The use of illustration to improve older adults’ comprehension of health-related information: Is it helpful?

Objective

To examine whether explanatory illustrations can improve older adults’ comprehension of written health information.

Methods

Six short health-related texts were selected from websites and pamphlets. Young and older adults were randomly assigned to read health-related texts alone or texts accompanied by explanatory illustrations. Eye movements were recorded while reading. Word recognition, text comprehension, and comprehension of the illustrations were assessed after reading.

Results

Older adults performed as well as or better than young adults on the word recognition and text comprehension measures. However, older adults performed less well than young adults on the illustration comprehension measures. Analysis of readers’ eye movements showed that older adults spent more time reading illustration-related phrases and fixating on the illustrations than did young adults, yet had poorer comprehension of the illustrations.

Conclusion

Older adults might not benefit from text illustrations because illustrations can be difficult to integrate with the text.

Practice implications

Health practitioners should not assume that illustrations will increase older adults’ comprehension of health information.     

Educational intervention for older people with asthma: A randomised controlled trial

Objectives

To improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.

Methods

Community dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. Outcome measures: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.

Results

Intervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.

Conclusion

Asthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.

Practical implications

Use of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.     

Effect of cognitive dysfunction on the relationship between age and health literacy

Objective

Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood.

Methods

We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction.

Results

Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r = −0.16, p = 0.001 vs. r = −0.35, p < 0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups.

Conclusion

Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults.

Practice implications

Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.     

Understanding the self-care strategies of patients with asthma

Objective

The objective was to understand how adults living with asthma deal with their chronic illness, perceive self-management and develop self-care strategies.

Methods

24 in-depth, semi-structured interviews were conducted in Montreal, Canada with low- and middle-income adults living with asthma. The interviews were tape-recorded and transcribed for purposes of analysis. The analysis consisted of debriefing sessions, coding and interpretive analysis.

Results

We identified 3 types of self-care strategies adopted by the participants in order to deal with asthma: (1) strategy of controlling symptoms leads to patients following the recommendations of their physician; (2) strategy of preventing symptoms involves a holistic approach to treating illness, and leads patients to prefer lay methods and alternative treatments for preventing symptoms instead of relying on medications; (3) strategy of tolerating symptoms leads people to experience aggravated symptoms and to seek emergency care.

Conclusion

This study reveals that important subjective as well social factors influence the way people deal with a chronic illness like asthma. Future research should: (1) identify the difficulties encountered by vulnerable patients in regard to treatment and care interactions; (2) provide health professionals with the right tools so that they can take into consideration the treatment perceptions and the effects of life conditions on self-management.

Practice implications

Patients with asthma need comprehensive care that addresses social conditions, reluctance to take medication, exploration of lay and alternative treatment and difficulties in accessing preventive care.     

Predictors of nutrition information comprehension in adulthood

Objective

The goal of the present study was to examine relationships among several predictors of nutrition comprehension. We were particularly interested in exploring whether nutrition knowledge or motivation moderated the effects of attention on comprehension across a wide age range of adults.

Methods

Ninety-three participants, ages 18–80, completed measures of nutrition knowledge and motivation and then read nutrition information (from which attention allocation was derived) and answered comprehension questions.

Results

In general, predictor variables were highly intercorrelated. However, knowledge, but not motivation, had direct effects on comprehension accuracy. In contrast, motivation influenced attention, which in turn influenced accuracy. Results also showed that comprehension accuracy decreased—and knowledge increased—with age. When knowledge was statistically controlled, age declines in comprehension increased.

Conclusion

Knowledge is an important predictor of nutrition information comprehension and its role increases in later life. Motivation is also important; however, its effects on comprehension differ from knowledge.

Practice implications

Health educators and clinicians should consider cognitive skills such as knowledge as well as motivation and age of patients when deciding how to best convey health information. The increased role of knowledge among older adults suggests that lifelong educational efforts may have important payoffs in later life.     

The association of health literacy with illness and medication beliefs among older adults with asthma

Objective

Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs.

Methods

Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n = 420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models.

Results

Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2–2.82; OR: 2.22, 95% CI: 1.29–3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (β = 0.92, p = .05), despite recognizing their necessity (β = −1.36, p = .01).

Conclusions

Older asthmatics with low HL endorse erroneous asthma beliefs.

Practice implications

Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.     

Factors that influence Italian consumers' understanding of over-the-counter medicines and risk perception

Objective

To evaluate information needs for safe self-medication we explored the Italian consumers’ functional health literacy, specific knowledge and risk awareness about over-the-counter (OTC) medicines.

Methods

A survey was conducted in the health sections of six large super stores. Data were collected from a convenience sample of 1.206 adults aged 18 years and older through a self-administered questionnaire.

Results

Around 42% confused the concept of “contraindications” with that of “side effects” and were unable to calculate simple dosages. Most respondents were aware of the OTC general potential for side effects but 64.3% did not know that people with high blood pressure should use painkillers with cautions and 14.0% and 20.0% were unaware of the risks of long-term use of laxatives and nasal decongestants respectively. Higher total scores were obtained from women, highly educated people and those citing package leaflets as information sources.

Conclusion

The study, the first of this type in Italy, showed an incomplete awareness of several risk areas, with regard to drug interactions and misuse/abuse.

Practice implications

The results of this study were the basis of a following intervention plan tailored to the observed consumer needs and including information tools for customers and courses for the retail pharmacists.     

Testing health literacy skills in older Korean adults

Objective

The purpose of this study was to develop a valid and reliable screening test for limited health literacy for older Korean adults.

Methods

A pool of 102 items was generated based on empirical referents, which, after expert review, field study, and content validity, was reduced to 29 items with three subscales. Construct validity and reliability were established using a convenience sample of 411 community dwelling elderly participants and exploratory factor analysis, and Cronbach's alpha was employed. Rasch analysis was also performed to assess the unidimensionality of the construct and item adequacy.

Results

Rasch analysis showed that the scale was unidimensional and the majority of the items demonstrated good fit. The final instrument, the Korean Health Literacy Scale (KHLS), is a 24-item questionnaire containing short passages, pictures, and graphs with multiple-choice answer format, with an internal consistency of .891. There are 13 comprehension and numeracy questions and 11 questions about health-related terms; the test requires 15–20 min for administration.

Conclusion

KHLS is culturally suitable as a screening test for limited literacy for older Korean adults in the community.

Practice Implications

Korean investigators now have a validated health literacy tool for research with elderly participants.     

Bereavement-related depression in the older adult population: A distinct disorder?

Background

Bereavement is a phenomenon that shares many symptoms with depression, and that a great number of older adults experience following the loss of a close relative. The objectives of the present study were to (1) determine whether the symptoms of depression reported by bereaved individuals differ from those with non-bereavement minor/major depression (NBRD), (2) assess whether BRD is as persistent during a one year follow-up as compared to NBRD, and (3) identify factors and consequences associated with BRD.

Methods

The data used for this study came from the Longitudinal Study ESA (Study Health of Elders), conducted between 2005 and 2008, using a representative sample (n=2811) of community-dwelling older adults, aged 65 and over. To test our hypothesis, an exploratory latent class analysis and multivariate logistic regression were used.

Results

BRD prevalence among older adults suffering from depression was 39%. BRD individuals report all symptoms of depression, but in lower probabilities, and BRD is as persistent as MDD over 12 months, suggesting that it does not differ from NBRD. The principal factors associated with BRD were widowhood and lower level of education. Individuals with BRD are less likely to consult medical services and be dispensed an antidepressant, compared to NBRD.

Limitations

We have to be cautious when generalizing our findings to individuals with major depression alone, since our results included both minor and major depressions in the same group.

Conclusion

No evidence was found that BRD differed from non BRD in terms of depressive symptoms and persistence. The bereavement exclusion criterion in the DSM-IV should be reconsidered.     

Age-dependent symptomatology of depression in hospitalized patients and its implications for DSM-5

Background

We investigated effects of current age and age at onset on symptomatology of depression with reference to proposed revisions in DSM-5.

Methods

The study entailed medical records of 326 inpatients diagnosed with major depressive disorder, including 520 depressive episodes, with 113 first episodes lifetime. Subjects were divided into three groups: young-adults, middle-aged adults and older adults.

Results

In young-adults, active suicidal ideation, lifetime suicidal attempts, irritability, anhedonia and persistent depressive symptoms between the episodes were more frequent than in the other groups. Among older adults, depression was associated with insomnia, hypochondriasis, somatization, decreased appetite, weight loss, memory impairment and decreased activity. The older age was not associated with higher number of previous episodes of depression, bigger severity or duration of a single episode or a different degree of remission. Early-onset depression was associated with more suicidal attempts.

Limitations

The study was retrospective and the sample may be treated only as representative for hospitalized depressed patients.

Conclusions

Age and age at onset are important factors influencing the course and symptomatology of a depressive episode. Depressive episodes with anxiety and with suicide risk severity are important specifiers that vary with the age at onset and/or age of the patient and should be considered for inclusion in the DSM-5 revision.     

Knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults

Objective

To measure knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults and examine the relationship to prior weight loss.

Methods

Knowledge of the health consequences of obesity was assessed among 410 Black and Hispanic adults with BMI ≥ 25 kg/m² enrolled in a behavior change weight loss study. The relationship between obesity risk knowledge and previous weight loss was also examined.

Results

The majority of participants were knowledgeable of the risk of hypertension (94%), diabetes (96%), high cholesterol (91%), joint pains/arthritis (89%) and sleep apnea (89%) associated with obesity. Among post-menopausal age women, 53% were aware of the increased risk of breast cancer. There was no significant relationship between obesity risk knowledge and previous weight loss of 10 pounds or more (OR = 1.075, 95% CI: [0.808, 1.430]).

Conclusions

We found that knowledge of the health consequences of obesity was high, except for knowledge of the risk of breast cancer. Obesity risk knowledge was not associated with past weight loss.

Practice implications

Further health education is needed regarding the increased risk of breast cancer associated with obesity. Our data suggest that knowledge of the health consequences of obesity is not associated with weight loss success.     

Effects of mild and global cognitive impairment on the prevalence of fear of falling in community-dwelling older adults

Objectives

Few studies have reported the relationship between fear of falling (FoF) and mild and global cognitive impairment in community-dwelling older adults. We aimed to determine whether the status of cognitive impairment affects the prevalence of FoF in community-dwelling older adults.

Study design

Cross-sectional study among 4474 community-dwelling older adults who participated in the Obu Study of Health Promotion for the Elderly.

Main outcome measures

Participants underwent cognitive tests and were divided into three groups: cognitive healthy, mild cognitive impairment (MCI), and global cognitive impairment (GCI). FoF and related variables, such as fall history, physical function, and depression, were also investigated.

Results

The prevalence of FoF was significantly different by group (p < 0.001; healthy: 43.6%, MCI: 50.6%, GCI: 40.6%). Logistic regression analysis showed that GCI (odds ratio = 0.63; 95% confidence interval = 0.526–0.76) was independently associated with FoF, after controlling for confounding factors. Older adults with GCI showed the lowest prevalence of FoF, although they had the lowest physical function comparing with the other groups (p < 0.001).

Conclusion

MCI and GCI in community-dwelling older adults affect the prevalence of FoF in a completely different manner. Further study is required to determine whether insensitivity to FoF with GCI increases the risk of falling in older adults.     

Self-management of health-behaviors among older and younger workers with chronic illness

Objective

To examine the self-management of health behaviors carried out by older (aged 50–69 years) and younger workers (aged 20–49 years) with a chronic illness.

Methods

Questionnaire data was collected from 759 employees with a diagnosed chronic illness. Four categories of self-managing health behaviors were examined: using prescribed medication, monitoring and responding to symptoms, managing an appropriate diet and exercising.

Results

The majority of participants (56–97%) reported being advised to carry out health behaviors at home and at work. Controlling for confounding factors, medication use was associated with younger and older workers. Managing an appropriate diet was associated with younger workers with asthma, musculoskeletal pain or diabetes. Exercising was associated with younger workers with asthma and with older workers with heart disease, arthritis and rheumatism or diabetes.

Conclusions

The findings indicate that there are differences in diet and exercise activities among younger and older workers.

Practice implications

To increase self-management in health behaviors at work, improved communication and understanding between the different health professions and the patient/employee is required so that different tailored approaches can be effectively targeted both by age and within the context of the working environment, to those managing asthma, heart disease, diabetes and arthritis and rheumatism.     

The development and comprehensibility of a pictorial asthma action plan

Objective

Written action plans are regarded as an important part of asthma self-management education and yet they may not be understood by those with limited literacy skills. This study was designed to produce an understandable pictorial asthma action plan.

Methods

With advice from a group of doctors and nurses a “standard” written action plan was translated by a medical artist into a series of pictorial images. These were assessed using the techniques of guessability and translucency by a series of adults attending a specialist asthma clinic in London and the same process was subsequently used to assess comprehensibility of the images and plans amongst a group of Somalis living in Manchester, UK and Malaysians in Seremban, Malaysia.

Results

Guessability testing showed that the majority of pictograms were well understood by each of the study groups. Translucency testing revealed close agreement with intended meaning for the majority of the images. One image, depicting extra use of reliever medication scored less well in all populations; two other images scored less well in the Somali and Malaysian groups and reflect less use of certain inhaler devices in other countries. The overall plan was well understood by all patients who were able to adequately recount the appropriate actions to take in different clinical scenarios.

Conclusion

We have developed a pictorial asthma action plan understandable by 3 different populations of patients with asthma.

Practice implications

Pictorial representations have been shown by other studies in other situations to be an effective method of reinforcing the spoken word. The pictorial asthma action plan developed for this study has been shown to be comprehensible, personalised to the individual in the usual fashion. It is now suitable for further evaluation in clinical practice.     

Trajectories of physical functioning and their prognostic indicators: A prospective cohort study in older adults with joint pain and comorbidity

Objectives

This study aimed to identify and characterize homogeneous subgroups of individuals with distinct trajectories of physical functioning (PF) and to examine prognostic indicators of deterioration in PF in a highly heterogeneous population of older adults with joint pain and comorbidity.

Study design

A prospective cohort study among 407 older adults with joint pain and comorbidity provided data over a period of 18 months, with 6 month time-intervals. We used latent class growth modelling (LCGM) to identify underlying subgroups (clusters) with distinct trajectories of PF. Next, we characterized these subgroups and applied multivariable logistic regression analysis to identify prognostic indicators for deterioration in PF.

Main outcome measures

We measures PF with the RAND-36 PF subscale and several potential sociodemographic, physical and psychosocial prognostic indicators.

Results

LCGM identified three clusters. Cluster 1 ‘good PF’ contained 140 participants with good baseline PF and small improvements over time. Cluster 2 ‘moderate PF’ contained 130 participants with moderate baseline PF and deterioration over time. Cluster 3 ‘poor PF’ contained 137 participants with poor baseline PF and deterioration over time. After backward selection, the final model that could best distinguish between improved participants (cluster 1) and deteriorated participants (cluster 2–3) included the following prognostic indicators: higher age, more depressive symptoms, less perceived self-efficacy and more activity avoidance.

Conclusions

Older adults with joint pain and comorbidity either improved or deteriorated in PF over time. The prognostic model facilitates the classification of patients, the provision of more accurate information about prognosis and helps to narrow the focus to the high risk group of poor PF.     

The content of diet and physical activity consultations with older adults in primary care

Objective

Despite numerous benefits of consuming a healthy diet and receiving regular physical activity, engagement in these behaviors is suboptimal. Since primary care visits are influential in promoting healthy behaviors, we sought to describe whether and how diet and physical activity are discussed during older adults’ primary care visits.

Methods

115 adults aged 65 and older consented to have their routine primary care visits recorded. Audio-recorded visits were transcribed and diet and physical activity content was coded and analyzed.

Results

Diet and physical activity were discussed in the majority of visits. When these discussions occurred, they lasted an average of a minute and a half. Encouragement and broad discussion of benefits of improved diet and physical activity levels were the common type of exchange. Discussions rarely involved patient behavioral self-assessments, patient questions, or providers’ recommendations.

Conclusions

The majority of patient visits include discussion of diet and physical activity, but these discussions are often brief and rarely include recommendations.

Practice implications

Providers may want to consider ways to expand their lifestyle behavior discussions to increase patient involvement and provide more detailed, actionable recommendations for behavior change. Additionally, given time constraints, a wider array of approaches to lifestyle counseling may be necessary.     

Motivation to quit smoking among parents of urban children with asthma

Objective

To identify factors associated with motivation to quit smoking among parents of urban children with asthma.

Methods

We analyzed data from parents who smoke and had a child enrolled in the School-Based Asthma Therapy (SBAT) trial. We assessed asthma symptoms, children's cotinine, and parent smoking behaviors. Motivation to quit smoking was assessed by a 10-point continuous measure (1, not at all motivated; 10, very motivated).

Results

209 parents smoked (39% of sample), and children's mean cotinine was 2.48 ng/ml. Motivation to quit was on average 6.9, and 47% of parents scored ≥8 on the scale. Parents who believed their child's asthma was not under good control, and parents who strongly agreed their child's asthma symptoms would decrease if they stop smoking had higher motivation to quit compared to their counterparts (p < .05). In a multivariate analysis, parents who believed their child's asthma was not under control had more than twice the odds of reporting high motivation to quit.

Conclusion

Parents’ perception of the risks of smoking to their child with asthma is associated with motivation to quit.

Practice implications

Raising awareness about the effect of smoking and quitting on children's asthma might increase motivation to quit among parents.     

Complex health care decisions with older patients in general practice: Patient-centeredness and prioritization in consultations following a geriatric assessment

Objective

To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior.

Methods

Observation of consultations embedded in a cluster randomized controlled trial,¹ in which 317 patients from 41 general practices received the STEP assessment followed by a care planning consultation with their GPs. GPs in the intervention group used a structured procedure for setting health (care) priorities in contrast to control GPs. A sample of 43 consultations (24 intervention; 19 control) were recorded, transcribed and analyzed with regard to priority setting and patient-centeredness.

Results

Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity. The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practiced, albeit more frequently in intervention consultations.

Conclusion

Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate. Yet a short structured guide for doctors cannot easily achieve this.

Practice implications

More research is needed in regard to handling complex health needs of older patients. It requires a professional approach and training in patient-centered holistic care planning.     

Serum methylarginines and incident depression in a cohort of older adults

Background

Methylarginines are endogenous nitric oxide synthase inhibitors that have been implicated in depression. This study measured serum concentrations of l-arginine, asymmetric (ADMA) and symmetric (SDMA) dimethylarginine in a representative sample of older community-dwelling adults and determined their association with incident depression over 6-years of follow-up.

Methods

Data on clinical, lifestyle, and demographic characteristics, methylated arginines, and l-arginine (measured using LC–MS/MS) were collected from a population-based sample of older Australian adults (Median age=64 years; IQR=60–70) from the Hunter Community Study. Clinical depression was defined as a Centre for Epidemiological Studies Depression Scale (CES-D) score ≥16 or use of antidepressant medications.

Results

In adjusted analyses ADMA (Q3), SDMA (Q2), l-arginine (Q2), gender, and asthma remained statistically significant predictors of incident depression at follow-up. Quartile 3 of ADMA concentration was associated with 3.5 times the odds of developing depression compared with Q1 (OR=3.54; 95% CI: 1.25–9.99).

Limitations

Limitations of our study include the use of a subjective self-reported questionnaire tool using a dichotomous cut-off, together with use of antidepressant medications, as proxies for clinical depression. Moreover, similarly to most population studies on methylated arginines, the measurement of ADMA and SDMA from blood does not necessarily reflect intracellular concentrations of these compounds. Finally, there were no measures of nitric oxide metabolites to determine if these levels were altered in the presence of elevated methylarginines and depression.

Conclusions

After adjusting for clinical, demographic, biochemical, and pharmacological confounders, higher serum ADMA was independently associated with incident depression at 6-years follow-up.