Interactive Health Literacy Among Hardly Reached Rural and Homebound Older Adults

Theoretical Background and research questions/hypothesis:  Interpersonal communication with providers is an element of health literacy that yields the most credible and actionable information for patients, yet it is too rarely addressed in health literacy improvement programs. Older adults more than other age groups need strong health information-seeking and processing skills, because they are more likely to suffer from chronic diseases which in turn trigger a daunting array of information needs and decision-making challenges.  Much health information received by older adults is transmitted during the health care provider/patient interaction and requires competency in oral more than written communication.  Taken as a whole, research on interactive health literacy (IHL) reveals that information transmission in medical encounters is abysmal.  By some measures, patients understand and recall only about half of what they are told in a physician’s office.

Methods:  Health Literacy on Wheels is a project that takes a novel approach to reaching older adults and advancing their IHL.  By partnering with several demographically diverse community-based organizations, this project advances a model of health literacy coaching wherein Meals on Wheels drivers and staff work with hard-to-reach older adults to improve their ability to interact with health care providers. Health Literacy Coaches impart IHL skills both to clients who enjoy some degree of mobility and therefore dine at congregate sites, as well as to homebound clients who qualify for home-delivered meals.   In this study we examine differences between rural/urban clients and congregate/homebound clients on several outcomes associated with health literacy such as self-reported health status, efficacy for chronic disease self-management, satisfaction with health care, overcoming barriers to health information, and listening comprehension to a health message.

Results:  Results for this sample (n=384) of older adults (M_age=74.70; s.d.=9.06) reveal statistically significant differences on several outcomes and process between rural/urban clients and homebound/congregate clients.  Generally, the “hardly-reached” rural and homebound clients were at higher risk for several outcomes compared to their urban congregate client counterparts.  Rural clients were at particular risk for low efficacy for chronic disease self-management (F=15.095; p<.01) and low satisfaction with health care (F=5.360; p<.05).  Homebound clients were at risk for low health message comprehension (F=7.626; p<.01), low efficacy for chronic disease self-management (F=50.045; p<.01), difficulty overcoming barriers to health information (F=3.366; p=.07), low satisfaction with health care (F=11.431; p<.01), low self-reported health status (F=21.759; p<.01), and written health literacy (F=43.445; p<.01).

Conclusions:  Although disadvantages to homebound and rural older adults were observed in most measured outcomes, rural clients scored higher on a measure of written health literacy than urban clients (F=13.541, p<.01) and homebound clients had longer talk times during post appointment telephone conversations than congregate clients (F=4.364, p<.05).  Perhaps isolated homebound clients were more willing and eager to talk during post appointment telephone conversations than more socially involved congregate clients.

Implications for research and/or practice:  Overall, this examination of interactive health literacy and related variables highlights disparities among a hardly-reached population of rural and a population of homebound older adults.  Interventions such as Health Literacy on Wheels are needed to reach this vulnerable population to advance their interactive health literacy and promote health equity.