Health Literacy and Older Community-dwelling Icelanders

Abstract

Aim The overall objective of the thesis was to investigate health literacy (HL), focusing on community-dwelling adults aged 65 and older in sparsely populated areas of northern Iceland, from a participatory occupational justice perspective. The three-part, interdependent research aimed to examine the dynamic interaction of personal and environmental factors influencing older adults' ability to perform HL tasks within their context. This included: I) translating, adapting, and validating the Health Literacy Questionnaire, short version (HLS-EU-Q16), as well as establishing norms for HL among the general Icelandic population; II) measuring HL and identifying challenging domains among older adults in northern Iceland using the HLS-EU-Q16-IS, and investigating the associations of HL points with various personal and environmental factors; and III) exploring the experiences and needs of older adults in northern Iceland regarding being health literate. Methods Project I was methodological and descriptive and involved: a) developing an Icelandic version of the HLS-EU-Q16 instrument using a three-step translation process that included translation-back-translation (n = 4), specialist reviews (n = 6), and cognitive interviewing of laypeople (n = 17); b) evaluating the psychometric properties in a stratified random sample that included 251 participants aged 18–85 (M = 55, ± SD 18.98), thereof were 52% women and 48% men. Internal consistency with Cronbach's α, exploratory factor analysis and principal component analysis, as well as multivariate linear regression, were used for analysis; c) establishing preliminary HL norms using the same sample as in the psychometric analysis. Project II was cross-sectional population-based with a random selection of 175 community-dwelling adults aged between 65 and 92 (M = 74.2, SD ± 6.3). The participants were selected from one urban and two rural areas in northern Iceland; 43% were women, 57% were men, and a total of 40% lived in rural areas. Data was collected via face-to-face interviews using the HL-EU-Q16-IS, three other internationally recognised instruments, and various single items representing contextual factors. Descriptive statistics, univariate, and multivariable linear regression analysis were used. Project III was qualitative, using an explorative design. Twenty people were purposefully selected from the 175 participants in Project II. All chosen participants, 12 women and eight men aged 70–96 (M = 77.3), accepted participation and were interviewed individually. The interviews were analysed using qualitative content analysis, which involved categorising and subcategorising the data. Results Project I: Eleven HLS-EU-Q16 items were reworded using the three-step process. The internal consistency was α = 0.88, and the principal component analysis presented four latent constructs with eigenvalues > 1.0 with 3–5 items each (α = 0.73–0.85). The analysis explained 62.6% of the variance. Preliminary norms for HL ranged from 2–16 points (M = 13.52, SD ± 2.69); 71.3% had sufficient HL (13–16 points), 22.1% had problematic HL (9–12 points), and 6.6% had inadequate HL (0–8 points). The most challenging domains of HL were health care and disease prevention related to a second opinion from a doctor and information in the media. Better self-rated health was an independent predictor for better HL (p = 0.008). Project II: HL levels ranged from 6–16 points (M = 13.25, SD ± 2.41); 65% of participants had sufficient HL, 31.3% problematic, and 3.7% inadequate HL. The most challenging domains of HL were disease prevention and health promotion related to information in the media. Better HL was associated with personal and environmental factors, with more education (p = 0.014) and driving a car (p = 0.017) as independent predictors of better HL. Project III: Four categories emerged from the content analysis: “Expectations for responsibility”, “A gap between expectancy and ability/context”, “Finding one’s own ways”, and “Bridging the gap”. The category “Expectations for responsibility” described the experience of older adults that individuals are expected to take responsibility for their health, which was also reflected in the participant's position. However, this responsibility often did not align with participants' skills/situations described in the “A gap between expectancy and ability/context” category, which pushed them to adapt with their own ways described in the category “Finding one’s own ways”. In the “Bridging the gap” category, participants highlighted the need for shared responsibility and more manageable options to facilitate informed health-related decisions and navigation within the healthcare system. Conclusion The HLS-EU-Q16-IS version was valid for use in Iceland. Older adults were measured with more limited HL compared to the general adult population in Project I. There was a correlation between HL points and various personal and environmental factors, indicating a complex interaction. Occupational injustice was apparent in the experienced tension between older adults' responsibility for health and often lack of environmental-related options to respond. This limits their participation in meaningful occupations essential for health and well-being. Therefore, it is necessary to consider power balance in all actions related to HL to work towards shared responsibility for health and inclusion of older adults