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J Am Geriatr Soc. 2019 Aug 19. doi: 10.1111/jgs.16129. [Epub ahead of print]

Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults.

Author information

1
Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California.
2
Department of Psychiatry, University of California, San Francisco, San Francisco, California.
3
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
4
Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.
5
Innovation and Implementation Center in Aging and Palliative Care Research), University of California, San Francisco, San Francisco, California.
6
Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.
7
Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California.
8
Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California.

Abstract

BACKGROUND:

Advance care planning (ACP) engagement is low among vulnerable populations, including those with limited health literacy (LHL). Limited knowledge about ACP may be a modifiable mediator of the relationship between LHL and ACP. Our goal was to determine whether health literacy is associated with ACP knowledge.

DESIGN:

Cross-sectional design.

SETTING:

A public health delivery system and Veterans Affairs Medical Center in San Francisco, CA.

PARTICIPANTS:

English- and Spanish-speaking patients (N = 1400).

MEASUREMENTS:

ACP knowledge was assessed with seven validated multiple-choice questions. Health literacy was measured using a validated scale. Sociodemographic measures included age, sex, language, education, race, health status, and social support. Prior ACP experience was defined as having documented legal forms and/or goals-of-care discussions in the medical record. We used Kruskal-Wallis tests and linear regression to examine associations of ACP knowledge with LHL, prior ACP experience, and sociodemographic factors.

RESULTS:

Mean age of participants was 65 (±10) years, 48% were women, 34% had LHL, 32% were Spanish speaking, 47% had high school education or less, and 70% were nonwhite. Mean 7-point knowledge scores were lower for those with limited vs adequate health literacy (3.8 [SD = 1.9 vs 5.5 (SD = 1.7); P < .001). In multivariable analysis, ACP knowledge scores were 1.0 point lower among those with LHL; 0.6 points lower among Spanish speakers and those with high school education or less; and 0.5 points lower among individuals of nonwhite race (P < .001 for all). Knowledge scores were 0.02 points lower per year of older age (P = .007) and 0.01 points higher per point of greater social support (P = .005). Prior ACP experience was not associated with knowledge after adjustment (P = .7).

CONCLUSIONS:

Health literacy and sociodemographics are stronger predictors than prior ACP experience of ACP knowledge. This study suggests that providing easy-to-understand ACP materials is paramount and should be offered even if patients have previous experience with the ACP process.

KEYWORDS:

advance care planning; health literacy; vulnerable populations

PMID:
31424575
DOI:
10.1111/jgs.16129

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