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Health Literacy

In Brief: How Much Do Health Literacy and Patient Activation Contribute to Older Adults' Ability to Manage Their Health?

Research Report

Joyce Dubow, M.U.P., AARP Public Policy Institute

May 2005


This In Brief summarizes the AARP Public Policy Institute Issue Paper, How Much Do Health Literacy and Patient Activation Contribute to Older Adults’ Ability to Manage Their Health? PPI Publication # 2005-05, by Jessica Greene, Judith Hibbard, and Martin Tusler of the University of Oregon.

Older persons are increasingly expected to make complex health care decisions and take more responsibility for their health care, but it is questionable whether all are capable of the tasks associated with this greater responsibility. National studies have found that older adults have lower literacy and patient activation levels than younger adults. (The term "health literacy" includes skills that encompass the ability to process and understand basic information needed to make appropriate health decisions. The term "patient activation" refers to having the knowledge, skills, beliefs, and confidence to manage one’s health.) There is increasing evidence that literacy—in particular, health literacy—and patient activation are related to how well patients understand and manage their health and health care.

The core initiatives of the landmark Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) are emblematic of this approach. Notably, the law’s prescription drug benefit will require beneficiaries to decide among private prescription drug plans that vary in terms of comprehensiveness, cost, and formularies. Beneficiaries will also have to weigh the costs and benefits of enrolling in the program during the initial start-up period or facing financial penalties if they enroll later. In addition, the MMA includes provisions that will require Medicare beneficiaries to be well-informed about their coverage and treatment options.

This study examines the independent influence of health literacy and patient activation in areas in which older adults must have skill or knowledge to manage their health and health care. These areas include Medicare decision making, health-care-related behaviors, healthy behaviors, and chronic disease self-management behaviors. The examination of health literacy and patient activation and their relative contribution to health-related behaviors and health care choices will inform the types of strategies that are likely to be most effective in supporting consumer engagement.

The data for this study were collected in spring 2004 from a convenience sample of 293 Medicare beneficiaries age 65 years or older in Eugene/Springfield, Oregon. Subjects first completed the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA) to assess their health literacy. A trained interviewer then administered a questionnaire that included the new Patient Activation Measure (PAM) and questions related to Medicare decision making, health-care-related behaviors, healthy behaviors, and chronic illness self-management. The relationships between the independent variables (health literacy and patient activation) and the dependent measures were examined in bivariate and multivariate models.

Compared with a national sample of non-institutionalized Medicare beneficiaries age 65 years and older, study participants are older, although they are in better health and have more education. Their health literacy and patient activation levels indicate a relatively high-functioning population.

The analysis indicates that both health literacy and patient activation are significantly and positively related to Medicare decision making and engagement in health-care-related behaviors, healthy behaviors, and chronic disease self-management behaviors. Health literacy, however, appears to have a stronger relationship to Medicare decision making than does patient activation. On the other hand, patient activation has slightly stronger relationships to health-care-related behaviors, healthy behaviors, and self-management behaviors.

This study is the first, to our knowledge, to examine the relative contributions of health literacy and patient activation on the skills and behaviors that older adults need to effectively manage their health. We find that both patient activation and health literacy are important for older adults; however, the two factors affect different health-related outcomes. Health literacy positively influences Medicare decision making, both one’s confidence to make decisions and one’s ability to use comparative information to effectively do so. Patient activation, on the other hand, has a greater influence on one’s engagement in health-care-related, healthy, and chronic illness self-management behaviors. Interventions that focus on improving patient activation will encourage better health-care-related, healthy, and self-management behaviors; those aimed at addressing literacy or the readability of materials will help older adults make sound Medicare decisions.

Written by Joyce Dubow, AARP Public Policy Institute
May 2005
©2005 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

Pub ID: INB98