Health literacy among older persons in Turkey

Abstract

Aim: The aim of this study was to investigate the health literacy and cognitive functions of individuals age 65 and over and the relationship between them.

Method: The research was conducted between September 2016 and February 2017, among individuals age 65 and over, at the Family Health Center. The participants were given the Health Literacy Survey – European Union (HLS-EU) scale and the Mini-Mental Test.

Results: In this sampling, health literacy was found as “problematic or inadequate” in 85.1% of the elderly population. Among the health literacy issues, rate of “problematic-inadequate” results was 63.5% in benefiting from health services, 86.9% in protection from diseases, and 87.6% in improvement of health. The issues that older persons feel most inadequate were adult vaccinations and periodic examinations and they felt sufficient in terms of what to do in emergency cases.

Conclusion: The older population needs support in health literacy issues particularly related to judgments. It would be appropriate to set up a standard care algorithm in older people.

Keywords:

• Elderly friendly
• health literacy
• periodic examinations
• vaccination
• primary care

Introduction

Health literacy can be described as the capacity of the individual to acquire, interpret, and use basic health information and services in terms of protecting health, improving health, and curing in case of impairment [1]. Health literacy also includes complicated reading, listening, and comprehension, analytical and decision making competence, and ability to use this competence in health-related issues. It is well known that low health literacy level causes weakness in the ability to understand health information, difficulties in fulfilling processes and instructions, and problems in effective use of health services [2–5].

It is indicated that the health literacy level is lower in the older population, those with a low level of education, the poor, minorities, and those who cannot use well the language of the country where they live [6]. It is reported in the European Health Literacy study that some groups within countries have a disadvantage in terms of health literacy as well as there being differences between countries. It has been shown that health literacy levels of those who indicate that their social status is low, those with lower educational and income level, those who perceive their health condition as bad, those who have limited activity due to health problems, and the older population are lower [6]. Pasaasce-Orlow et al. reported that a low level of health literacy is associated with education level, age, ethnic origin, and income level [7].

A low level of health literacy is assumed to be an important obstacle in terms of application of screening tests. For example, in a colon cancer screening program in England, written material with information on screening is sent to individuals’ home address as the first means of communicating with them. Non-screening of some individuals despite this is linked to limited health literacy [8]. Similarly, it is reported that lack of breast self-examination and mammography processes, which are among breast cancer screening behaviours, is also associated with a low level of health literacy [9]. Likewise, in health literacy studies performed about hospitalization and presentation to the emergency service, moderate proofs were achieved showing increased usage of both services among those with low health literacy levels [1,10–12].

Inadequate health literacy goes together with an increased risk of dementia [13]. In one study, it was shown that a decrease in cognitive function in the elderly is associated with a decrease in health literacy, impairment of physical health, and more depression [14]. The aim of this study was to investigate the health literacy and cognitive functions of older individuals and to understand the health issues that elderly people have difficulty to overcome.

Methods

This research was performed between September 2016 and February 2017 with 400 volunteer individuals 65 years of age and over who were registered with the Family Health Center. Twelve thousand four hundred and sixty-eight people were registered with the center in the same period and 789 of them were age 65 and over. Inclusion criteria for the study were: registration at a Family Health Center, 65 years of age and over, accepting to participate in the study, no vision problems, and no cognitive disease. The consent of 400 registered individuals who were accepted to participate in the study was obtained. The research was performed with a face to face survey method with the patients. Ethics committee approval for the research was obtained from the ethics committee of the hospital.

In this research, patients’ socio-demographic features, the Standardized Mini-Mental Test to evaluate cognitive functions, and the Turkish translation of the European Health Literacy Survey (HLS-EU-Q) to measure health literacy level were recorded. Thirty patients with a history of dementia were not asked the health literacy survey. And, 27 persons with newly diagnosed dementia were also excluded from the study. Twelve people refused to participate in the study.

Socio-demographic information, gender, age, marital status, education level, height, weight, body mass index, smoking status, alcohol usage, occupation, income level, and chronic diseases of the participants were recorded.

The Mini-Mental Test composed of 11 articles under five major topics: tendency, recording memory, attention and calculation, remembering and language, and it is evaluated with a total score of 30. Scores 24–30 are normal, scores 18–23 mean slight dementia, and scores 17 and below mean severe dementia in the test [15]. We determined the dementia limit as 23/24 in order to provide standardization in our study (≤23; there is dementia).

The Health Literacy Survey-EU (HLS-EU) composed of 47 questions. Each of the 47 questions is evaluated on a scale of 1–4 points (1 = very difficult, 2 = difficult, 3 = easy, 4 = very easy). This scale is based on the principle of evaluating the “easiness” or “difficulty” of the behaviour indicated in each question according to the person’s self-perception. Within the framework of the HLS-EU concept, sub-indexes are formed depending on the average values of health literacy parameters. Answers given to the HLS-EU are evaluated in the context of general indexes and sub-indexes [16].

Statistical analysis

Normal distribution suitability of variables was analyzed by Shapiro–Wilk test. Variables are expressed as mean, standard deviation, or median (minimum: maximum) values. Internal consistency of the scales was analyzed with Cronbach alpha coefficient. SPSS (IBM Corp, Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp) program was used for statistical analysis.

Results

The mean age of the participants was calculated as 70.68 ± 5.92. Socio-demographic status and general health features of the participants are given in Table 1. Fifty-six percent of the participants were female (n = 224) and 44% were male (n = 176).

Table 1. Socio-demographic status and general health features of the participants.

	Frequency (n)	Percentage (%)
Gender
Male	176	44
Female	224	56
Educational level
Illiterate	51	12.8
Primary school	285	71.3
Secondary school	22	5.5
High school	30	7.5
College	12	2.9
Economic status
Poor	30	7.5
Moderate	276	69
Good	94	23.6
Marital status
Married	303	75.7
Single	97	24.3
Employment
Housewife	176	44
Retired	222	55.5
Farmer	1	0.3
Self-employment	1	0.3
Chronic disease
Yes	358	89.5
No	42	10.5
Smoking
Yes	94	23.5
No	306	76.5
Alcohol
No	400	100

Co-morbid diseases of the patients are shown in Table 2. And, 69.2% of the participants had hypertension, 35.5% had diabetes mellitus, and 27.8% had hyperlipidemia. There were 27 cases with newly diagnosed dementia. Including 30 patients with a history of dementia, the dementia frequency, in this sampling, was 14.3%.

Table 2. Data related to co-morbid diseases of the participants.

	Frequency (n)	Percentage (%)
Cardiovascular disease
Yes	87	21.8
No	313	78.2
Hyperlipidemia
Yes	111	27.8
No	289	72.2
Diabetes mellitus
Yes	142	35.5
No	258	64.5
Hypertension
Yes	277	69.2
No	123	30.8
Chronic obstructive pulmonary disease
Yes	64	16
No	336	84
Asthma
Yes	19	4.8
No	381	95.2
Nephropathy
Yes	9	2.2
No	391	97.8
Hepatopathy
Yes	2	0.5
No	398	99.5
Stroke/paralysis
Yes	39	9.8
No	361	90.2
Rheumatic diseases
Yes	2	0.5
No	398	99.5
Cancer
Yes	17	4.3
No	383	95.7
Psychiatric disease
Yes	11	2.8
No	389	97.2
Other diseases
Yes	54	13.5
No	346	86.5

Cronbach alpha values calculated for general health literacy and sub-indexes are given in Table 3. This value was calculated as 0.98 for the general health index.

Table 3. Internal reliability coefficients of the health literacy and sub-indexes.

Health literacy domain	Cronbach alpha
General health literacy	0.980
Health care	0.932
Disease prevention	0.954
Health promotion	0.954

Results obtained for the 47 questions of the HLS-EU by classifying the participants’ answers to each question as “very difficult and difficult” or “very easy and easy” are shown in Table 4. In the difficulty range of the questions, percentage distributions for “very easy” varied from 1.2% (Q26, decision on which vaccination you need) to 56.3% (Q15, calling an ambulance in emergency); and percentage distributions for “very difficult” varied from 0% (Q14, following the instructions of the medications) to 34.5% (Q26, decision on which vaccination you need).

Table 4. Answers to the Health Literacy European Union Survey Questions.

					Difficult and fairly difficult (%)
Questions	Fairly easy (%)	Easy (%)	Difficult (%)	Fairly difficult (%)	Europe	Turkey	Results of the present study
Q.1. Find information about symptoms of illnesses that concern you?	8.5	35.9	49.9	5.8	22.8^a	32.2^a	55.7
Q.2. Find information on treatments of illnesses that concern you?	9	37	48.4	5.5	26.9^a	32.3^a	53.9
Q.3. Find out what to do in case of a medical emergency?	12.2	71.4	15.7	0.6	21.8^a	39.1^a	16,3
Q.4. Find out where to get professional help when you are ill?	46.4	51	2.6	0	11.9^a	19.4^a	2.6
Q.5. Understand what your doctor says to you?	18.7	73.2	7.9	0.3	15.3^a	22.5^a	8.2
Q.6. Understand the leaflets that come with your medicine?	9	34.7	53.6	2.6	28.0^a	42.9^a	56.2
Q.7. Understand what to do in a medical emergency?	10.2	67.9	20.7	1.2	21.7^a	42.0^a	21.9
Q.8. Understand your doctor’s or pharmacist’s instruction on how to take a prescribed medicine?	44.9	51.9	2.9	0.3	6.5^a	11.9^a	3.2
Q.9. Judge how information from your doctor applies to you?	7.3	43.6	47.1	2	18.0^a	19.6^a	49.1
Q.10. Judge the advantages and disadvantages of different treatment options?	3.8	12	70.8	13.4	42.6^a	43.1^a	84.3
Q.11. Judge when you may need to get a second opinion from another doctor?	3.5	18.7	73.1	4.7	38.6^a	32.3^a	77.8
Q.12. Judge if the information about illness in the media is reliable?	5.3	27.4	62.3	5	49.7^a	48.2^a	67.3
Q.13. Use information the doctor gives you to make decisions about your illness?	10	64.2	24.9	0.9	23.1^a	28.4^a	25.8
Q.14. Follow the instructions on medication?	56	43.7	0.3	0	6.8^a	11.9^a	0.3
Q.15. Call an ambulance in an emergency?	56.3	41.4	2	0.3	8.8^a	13.0^a	2.3
Q.16. Follow instructions from your doctor or pharmacist?	54.7	42.1	2.9	0.3	5.6^a	8.7^a	3.2
Q.17. Find information about how to manage unhealthy behaviour such as smoking, low physical activity and drinking too much?	8.5	42	44	5.5	14.7^a	30.3^a	49.5
Q.18. Find information on how to manage mental health problems like stress or depression?	8.7	34.1	52.5	4.7	33.5^a	41.1^a	57.2
Q.19. Find information about vaccinations and health screenings that you should have?	8.7	38.5	47.8	5	24.0^a	38.4^a	52.8
Q.20. Find information on how to prevent or manage conditions like being overweight, high blood pressure or high cholesterol?	9.1	44.1	42.1	4.7	18.1^a	34.1^a	46.8
Q.21. Understand health warnings about behaviour such as smoking, low physical activity and drinking too much?	15.2	72	12.2	0.6	10.3^a	21.0^a	12.8
Q.22. Understand why you need vaccinations?	11.4	68.7	19.3	0.6	16.6^a	22.6^a	19.9
Q.23. Understand why you need health screenings?	11.4	69.7	17.8	1.2	10.4^a	20.5^a	19.0
Q.24. Judge how reliable health warnings are, such as smoking, low physical activity and drinking too much?	14.3	71.4	11.7	2.6	14.4^a	31.2^a	14.3
Q.25. Judge when you need to go to a doctor for a check-up?	4.1	24.2	62.3	9.4	16.3^a	27.8^a	71.7
Q.26. Judge which vaccinations you may need?	1.2	4.1	60.2	34.5	32.7^a	47.2^a	94.7
Q.27. Judge which health screenings you should have?	1.5	5	60.2	33.3	25.1^a	45.9^a	93.5
Q.28. Judge if the information on health risks in the media is reliable?	3.5	18.7	67.6	10.2	42.1^a	49.2^a	77.8
Q.29. Decide if you should have a flu vaccination?	9.3	56.3	30.6	3.8	26.2^a	33.4^a	34.4
Q.30. Decide how you can protect yourself from illness based on advice from family and friends?	5.2	61.8	30	2.9	22.2^a	28.9^a	32.9
Q.31. Decide how you can protect yourself from illness based on information in the media?	6.4	47.7	42.7	3.2	36.9^a	36.0^a	45.9
Q.32. Find information on healthy activities such as exercise, healthy food and nutrition?	7.6	48.4	38.2	5.8	14.3^a	27.8^a	44.0
Q.33. Find out about activities that are good for your mental well-being?	7.3	31.5	56.3	5	22.6^a	34.0^a	61.3
Q.34. Find information on how your neighbourhood could be more health-friendly?	7.3	26.3	61.1	5.3	40.3^a	33.6^a	66.4
Q.35. Find out about political changes that may affect health?	5.3	17.5	70.4	6.8	53.2^a	50.9^a	77.2
Q.36. Find out about efforts to promote your health at work?	7.6	26.6	60.8	5	34.8^a	36.5^a	65.8
Q.37. Understand advice on health from family members or friends?	13.7	77.8	7.9	0.6	13.0^a	16.7^a	8.5
Q.38. Understand information on food packaging?	7.6	27.7	61.8	2.9	36.2^a	32.9^a	64.7
Q.39. Understand information in the media on how to get healthier?	9.3	70.8	18.1	1.7	23.3^a	30.8^a	19.8
Q.40. Understand information on how to keep your mind healthy?	8.2	68.9	21.4	1.5	26.1^a	31.7^a	22.9
Q.41. Judge where you live affects your health and well-being?	7.3	61.1	29.8	1.8	24.6^a	27.5^a	31.6
Q.42. Judge how your housing conditions help you to stay healthy?	6.7	53.9	37.6	1.7	19.5^a	19.7^a	39.3
Q.43. Judge which everyday behaviour is related to your health?	7.6	65.6	24.8	2	12.6^a	21.3^a	26.8
Q.44. Make decisions to improve your health?	4.7	48.4	41.6	5.3	21.7^a	21.7^a	46.9
Q.45. Join a sports club or exercise class if you want to?	1.7	10.5	58.3	29.4	24.1^a	44.3^a	87.7
Q.46. Influence your living conditions that affect your health and wellbeing?	1.5	19	55.1	24.5	25.5^a	38.6^a	79.6
Q.47. Take part in activities that improve health and well-being in your community?	1.8	26.1	49.9	22.3	38.9^a	44.7^a	72.2

^a Berkman et al. [17].

The health literacy index of individuals over 65 years included in the study group was calculated as 27.0. In the categorical evaluation, 85.1% were in the inadequate (44.6%) or problematic (40.5%) health literacy category (Table 5).

Table 5. Prevalence values of general health literacy and sub-literacy indexes.

	Inadequate HL (%)	Problematic HL (%)	Sufficient HL (%)	Excellent HL (%)
General HL	44.6	40.5	8.7	6.1
Health care	23	40.5	28.6	7.9
Disease prevention	53.1	33.8	6.7	6.4
Health promotion	56.9	31.2	7	5

HL: health literacy.

Discussion

In the sampling of the study, health literacy was found to be “problematic or inadequate” in 85.1% of the older persons. The rate of the “problematic-inadequate” category was 63.5% in benefiting from health care services, 86.9% in disease prevention, and 87.6% in promotion of health. The prevalence of dementia in the same population was 14.3% and there was a linear relationship between general health literacy status and Mini-Mental Test scores. The issues in which the older persons feel themselves most inadequate are judgments on adult vaccinations and periodic examinations.

In a study that compiled researches performed using different scales, the inadequate literacy level was found to be between 22% and 29% [18]. However, in a systematic review, it was reported that the inadequate health literacy prevalence was between 34% and 59% [17]. In addition to this, according to European Health literacy research, the low health literacy level of eight countries varied between 2% and 27% [7]. In the study performed by Ozdemir et al., the inadequate health literacy level in adults was 41% according to the REALM scale, and 72% according to the NVS scale [19]. These data reflect the health literacy status of the adults. Use of different scales in various studies is an obstacle in making comparisons. In a study carried out with a geriatric age group, limited and inadequate health literacy was found to be 27% [20]. In another study, marginal and limited HL was reported as 48.2% in old adults [21]. It was observed in the current study, based on the European Health Literacy Scale (HLS-EU), that 85.1% of the society is in the “problematic or inadequate” health literacy category.

The relationship between cognitive function loss and degradation in health literacy can be considered as an obstacle for elderly individuals to benefit sufficiently from health services [22–25]. Participants answered that they were inadequate especially for questions starting with “to judge”. It was noteworthy that there is a problem with “judgment” in the study group of older persons. For this reason, it can be viewed as an important necessity to create algorithms for older persons care such as for adult vaccinations and periodic examinations in the health services for the elderly.

Limitations: Only cognitive functions were measured in our study but delirium status was not distinguished. If delirium had also been interrogated, we could also have commented on the health literacy status of these patients. Additionally, the research was performed only on elderly presenting to the Family Health Center for whom we could gain knowledge on dementia and health literacy status of elderly and immobile people.

Conclusions

The elderly population needs more support in health literacy. Besides increasing the health literacy of elderly people, it would be appropriate to create a standard care algorithm considering loss of cognitive function.

Acknowledgements

The authors thank Mrs Nazli Demirci (Philologist) for her contribution to the study.

Disclosure statement

No potential conflict of interest was reported by the authors.