Association between low functional health literacy and mortality in older adults: longitudinal cohort study

Sophie Bostock, Andrew Steptoe, Sophie Bostock, Andrew Steptoe

Abstract

Objective: To investigate the association between low functional health literacy (ability to read and understand basic health related information) and mortality in older adults.

Design: Population based longitudinal cohort study based on a stratified random sample of households.

Setting: England.

Participants: 7857 adults aged 52 or more who participated in the second wave (2004-5) of the English Longitudinal Study of Ageing and survived more than 12 months after interview. Participants completed a brief four item test of functional health literacy, which assessed understanding of written instructions for taking an aspirin tablet.

Main outcome measure: Time to death, based on all cause mortality through October 2009.

Results: Health literacy was categorised as high (maximum score, 67.2%), medium (one error, 20.3%), or low (more than one error, 12.5%). During follow-up (mean 5.3 years) 621 deaths occurred: 321 (6.1%) in the high health literacy category, 143 (9.0%) in the medium category, and 157 (16.0%) in the low category. After adjusting for personal characteristics, socioeconomic position, baseline health, and health behaviours, the hazard ratio for all cause mortality for participants with low health literacy was 1.40 (95% confidence interval 1.15 to 1.72) and with medium health literacy was 1.15 (0.94 to 1.41) compared with participants with high health literacy. Further adjustment for cognitive ability reduced the hazard ratio for low health literacy to 1.26 (1.02 to 1.55).

Conclusions: A third of older adults in England have difficulties reading and understanding basic health related written information. Poorer understanding is associated with higher mortality. The limited health literacy capabilities within this population have implications for the design and delivery of health related services for older adults in England.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

References

    1. Ratzan SC, Parker R. National Library of Medicine current bibliographies in medicine: health literacy (introduction). National Institutes of Health, 2000.
    1. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. National Academies Press, 2004.
    1. World Health Organization. Health literacy and health behaviour. 2011. .
    1. US Department of Health and Human Services. Healthy people 2020. 2010. .
    1. Public Health Agency Canada. The chief public health officer’s report on the state of public health in Canada 2010. 2011. .
    1. Bankson HL. Health literacy: an exploratory bibliometric analysis, 1997-2007. J Med Libr Assoc 2009;97:148-50.
    1. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns 2003;51:267-75.
    1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155:97-107.
    1. Kondilis BK, Kiriaze IJ, Athanasoulia AP, Falagas ME. Mapping health literacy research in the European Union: a bibliometric analysis. PLoS One 2008;3:e2519.
    1. Department of Health. Equity and excellence: liberating the NHS. DoH, 2010.
    1. Department of Health. Healthy lives, healthy people: our strategy for public health in England. DoH, 2010.
    1. Nutbeam D. The evolving concept of health literacy. Soc Sci Med 2008;67:2072-8.
    1. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med 1995;10:537-41.
    1. Jordan JE, Osborne RH, Buchbinder R. Critical appraisal of health literacy indices revealed variable underlying constructs, narrow content and psychometric weaknesses. J Clin Epidemiol 2011;64:366-79.
    1. Rudd R. Health literacy skills of US adults. Am J Health Behav 2007;31(Suppl 1):S8-18.
    1. Levinthal BR, Morrow DG, Tu W, Wu J, Murray MD. Cognition and health literacy in patients with hypertension. J Gen Intern Med 2008;23:1172-6.
    1. Federman AD, Sano M, Wolf MS, Siu AL, Halm EA. Health literacy and cognitive performance in older adults. J Am Geriatr Soc 2009;57:1475-80.
    1. Von Wagner C, Steptoe A, Wolf M, Wardle J. Health literacy and health actions: a review and a framework from health psychology. Health Educ Behav 2009;36:860-77.
    1. Sudore RL, Schillinger D. Interventions to improve care for patients with limited health literacy. J Clin Outcomes Manag 2009;16:20-9.
    1. Sudore RL, Yaffe K, Satterfield S, Harris TB, Mehta KM, Simonsick EM, et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med 2006;21:806-12.
    1. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med 2007;164:1503-9.
    1. Marmot M, Banks JA, Blundell R, Lessof C, Nazroo J, eds. Health, wealth and lifestyles of the older population in England: the 2002 English Longitudinal Study of Ageing. Institute for Fiscal Studies, 2003.
    1. Banks JA, Breeze E, Lessof C, Nazroo J, eds. Retirement, health and relationships of the older population in England: the 2004 English Longitudinal Study of Ageing (Wave 2). Institute for Fiscal Studies, 2006.
    1. Organisation for Economic Cooperation and Development and Statistics Canada Literacy in the information age: final report of the International Adult Literacy Survey. OECD and Statistics Canada, 2000.
    1. Learning a living: first results of the adult literacy and life skills survey. Statistics Canada and Organisation for Economic Cooperation and Development, 2005.
    1. Kirsch I. The International Adult Literacy Survey: understanding what was measured. Educational Testing Service, 2001.
    1. Steffick DE. Documentation of affective functioning measures in the Health and Retirement Study. Documentation report DR-005. HRS/AHEAD, 2000.
    1. Health and Retirement Study. Questionnaire. 2000. .
    1. Peterson PN, Shetterly SM, Clarke CL, Bekelman DB, Chan PS, Allen LA, et al. Health literacy and outcomes among patients with heart failure. JAMA 2011;305:1695-701.
    1. Sterne JAC, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ 2009;338:b2393.
    1. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav 2007;31(Suppl 1):S19-26.
    1. Baker DW, Wolf MS, Feinglass J, Thompson JA. Health literacy, cognitive abilities, and mortality among elderly persons. J Gen Intern Med 2008;23:723-6.
    1. Braveman PA, Cubbin C, Egerter S, Chidveya S, Marchi KS, Metzler M, et al. Socioeconomic status in health research: one size does not fit all. JAMA 2005;294:2879-88.
    1. Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med 1991;23:433-5.
    1. Von Wagner C, Steptoe A, Wolf MS, Wardle J. Health literacy and health actions: a review and a framework from health psychology. Health Educ Behav 2009;36:860-77.
    1. Wolf MS, Feinglass J, Thompson J, Baker DW. In search of “low health literacy”: threshold vs gradient effect of literacy on health status and mortality. Soc Sci Med 2010;70:1335-41.
    1. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns 1996;27:33-9.
    1. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, et al. Health literacy and use of outpatient physician services by Medicare managed care enrollees. J Gen Intern Med 2004;19:215-20.
    1. Kriegsman DM, Penninx BW, van Eijk JT, Boeke AJ, Deeg DJ. Self-reports and general practitioner information on the presence of chronic diseases in community dwelling elderly. A study on the accuracy of patients’ self-reports and on determinants of inaccuracy. J Clin Epidemiol 1996;49:1407-17.
    1. Baumeister H, Kriston L, Bengel J, Harter M. High agreement of self-report and physician-diagnosed somatic conditions yields limited bias in examining mental-physical comorbidity. J Clin Epidemiol 2010;63:558-65.
    1. Wilson RS, Beck TL, Bienias JL, Bennett DA. Terminal cognitive decline: accelerated loss of cognition in the last years of life. Psychosom Med 2007;69:131-7.
    1. Osborn CY, Paasche-Orlow MK, Bailey SC, Wolf MS. The mechanisms linking health literacy to behavior and health status. Am J Health Behav 2011;35:118-28.
    1. Von Wagner C, Knight K, Steptoe A, Wardle J. Functional health literacy and health-promoting behaviour in a national sample of British adults. J Epidemiol Community Health 2007;61:1086-90.
    1. Von Wagner C, Semmler C, Good A, Wardle J. Health literacy and self-efficacy for participating in colorectal cancer screening: the role of information processing. Patient Educ Couns 2009;75:352-7.
    1. Cavanaugh KL, Wingard RL, Hakim RM, Eden S, Shintani A, Wallston KA, et al. Low health literacy associates with increased mortality in ESRD. J Am Soc Nephrol 2010;21:1979-85.
    1. Macabasco-O’Connell A, Dewalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, et al. Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure. J Gen Intern Med 2011;26:979-86.
    1. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998;114:1008-15.
    1. Osborn CY, Bains SS, Egede LE. Health literacy, diabetes self-care, and glycemic control in adults with type 2 diabetes. Diabetes Technol Ther 2010;12:913-9.
    1. Smith SK, Dixon A, Trevena L, Nutbeam D, McCaffery KJ. Exploring patient involvement in healthcare decision making across different education and functional health literacy groups. Soc Sci Med 2009;69:1805-12.
    1. Manning DL, Dickens C. Health literacy: more choice, but do cancer patients have the skills to decide? Eur J Cancer Care (Engl) 2006;15:448-52.
    1. Kelly PA, Haidet P. Physician overestimation of patient literacy: a potential source of health care disparities. Patient Educ Couns 2007;66:119-22.
    1. Shaw A, Ibrahim S, Reid F, Ussher M, Rowlands G. Patients’ perspectives of the doctor-patient relationship and information giving across a range of literacy levels. Patient Educ Couns 2009;75:114-20.
    1. Wolf MS, Wilson EA, Rapp DN, Waite KR, Bocchini MV, Davis TC, et al. Literacy and learning in health care. Pediatrics 2009;124(Suppl 3):S275-81.
    1. Moscovitch M. A neuropsychological approach to perception and memory in normal and pathological aging. In: Craik FIM, Trehub S, eds. Aging and cognitive processes. Plenum Press, 1982.
    1. Feinstein L. Inequality in the early cognitive development of British children in the 1970 cohort. Economica 2003;70:73-97.
    1. Murray C, Johnson W, Wolf M, Deary IJ. The association between cognitive ability across the lifespan and health literacy in old age: the Lothian birth cohort 1936. Intelligence 2011;39:178-87.
    1. Bennett I, Chen J, Soroui J, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviours in older adults. Ann Fam Med 2009;7:3.
    1. Schillinger D, Barton L, Karter A, Wang F, Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep 2006;121:245-54.
    1. Protheroe J, Nutbeam D, Rowlands G. Health literacy: a necessity for increasing participation in health care. Br J Gen Pract 2009;59:721-3.
    1. Machtinger EL, Wang F, Chen LL, Rodriguez M, Wu S, Schillinger D. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Safety 2007;33:625-35.
    1. Sheridan SL, Halpern DJ, Viera AJ, Berkman ND, Donahue KE, Crotty K. Interventions for patients with low literacy: a systematic review. J Health Commun 2011;16(Suppl 3):30-54.
    1. Rothman R, DeWalt D, Malone R, Bryant B, Shintani A, Crigler B, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. JAMA 2004;292:1711-6.
    1. DeWalt D, Malone R, Bryant B, Kosner MC, Corr KE, Rothman R, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res 2006;13:30.
    1. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14,1:32-8.
    1. Baker DW. The meaning and the measure of health literacy. J Gen Intern Med 2006;21:878-83.
    1. Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ 2010;341:c5814.
    1. Chinn D. Critical health literacy: a review and critical analysis. Soc Sci Med 2011;73:60-7.

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