超越冰山一角：老年人的健康素养
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作者：NursingResearch护理研究前
分享智慧
共同成长
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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’ (Sørensen 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).
2 COVID-19 AND HEALTH LITERACY IN OLDER PEOPLE
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 (Sørensen 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.
3 IMPORTANCE OF NURSING IN HEALTH LITERACY FOR OLDER ADULTS
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.
4 HEALTH LITERACY AND NURSE EDUCATION
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.
5 ASSESSMENT OF HEALTH LITERACY 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.
全文翻译（仅供参考）
1 介绍
全球老龄化导致老年人越来越需要获得医疗保健服务、健康信息和教育，以识别和处理可能与衰老相关的健康相关问题。老龄化还会增加脆弱性的风险，这会影响生活质量和健康。护士通常能够从不同的角度批判性地分析老年人的脆弱性，包括健康素养，这是自我保健和健康行为的可改变决定因素。尽管人们越来越意识到健康素养的重要性，但发现对老年人这一概念的关注有限，这也许令人惊讶。健康素养可以从公共卫生的角度定义为“与素养相关联，需要人们获取、理解、评估和应用健康信息以在日常生活中做出有关医疗保健、疾病预防和健康的判断和决定的知识、动机和能力。促进在生命过程中维持或改善生活质量”（Sørensen 等人，2012 年，第 3 页）。在老年人中，老年人的健康素养较低与健康和健康结果的次优水平有关，例如对治疗方案的依从性、药物依从性和自我管理能力。健康素养低可能与较差的健康状况和生活质量受损直接相关。在生物医学模型中，老年人健康素养低下的大多数与年龄相关的问题都可以用认知能力的差异来解释，包括与传统衰老理论一致的思维过程的速度。从社会学的角度来看，健康素养被视为健康的潜在社会决定因素，可以解决健康不平等问题。为了将健康素养概念化为健康的社会决定因素，Nutbeam 和 Lloyd（2021）报告了基于人群的研究中社会梯度的有力证据。健康素养越来越被视为比许多其他健康问题社会决定因素（包括种族、教育和就业状况）更好的健康预测指标。事实上，即使不是健康的最强预测指标之一，健康素养也已成为健康的最强社会决定因素（Ho & Smith，2020）。
2 COVID-19 和老年人的健康素养
COVID-19 全球大流行表明了老年人健康素养的重要性。尽管所有年龄组都有感染 COVID-19 病毒的风险，但老年人更容易死于与病毒感染相关的死亡率和发病率（Smith 等，2020）。COVID-19 大流行的出现为健康素养提供了重要考验，使其有机会强调其对人口健康和福祉的重要性。世界各地的政府和卫生提供机构似乎越来越意识到，以人口为基础的健康素养提高可能等同于减少健康不平等和改善健康结果。迄今为止，缺乏专门针对全球大流行期间老年人健康素养低下的影响的研究。可以通过 Sorensen 的健康素养综合模型将其合理化，假设较低的健康素养水平可能与健康行为中的次优水平有关（Sørensen 等，2012）。提高老年人健康素养的潜在好处是巨大的，也许现在是重新评估老年人健康素养研究前景的时候了。在这篇社论中，我们将强调护理在健康素养中的重要性，考虑护士教育中的挑战，批判健康素养评估的方法，并强调健康素养赋权和恢复力之间可能存在的潜在联系。
3 护理对老年人健康素养的重要性
无论在何种护理环境、医院或社区，护理人员都是患者教育和健康相关信息的主要提供者。因此，尽管护理专业承担了提供与健康相关的患者教育的大部分责任，但全球对健康素养的护理意识、知识和应用的关注有限，尤其是在老年人的护理方面，这有点令人惊讶。.尽管如此，为老年人提供无耻的健康素养支持与更高水平的赋权、参与、激活和最佳健康相关结果相关（Loan 等，2018）。无论护理专业如何，健康素养都是一项必不可少的技能，可增强有效沟通并有助于为老年人提供以人为本的护理，这可能反映在患者对护理满意度的提高上。
高质量的研究是必不可少的，以确保有效的循证健康素养实践。在充分认识到需要探索疾病和认知在老年人健康素养中的作用的同时，可以更加重视健康素养的决定因素和相关因素。我们将明确定义的术语和使用有效测量工具的重要性视为旨在了解老年人健康素养作用的任何研究的基本要求。
健康和成功的老龄化很重要，也许可以更多地关注评估对老年人更有意义的问题，例如体育活动和饮食，这些可以提高老年人的生活质量并确保他们能够更好地对这些日常活动做出与健康相关的偏好和决定并采取行动。显然有更多的护理研究可以帮助确定障碍和促进因素，以提供适当和有效的健康素养实践。现在也可能是开展重要的纵向研究以探索老年人健康素养与健康相关结果之间关系的好时机。
4 健康素养和护士教育
十多年前，Scheckel 等人在《临床护理杂志》上撰文。(2010) 强调了健康素养教育的重要性。他们特别提倡护理专业健康素养教学的新方法，强调健康素养实践中的专门教学将扩展学生现有的技能和知识，为他们的专业实践做好准备。迄今为止，尽管它很重要，但并非所有护理教育机构似乎都赞同这种教育方法。在所有形式的护理评估中包含与健康素养相关的问题可能是一个很好的起点。在向老年人提供与健康相关的信息时，可以鼓励学生提出开放式问题并使用“回授”方法。使用“回授”方法有助于验证护士是否以可理解的格式提供了信息，当患者可以用自己的话重述信息时，可以验证他们的理解。“回授”方法的价值在于，它可以使护士能够验证老年人的理解并纠正错误信息。尽管自 Scheckel 的工作以来发展了几项有前途的护理健康素养计划，提供了创新的解决方案和策略，但人们认为其中许多被该行业严重利用（Loan 等人，2018 年）。
随着全球人口老龄化，现在是时候更加关注社会中老年人的教育相关健康素养研究了。根据可靠的证据，为所有本科护理专业学生制定健康素养教育方法，可能是改善和缓解问题的最佳途径，并为促进更健康的老龄化进程提供途径。从注册后的角度来看，建立以战略能力为基础的健康素养教育可以提升护士的健康素养专业水平。由于健康素养的快速变化和动态性质，这些针对老年人的举措是当务之急。
变老本身并不是获取互联网或其他形式的基于计算机的技术（如远程医疗服务）的障碍。越来越多的老年人正在访问大量可用的健康相关信息，尽管需要谨慎对待其中一些信息的可靠性和可靠性。数字健康素养正在发挥越来越重要的作用。为了提高老年人使用互联网的能力，在专门为老年人设计材料时，需要考虑与年龄相关的视力和认知健康相关网站的变化。由于工作记忆、知觉速度、文本理解和空间记忆的潜在限制，否则可能会影响老年人对互联网的访问。通过使用适当的字体、书写风格、导航结构和可访问性，可以使所有形式的健康相关信息更加用户友好。
在世界各地，护士不仅应该意识到与老年人健康文盲相关的潜在问题，而且还应该能够积极尝试纠正这种情况。与年龄和种族等不可改变的社会人口特征不同，有合理的证据表明，老年人的健康素养水平可以改变和提高。可以设计健康素养干预措施来直接解决认知困难，这可能会限制老年人获取和理解与健康相关的信息的能力。迄今为止，大多数电子干预措施
提高老年人健康素养水平的重点是降低认知需求，通常涉及提高材料的可读性或确保由适当的医疗保健人员提供帮助。与老年人一起工作的护士应该意识到可以采取相对简单的方法来解决健康素养不足的潜在好处，包括在提供与健康相关的信息时使用简单的语言和非行话术语。满足这些基本的先决条件可能会有效地促进对老年人的了解，从而有可能增强赋权和复原力。
以患者为中心的健康素养方法侧重于识别个人获取、理解和应用健康相关信息的知识、动机和技能。一般来说，鼓励这种交流方式，尤其是在处理老年人的健康素养问题时。
5 老年人健康素养评估
开发健康素养干预措施是研究过程的一个方面，但是，还需要衡量健康素养，众所周知，这是一个要求很高的过程。识别低水平的健康素养对老年人来说显然很重要；然而，围绕捕捉这个复杂而动态的概念的最佳方式存在一些争论。从历史上看，研究人员在老年人研究中应用了客观衡量标准，例如成人医学识字率快速估计 (REALM)。从那时起，出现了更全面的主观测量工具。其中之一，最初在欧洲开发和验证的 HLS-EU 现在在世界各地广泛使用。欧洲健康素养调查问卷 (HLS-EU) 为研究人员提供了一个量表，该量表专注于特定任务的能力，例如疾病预防和健康促进，这对于在评估健康素养时捕捉活跃老龄化的重要方面可能很重要。老年人。最近，出现了其他衡量特定年龄状况的重要方面的措施，例如痴呆症识字率。
6 赋权和韧性
世界卫生组织已经宣传健康素养在老年人赋权和适应能力发展中的重要性（WHO，2013）。赋权被视为一个过程，通过该过程人们可以更好地控制自己的生活、健康及其决定因素。通过赋权，健康素养计划有助于实现医疗保健系统的民主化，并在社区和整个社会中实现对健康和福祉的更有力的承诺。韧性被视为一种适应、恢复和在逆境中“反弹”的形式。就这两个特征而言，健康素养被视为个人和社区的资产，因此，任何为加强老年人健康素养而进行的投资都可能在增强健康和福祉方面产生可观的回报。与适当的社会资源相结合，健康素养可以成为一项宝贵的资产，有助于支持老年人在积极老龄化方面变得更有能力和适应力。目前，我们认为老年人健康素养领域存在重大研究空白，包括最新系统评价的范围，研究老年人健康素养、复原力和赋权之间的关系。
7 总结
这篇社论的目的是捕捉老年人健康素养最相关的护理方面。如前所述，我们认为健康素养已成为老年人健康的最重要决定因素之一，可以将其视为健康方面社会经济不平等的一个可改变因素。越来越多的证据表明，健康素养在社会经济地位和健康不平等之间起到中介作用。
因此，健康素养具有改善健康结果的潜力，并可能被证明对世界老年人口的复原力和赋权的发展具有决定性作用。护士应该有助于提高老年人的健康素养水平，在护士教育中需要更多地关注老年人健康素养的特定年龄方面。
正如这篇社论的标题所表明的，我们推测老年人的健康素养问题可能被比作冰山模型，只有部分问题是显而易见的，也许与年龄有关的疾病，大多数仍然是隐藏的表面之下。我们认为，护士处于理想的位置，可以在识别和解决后一组人员的健康素养相关问题方面发挥重要作用。
原文链接：
https://onlinelibrary.wiley.com/doi/10.1111/jocn.16109
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