Journal of Aging Research and Healthcare
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Research Article | Open Access
  • Available online freely | Peer Reviewed
  • Health Literacy and Older Adults: Fall Prevention and Health Literacy in a Midwestern State

    Amy K. Chesser 1       Nikki Keene Woods 1     Jared Reyes 2     Nicole L. Rogers 1    

    1Department of Public Health Sciences, Wichita State University

    2Department of Communication Sciences Disorders, Wichita State University

    Abstract

    Falls continue to be a health concern for older adults. Gender and age are key predictors of falls, particularly for those with low health literacy. Data were collected by a State Health Department using the state-led supplemental question option for the Centers for Disease Control and Prevention (CDC) Behavior Risk Factor Surveillance System (BRFSS) survey. Specifically, trend data for respondents were examined by gender, geographic location and health literacy rate. Results indicated the highest mean number falls occurred with men for those within the metropolitan statistical area (MSA) city code, lowest in suburban areas. Females reported to have a higher estimated mean number of falls and injuries than males. For males, the number of falls and injuries tended to decrease with higher health literacy. The findings support the importance of addressing fall prevention for older adults. Long term implications for improving fall prevention and health literacy for older adults include impact on individual outcomes.

    Received 19 Dec 2017; Accepted 17 Jan 2018; Published 22 Jan 2018;

    Academic Editor:Ian James Martins, Edith Cowan University, Australia, Email: [email protected]

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright©  2018 Amy K. Chesser, et al.

    License
    Creative Commons License    This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Citation:

    Amy K. Chesser, Nikki Keene Woods, Jared Reyes, Nicole L. Rogers (2018) Health Literacy and Older Adults: Fall Prevention and Health Literacy in a Midwestern State. Journal of Aging Research And Healthcare - 2(2):31-40.
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    DOI10.14302/issn.2474-7785.jarh-17-1911

    Introduction

    Among older adults, falls are the number one cause of fatal and non-fatal injuries {Centers for Disease, 2006 #67}. In 2014, the number of falls experienced by older adults was 29 million. That number is estimated to increase and the need for fall prevention continues to be supported by the evidence {Larson, 2017 #68}. Gender and age are key predictors of falls 1, 2, 3, 4. For adults ≥65 years of age, the risk for falls can increase due to a number of concomitant factors related to ageing. Cognitive decline, changes in visual acuity, decreases in muscle strength, polypharmacy, and changes in balance and gait are commonplace sequelae of the ageing process; each of which is associated with an additional risk for accidental falls. Most of the identified risk factors for falls are modifiable, and a number of falls prevention programs and interventions exist 5. However, the effectiveness of such programs can be attenuated or negated in populations with low health literacy 6, 7.

    Understanding how health literacy and demographic factors contribute to the incidence of falls, particularly falls that result in injury, is key to modifying existing fall prevention interventions to be more efficacious with older adults with low health literacy. A few studies have examined health literacy and falls in an older adult population. For example, Jaffee et al. (2016) examined hospital readmission rates and falls after hospital discharge. Poor vision was found to be an independent predictor of a post-discharge fall. While low health literacy was associated with greater readmissions, low health literacy was determined to be a non-significant factor in fall risk. However, Jaffee et al. only investigated 30-post discharge follow-up using inpatients from one hospital. The CDC reports less than half of fall victims go to the doctor to seek help following a fall, meaning there is very little information regarding the association between falls and health literacy in the larger population. In addition, health literacy levels are not frequently measured by health providers. This gap in the literature is more important when the disparities in health care access in rural populations is considered.

    The objective of this study was to examine health literacy rates and falls for adults age 65 and older using data from the Kansas Behavioral Risk Factor Surveillance System (BRFSS).

    Methods

    This study was a retrospective analysis of state-wide data. Data were collected as part of a state wide Behavioral Risk Factor Surveillance System (BRFSS) survey. The BRFSS is a randomly sampled national telephone survey conducted by the Centers for Disease Control and Prevention (CDC) which collects self-reported information about health-related risk behaviors, preventive service use, and chronic health conditions for adults aged 18 years and older. Detailed survey methodology has described by the Chesser, et al. 8. Health literacy data were collected through the supplemental, state-specific module of the BRFSS telephone survey. Data were analyzed using SPSS release 24.0 (IBM Corp., Armonk, New York) for complex samples. The data were split into demographic profiles so trends could be visualized. Specifically, we looked at the interaction between rural or urban residency, gender, and health literacy levels on the number of falls experienced in the past 30 days and the number of injuries that resulted from falls.

    The health literacy assessment consisted of the following three questions and responses on a 5 point Likert scale:

    1) How confident are you in filling out medical forms by yourself? For example, insurance forms, questionnaires, and doctor’s office forms. Would you say Possible responses were: 1) Not at all, 2) A little, 3) Somewhat, 4) Quite a bit, 5) Extremely, 7) Don’t know/not sure, 9) Refused.

    2) How often do you have problems learning about your health condition because of difficulty in understanding written information? Would you say… Interviewer Probe: If respondent states they do not have a health condition, say: “This would include any routine visit to a doctor’s office for a physical exam, women’s health exam or men’s health exam.” Possible responses were: 1) Always, 2) Often, 3) Sometimes, 4) Rarely, 5) Never, 6) Never visited doctor’s office, 7) Don’t know/not sure, 9) Refused.

    3) How often do you have someone help you read medical materials? For example: family member, friend, caregiver, doctor, nurse or other health professional. Would you say Possible responses were: 1) Always, 2) Often, 3) Sometimes, 4) Rarely, 5) Never, 7) Don’t know/not sure, 9) Refused.

    Falls were defined as “when a person unintentionally comes to rest on the ground or another lower level.” Fall rates were assessed using a single question:

    In the past 12 months, how many times have you fallen? Possible responses were: 1) number of times, 2) None, 3) Don’t know/Not sure and 4) Refused.

    A follow up question was asked “Did this fall cause an injury?” only if the respondent indicated yes on the previous question. If more than one fall was reported, the prompt include How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor. Possible responses included: 1) number of falls, 2) none, 3) Don’t know/Not sure, 4) Refused.

    Cumulative scores were calculated for responders who answered all three health literacy questions. We categorized respondents in the following manner: low health literacy (scores 3-8), moderate health literacy (scores 9-14) and high health literacy (score = 15). Therefore, all analyses utilized this trichotomized health literacy variable as the outcome rather than a scaled score. This study was approved by the Kansas Department of Health and Environment (KDHE) Institutional Review Board (IRB) and the Wichita State University IRB (HSC#3473).

    Results

    Among the 11,801 responders of the BRFSS survey, 5,638 participants were asked the specific supplemental questions including the health literacy questions and 5,494 responders answered all three health literacy questions (response rate = 97.5%). Most respondents reported moderate health literacy (61.1%), followed by high health literacy (31.4%), and low health literacy (7.5%). Respondents ≥ 65 years of age represented the second largest proportion of the low health literacy group (7.9%), following 45-54 year olds. young adults and the middle-aged were equally represented in the high health literacy group (Table 1).

    Table 1. Weighted demographic and health status characteristics of Kansas BRFSS sample in relation to their health literacy (HL) (N=1,944,274)
    Variable Low HL Moderate HL High HL  
      N % N % N % p-value
    Overall 146,666 7.5 1,187,318 61.1 610,291 31.4  
    Sex             <.001
    Male 88,129 9.2 606,077 63.5 260,127 27.3  
    Female 58,537 5.9 581,352 58.7 350,164 35.4  
    Age             <.001
    18 to24 years 18,874 6.9 207,028 75.2 49,510 18.0  
    25 to 34 years 19,705 6.1 199,498 61.8 103,578 32.1  
    35 to 44 years 22,100 7.1 171,242 55.3 116,210 37.5  
    45 to 54 years 32,074 9.6 179,886 54.0 120,992 36.3  
    55 to 64 years 24,362 7.4 193,971 59.0 110,505 33.6  
    65 and older 29,552 7.9 235,803 62.9 109,496 29.2  
    Race             <.001
    N-H white 89,571 5.7 967,363 61.9 505,892 32.4  
    N-H black 5,559 5.5 59,418 59.1 35,597 35.4  
    N-H other 4,613 8.2 36,892 65.3 15,008 26.6  
    N-H multi race 3,449 8.8 20,994 53.6 14,722 37.6  
    Hispanic 42,249 24.9 93,771 55.3 33,700 19.9  
    Marital status             <.001
    Partnered 76,568 6.6 677,014 58.2 410,452 35.3  
    Not partnered 69,990 9.0 505,506 65.3 198,372 25.6  
    Education             <.001
    Did not graduate high school 51,752 27.8 114,420 61.4 20,223 10.8  
    High school graduate 54,405 10.3 346,500 65.9 124,793 23.7  
    Some college or technical school 32,839 4.8 439,990 64.0 214,241 31.2  
    Graduated college or technical school 6,899 1.3 285,171 52.5 250,658 46.2  
    Employment             <.001
    Employed full time 66,372 5.7 692,566 59.5 404,590 34.8  
    Not employed 13,822 15.1 56,991 62.3 20,723 22.6  
    Homemaker 10,973 9.1 70,848 58.6 39,167 32.4  
    Student 2,770 2.4 90,065 79.3 20,792 18.3  
    Retired 23,821 7.1 206,243 61.8 103,490 31.0  
    Unable to work 24,729 22.6 64,498 58.9 20,315 18.5  
    Income             <.001
    <$15,000 23,491 17.2 87,995 64.3 25,327 18.5  
    $15,000 to <$25,000 32,548 12.9 168,057 66.9 50,787 20.2  
    $25,000 to <$35,000 15,976 7.9 124,615 61.4 62,343 30.7  
    $35,000 to <$50,000 13,269 4.7 188,846 66.9 80,366 28.5  
    $50,000+ 22,680 2.9 430,286 55.5 322,531 41.6  
    Home ownership             <.001
    Own 81,400 5.9 833,414 60.3 467,880 33.8  
    Rent 52,838 12.0 279,378 63.3 108,850 24.7  
    Other arrangement 12,428 11.2 67,786 61.2 30,501 27.5  
    Insurance status             <.001
    Has health care coverage 103,414 6.1 1,023,766 60.8 556,816 33.1  
    Does not have health care coverage 40,778 16.4 156,073 62.6 52,354 21.0  
    Metropolitan status code             <.001
    In MSA city code 26,873 8.0 195,205 58.4 112,096 33.5  
    Within MSA city suburb but not city center 16,330 4.0 239,317 58.7 151,852 37.3  
    Outside MSA 37,728 9.5 249,618 62.9 109,638 27.6  
    Veteran status             0.476
    Yes 19,081 8.3 134,338 58.6 75,993 33.1  
    No 127,585 7.4 1,051,431 61.4 533,686 31.2  
    General health rating             <.001
    Good or better health 81,689 5.0 1,003,022 61.1 556,244 33.9  
    Poor or fair health 63,774 21.3 181,287 60.6 54,047 18.1  

    With respect to falls self-reported in the prior month, females appear to have a higher estimated mean number of falls than males, although there is a great deal of interaction between location of residence and health literacy levels (Table 2; Figure 1, Figure 2, Figure 3 & Figure 4). For males, the number of falls and injuries decreased with higher health literacy; metropolitan statistical area (MSA) city 1.4 to 0.2, MSA city suburb 1.0 – 0.3, Outside MSA city 1.0-0.5) (Table 2). The place of residence does not appear to significantly affect the number of falls experienced once the standard errors of measurement are taken into account, however, it may be likely that individuals with low health literacy experience more falls, particularly in urban environments. For females, these trends are more difficult to ascertain as many of the estimated profile means have larger standard errors. However, the trends do appear to be consistent with the male findings (Table 2).

    Table 2. Weighted estimates of number of falls and fall related injuries within the past 12 months for individuals ≥ 65 years of age
      Estimated population size Falls in last 12 months Estimated population size Falls that resulted in injury
    (n) (n)
    Profile   Mean (95% CI)   Mean (95% CI)
    Overall 3,26,559 0.7 (0.55-0.77) 1,01,790 0.5 (0.41-0.57)
    Males
    Male x In MSA City x Low HL 3718 1.4 (0.28-2.46) 1971 0.8 (0.15-1.40)
    Male x In MSA City x Moderate HL 23,628 0.6 (0.28-0.88) 7,153 0.2 (0.07-0.39)
    Male x In MSA City x High HL 13025 0.2 (0.10-0.39) 2390 0.5 (0.19-0.79)
    Male x MSA City Suburb x Low HL 3719 1.0 (-0.05-2.09) 1397 1.0 (0.28-1.70)
    Male x MSA City Suburb x Moderate HL 31325 0.6 (0.38-0.85) 10988 0.5 (0.19-0.77)
    Male x MSA City Suburb x High HL 15225 0.3 (0.12-0.39) 3508 0.2 (-0.01-0.40)
    Male x Outside MSA City x Low HL 6415 1.0 (0.32-1.64) 2544 0.1 (-0.09-0.30)
    Male x Outside MSA City x Moderate HL 34531 0.7 (0.38-0.96) 9434 0.3 (0.11-0.53)
    Male x Outside MSA City x High HL 9354 0.5 (0.19-0.83) 2524 0.3 (-0.00-0.55)
    Females
    Female x In MSA City x Low HL 3540 2.9 (-0.89-6.70) 1826 0.6 (0.17-1.13)
    Female x In MSA City x Moderate HL 32899 0.7 (0.46-0.93) 11498 0.5 (0.25-0.84)
    Female x In MSA City x High HL 16784 0.3 (0.16-0.50) 3553 0.1 (0.01-0.28)
    Female x MSA City Suburb x Low HL 1701 0.3 (-0.05-2.09) 488 0.4 (-0.27-1.05)
    Female x MSA City Suburb x Moderate HL 41730 0.6 (0.38-0.89) 13099 0.6 (0.37-0.76)
    Female x MSA City Suburb x High HL 21980 1.0 (0.04-2.04) 7867 0.6 (0.34-0.83)
    Female x Outside MSA City x Low HL 5746 1.1 (0.32-1.97) 2452 0.5 (0.10-0.89)
    Female x Outside MSA City x Moderate HL 44353 0.7 (0.49-0.86) 15111 0.7 (0.39-0.99)
    Female x Outside MSA City x High HL 16888 0.4 (0.23-0.61) 3986 0.5 (0.24-0.76)

    Figure 1. The average number of falls, with 95% confidence intervals, experienced by males in the past 12 months by residency and health literacy level.
    Figure 1.

    Figure 2. The average number of falls, with 95% confidence intervals, experienced by females in the past 12 months by residency and health literacy level.
    Figure 2.

    With respect to falls that resulted in injury in the prior month, females appear to have a higher estimated mean number of falls than males, although there is a great deal of interaction between location of residence and health literacy levels (Table 2; Figure 1 and Figure 2). For males, the number of falls and injuries decreased with higher health literacy (Table 2). For females, these trends are more difficult to ascertain as many of the estimated profile means have larger standard errors. However, the trends do appear to be consistent with the male findings (Table 2).

    Figure 3. The average number of injurious falls, with 95% confidence intervals, experienced by males in the past 12 months by residency and health literacy level.
    Figure 3.

    Figure 4. The average number of injurious falls, with 95% confidence intervals, experienced by females in the past 12 months by residency and health literacy level.
    Figure 4.

    Discussion

    This study utilized a three question screening tool as part of the statewide BRFSS survey 9. Study findings reinforces the literature that health status is related to health literacy particularly for older adults 10, 11. However, limited evidence investigating health literacy and older adults exists. The findings support the importance of addressing fall prevention for older adults. Although a number of viable fall prevention programs have shown promise 12, 13, 14, 15, 16, 17, none of these interventions applied plain language methodology specifically addressing low health literacy. Education about falls, specifically fall prevention, should include materials developed with low health literacy in mind 5. As identified in our study results, fall prevention programs that target the recruitment and education of women and caretakers of female older adults are needed 4. It also appears that interventions in metropolitan areas of Kansas are warranted. Implications for the dual approach of addressing fall prevention and health literacy for the older adult include quality of life, clinician patient communication and treatment compliance. Physician prescribed physical activity is one method that has shown success and may be a viable option for fall prevention interventions for this population 18. Demographic differences in fall rates continue for older adults. Health literacy rates appear to be impacting these demographic characteristics.

    Limitations

    This study utilized cross-sectional data from one Midwestern state with validated methodology 9, 19, 20. Several limitations should be considered. This is a brief report of a sub-set of data including self-reported health literacy rates, falls, related injuries. Self-reported survey data and are subject to possible response bias, although self-reported health literacy rates have been demonstrated as reliable for a variety of skills 21. Due to the length, survey fatigue may have affected responses. Additionally, as part of the study design, data were limited to questions included for the supplemental (optional) arm for the BRFSS module. The cross-sectional nature of the data study results may not be generalizable to other states with different population characteristics.

    Conclusions

    Implications for population level issues include cost savings for the health care system and evidence for building public health interventions for the increasing older adult population.

    The implications of this study’s findings are relevant to both health practitioners and researchers. Interventions and programs directed at multiple levels are necessary to improve health literacy and the poorer outcomes associated with health literacy rates for the older adults population. Targeted educational interventions for the female population of older adults living in both urban and rural settings for fall prevention are needed. Future research is needed to assess the validity of these results using a multi-state approach.

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