Abstract
[Purpose] This pilot study aimed to assess the health literacy of urban community-dwelling older adults participating in exercise classes to inform future educational interventions. [Participants and Methods] We included 58 older adults from Ward A in Tokyo who attended exercise classes and completed a physical fitness assessment in November 2022. The participants were surveyed using a modified version of the European Health Literacy Survey Questionnaire to evaluate their ability to access, understand, appraise, and apply health information for healthcare and disease prevention. [Results] Of the surveyed participants, 74% expressed that healthcare information easy to understand and apply, whilst 64% had difficulty appraising the information. Similarly, 74–90% expressed that accessing, understanding, and applying information related to disease prevention is easy; however, 52% struggled with appraising the information. [Conclusion] This study highlights a gap in the ability of older adults to critically evaluate health information, emphasizing the need for targeted interventions to improve appraisal skills and support informed health decision-making.
Keywords: Health literacy, Older adult care prevention, Exercise classes
INTRODUCTION
Health literacy (HL) refers to people’s knowledge, motivation, and competencies to access, understand, appraise, and apply health information. HL enables individuals to make judgments and decisions about health-related issues, such as healthcare and disease prevention, to maintain and improve their quality of life (QOL)1).
Low HL is associated with poor self-management of lifestyle habits, such as physical activity, chronic diseases, and increased mortality risk2,3,4,5).
Matsuda et al. demonstrated that higher functional HL, including reading and writing skills, correlates with greater life space in older Japanese adults6). Additionally, a study of older females found that HL was associated with self-rated health status and exercise habits7).
Community-dwelling older adults in urban areas often show high interest in health and are exposed to abundant health information. However, they face challenges in independently accessing necessary information and appraising its reliability8). Furthermore, older adults with higher comprehensive HL reportedly have lower frailty risk 2 years later than younger adults9).
This pilot study investigated HL in urban residents who participated in exercise classes to obtain information about their HL characteristics and inform the design of educational interventions.
PARTICIPANTS AND METHODS
Ward A in Tokyo offers exercise classes at 18 venues as part of a care prevention program for older ward residents. Among the 129 participants attending exercise classes at four venues during the fiscal year 2022, 83 participated in a physical fitness assessment, and these individuals were included in the study. The physical fitness assessments were conducted in November 2022 or February 2023, depending on the class venue. This study included participants from four locations where the assessments were conducted in November 2022.
“Exercise classes” were primarily designed to improve physical function and were organized by the residents themselves. Weekly sessions included preparatory exercises, fall prevention exercises, and strength training, lasting approximately 1 hour. These classes targeted residents aged ≥65 years. In fiscal year 2022, 640 participants (mean age: 77.4 years, male female ratio=9.8%:91.2%) attended classes at 18 venues.
Ward A is located in the northeastern part of Tokyo’s 23 wards, with about 75% of the area classified as semi-industrial, housing many small and medium-sized enterprises. In 2022, the population was approximately 210,000, with older adults comprising 23.0% (as of April 2022), a percentage similar to Tokyo’s overall rate (22.8%), reflecting a national trend of declining birthrates and an aging population10).
The survey procedure was as follows: When they visited the physical fitness assessment site, the participants were provided with an explanation of the study’s details. Participants who provided consent were asked to complete self-administered questionnaires collected before the physical fitness assessment began.
The questionnaire was based on the European Health Literacy Survey Questionnaire (HLS-EU-Q47), a comprehensive health literacy tool11). The HLS-EU-Q47 is a comprehensive health literacy instrument that measures four competencies (access: obtain information relevant to health, understand: understand information relevant to health, appraise: appraise information relevant to health and apply: use information relevant to health) across three domains (healthcare, disease prevention, and health promotion) in 12 dimensions. The reliability and validity of the HLS-EU-Q47 for the Japanese population have been confirmed by Nakamura et al12). As this was a pilot study with time constraints, the health promotion domain was excluded, resulting in an 8-item questionnaire focused on healthcare and disease prevention. Respondents chose from five answer options: “very difficult”, “difficult”, “easy”, “very easy”, and “do not know or not applicable”. The questions are listed in Table 1.
Table 1. Health Literacy Survey Questionnaire.
| Relation to Health Literacy Survey matrix | On a scale from very easy to very difficult, how easy would you say it is to: … | Very difficult | Difficult | Easy | Very easy | Don’t know or not applicable | |
| Healthcare | Access information | find information on treatments of illnesses that concern you? | |||||
| Understand information | understand what your doctor says to you? | ||||||
| Appraise information | judge the advantages and disadvantages of different treatment options? | ||||||
| Apply information | use information the doctor gives you to make decisions about your illness? | ||||||
| Disease prevention | Access information | find information about how to manage unhealthy behaviour such as smoking, low physical activity and drinking too much? | |||||
| Understand information | understand health warnings about behaviour such as smoking, low physical activity and drinking too much? | ||||||
| Appraise information | judge if the information on health risks in the media is reliable? | ||||||
| Apply information | decide how you can protect yourself from illness based on advice from family and friends? | ||||||
Responses were categorized into two groups for statistical analysis: “very difficult” and “difficult” into “difficult”, “easy”, and “very easy” into “easy”. The two tests were used to examine whether the percentages of the difficult and easy groups differed in accessing, understanding, appraising, and applying competencies for healthcare and disease prevention. A Z-test was performed if a significant difference was observed.
This study was approved by the Ethics Review Committee of Mejiro University (approval number 22-I 016). The study was conducted with the informed consent of all participants.
RESULTS
Responses to the questionnaire were obtained from 59 of 83 participants (response rate: 71.0%) during the physical fitness assessment. Data from 58 participants were included after excluding one respondent who did not complete the questionnaire. According to 74% of respondents indicated that it was easy (“very easy” or “easy”) to understand (understanding what was told by the doctor) and apply the healthcare information (using the information obtained from the doctor to make decisions about their illness). Half the respondents reported that access to healthcare information (finding information on the treatment of the disease they are concerned about) was easy. On the other hand, 64% found it difficult to appraise healthcare information (analyzing the advantages and disadvantages of treatment methods) (“very difficult” or “difficult”).
Regarding disease prevention, 74%, 90%, and 59% of respondents found it easy to access (finding information on how to improve unhealthy lifestyle habits), understand (understanding that certain lifestyle habits such as smoking, lack of exercise, and drinking too much alcohol are bad for health), and apply the information (deciding how to protect themselves from disease based on advice from family and friends), respectively, while 52% reported appraising the information (judging whether information on health risks obtained from the media is reliable) as difficult. Many respondents found it easy to access, understand, and apply information on both healthcare and disease prevention, whereas others found it difficult to appraise the information.
Statistical tests revealed associations between responses (easy or difficult) and the dimensions of access, understand, appraise, and apply for both healthcare and disease prevention. Many respondents found it “easy” to understand information regarding both healthcare and disease prevention; however, many also found appraising the information “difficult” (Table 2).
Table 2. Difficulty level of health literacy in healthcare and disease prevention.
| Access information | Understand information | Appraise information | Apply information | χ2 | df | p | ||
| Healthcare | Difficult | 25 | 14 | 37 | 13 | 27.92*** | 3 | p<0.001 |
| Easy | 29 | 43 | 20 | 43 | ||||
| Disease prevention | Difficult | 12 | 5 | 30 | 21 | 32.96*** | 3 | p<0.001 |
| Easy | 43 | 52 | 23 | 34 |
Difficult: very difficult/difficult, Easy: very easy/easy.
DISCUSSION
The HLS-EU-Q47 is a comprehensive health literacy instrument upon which the questionnaire in this study was based. Comprehensive health literacy is defined as “people’s knowledge, motivation, and competencies to access, understand, appraise, and apply health information” and can be used to “make judgments and decisions in everyday life concerning healthcare, disease prevention, and health promotion to maintain and improve QOL1)”.
This study found that many respondents perceived healthcare and disease prevention information as easy to understand but difficult to appraise. Similarly, a previous study using the HLS-EU-Q47 in older adults reported that “appraise” had the lowest score in both healthcare and disease prevention8).
In HLS-EU, understand and appraise are defined as “understanding what it means (understand)” and “how it applies to me, whether it is correct, reliable information, and whether it is error-free (evaluate, appraise)”, respectively1). Correct understanding is a prerequisite for critically evaluating and judging the pros and cons of the participant.
Responses in this study indicated inconsistencies, as many participants reported that they “could understand but had difficulty judging” the information. This inconsistency might stem from their interpretation of questions, such as “understanding what was told by the doctor” and “understanding that certain lifestyle habits, such as smoking, lack of exercise, and excessive alcohol consumption, are bad for health”, as implying “believing or agreeing with the doctor or health information without doubt”. Consequently, they may have found it challenging to “appraise” the information because it required them to be able to judge whether the information was correct.
Japanese individuals reportedly have lower health literacy compared to those in other countries. Many avoid decision-making due to limited media literacy and the influence of the Japanese education system13, 14). Older adults in Japan, in particular, often defer health-related decisions to family members and doctors rather than asserting their own opinions.
This passive attitude among older adults toward health decision-making about their own health to others, such as family members, doctors, and government officials, has not been considered a problem to date. However, as Japan’s birth rate declines and the population ages, a community-based integrated care system is being established to enable older adults to live in their own neighborhoods as independently as possible. In this system, “self-help” (older adults take care of themselves) and “mutual help” (older adults help each other) are considered important15). In the future, older adults will need to maintain and improve their self-care competency and be expected to make health-related decisions independently. Therefore, older adults and healthcare service providers should intentionally devote efforts to improving the health literacy skills of this population.
As limitations of this study, the response rate was approximately 70%. This may be partly due to the fact that participants were recruited from those who attended for the purpose of physical fitness measurement. Additionally, the survey did not allow for a detailed understanding of the participants’ characteristics, and no further investigations were conducted to support the findings of this study. This study is a pilot study, and in the future, it will be necessary to increase the number of participants, measure all items of the HLS-EU-Q47, and add survey items to validate the results.
Funding
This work was supported by a research fund from Mejiro University.
Conflict of interest
The authors declare no conflict of interest.
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