"Health literacy is an umbrella term for specific abilities involving comprehension and memory capacity," said Daniel Morrow, a professor of educational psychology and member of the Cognition, Lifespan Engagement, Aging, and Resilience Group. "As we get older, we’re more likely to suffer from chronic illnesses, such as diabetes, hypertension, and cardiovascular disease that require us to monitor symptoms, take blood pressure, or remember medications. At the same time, we’re facing processing constraints that come with aging, like less working memory capacity. This can make self-care very challenging."
That certainly could be the case for the one in four adults over 65 years old who take five medications every day. In fact, cognitive decline may be partly responsible for the statistics that indicate that half of those older adults may not be taking their medications correctly, which can reduce the efficacy of their treatment or even threaten their safety.
But there is good news, explained Morrow. "While we find that working memory declines with age, knowledge tends to sustain or increase with age. So the hope is that as you have more experience with your illness, you develop expertise. Knowledge can compensate for the constraints of memory."
Finger on the Pulse
A recent study by Morrow and his collaborators bears this out. Together with Elizabeth Stine-Morrow, a professor of educational psychology and member of the Cognition, Lifespan Engagement, Aging, and Resilience Group, Jessie Chin, a former Beckman graduate fellow who earned a Ph.D. in educational psychology, and Elise Duwe, an M.D./Ph.D. student, Morrow assessed 75 older adults as part of a project working on developing a process/knowledge model of health literacy.
First, participants were given a common measure of health literacy that required them to read health-related passages, such as those from a patient consent form. Then, they were given the passages again with words missing and asked to choose from four words to fill in the blank. It may be a simple test, but it is a strong predictor of many health behaviors and outcomes, explained Morrow. They also completed measures of processing capacity, such as working memory capacity and knowledge about language (through vocabulary tests) and about health (specifically, hypertension).
In addition, the 75 participants, all of whom suffered from hypertension, read passages about self-care specific to their illness and then were questioned about what they remembered.
"We found that people who did better on health literacy measures recalled more from the passages," Morrow said. "Moreover, this relationship was explained by the processing capacity and knowledge measures, suggesting that those participants with better health literacy could better remember the passages because their comprehension was supported by higher levels of processing capacity and knowledge. We also found that those with more knowledge had higher levels of recall regardless of their level of processing capacity.
"If you’re knowledgeable, you can understand more efficiently even if you don’t have the same working memory capacity that you used to. This fits with theories of comprehension and our process/knowledge model, and it helps provide a general framework about how we might help older adults make decisions on ways to ensure the most effective self-care."
Morrow’s current project, which focuses on those patient health care portals, builds on that framework.
"The technology has the potential to revolutionize patient-centered care, providing information that can allow us to be more effective in taking care of ourselves," Morrow said. "But the downside is that the people who would benefit the most don’t have the health literacy to use a system that isn’t well designed. Unfortunately, that’s the case for many electronic medical records systems."
For instance, patients can log in to their portal to retrieve cholesterol test results, but the numbers alone leave many older adults scratching their heads. "Many systems are more of a repository of information rather than a tool to engage patients," he explained. "The goal is to improve the way numerical information is presented to patients in these portals."
How does he plan to do that? The first step is to leverage the abilities that patients do have and use that to improve the messages provided by the portal.
"The most effective way for a patient to understand numerical information is to talk with his or her provider," Morrow said. "Patients really just want to know the bottom line about what their numbers mean—are their numbers increasing or decreasing, what it means for their risk, and what they can do about it. That brings up the question: Can we make the portal a little more like having a conversation?"
The Right Medicine
That’s where the second step comes in—engaging the collaborative power of other Beckman researchers. For this project, the team includes Mark Hasegawa-Johnson, a professor of electrical and computer engineering and a member of Beckman’s Organizational Intelligence and Computational Social Science Group, and Thomas Huang, a professor of electrical and computer engineering and a member of the Organizational Intelligence and Computational Social Science Group. William Schuh, chief medical information officer at Carle Foundation Hospital, also is part of the team.
Together, they’re focusing on ways to make the information in the portal more usable—and that means more engaging. The modes range from the simple—a number line that is color coded in red, yellow, or green to indicate risk levels, or emoticons, like smiley or frowning faces, that quickly and easily portray your health status—to the more complex, like a computer agent (or an "avatar" as Huang and Hasegawa-Johnson call it) that is programmed to talk to you about your test results. While it wouldn’t substitute for time with a physician, it could provide the kind of conversational experience that promotes comprehension in between visits with a provider.
"What we’re doing is trying to emulate in a portal environment some of the dynamics of face-to-face communication," Morrow said. "We’re examining what could be the best way to design the computer agent to make it interactive and effective so patients can use it to make good decisions. We’re just scratching the surface of this promising idea."