Practice Tip of the Week | Health Literacy and Older Adults

By Teresa Wagner, DrPH, MS, CPH, RD/LD, CPPS, FNAP, CHWI, DipACLM, CHWC and Kate Taylor, DNP, FNP-C, CPPS, FNAP

According to the United States Census Bureau 2020: “Between 2010 and 2020, the population 65 years and over saw the largest and fastest growth in any decade since 1880 to 1890, reaching 16.8 percent (one in six people) of the total population.” The 2018 United States Census Bureau stated: “By 2030, one in every five people in the U.S. will be 65 or older. And by 2035, the number of adults over 65 will be greater than the number of children under 18. By 2060, that number is expected to climb to nearly 25% of U.S. residents.”

Older adults may experience several health-related issues including loss of memory, loss of hearing, decreased mobility, and weakened vision. Thus, older adults face risks for low health literacy due to cognitive decline, which impacts their ability to promote health and self-manage disease (CDC, 2020). 

Low health literacy and declining cognitive functioning pose barriers for person-centered care, even in relatively young older adults (Goebers et al., 2018). A systematic review found that low health literacy reduces ability to understand and follow medical advice, worsens health outcomes, increases mortality among the elderly, and impacts use of some health care services, including increased hospitalizations and emergency care and decreased use of preventive services. Access to these types of services is just part of the integrated model of health literacy which extends to include understanding, appraising, and applying health information to make informed decisions (Sorensen, 2012). 

These barriers impact care for older adults warranting providers’ use of health literate practices. The clinical practice at the University of North Texas Health Science Center (HSC Health) at Fort Worth consists of 13 different service lines, including the Center for Older Adults (COA) which supports an office-based practice, a WellMed managed care clinic, and a house calls program. The COA obtained Age-Friendly Designation for the outpatient clinic in 2019, and the Family Medicine Clinic in 2021. In addition, our new College of Nursing takes a Whole Health approach focusing on all of the factors that impact patient care including their environment, community, spiritual, and self-care.

Several projects we’ve facilitated incorporating those practices for older adults have included helping MedStar Mobile Healthcare receive age-friendly designation, helping deploy Community Health Workers to assist older adults in times of disruption, health literate advanced care planning (ACP) and an upcoming project will incorporate provider-led health literate dementia care through our Health Literacy Lab and CHW Center along with other community helper deployment assisting communities to understand their care. 

Nursing practices to deploy health literate care include using plain language and the teach-back method (RNAO, n.d.). Plain language, or simple, everyday wording helps to make written and oral information easier to understand. Principles include placing information, so the most important points are first, chunking complex information into smaller bites that are easier to understand, omitting unnecessary words and content, avoiding medical jargon and defining any complex terms or medical terminology, using headings, lists, and tables to make following easier, using pronouns and the active rather than the passive voice, focusing on needed behavior change rather than on underlying medical principles, using visuals that convey a message, rather than decorate a page, and using a minimum 12-point font while avoiding all capitals, italics, and fancy fonts (RNAO, n.d.).

Teach-back engages the learner in a shame-free manner by asking them to repeat, in their own words, what was just explained placing some of the accountability for patient learning on the provider. This creates an opportunity for the provider to evaluate the effectiveness of the education while engaging the learner and their family. The provider can then clarify any miscommunication or misunderstanding and reteach. For example, after educating the person on their medicines and schedule, the provider may ask: “Please tell me how you will take your medicine at home?” Then, use open-ended questions to close the conversation instead of yes/no questions. Open-ended questions open the dialogue and let the learner know that questions are normal and expected. For example, asking: “What questions do you have for me?” is preferable to asking, “Do you have any questions?” (RNAO, n.d.).

Overall, using health literate best practices in healthcare benefits both the provider and the patient. Not only does it save time in understanding by the patient but also money by avoiding unnecessary readmissions and potential patient harm while ensuring the patient recovers, stays healthy or manages chronic conditions appropriately. Nurses stand ready to lead this charge by role modeling for other providers since they provide most of the patient education. Using the tips provided for health literate care can remove barriers for person-centered care not only for older adults but for all our patients.

Centers for Disease Control and Prevention. (2020). Health literacy: Older adults. https://www.cdc.gov/healthliteracy/developmaterials/audiences/olderadults/index.html

Geboers, B., Uiters, E., Reijneveld, S. A., & Jansen, C. J. M. (2018). Health literacy among older adults is associated with their 10-years’ cognitive functioning and decline: The Doetinchem Cohort Study. BMC Geriatrics, 18(77). https://doi.org/10.1186/s12877-018-0766-7

Mercer University. (2024, May 22). Why the role of nurses is important in healthcare. https://absn.mercer.edu/blog/why-the-role-of-nurses-is-important-in-healthcare/

Registered Nurses Association of Ontario. (n.d.). Nursing best practice guidelines: Principles of health literacy. https://bpgmobile.rnao.ca/node/1292

Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., & Brand, H. (HLS-EU Consortium Health Literacy Project European). (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12, 80. https://doi.org/10.1186/1471-2458-12-80

U.S. Census Bureau. (2018, December 3). Older people projected to outnumber children. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html

U.S. Census Bureau. (2023, May 25). U.S. older population grew from 2010 to 2020 at fastest rate since 1880 to 1890. https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html