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                      • 2021-11-25
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                      1 INTRODUCTION

                      Global ageing brings with it an increasing need for older people to access healthcare services, health information and education to recognise and deal with health-related issues that may be associated with growing older. Ageing also carries with it an increased risk of vulnerability, which can affect quality of life and health. Nurses are commonly in the position to critically analyse vulnerability in older people from differing perspectives, including health literacy, a modifiable determinant of self-care and health behaviour. Despite increasing awareness of the importance of health literacy, it is perhaps surprising to discover that limited attention has been given to this concept in older people. Health literacy can be defined from a public health perspective as ‘linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course’ (S?rensen et al., 2012, p.3). In older people, lower health literacy in older people has been associated with sub-optimal levels of health and health outcomes, such as compliance with treatment regimes, medication adherence and capacity for self-management. Low health literacy can be directly linked with poorer health status and impairment to quality of life. Within the biomedical model, most age-related issues with low health literacy in older people have been explained in terms of differences in cognitive abilities including speed of thought processes aligned with traditional theories of ageing. From a sociological perspective, health literacy has been viewed as a potential social determinant of health that can address health inequities. To conceptualise health literacy as a social determinant of health, Nutbeam and Lloyd (2021) reported strong evidence of a social gradient in population-based studies. Health literacy is increasingly being seen as a better predictor of health than many other social determinants of health including, ethnicity, education and employment status. Indeed, if not one of the strongest predictors of health, health literacy has become the strongest social determinant of health (Ho & Smith, 2020).


                      The importance of health literacy in older people has been illustrated by the COVID-19 global pandemic. Although all age groups are at risk of contracting the COVID-19 virus, older people are more vulnerable to mortality and morbidity associated with the viral infection (Smith et al., 2020). The emergence of the COVID-19 pandemic provided a critical test for health literacy, giving it the opportunity to highlight its importance in relation to population health and well-being. Governments and health providing agencies around the world would appear to be increasingly aware that population-based enhancement of health literacy may be equated with decreased health inequalities and improved health outcomes. To date, there is a paucity of research which specifically addresses the impact of low health literacy in older people during the global pandemic. It could be potentially rationalised through Sorensen’s integrated model of health literacy, hypothesising that lower levels of health literacy may be associated with sub-optimal levels of empowerment in health behaviour (S?rensen et al., 2012). The potential benefits of enhanced health literacy in older people are vast, perhaps now is the time to re-evaluate perspectives of health literacy research in older people. In this editorial, we will highlight the importance of the nursing role in health literacy, consider challenges in nurse education, critique approaches towards health literacy assessment and highlight the potential links that may exist between health literacy empowerment and resilience.


                      Regardless of caring environment, hospital or community-based, nursing staff are key providers of patient education and health-related information. Therefore, it is somewhat surprising that although the nursing profession shoulders most of the responsibility for the delivery of health-related patient education, limited global attention has been given to nursing awareness, knowledge and application of health literacy, especially in the care of older people. Despite this, the provision of shame-free health literacy support for older people has been associated with greater levels of empowerment, engagement, activation and optimal health-related outcomes (Loan et al., 2018). Regardless of nursing specialty, health literacy is an essential skill that enhances effective communication and aids in the provision of person-centred care for older people, potentially reflected by increased patient satisfaction of care.

                      High-quality research is essential, to ensure effective evidence-based health literacy practice. Whilst fully appreciating the need to explore the role of illness and cognition in the health literacy of older, more emphasis could be placed on the determinants and correlates of health literacy. We view the importance of clearly defined terms and the use of valid measurement tools as the basic requirements in any research that aims to understand the role of health literacy in older people.

                      Healthy and successful ageing is important, perhaps more attention could be given towards the assessment of issues that may be more meaningful to the older person, such as physical activity and diet, these may enhance the quality of life of the older person and ensure that they are in a better position to make and act health-related preferences and decisions upon these day-to-day activities. There is clearly scope for more nursing research to help to identify barriers and facilitators for the delivery of appropriate and effective health literacy practices. Now may also be an opportune time to develop important longitudinal studies that explore the relationship between health literacy and health-related outcomes in older people.


                      Over a decade ago, writing in the Journal of Clinical Nursing, Scheckel et al. (2010) highlighted the importance of health literacy education. They specifically advocated for novel approaches towards the instruction of health literacy in the nursing profession, stressing that dedicated teaching in the practice of health literacy would expand students’ existing skills and knowledge in preparation for their professional practice. To date, despite its importance, not all nursing educational institutes would appear to subscribe to this educational approach. The inclusion of health literacy-related questions in all formats of nursing assessment may provide a good starting point. Students could be encouraged to ask open-ended questions and using ‘teach-back’ methods when providing health-related information to older people. Using the ‘teach-back’ approach helps to validate that the nurse has provided information in an understandable format, patient understanding can be verified when they can restate the information in their own words. The value of the ‘teach-back’ approach is that it can empower nurses to authenticate understanding and correct erroneous information with older people. Despite the development of several promising nursing health literacy initiatives since Scheckel’s work, providing innovative solutions and strategies, it is thought that many of these have been grossly under-utilised by the profession (Loan et al., 2018).

                      With a global ageing population, now is the time to give more attention to the education-related health literacy research for older people in society. Developing educational approaches in health literacy for all undergraduate nursing students, based upon sound evidence, may be the best way forward to ameliorate and allay against problems and provide a path towards promoting a healthier ageing process. From a post-registration perspective, the establishment of strategic competency-based health literacy education may enhance the health literacy professionalism of nurses. Due to the fast-changing and dynamic nature of health literacy, these initiatives for older people are required as a matter of urgency.

                      Getting older is not in itself a barrier to being able to source the Internet or other forms of computer-based technology, like telemedicine services. Increasingly, older people are accessing vast amount of health-related information is available, although carefulness needs to be taken in relation to the reliability and dependability of some of this information. Digital health literacy is increasingly playing an important role. To enhance the ability of older people to use the Internet, age-related changes in vision and cognition health-related websites need to be considered when specifically designing material for older people. Failure to do so may affect the accessibility of Internet for older people due to potential limitations of working memory, perceptual speed, text comprehension and spatial memory. All forms of health-related information could be made more user-friendly by using an appropriate typeface, writing style, navigational composition and accessibility.

                      Around the world, nurses should not only be aware of the potential problems associated with health illiteracy in older people, but they should also be able to actively try to remedy the situation. Unlike socio-demographic characteristics, like age and ethnicity, which are non-modifiable, there is reasonable evidence to suggest that levels of health literacy can be modified and enhanced in older people. Health literacy interventions could be designed to directly tackle the cognitive difficulties, which may limit older people’s ability to access and understand health-related information. To date, most e-interventions for improving levels of health literacy in older people have focused on reducing the cognitive demands, usually involving increasing the readability of materials or to ensure that assistance is being provided by an appropriate member of healthcare staff. Nurses working with older people should have an awareness of the potential benefits of relatively straightforward approaches that can be taken to address health literacy deficits, including using plain language and non-jargonistic terms when delivering health-related information. Attending to these basic prerequisites may be effective to facilitate the understanding of older people, potentially enhancing empowerment and resilience.

                      Patient-centred approaches to health literacy place a focus on identifying an individual’s knowledge, motivation and skills to gain, comprehend and apply health-related information. In general, this approach to communication is encouraged, especially when dealing with health literacy issues in older people.


                      Developing health literacy interventions is one aspect of the research process, however, measurement of health literacy is also required, and this has been known to be a demanding process. Identifying low levels of health literacy is clearly important in older people; however, there is some debate around the best way to capture this complex and dynamic concept. Historically, researchers have applied objective measures, like the Rapid Estimate of Adult Literacy in Medicine (REALM), within older people research. Since then, more comprehensive subjective measurement tools have emerged. One of these, the HLS-EU, originally developed and validated in Europe is now used widely around the world. The European Health Literacy Survey Questionnaire (HLS-EU) provides the researcher with a scale which is focused on task-specific competencies, such as illness prevention and health promotion, potentially important in capturing vital aspects of active ageing in the assessment of health literacy in older adult. More recently, other measures have surfaced which capture important aspects of age-specific conditions, like dementia literacy.

                      6 EMPOWERMENT AND RESILIENCE

                      The World Health Organization has promoted the importance of the role of health literacy in the development of empowerment and resilience in older people (WHO, 2013). Empowerment is seen as a process through which people gain more control over their lives, their health and its determinants. Through empowerment, health literacy programmes contribute to democratising the healthcare system and to achieving a stronger commitment to health and well-being in communities and in society at large. Resilience is viewed as a form of adaptation, recovery and ‘bouncing back’ in the face of adversity. In relation to both traits, health literacy is viewed as an asset for individuals and communities, as such, any investment that is made to strengthen health literacy in older people may yield a substantial return in enhanced health and well-being. In conjunction with appropriate social resources, health literacy can become an valuable asset that will help to support older people to become more empowered and resilient for active ageing. Presently, we believe that there are significant research gaps in the area of health literacy in older people, including scope for up to date systematic reviews, examining the relationship between health literacy, resilience and empowerment in older people.

                      7 SUMMARY

                      It was the aim of this editorial to capture the most relevant nursing aspects of health literacy in older people. As stated, we believe the health literacy has become one of the most important determinants of health in older people, which can be considered as a modifiable element of socioeconomic inequalities in health. Increasingly, evidence suggests that health literacy mediates the relationship between socioeconomic standing and health inequalities.

                      Therefore, health literacy has the potential to improve health outcomes and may prove to be decisive in the development of resilience and empowerment in the world’s older population. Nurses should be instrumental in enhancing levels of health literacy in older people and greater attention needs to be given to age-specific aspects of health literacy in older adults in nurse education.

                      As the title of this editorial indicates, we speculate that the issue of health literacy in older people may be likened to that of the iceberg model, only part of the problem is readily seen, perhaps those with age-related disorders, the majority remain hidden beneath the surface. We believe that nurses are in an ideal position to play a vital role in identifying and tackling the health literacy-related issues of those in the latter group.


                      1 介紹

                      全球老齡化導致老年人越來越需要獲得醫療保健服務、健康信息和教育,以識別和處理可能與衰老相關的健康相關問題。老齡化還會增加脆弱性的風險,這會影響生活質量和健康。護士通常能夠從不同的角度批判性地分析老年人的脆弱性,包括健康素養,這是自我保健和健康行為的可改變決定因素。盡管人們越來越意識到健康素養的重要性,但發現對老年人這一概念的關注有限,這也許令人驚訝。健康素養可以從公共衛生的角度定義為“與素養相關聯,需要人們獲取、理解、評估和應用健康信息以在日常生活中做出有關醫療保健、疾病預防和健康的判斷和決定的知識、動機和能力。促進在生命過程中維持或改善生活質量”(S?rensen 等人,2012 年,第 3 頁)。在老年人中,老年人的健康素養較低與健康和健康結果的次優水平有關,例如對治療方案的依從性、藥物依從性和自我管理能力。健康素養低可能與較差的健康狀況和生活質量受損直接相關。在生物醫學模型中,老年人健康素養低下的大多數與年齡相關的問題都可以用認知能力的差異來解釋,包括與傳統衰老理論一致的思維過程的速度。從社會學的角度來看,健康素養被視為健康的潛在社會決定因素,可以解決健康不平等問題。為了將健康素養概念化為健康的社會決定因素,Nutbeam 和 Lloyd(2021)報告了基于人群的研究中社會梯度的有力證據。健康素養越來越被視為比許多其他健康問題社會決定因素(包括種族、教育和就業狀況)更好的健康預測指標。事實上,即使不是健康的最強預測指標之一,健康素養也已成為健康的最強社會決定因素(Ho & Smith,2020)。

                      2 COVID-19 和老年人的健康素養

                      COVID-19 全球大流行表明了老年人健康素養的重要性。盡管所有年齡組都有感染 COVID-19 病毒的風險,但老年人更容易死于與病毒感染相關的死亡率和發病率(Smith 等,2020)。COVID-19 大流行的出現為健康素養提供了重要考驗,使其有機會強調其對人口健康和福祉的重要性。世界各地的政府和衛生提供機構似乎越來越意識到,以人口為基礎的健康素養提高可能等同于減少健康不平等和改善健康結果。迄今為止,缺乏專門針對全球大流行期間老年人健康素養低下的影響的研究。可以通過 Sorensen 的健康素養綜合模型將其合理化,假設較低的健康素養水平可能與健康行為中的次優水平有關(S?rensen 等,2012)。提高老年人健康素養的潛在好處是巨大的,也許現在是重新評估老年人健康素養研究前景的時候了。在這篇社論中,我們將強調護理在健康素養中的重要性,考慮護士教育中的挑戰,批判健康素養評估的方法,并強調健康素養賦權和恢復力之間可能存在的潛在聯系。

                      3 護理對老年人健康素養的重要性

                      無論在何種護理環境、醫院或社區,護理人員都是患者教育和健康相關信息的主要提供者。因此,盡管護理專業承擔了提供與健康相關的患者教育的大部分責任,但全球對健康素養的護理意識、知識和應用的關注有限,尤其是在老年人的護理方面,這有點令人驚訝。.盡管如此,為老年人提供無恥的健康素養支持與更高水平的賦權、參與、激活和最佳健康相關結果相關(Loan 等,2018)。無論護理專業如何,健康素養都是一項必不可少的技能,可增強有效溝通并有助于為老年人提供以人為本的護理,這可能反映在患者對護理滿意度的提高上。



                      4 健康素養和護士教育

                      十多年前,Scheckel 等人在《臨床護理雜志》上撰文。(2010) 強調了健康素養教育的重要性。他們特別提倡護理專業健康素養教學的新方法,強調健康素養實踐中的專門教學將擴展學生現有的技能和知識,為他們的專業實踐做好準備。迄今為止,盡管它很重要,但并非所有護理教育機構似乎都贊同這種教育方法。在所有形式的護理評估中包含與健康素養相關的問題可能是一個很好的起點。在向老年人提供與健康相關的信息時,可以鼓勵學生提出開放式問題并使用“回授”方法。使用“回授”方法有助于驗證護士是否以可理解的格式提供了信息,當患者可以用自己的話重述信息時,可以驗證他們的理解。“回授”方法的價值在于,它可以使護士能夠驗證老年人的理解并糾正錯誤信息。盡管自 Scheckel 的工作以來發展了幾項有前途的護理健康素養計劃,提供了創新的解決方案和策略,但人們認為其中許多被該行業嚴重利用(Loan 等人,2018 年)。






                      5 老年人健康素養評估

                      開發健康素養干預措施是研究過程的一個方面,但是,還需要衡量健康素養,眾所周知,這是一個要求很高的過程。識別低水平的健康素養對老年人來說顯然很重要;然而,圍繞捕捉這個復雜而動態的概念的最佳方式存在一些爭論。從歷史上看,研究人員在老年人研究中應用了客觀衡量標準,例如成人醫學識字率快速估計 (REALM)。從那時起,出現了更全面的主觀測量工具。其中之一,最初在歐洲開發和驗證的 HLS-EU 現在在世界各地廣泛使用。歐洲健康素養調查問卷 (HLS-EU) 為研究人員提供了一個量表,該量表專注于特定任務的能力,例如疾病預防和健康促進,這對于在評估健康素養時捕捉活躍老齡化的重要方面可能很重要。老年人。最近,出現了其他衡量特定年齡狀況的重要方面的措施,例如癡呆癥識字率。

                      6 賦權和韌性


                      7 總結









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