles about health literacy has been published between 1997 and
2007 (Bankson, 2009; Chinn, 2011). National surveys of functional literacy
in the United States, which exposed large pockets of low literacy, initially
triggered interest in health literacy skills (Kirsch et al., 1993).
In light of national literacy surveys, direct measures of health literacy were developed such as the Rapid Estimate of Adult Literacy in
Medicine (REALM) and the Short Test of Functional Health Literacy in
Adults (STOFHLA) to assess comprehension skills in medical settings (Chinn,
2011). Although several measurements of health literacy are available in the
United States such as TOFLA and REALM measures that have been tested
and validated as short screening tools, some researchers claim that these
two measures are inadequate and recommend the Health Activity Literacy
Scale (HALS), which, by comprehensiveness, includes different health-related
competencies in the five categories of health promotion, health protection, disease prevention, health care maintenance, and systems navigation
(Nutbeam, 2008; Baker, 2006; Rudd, 2007). Few health literacy measurement
tools, however, are uniquely tailored for older adults.
We are now experiencing what has been deemed the “second wave of
health literacy research” influenced by sophisticated understandings of educational, political, and social theories regarding “multiple literacies” (such as
e-literacy and political literacy) and their associations with individual autonomy, social justice, social change, and empowerment (Chinn, 2011, p. 61;
Nutbeam, 2009; Hill, 2004). Currently, much literature stresses the socially
contextualized view of literacy users as proactive, community-changing
agents, and this paradigm harmonizes well with developments in the wider
fields of health promotion, ecological systems thinking and social work
(Nutbeam, 2009; Chinn, 2011).
Against this conceptual background, Nutbeam’s (2000) model of health
literacy as advancing through different levels of cognitive, interpersonal,
and social skills has been appreciably influential, building on the concept
that health literacy entails not only psychological but social, political, and
community-building activities. A detailed reading of Nutbeam’s consequential works (2000, 2008, 2009) suggests that the concept of critical health
literacy can be divided into three areas: (1) the critical analysis of information, (2) an understanding of the social determinants of health such as
race, education, and socioeconomic status, and (3) engagement in collective,
politicized action (Chinn, 2011).
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NEGLECTED ISSUES IN THE LITERATURE
Most health literacy studies concerning older adults have depended on quantitative measures, but more qualitative approaches are needed that involve
observations, case studies, and interviews to highlight how older adults actually feel and interact with health information and health care providers in
real-life situations (Chinn, 2011). Health literacy studies need to continue to
highlight the socially contextualized nature of health and literacy.
Many studies on health literacy have not fully included members of
minority and non-English speaking populations, though there are admirable
exceptions (see Crane, 1997; Manson, 1988; Perez-Stable et al., 1997; Brach,
2005; Cordasco et al., 2009). Very few health literacy articles address the
unique concerns and voices of lesbian, gay, bisexual, and transgender
(LGBT) older adults (Chinn, 2011).
Historically disadvantaged groups—including minority and LGBT
adults—within the older adult population continue to have higher levels
of illness, disability, and premature death (Fredriksen-Goldsen & Muraco,
2010). Even though older adults are increasingly diverse, aging services and
health needs of LGBT older adults are often neglected in policies, research,
and health literacy studies (Institute of Medicine, 2011). One seminal health
report found that—among older LGBT adults—approximately 50% have a
disability and 33% report depressive symptoms (Fredriksen-Goldsen et al.,
2011).
These unresolved issues involving studies of minority, non-English
speaking, and LGBT older adults can be rectified through surveys, tests, and
qualitative interviews involving members of these three under-represented
groups in the social work and nursing literature on health literacy.
SUGGESTIONS FOR MACRO AND MICRO SOCIAL WORK
INTERVENTIONS
Social workers care about the issues related to health literacy: health equality,
quality of care, health care access, biopsychosocial and spiritual well-being,
cultural competence, structural, financial, and organizational barriers to
health care, consumer empowerment, and the empowering nature of information and education as tools for individual and social change (Liechty,
2011; Bergsma, 2004).
Empowering education related to health literacy is an effective social
work intervention, yet social workers often overlook this form of intervention or relegate it to the valuable work of nurses. Although the breadth
of health literacy is deceptively complex (Cagle & Kovacs, 2009), health and
geriatric social workers are well positioned to provide critical feedback about
Low Health Literacy and Older Adults
73
health literacy to advisory and interdisciplinary teams at the organizational,
local, state, and national levels. Schooled in ecological thinking and interorganizational community building, social workers are trained to identify
barriers to health, engage with supporting groups and communities, and
can reverse negative health outcomes through health literacy promoting
activities.
Effective social work interventions need to keep in mind that health
literacy affects health outcomes at three critical points: (1) access to health
care, (2) the interaction between clients and their health care professionals, and (3) self-care (Paasche-Orlow & Wolf, 2007). Correcting low levels
of health literacy necessitates improving access to effective school education
and improving the quality of health care provider and client communications (Nutbeam, 2008). The adverse outcomes associated with low health
literacy can be lessened through “patient education and support, systems
improvements, and health care provider accommodations” as well as through
government-funded research and pro-health legislation and policies (Liechty,
2011, p. 99).
On the macro level, social workers can advocate on local, state, and
federal policy levels for changes in practice related to health literacy. On the
micro level, they can offer a variety of interventions: providing information
in age-friendly formats, avoiding complex medical jargon whenever possible,
asking clients to rephrase what has been communicated, gently identify and
correct maladaptive thoughts or medical beliefs, encourage clients to “challenge conventional assumptions” about illness and dying, provide clients
with external sources of answers when they forget or feel overwhelmed with
too much information, educate families about “group and family dynamics”
related to health and illness, educate clients and their caregivers about their
rights and resources, and encourage a “sense of control” through activities
that clients can do to manage their own diseases (Cagle & Kovacs, 2009,
pp. 24–25; Liechty, 2011).
It is crucial for social and legislative policies to encourage greater interaction between researchers working with health literacy in the medical
communities like nursing on the one hand and social work and public health
on the other hand (Nutbeam, 2008). Social workers should use and expect
more evidence-based and empirically validated measurements of health literacy such as STOFHL, which policymakers, social scientists, and shareholders
will require to justify investments and grants in such social welfare initiatives.
Present and future policies, from the community and state to the national
level, should keep in mind that health literacy can save and prolong lives,
salvage money, and enhance the health and quality of life for millions of
Americans (Sorrell, 2006). A strong consumer, patient-centered movement
exists to engage consumers in their health care information and decisions,
and social workers can uniquely embody and advocate for such a movement.
Social workers have an in-depth expertise in working with patients with
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low health literacy and can easily spearhead and implement health literacy
programs in a variety of community and medical settings ranging from Area
Agencies on Aging, houses of worship, and senior community centers to
assisted living communities, hospitals, and long-term care nursing facilities
(Liechty, 2011).
Social workers need to address health literacy disparities along racial,
cultural, and socioeconomic lines through systematic outreach. Research
consistently reveals that older African Americans especially sustain “higher
incidences of certain diseases” (such as asthma, stroke, hypertension) and
experience elevated rates of co-morbidity and death as a result of diseases
like cancer and diabetes than members of the larger population (Gollop,
1997, p. 141). Also, to anticipate the health needs of a growing, non-Englishspeaking population and lessen the adverse health outcomes associated with
low literacy, safety-net hospitals, senior centers, geriatric physicians, and all
health care providers can prioritize the implementation of educational materials, programs, and services targeted for individuals of low literacy or those
with limited English language apprehension (Cordasco et al., 2009).
Several hospital-level health literacy initiatives already exist in which
social workers are and can be spirited leaders such as: (1) “plain language
review panels” that promote jargon-free medical documents and effective
doctor–patient communication, (2) hospital “staff training” in health literacy,
(3) low health literacy problems as a “social work referral criterion” incorporated into standardized documents and multidisciplinary staff meetings,
and (4) “low health literacy screenings,” which use validated measurements
(Liechty, 2011, p. 105). Health social workers can be trained to use validated measurements like the Rapid Estimate of Adult Literacy in Medicine or
STOFHLA to justify or petition for the critical role of social work interventions in health care settings and contribute to measurable, positive patient
health outcomes (Liechty, 2011; Baur, 2011).
With the conceptualization of “empowerment education” (Bergsma,
2004) as a template for individual and social change, social workers can intervene in countless ways to collaborate with older clients, their families, and
health providers such as: encourage ongoing involvement in intellectual and
social activities; acknowledge older adults’ strengths; encourage and normalize older adults and their family caregivers to ask questions about diseases,
medications, and health-related topics; enhance computer skills and Internet
access for health websites; act as a facilitator of clear health communication
between physicians and family members; develop targeted health information outreach events for older adults at local senior centers; share critical
resources such as the National Institutes on Health’s guide for older adults to
help them communicate with their doctors effectively; and generate health
information media campaigns with specific knowledge of the cultural characteristics, media habits, and language preferences for diverse older adults
(SOPHE, 2011; Baur, 2011, Liechty, 2011).
Low Health Literacy and Older Adults
75
Many commonsensical and empirically validated strategies can be used
to enhance health literacy among older adults: using simple language and lay
terms, using printed materials with larger font sizes, speaking slowly, screening for hearing or visual impairments as barriers to health literacy, asking
patients to review follow-up medical instructions with staff, using visuals
and models to explain health information, following up with a phone call to
monitor adherence, asking older adults for their feedback in the design of
health-related printed materials and websites, referring older adults to legitimate health websites, and using visual aids and story boards to improve the
comprehension of health information for limited English-speaking patients
(Liechty, 2011; Schwartzberg et al., 2007; Valle, Yamada, & Matiella, 2006).
Simple solutions include asking older adult patients to read aloud a portion
from printed materials related to their health condition and care plan or use
more open-ended questions such as: “Please explain to me when you will
take these pills” or “Can you please tell me what this medication is for?”
(Sorrell, 2006, p. 18). Accurate information frequently exposes unrealistic or
faulty assumptions family members and patients have about the interaction
of medications, the length of recovery after surgery, the dying process, and
the costs and coverage of health care services (Cagle & Kovacs, 2009).
Social workers’ assessment and attending skills are fundamental for
effective health literacy interventions. Studies say reflective listening and
rephrasing are efficacious techniques to check and reassure that health information has been effectively understood (Mitty & Flores, 2008). One clear sign
of a literacy problem in older adults may include poor eye contact when
asked to read anything, defensive behavior regarding understanding what is
said, and making excuses that they do not have the necessary glasses or hearing devices (Sorrell, 2006). Identification of low literacy has to be done with
cultural sensitivity and with the knowledge that concealment and embarrassment are common psychosocial reactions among those with functional
illiteracy (Mitty & Flores, 2008).
Targeted “community-based educational outreach” to older adults who
are at-risk for low health literacy is another form of social work intervention (Nutbeam, 2008, p. 2077). Area Agencies on Aging (AAAs), local senior
centers, houses of worship, assisted living facilities, health care providers,
short-term rehabilitation and nursing facilities, and hospitals can sponsor
educational outreach programs to enhance health and digital literacy.
The Centers for Disease Control and Prevention (CDC) recommends that
health professionals should adjust their assumptions and demands concerning older adults, become conscious about literacy when interacting with all
older adults, consider the literacy and cultural environment of their clients,
improve their written, oral and visual communication skills to incorporate
plain language as much as possible, and develop age-friendly printed materials for older adults such as including bullet points and larger text font size
(CDC, 2009).
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Issued in 2010, The National Action Plan to Improve Health Literacy—
the work of the U.S. Department of Health and Human Services (HHS) and
the Office of Disease Prevention and Health Promotion (ODPHP)—is an
estimable framework and tool which social workers, public health advocates,
nurses, and all health care providers can employ to describe, guide, and
attend to health literacy barriers (Baur, 2011). The Action Plan includes seven
high-level goals and strategies to achieve each of the goals such as generating
and distributing “health and safety information that is accurate, accessible,
and actionable” (Baur, 2011, p. 64). For example, one goal of the Action
Plan is to include the creation of official statewide health literacy initiatives
such as those already implemented in states like Missouri, Arkansas, and
Wisconsin (Baur, 2011). The Action Plan recommends developing curricula
in social work and nursing schools to teach students about health literacy
in such areas as disease management, health promotion, communication
with patients, and culturally sensitive communication with underserved and
minority communities; moreover, professors are encouraged to “research and
train students in health literacy,” and funding for health literacy research and
practice is prioritized (Baur, 2011, p. 68).
Internet health coaching (e-coaching) is another promising intervention for increasing health literacy among older adults. Internet coaching
augments individuals’ sense of control about their health and assists individuals how to read, interpret, and assess the reliability of sources of online
health information (Khazaal et al., 2009). Social workers are encouraged
to work with older adults in residential and community settings such as
subsidized housing facilities where underserved older adults may have computers but are not using computers to acquire health information (Bertera
et al., 2007). Sorrell (2006) recommends that social workers routinely refer
to trusted websites such as the Center for Medicare Education and the
Pfizer Clear Health Communication Initiative. Researchers have discovered
a link between higher digital literacy (use of e-mail/Internet) and a reduction in cognitive decline among older adults (Xavier et al., 2014). The use
of computer training outreach programs and trusted health websites can
reduce health inequalities by encouraging health promotion, disease prevention, disease management, and greater patient advocacy. Participants in one
study involving predominantly African-American older women demonstrated
marked improvements in computer and website navigation for accessing
online health information after a computer training program (Bertera et al.,
2007).
Health literacy extends even to end of life care. Palliative and hospice care social workers can dispel many misconceptions about hospice and
palliative care; for example, social workers can expose the myth that admission into hospice care implies giving up hope, and they can help families
reframe it as hope for dignity, comfort, and deepened relationship-building
(Cagle & Kovacs, 2009). Social workers in hospice, palliative care, or other
Low Health Literacy and Older Adults
77
health settings need to be aware that some health information could be
psychological unsettling, and a wide variety of conflicting psychosocial and
spiritual responses could arise that may call for critical psychosocial skills and
interventions (Cagle & Kovacs, 2009, Taylor-Brown, Blacker, Walsh-Burke,
Christ, & Altilio, 2001).
CONCLUSION
In summary, knowledge about health is insufficient. Health literacy among
social workers involves much more than conveying health facts. It entails
empowering older adults to become more self-assured as they act on their
health information, advocate for greater clarity of health information, and
learn to navigate the health care system more effectively. Improved health
literacy empowers older adults to exercise greater control over their lives
(Nutbeam, 2008), reduces health care costs, and improves physical and
psychosocial well-being.
ACKNOWLEDGMENTS
The author expresses special thanks to his fiancé and family for their
steadfast support.
REFERENCES
Angner, E., Miller, M.J., Ray, M.N., Saag, K.G., & Allison, J.J. (2010). Health literacy and happiness: A community-based study. Social Indicators Research, 95,
325–338.
Baker, D.W. (2006). The meaning and measure of health literacy. Journal of General
Internal Medicine, 21, 878–883.
Baker, D.W., Gazmararian, J.A., Sudano, J., & Patterson, M. (2000). The association
between age and health literacy among elderly persons. Journal of Gerontology:
Social Sciences, 55B(6), 368–374.
Bankson, H.L. (2009). Health literacy: An exploratory bibliometric analysis,
1997–2007. Journal of the Medical Library Association, 97(2), 148–150.
Baur, C. (2011). Calling the nation to act: Implementing the national action plan to
improve health literacy. Nursing Outlook, 59, 63–69.
Bergsma, L.J. (2004). Empowerment education: The link between media literacy and
health promotion. The American Behavioral Scientist, 48(2), 152–163.
Bertera, E.M., Bertera, R.L., Morgan, R., Wuertz, E., & Attey, A.M.O. (2007).
Training older adults to access health information. Educational Gerontology,
33, 483–500.
Brach, C. (2005). Crossing the language chasm. Health Affairs, 24(2), 424–434.
78
A. Findley
Brodie, M., Flournoy, R.E., Altman, D.E., Blendon, R.J., Benson, J.M., & Rosenbaum,
M.D. (2000). Health information, the internet, and the digital divide. Health
Affairs, 19(6), 255–265.
Cagle, J.G., & Kovacs, P.J. (2009). Education: A complex and empowering social
work intervention at the end of life. Health & Social Work, 34(1), 17–27.
Castro, C.M., Wilson, C., Wang, F., & Schillinger, D. (2007). Babel babble: Physicians’
use of unclarified medical jargon with patients. American Journal of Health
Behavior, 31(1), 85–95.
Centers for Disease Control and Prevention (CDC). (2009). Improving Health Literacy
for Older Adults: Expert Panel Report 2009. Atlanta, GA: U.S. Department of
Health and Human Services. Retrieved from http://www.cdc.gov/healthliteracy/
pdf/olderadults.pdf
Chang, B.L., Bakken, S., Brown, S.S., Houston, T.K., Krebs, G.L., Kukafka, R., &
Stavri, P.Z. (2004). Bridging the digital divide: Reaching vulnerable populations.
Journal of the American Medical Informatics Association, 11, 448–457.
Chinn, D. (2011). Critical health literacy: A review and critical analysis. Social Science
& Medicine, 73, 60–67.
Cordasco, K.M., Asch, S.M., Franco, I., & Mangione, C.M. (2009). Health literacy and
English language comprehension among elderly inpatients at an urban safetynet hospital. Paper presented at The Robert Wood Johnson Clinical Scholars
Annual (JHHSA) Meeting, Fort Lauderdale, FL, November 15, 2007.
Crane, J.A. (1997). Patient comprehension of doctor-patient communication on discharge from the emergency department. The Journal of Emergency Medicine,
15(1), 1–7.
DeLia, D. (2006). Caring for the new uninsured: Hospital charity care for older
people without coverage. Journal of American Geriatric Society, 54(12),
1933–1936.
DeWalt, D.A., Berkman, N.D., Sheridan, S., Lohr, K.N., & Pignone, M.P. (2004).
Literacy and health outcomes: A systematic review of the literature. Journal
of General Internal Medicine, 19, 128–139.
Fredriksen-Goldsen, K., & Muraco, A. (2010). Aging and sexual orientation: A 25-year
review of the literature. Research on Aging, 32(3), 372–413.
Fredriksen-Goldsen K.I., Kim H.J., Emlet C.A., Muraco, A., Erosheva, E.A., HoyEllis, C.P., & Petry, H. (2011). The aging and health report: Disparities and
resilience among lesbian, gay, bisexual, and transgender older adults. Seattle,
WA: Institute for Multigenerational Health.
Gollop, C.J. (1997). Health information-seeking behavior and older African American
women. Bulletin of the Medical Library Association, 85(2), 141–146.
Hill, L.H. (2004). Health literacy is a social justice issue that affects us all. Adult
Learning, 15(1), 4–6.
Hickey, K.T., Sciacca, R.R., Gonzalez, P., Castillo, C., & Frulla, A. (2014).
Assessing health literacy in urban patients with implantable cardioverter defibrillators and pacemakers. Journal of Cardiovascular Nursing.
DOI:10.1097/JCN.0000000000000184.
Institute of Medicine. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender
People: Building a Foundation for Better Understanding. Washington, DC: The
National Academies Press.
Low Health Literacy and Older Adults
79
Keifer, K. (2001). Health Literacy: Responding to the Need for Help. Center for
Medicare education and center on aging society. Retrieved from http://ihcrp.
georgetown.edu/agingsociety/pdfs/CMEReport1.pdf
Kim, S.H. (2009). Health literacy and functional health status in Korean older adults.
Journal of Clinical Nursing, 18, 2337–2343.
Khazaal, Y. Chatton, A., Cochand, S., Coquard, O., Fernandez, S., Khan, R., Billieux,
J., & Zullino, D. (2009). Brief DISCERN, six questions for the evaluation
of evidence-based content of health-related websites. Patient Education and
Counseling, 77, 33–37.
Kirsch, I., Jungeblut, A., Jenkins, L., & Kolstad, A. (1993). Adult Literacy in America:
A First Look at the Results of the National Adult Literacy Survey. Washington, DC:
National Center for Education Statistics, U.S. Department of Education.
Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of
America’s Adults: Results from the 2003 National Assessment of Adult Literacy
(NCES 2006–483). Washington, DC: National Center for Education Statistics, U.S.
Dept of Education.
Kutner, M., Greenberg, E., Jin, Y., Boyle, B., Hsu, Y., & Dunleavy, E. (2007). Literacy
in Everyday Life: Results from the 2003 National Assessment of Adult Literacy.
Washington, DC: National Center for Education Statistics, U.S. Department of
Education.
Liechty, J.M. (2011). Health literacy: Critical opportunities for social work leadership
in health care research. Health & Social Work, 36(2), 99–107.
Manson, A. (1988). Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Medical Care, 26(12),
1119–1128.
McCormack, L., Bann, C., Uhrig, J., Berkman, N., & Rudd, R. (2009). Health insurance
literacy of older adults. The Journal of Consumer Affairs, 43(2), 223–248.
McDougall, G.J., Jr., Mackert, M., & Becker, H. (January/February 2012). Memory
performance, health literacy, and instrumental activities of daily living of
community residing older adults. Nursing Research, 61(1), 70–75.
McInnis-Dittrich, K. (2009). Social Work With Older Adults: A Biopsychosocial
Approach to Assessment and Intervention. Boston, MA: Allyn & Bacon.
Mitty, E., & Flores, S. (2008). Assisted living nursing practice: Health literacy and
chronic illness management. Geriatric Nursing, 29(4), 230–235.
Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century.
Health Promotion International, 15(3), 259–267.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science &
Medicine, 67, 2072–2078.
Nutbeam, D. (2009). Defining and measuring health literacy: What can we learn
from literacy studies? International Journal of Public Health, 54(5), 303–305.
Paasche-Orlow, M.K., & Wolf, M.S. (2007). The causal pathway linking health literacy
to health outcomes. American Journal of Health Behaviour, 31, 19–26.
Perez-Stable, E.J., Napoles-Springer, A., & Miramontes, J.M. (1997). The effects of
ethnicity and language on medical outcomes of patients with hypertension or
diabetes. Medical Care, 35(12), 1212–1219.
80
A. Findley
Rudd, R.E. (2007). Health literacy skills of U.S. adults. American Journal of Health
Behavior, 31, 8–18.
Society for Public Health Information (SOPHE). (2011). National health education
week, October 16–22, 2011: Seniors: Health literacy and healthy aging. Retrieved
from http://www.sophe.org/Sophe/PDF/NHEW2011/NHEWThurs_Seniors.pdf
Sorrell, J.M. (March 2006). Matters: Low health literacy: Addressing issues related
to geropsychiatry and the well-being of older adults. Journal of Psychosocial
Nursing, 44(3), 17–20.
Taylor-Brown, S.T., Blacker, S., Walsh-Burke, K., Christ, G.H., & Altilio, T. (2001).
Care at the End of Life. Philadelphia, PA: Society of Social Work Leadership in
Health Care.
Valle, R., Yamada, A., & Matiella, A.C. (2006). Fotonovelas: A health literacy tool for
educating Latino older adults about dementia. Clinical Gerontologist, 30, 71–88.
Xavier, A.J., d’Orsi, E., de Oliveira, C.M., Orrell, M., Demakakos, P., Biddulph, J.P., &
Marmot, M.G. (2014). English longitudinal study of aging: Can Internet/E-mail
use reduce cognitive decline? The Journals of Gerontology, Series A: Medical
Sciences, 69(9), 1117–1121.
Zamora, H., & Clingerman, E.M. (2011). Health literacy among older adults: A
systematic literature review. Journal of Gerontological Nursing, 37(10), 41–51.
ONLINE RESOURCES
American Medical Association. (2007). Health literacy videos. Retrieved from http://
www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/publichealth/health-literacy-program/health-literacy-video.page
American Medical Association. (2007). Health literacy resources and toolkits.
Retrieved from http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/
our-programs/public-health/health-literacy-program/health-literacy-kit.page
American Medical Association. (2014). Partnership for Clear Health Communication.
Retrieved from http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/
our-programs/public-health/health-literacy-program/partnerships.page
Centers for Medicare and Medicaid Services. (2014). Educational Resources.
Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/EducationalMaterials.html
Harvard University School of Public Health. (2011). Health literacy policy: reports
and initiatives. Retrieved from http://www.hsph.harvard.edu/healthliteracy/
policy/
Literacy Assistance Center. (2014). Retrieved from www.lacnyc.org.
Making Text Legible. (2014). Designing for people with partial/limited sight.
Retrieved from http://www.lighthouse.org/accessibility/design/accessible-printdesign/making-text-legible
Minnesota Health Literacy Partnership. (2012). Retrieved from http://
healthliteracymn.org/ The Minnesota Health Literacy Partnership offers
the HELP Seniors Workshop Program materials to provide everything one needs
to conduct one’s own health literacy program in local communities (SOPHE,
2011).
Low Health Literacy and Older Adults
81
National Institute on Aging and the National Library of Medicine. (2002). Making
your website senior friendly: A checklist. Retrieved from www.nlm.nih.gov/
pubs/checklist.pdf.
Plain Language Action and Information Network. (2011). Retrieved from www.
plainlanguage.gov
The Gerontological Society of America. (2012). Communicating with older adults:
An evidence-based review of what really works. Retrieved from http://www.
agingresources.com/cms/wp-content/uploads/2012/10/GSA_Communicatingwith-Older-Adults-low-Final.pdf
The National Institutes of Health. (2014). Retrieved from http://www.nih.gov/