How Health Literacy Develops the 'Four Aims' of Better Health Care.

The chapter's audience and purpose are twofold. First, the chapter introduces the 'Quadruple Aim' to policy makers and provides a general overview of health literacy strategies and tools to meet the Quadruple Aim to enhance care delivery while reducing costs. Second, the chapter identifies gaps in health literacy related research and encourages a research agenda to further the evidence base of health literacy to reduce cost, enhance quality, increase access, improve satisfaction, and achieve health equity.

The Use of Wearable Activity Trackers Among Older Adults: Focus Group Study of Tracker Perceptions, Motivators, and Barriers in the Maintenance Stage of Behavior Change.

BACKGROUND: Wearable activity trackers offer the opportunity to increase physical activity through continuous monitoring. Viewing tracker use as a beneficial health behavior, we explored the factors that facilitate and hinder long-term activity tracker use, applying the transtheoretical model of behavior change with the focus on the maintenance stage and relapse. OBJECTIVE: The aim of this study was to investigate older adults' perceptions and uses of activity trackers at different points of use: from nonuse and short-term use to long-term use and abandoned use to determine the factors to maintain tracker use and prevent users from discontinuing tracker usage. METHODS: Data for the research come from 10 focus groups. Of them, 4 focus groups included participants who had never used activity trackers (n=17). These focus groups included an activity tracker trial. The other 6 focus groups (without the activity tracker trial) were conducted with short-term (n=9), long-term (n=11), and former tracker users (n=11; 2 focus groups per user type). RESULTS: The results revealed that older adults in different tracker use stages liked and wished for different tracker features, with long-term users (users in the maintenance stage) being the most diverse and sophisticated users of the technology. Long-term users had developed a habit of tracker use whereas other participants made an effort to employ various encouragement strategies to ensure behavior maintenance. Social support through collaboration was the primary motivator for long-term users to maintain activity tracker use. Short-term and former users focused on competition, and nonusers engaged in vicarious tracker use experiences. Former users, or those who relapsed by abandoning their trackers, indicated that activity tracker use was fueled by curiosity in quantifying daily physical activity rather than the desire to increase physical activity. Long-term users saw a greater range of pros in activity tracker use whereas others focused on the cons of this behavior. CONCLUSIONS: The results suggest that activity trackers may be an effective technology to encourage physical activity among older adults, especially those who have never tried it. However, initial positive response to tracker use does not guarantee tracker use maintenance. Maintenance depends on recognizing the long-term benefits of tracker use, social support, and internal motivation. Nonadoption and relapse may occur because of technology's limitations and gaining awareness of one's physical activity without changing the physical activity level itself.

The Physical-Digital Divide: Exploring the Social Gap Between Digital Natives and Physical Natives.

Older adults are the most digitally divided demographic group. The present study explores how older adults perceive the physical use of information and communication technologies (ICTs), particularly across generations and contexts. Data for the present study come from nine focus groups. Seniors acknowledge that ICTs help them connect with geographically distant social ties, but that they lead to feelings of disconnection with geographically close social ties. We label this phenomenon the "physical-digital divide," which exists when a group feels ostracized or offended when those around them engage with ICTs while they themselves are not or cannot engage with ICTs. Younger generations are often referred to as "digital natives" and older generations as "digital immigrants." A more apt label for older adults may be "physical natives," as their preferred method of communication involves physical face-to-face interactions and traditional codes of etiquette. Suggestions are made for reducing the physical-digital divide.

Discontinued Information and Communication Technology Usage among Older Adults in Continuing Care Retirement Communities in the United States.

BACKGROUND: Older adults are increasingly using information and communication technologies (ICTs). Recent studies show beneficial effects of using ICTs for older adults, particularly in terms of reducing loneliness and depression. However, little is known about the factors that may prevent discontinued ICT use in populations that may be at greater risk, such as those in continuing care retirement communities (CCRCs). OBJECTIVES: The purpose of this study is to examine a range of factors that may influence discontinued (1) ICT use, (2) searching for health information, and (3) searching for general information over time among CCRC residents. METHODS: We use longitudinal data from a randomized controlled trial conducted with residents of 19 CCRCs. We use flexible parametric models to estimate the hazard ratio or hazard rate over 5 waves of data to determine what factors significantly predict discontinued (1) ICT use, (2) health information searching, and (3) general information searching. RESULTS: The analysis reveals that independent living residents who took part in an 8-week ICT training intervention were less likely to stop using ICTs. Age and the number of instrumental activities of daily living (IADL) impairments significantly predicted an increased likelihood of stopping ICT use. When examining specific ICT-related activities, the analysis reveals that independent living residents who took part in the ICT training intervention were less likely to stop searching for health information and general information online. In addition, age and the number of IADL impairments were associated with increased likelihood of discontinued health information searches and discontinued general information searches. CONCLUSION: ICT training interventions may motivate residents of CCRCs to stay connected by increasing the ICT skill level and promoting confidence, thus decreasing the probability that they will discontinue using ICTs and searching for general information. However, the effects of ICT training on motivating continued ICT usage may be more pronounced among independent living residents. Limitations in the number of IADL impairments is a key factor leading to discontinued use of ICTs among CCRC residents, suggesting that designers of ICTs should be cognizant of the cognitive and physical limitations among this group.

Learning from the Field and Its Listserv: Issues That Concern Health Literacy Practitioners.

This study assesses the content of email messages posted to the Health Literacy Discussion List (HLDL) during a two-year period. The study identifies issues of concern to list subscribers, describes the purposes the list serves for health professionals, and contributes to the health literacy literature by providing an email listserv as a research corpus. The authors conducted an inductive qualitative analysis of email posts to the HLDL from October 2013 to October 2015. Using an iterative process, the authors identified descriptive categories for types of posts and topics of posts. The first (SKR) and second (JM) authors reviewed subject lines of all 2,036 posts and brainstormed type and topic categories, independently read and sorted a random sample of 200 posts into those categories, and then discussed discrepancies. Based on the latter experience, the authors combined, added, or excluded certain categories and jointly created a detailed description for each type and topic category. We then sorted another random sample of 200 posts and generated a list of key words relating emails to topic categories. A Cohen's kappa reliability coefficient was calculated to establish intercoder reliability. The third author (RVR) then conducted key word searches for sorting the remaining 1,836 email posts. The existence and frequency of email clusters and the content of emails in these clusters were used to identify and explore in greater detail the "hot topics" of interest to the field. Our analysis suggests the utility of the HLDL as a platform for sharing information and resources, announcements and calls for action, technical assistance and professional discourse.

Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL).

BACKGROUND: In the United States, disparities in health literacy parallel disparities in health outcomes. Our research contributes to how diverse indicators of social inequalities (i.e., objective social class, relational social class, and social resources) contribute to understanding disparities in health literacy. METHODS: We analyze data on respondents 18 years of age and older (N = 14,592) from the 2003 National Assessment of Adult Literacy (NAAL) restricted access data set. A series of weighted Ordinary Least Squares (OLS) regression models estimate the association between respondent's demographic characteristics, socioeconomic status (SES), relational social class, social resources and an Item Response Theory (IRT) based health literacy measure. RESULTS: Our findings are consistent with previous research on the social and SES determinants of health literacy. However, our findings reveal the importance of relational social status for understanding health literacy disparities in the United States. Objective indicators of social status are persistent and robust indicators of health literacy. Measures of relational social status such as civic engagement (i.e., voting, volunteering, and library use) are associated with higher health literacy levels net of objective resources. Social resources including speaking English and marital status are associated with higher health literacy levels. CONCLUSIONS: Relational indicators of social class are related to health literacy independent of objective social class indicators. Civic literacy (e.g., voting and volunteering) are predictors of health literacy and offer opportunities for health intervention. Our findings support the notion that health literacy is a social construct and suggest the need to develop a theoretically driven conceptual definition of health literacy that includes a civic literacy component.

Problem posing and cultural tailoring: developing an HIV/AIDS health literacy toolkit with the African American community.

The rate of HIV infection among African Americans is disproportionately higher than for other racial groups in the United States. Previous research suggests that low level of health literacy (HL) is an underlying factor to explain racial disparities in the prevalence and incidence of HIV/AIDS. The present research describes a community and university project to develop a culturally tailored HIV/AIDS HL toolkit in the African American community. Paulo Freire's pedagogical philosophy and problem-posing methodology served as the guiding framework throughout the development process. Developing the HIV/AIDS HL toolkit occurred in a two-stage process. In Stage 1, a nonprofit organization and research team established a collaborative partnership to develop a culturally tailored HIV/AIDS HL toolkit. In Stage 2, African American community members participated in focus groups conducted as Freirian cultural circles to further refine the HIV/AIDS HL toolkit. In both stages, problem posing engaged participants' knowledge, experiences, and concerns to evaluate a working draft toolkit. The discussion and implications highlight how Freire's pedagogical philosophy and methodology enhances the development of culturally tailored health information.

Health literacy measurement: a proposed research agenda.

Although the field of health literacy is experiencing tremendous growth in terms of producing peer-reviewed journal articles and attracting practitioners, the foundation of that growth is potentially unstable. Despite a steady increase in their number, existing measures and screeners of health literacy are not based on an accepted conceptual framework and fail to align with the growing body of theoretical and applied work. Existing measures are mainly focused on assessing what individuals can read and understand in clinical contexts. This leaves important factors untested, such as how individuals use information, and how health professionals and systems communicate with patients. This article outlines key elements of a proposed research agenda focusing on development of a new, comprehensive approach to measuring health literacy.

The strength of strong ties for older rural adults: regional distinctions in the relationship between social interaction and subjective well-being.

Classic and contemporary sociological theories suggest that social interaction differs in rural and urban areas. Intimate, informal interactions (strong ties) are theorized to characterize rural areas while urban areas may possess more formal and rationalized interactions (weak ties). Aging and social support literature stresses social interaction as a predictor of health among the aged. Using data from Wave III of the Americans' Changing Lives (ACL) study, this study examines the hypothesized differences between informal strong ties and formal weak ties on the subjective well-being of older adults in rural, urban, and suburban areas. Visiting with friends, neighbors, or relatives has a stronger positive effect on subjective well-being for rural older adults than urban. These findings highlight that: a) informal strong ties increase subjective well-being; and b) the effect of informal strong ties differs by region. We discuss the potential of our findings for policy and urge continued attention to regional variation in aging studies.

The association between aging inmate housing management models and non-geriatric health services in state correctional institutions.

One of the current debates in the literature on aging inmates asks, what is the most efficient housing/health care model for this "special needs" population? State and federal correctional systems place elderly inmates either in specialized segregated housing units away from the general inmate population, consolidate elderly inmates in housing units within the prison, or provide a combination of both models. In general, proponents of the segregated housing model argue that aging inmates will receive specialized medical services in geriatric units. However, proponents of consolidated housing model argue that aging inmates will have the benefit of both geriatric and non-geriatric health services. This paper examines the association between the type of housing management model for aging inmates and the availability of non-geriatric physical and mental health services. Data for the analysis come from the 2000 Bureau of Justice Statistics Census of State and Federal Adult Correctional Facilities. The results suggest that institutions offering consolidated geriatric care provide more mental health services and that these effects are independent of the characteristics of prison facility.