Prior to the pandemic, we were beginning to prioritize the need for shared-decision making between older care-recipients and care-providers, to empower patients to make well-informed choices. As we attempt to keep everyone informed about the coronavirus public health crisis, it has become even more important to assess and increase health literacy among older adults. Seniors are more vulnerable to contract the coronavirus and to become ill after being exposed. It is crucial for seniors to understand symptoms and safety precautions. Also, they need to be aware of when it is necessary to go to health care providers or to the emergency room (including for reasons other than the coronavirus).
Definition of Health Literacy
Health literacy is defined by the CDC as the “degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions.” Health literacy levels are associated with a variety of factors, including education, culture, age, and socioeconomic status. Lower levels of health literacy are linked with advanced age. This is related to some changes associated with aging as well as with impairment in sensory status (hearing, vision impairment), with physical health status, and with cognitive processing limitations.
Health literacy is a complicated concept. Familiarity with the following play in to the level of health literacy: basic mathematical skills, knowledge about health insurance options, reading comprehension, communication skills, understanding about financial matters, skill in interpreting bar graphs, adeptness with computer use. Those who have lower health literacy levels tend to come into the health care system when they are more ill. They are more likely to use services that are meant to treat problems or deal with medical “crises” in an emergency room setting. In contrast, those who have higher health literacy levels use preventive care and are less likely to use the emergency room to secure services when problems arise. In other words, they seek health care when symptoms can be assessed and managed, before crisis situations occur. Thereby, health care expenses are lowered in the long run. Outcomes are more likely to be positive, e.g., the likelihood of recovering is maximized.
There is a complex relationship between levels of health literacy and compliance with physician orders at any time, and during this pandemic. Research findings indicate that patients with limited health literacy are more likely to be noncompliant. However, there is a difference between patients being noncompliant due to limited health literacy versus being noncompliant when they have high health literacy and knowledge about critical issues. Older patients are more likely to take history and knowledge about their specific illnesses into account – assessing risks versus benefits for some tests, medications, types of health service used. During this pandemic, patients may not schedule and follow-through on tests and procedures due to fear of being exposed to the coronavirus and contracting it, even with safety precautions in place. It makes sense that seniors – regardless of health literacy levels -- might feel it would be best to deal with these matters after the dust settles.
Health Literacy Issues During This Pandemic
It is essential to access credible websites to keep on top of the coronavirus situation, to be able to see graphics or images that show what the safety precautions are. Seniors can be made more aware of symptoms, of facts about why physical distancing is required, and of when it is critical to self-quarantine. However, not all seniors feel comfortable with relying on high-tech approaches or with social media platforms. So we can’t rely on those mechanisms to keep seniors informed.
A team of partners at the Ashland County Older Adult Behavioral Health Coalition plan to conduct a survey of older adults to assess their needs. As part of the survey, seniors will be asked about barriers to connect well (e.g., the extent to which increased reliance on technology is difficult). For example, what type of training do they need, what devices would be helpful to have at their fingertips?
Graphics and images work in “reaching” patients, in simple yet effective and understandable ways. However, we need to consider what other types of resources or tools need to be designed for specific audiences, especially seniors. Also, we need to consider what verbal communication strategies will be most effective as telehealth is prioritized.
Seniors must take responsibility for self-care, for preventing or minimizing health care problems, and for communicating with health care providers. However, health care providers must ensure that seniors understand what is needed to stay well, are provided with opportunities to ask questions and to receive answers that make sense. The continuing need for engagement in shared-decision making must be prioritized. As is the case with designed materials and websites, there is a necessity to avoid medspeak or technical jargon, to use words that are understandable by those who are not professional health care providers.
Communication and Telehealth: Issues
Particularly at this time, effective and informative communication between health care providers and older patients matter. Respect matters. Allowing the patient to make decisions and taking the lead on what is most urgent to address matters. Having another party, interpreter, or advocate (if OK with older adults) engaged in discussions especially when complex issues are addressed matters. Simplification of information about treatment options matters.
The jury is out as to whether or not seniors feel comfortable with telehealth, with finding this more of a barrier to connecting well with their health care providers. Using telehealth over the phone means that you won’t see facial expressions or be able to lip read if hearing-impaired. You won’t be able to see materials that are designed well, you won’t be able to take your bag of medications to appointments. You may not have sufficient time to address your concerns, and it may not be easy to hear what is being said.
We don’t know to what extent the streamlined telehealth approach will be therapeutic and beneficial. Over the phone, the physician will not be able to see, touch, assess “problems” as well as when he/she is able to conduct a physical examination. Certain questions are typically asked in appointments about health status, and symptomatology. Especially now, it is important for care providers to assess level of sadness and anxiety. They need to build in questions – routinely -- about suicidal ideation and intent to commit suicide.
Health care providers may need to be prepared to provide recommendations on resources and agencies that can provide assistance in navigating multiple systems. It would be ideal if they could take on the role of informing seniors about which organizations can help during this pandemic (in terms of food, medical supplies, transportation options, mental health services, and more). Admittedly, offering this type of practical information is not tightly linked with traditional health care services.
Constantly updated information about the coronavirus crisis can be found on trusted websites: www.coronavirus.ohio.gov, www.mha.ohio/coronavirus. An ODH Call Center is available to answer questions from 9am to 8pm daily – 1-833-474-5634. In Ashland County, the crisis line for addressing mental health concerns is 419-289-6111. The responsive Ashland community support line, created during this pandemic, is 419-496-0140.
Mental health services are available by agencies under the umbrella of the Mental Health and Recovery Board of Ashland County (Appleseed Community Mental Health Center, Ashland County Council on Alcoholism and Drug Abuse, and Catholic Charities Services of Ashland County). At this point, these agencies are providing both telehealth and face-to-face services, contingent on preferences and circumstances. In general, those who are especially at risk of contracting coronavirus or who are medically fragile would be encouraged to use telehealth options. However, crisis services would best be provided in person.
The website for the MHRB is continually providing updated information regarding meeting mental health needs during this pandemic, and about the coronavirus public health emergency (www.ashlandmhrb.org).
For information about community services and resources that are available, contact the Ashland County Council on Aging (419-281-1477).
Diana Spore, PhD, MGS
Consultant, Mental Health and Recovery Board of Ashland County, formerly a Board member
Member, Ashland County Older Adult Behavioral Health Coalition« Back to Blog