Health Literacy in Older Latinos With Heart Failure: A Systematic Review

Delgado, Janet M. MN, RN, ACNP, ANP, ACNS, CHFN; Ruppar, Todd M. PhD, RN, GCNS-BC, FAHA

Journal of Cardiovascular Nursing: March/April 2017 - Volume 32 - Issue 2 - p 125–134
doi: 10.1097/JCN.0000000000000314
ARTICLES: Systematic Reviews

Background: By 2050, one-third of US residents will be Latino, with an incidence of heart failure (HF) higher than other ethnicities. Culturally linked risk factors and socioeconomic challenges result in cardiometabolic risks, healthcare disparities, and worsening health outcomes. Individuals with low health literacy (HL) and HF are less likely to possess tools for optimal self-care, disease management, or preventative health strategies.

Objective: In this systematic review, we analyzed the literature studying older Latinos with HF and limited HL.

Method: We searched the literature and used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in an iterative process. Inclusion criteria were research studies, Latinos, HF, and HL.

Results: Eight quantitative studies were identified for final review. Inadequate HL was reported in 87.2% of elderly Latinos. Higher HL was associated with more HF knowledge. Clinics serving minorities reported lower HL levels and higher medical complexity.

Conclusions: Nurses and advanced practice nurses serve a pivotal role improving access and understanding of health information. Before conducting intervention research affecting clinical outcomes, it is essential to describe elderly Latinos with HF and their HL and self-care levels. Barriers identified confirm the need to alter research protocols for older adults and ensure the availability of assistive devices. The need to examine HL in older Latinos with HF is confirmed by the medical complexity of ethnic minority patients with limited HL, limited HL in the elderly, and the relationship of HL with HF knowledge. In culturally diverse populations, HL levels alone may not be reliable predictors of a person’s ability to self-manage, recognize symptoms, and develop, implement, and revise a self-care action plan to manage their health.

Janet M. Delgado, MN, RN, ACNP, ANP, ACNS, CHFN PhD Candidate, University of Missouri–Sinclair School of Nursing, Columbia.

Todd M. Ruppar, PhD, RN, GCNS-BC, FAHA Assistant Professor and Robert Wood Johnson Foundation Nurse Faculty Scholar, University of Missouri–Sinclair School of Nursing, Columbia.

The authors have no funding or conflicts of interest to disclose.

Correspondence Janet M. Delgado, MN, RN, ACNP, ANP, ACNS, CHFN, S423 School of Nursing, Sinclair School of Nursing, University of Missouri, Columbia, MO 65211 (

Article Outline

Cardiovascular disease, the leading cause of death for adults in the United States, is a major health problem that accounts for 31% of all deaths worldwide and results in 1 in 3 deaths annually.1,2 Heart failure (HF) is a cardiovascular disorder estimated to affect approximately 6 million persons, primarily older adults. The effects of HF in the elderly are multifaceted and can be devastating to a person’s daily life, including adverse effects on activity, independence, self-care, and the development of other comorbid conditions.3 In the United States, the population is aging overall. By 2050, an estimated 89 million people will be older than 65 years, many of whom will face the challenges of living with HF.4

By the year 2050, an estimated one-third of all US residents will be Latino.5 This expected increase in the number of Latinos is expected to lead to particular challenges in meeting the healthcare needs of the older Latino population, including those with HF.5 Definitions for what constitutes the Latino population are varied. The US Office of Management and Budget defines Hispanic or Latino as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.”6 This definition includes both regional and language criteria, encompassing not only persons from Spanish-speaking countries but also those with origins from non–Spanish-speaking Central or South American origins, such as those from Portuguese-speaking Brazil.

Addressing the cardiovascular health of high-risk groups promotes optimal health and well-being.7 Race- and ethnicity-related risk factors such as diabetes, hypertension, and insulin resistance; culturally linked behaviors such as diet; as well as socioeconomic challenges result in the population of aging Latinos having a propensity for cardiometabolic risks and healthcare disparities.5 For example, the prevalence of metabolic syndrome in the Latino elderly is reported as 62% in those aged 64 to 75 years, with central obesity occurring in 96% of the women and 73% of the men.8 Hyperglycemia occurs in 62% of women and 73% of men with metabolic syndrome.8 This varies significantly from the age-adjusted prevalence of metabolic syndrome of 34% to 39% in the United States overall.8 Metabolic syndrome and other comorbid conditions such as diabetes mellitus and obesity are common in persons with HF.9 The increased prevalence of cardiac disease and other comorbid conditions in the Latino population, particularly those of Mexican heritage, is a new and escalating challenge. The effects of cardiometabolic risk factors on the development and management of HF need to be monitored.10 These risk factors contribute to poor health outcomes and exacerbate health disparities in vulnerable populations such as elderly Latinos with HF and inadequate health literacy (HL).11

Successful management of chronic cardio-metabolic disease requires an adequate level of HL to understand healthcare instructions and perform necessary health behaviors. Health literacy, according to the Institute of Medicine (IOM), is “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”12 This IOM definition has also been adopted by The Plain Language Act of 2010,13 Healthy People 2020,14 and The Agency for Healthcare Research and Quality.15 In addition to the above core definition, a more functional definition has been posed by The Calgary Charter,16 further expanding the IOM definition to discuss skills viewed as key components of HL:

Health literacy is the use of a wide range of skills that improve the ability of people to act on information in order to live healthier lives. These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as other communication and interaction skills. Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information.

Individuals with low HL and HF are not likely to possess the tools for successful self-care, disease management, or preventative health strategies, such as understanding medications, treatment plans, dietary interventions, self-care, or even making and keeping appointments—all of which may lead to worsening outcomes.17,18 In addition, lower HL levels in community-dwelling elderly people are associated with worsening health outcomes, regardless of types of comorbidities.19 As a component of HL, adequate numeracy skills are critical for proper dosing, weight monitoring, management of sodium intake, and higher-level self-management skills such as titrating diuretics. Cardiovascular nurses have a responsibility to identify individuals with potentially low HL and use multiple methods to optimize their care with tailored interventions.20

The 2003 National Assessment of Adult Literacy reports that 66% of Hispanic adults have basic or below-basic levels of HL. Hispanic and Latino adults also have the lowest average HL levels when compared with any other race or ethnicity.21 In addition, an inadequate HL level was reported in 59% of all ethnicities older than 65 years.21 Health literacy among Latinos in the United States may also be linked to English proficiency. The California Health Interview Survey data shows that 45.3% of Latinos with limited English proficiency had low levels of HL as compared with 17.9% who were English proficient.22

Given the growing population of Latinos in the United States, combined with the growth in HF prevalence and the higher rates of inadequate HL among Latinos, healthcare providers must be prepared to address HL with their Spanish-speaking patients to promote successful HF self-care. Active self-care and management of chronic diseases such as HF are shown to affect clinical outcomes.18 Self-care interventions that can reduce HF readmissions may reduce mortality among older adults, as there is a 38.7% mortality rate among older adults who are readmitted to hospitals within 30 days of discharge.23 No established guidelines exist for addressing HL among Latinos with HF or other cardiovascular diseases. Nursing science is in a unique position to examine patterns and develop interventions that will improve outcomes for Latino HF patients with low HL. The purpose of this article is to summarize the research literature related to older Latinos with HF who have limited HL and to answer the following research question: What is known about HL among elderly Latinos with HF?

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This systematic review was developed and conducted following the components of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.24,25 The PubMed and Comprehensive Index to Nursing and Allied Health databases were initially searched using the following terms: Intervention, Treatment, Therapy; and Self-Care,*care, disease manag*, manag*; and Older, Elder*, Old*, Aged, Senior; and Latino, Latin*, Hispanic*, Spanish*, Mexican*; and Heart Failure, *Heart Failure; and Health Literacy. This combination of key words yielded no results; therefore, the list of key words was revised to identify citations specifically focusing on older Latinos, heart failure, and health literacy.

The inclusion criteria for this review encompassed research studies that included samples or subgroups of samples of Latinos older than 65 years living with HF. All research articles identified study the Latino population.

Studies that did not include the Latino population and those not reporting research findings were excluded from the systematic review. Health literacy levels, literacy levels, and English proficiency were mentioned in most of the studies, but these concepts were not included in the inclusion criteria of this systematic review, as it would have eliminated research studies worthy of examination.

For this systematic literature review, there was no starting year identified, as part of the objective of this comprehensive review was to include the entire body of literature, regardless of inclusive dates. The search, study screening and identification, and evaluation for eligibility were conducted and repeated over a 20-month period until August 2014, yielding consistent results (Table). This process led to a group of 8 research articles eligible for analysis. Study selection is summarized in the Figure.

Four reports were initially identified from the electronic database searches. Of those 4 reports,18,26–28 1 was eliminated as it described a study protocol and did not report research results.26 However, an additional search using the authors’ names yielded a completed research report related to the eliminated article; that completed research report was added to the literature review.29

In an editorial comment by Pignone and DeWalt,30 an additional article was described regarding nurse-led interventions in minority communities; this additional study on the topic of nurse-led interventions was added to the literature matrix.31 After review of the reference lists of the studies yielded from the original search, an additional 3 research studies were added.32–34

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The 8 research studies analyzed for this systematic review used quantitative methodology; no qualitative research studies were identified. Of the 8 studies reviewed, 7 were published between the years 2009 and 2011. The settings for the studies varied from university medical centers to community clinics and a telephone survey. Sample sizes ranged from 153 to 780 subjects.27,33 The average age reported ranged from 55 to 63 years. All of the studies reported some Hispanic/Latino participants, ranging from 4.3% to 100% of the sample, and 100% of the studies reported the presence of comorbid diseases. Inadequate HL was reported in 37% to 87% of participants, many of whom were older than 65 years and Latino.28,29,35

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Descriptive Studies

Most (75%) of the studies were cross-sectional and descriptive. One study culturally adapted and validated an HF knowledge tool for future use in the Brazilian population,33 a tool previously developed by Artinian et al.36 Heart failure knowledge was similar, although generally higher, among the Brazilian sample than the original US sample.33 One of the studies used secondary analysis to develop a series of themes regarding women’s knowledge, worry, and motivational levels regarding heart disease after a questionnaire was administered.32 Most of the studies focused on the elderly, as those persons older than 50 years are most likely to experience HF.

Cordasco et al28 examined the relationship between HL and age in chronically ill persons and reported that age is negatively and independently correlated with HL. They also noted that 87.2% of the elderly patients examined have inadequate HL and that worried and knowledgeable women older than 45 years are more motivated to modify their heart disease risk factors.28,32 Another study found that for patients with higher levels of HL, patient knowledge of HF was greater.18 Finally, Varkey and colleagues27 noted that clinics serving more minorities have patients who are more depressed, have lower HL, and are more medically complex.

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Intervention Studies

Neither of the 2 intervention studies reviewed were identified using the initial database search; they were identified by using additional sources.19,31 The intervention studies comprised 25% of the total studies reviewed. Although both studies reported HL levels, only 1 intervention study discussed the importance of using a specific HL instrument to objectively measure HL in individuals with HF.29 This was the only intervention study to describe the instrument used to measure HL.29

One of the intervention studies evaluated nursing interventions and educational interventions in a disease management program.31 Bilingual nurses counseled 203 (random assignment) community-dwelling adults from ambulatory care practices on diet, medication adherence, and self-management of HF over a 12-month period. Hispanics comprised 32.5%, and those older than 65 years included 36.7% of the total of 406 subjects from 4 inner city hospitals. Temporary and nonsignificant improvement in rehospitalization rates and physical function were reported; these improvements disappeared after there was no longer a telephone or face-to-face intervention.

The second intervention study was identified by searching the names of authors listed on the articles excluded from this review. Subjects were randomly assigned to either a control group consisting of brief (in-person) educational session or to teach to goal educational program consisting of the same in-person education with a series of follow-up educational calls.29 The study was carried out in 4 university medical centers in urban settings throughout the United States. Of the 531 subjects analyzed, 259 had been assigned to the brief (in-person) educational session group and 272 subjects completed the teach to goal educational program intervention. Of the total subjects randomized into groups, the mean age was 61 years, 16% were Hispanic, 37% had low literacy levels, and 52% reported an annual income of less than $15 000 per year. Intervention group subjects received 3 to 5 calls over a 1-month period with repeat measures at 30 to 60 days. General knowledge regarding HF and self-efficacy scores were not significantly different between the control and intervention groups when stratified to inadequate/marginal levels of HL. Overall, the TTG group improved in general knowledge and salt knowledge and the greatest improvement was in self-care behavior. The researchers purport that less of a focus on structured education and more focus on self-care may be more effective for HF disease management.

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The purpose of this systematic review was to summarize the literature of older Latinos with HF and their HL. The limited number of research studies identified in our search demonstrates that this is a vastly understudied area of science. Additional research is needed to further describe and address HL among Latinos with HF to improve HF self-care practices and, ultimately, clinical outcomes.

Only 1 of the reviewed studies reported the use of a theoretical framework guiding their research. The study by Baker et al29 reports using Social Cognitive Theory as part of their conceptual framework; however, they did not provide details as to how the framework was used to guide the development or delivery of the intervention. Conceptual models and theories are helpful to guide researchers from the original formulation of relevant research questions through the process of data analysis and discussion of implications. Other theoretical models, such as the theory of self-care of chronic illness, have been developed to examine chronic illness and its challenges, particularly for the care of persons with HF.37,38 Using such a model will facilitate exploration and explanation of the relationships among variables that impact HF outcomes. A theoretical model will be beneficial to examine the life challenges and themes faced by a person with HF and other comorbidities, both in clinical practice and while conducting research.

All of the studies in this review discussed the issue of HL of older Latinos with HF, but not all of the studies measured or specifically described HL. Of the studies analyzed, 63% reported measuring medical or HL; from that subgroup, 40% either did not describe a specific method by which HL was measured or used a tool that does not directly measure HL.

None of the articles in this review were solely focused on elderly Latinos with HF. As no one has specifically studied the elderly Latino with HF and inadequate HL, it would be crucial to describe the elderly Latino with HF and varying levels of HL as well as their ability to care for themselves as a foundational step before embarking on intervention research.

Barriers to subjects’ ability to complete the studies were discussed, such as providing the subjects with reading glasses or evaluating the subjects at times when they were not fatigued.28 Identification of these logistic barriers confirms the need for advanced practice nurses to alter research protocols to allow older adults more time with HL testing or to ensure the availability of any necessary assistive devices.39

In 1 study, quality of life was measured using an HF symptom scale, so it is unclear as to what construct was actually measured.18 Future studies should carefully choose validated instruments that match the concepts of interest. Another study reported the effects of a nurse-led intervention; however, the intervention was not developed by nurses, nor were there nurses as authors of the research.31 The telephone survey reports women older than 40 years being motivated to modify their risk factors as clinically but not statistically significant, but this reported level of motivation is not generalizable to men.32 The information provided in the articles reviewed illustrates that inadequate HL is a challenge for elderly Latinos with HF. The level of evidence available to design intervention studies in this clinical area is quite low and requires confirmation. In addition, the medical complexity of ethnic minority patients with limited HL, the limited HL of the elderly, and the relationship of HL and HF knowledge clearly identify the need to examine HL in elderly Latinos with HF in more detail. Researchers studying HL and HF self-care should look for differences in outcomes based on ethnicity to help to better identify and address the existing health disparities. Furthermore, cultural beliefs regarding health may also have effects on Latinos overcoming inadequate HL. In culturally diverse populations, HL levels alone may not be reliable predictors of people’s ability to maintain their health, as they also need enough knowledge to self-manage, recognize symptoms, and develop, implement, and revise a self-care action plan.40

There were several limitations to this systematic review. Few research studies exist focusing on elderly Latinos with HF and limited HL. The foundational knowledge for developing effective interventions in this population remains inadequate. Although the research articles in the existing literature included elderly Latinos with HF, none focused solely on the elderly Latino with HF along with limited HL. In addition, this review may have inadvertently not identified all the articles available regarding this at-risk population. Another limitation noted is the lack of differentiation of Latino subgroups. The lack of delineation of Latino subgroups based on country of origin is consistent throughout the research literature and is substantiated by the current available definitions of “Latino” and data collected in published documents. In future research, Latino subgroups demonstrating varying results based on racial-ethnic differences are worth further examination.

The research base on HL in the Latino population is currently insufficient for developing clinical practice guidelines. Health literacy is often confused with functional literacy, even in the health sciences literature; this was evident in a review of the National Guideline Clearinghouse (NGC) guidelines. A search of the NGC using the term health literacy yielded 34 guidelines (health literacy + Latino yielded no results). Health literacy was not defined in any of the guidelines and was mentioned as a concept to be aware of, be sensitive to, and to assess the level of to promote self-management. Of the 34 guidelines identified, 41% used the term HL, the remainder mentioned the terms health or literacy separately. A summary of commonly used interventions including the promotion of HL with a geriatric population was described in a guideline summarizing a review of the literature.41,42 A second guideline promoted the use of universal approaches to promote HL, including the use of plain language, pictures, and illustrations.43,44 The recommendations identified from the NGC are general, focus on functional literacy, and are based on expert opinion, rather than cumulative empirical research. Further research is needed to develop evidence-based practice guidelines to help clinicians address low HL in elderly Latinos.

Nurses have a strong influence on the health outcomes of patients. Nurses are positioned in a crucial role to impact the role of HL and culturally competent and equitable care as it relates to patient outcomes.45–48 Healthy People 2020 calls for HL to be integrated into undergraduate and graduate nursing and health education curricula on preventive healthcare and population health.49–52 Health literacy levels will impact the ability for generalist and advanced practice nurses to improve patients’ knowledge and change health behaviors (eg, medication adherence, self-management, self-monitoring, disease knowledge) that have been shown to mediate health outcomes of chronically ill patients with HF.53–56

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A recent systematic review of HL in HF reported that only 17% of studies examined the relationship between ethnicity and HL, and of those identified studies, 50% reported that those individuals with limited HL tended to be Hispanic and 50% were African American.57 In addition, in the studies reviewed, age and HL levels were inversely associated. The relationship between HL and access to health information has been examined; nurses are in a pivotal position to promote wellness and disease self-management by facilitating patients’ access to health information.58,59 Communication strategies such as those outlined in the Agency for Health Research & Quality Health Literacy Universal Precautions Toolkit were recommended.57 It would be a contribution to HL science to empirically test the recommendations listed in the Toolkit.15

At this time, the evidence base is insufficient to develop clinical guidelines and science-based recommendations. This systematic review yielded limited descriptive research and only 2 intervention studies. The clinical guidelines developed at this time can currently only be based on clinical expertise and experience. In addition, the limited use of theoretical frameworks used to guide the available research studies is also problematic.

This project’s comprehensive search strategies yielded surprisingly few research studies on HL among Latinos with HF. No consistent findings were identified among the diverse few studies currently available in the published literature. This demonstrates the need for further research to more fully understand the experience of the older Latino population with HF and limited HL and for nurse scientists to develop interventions to help this population achieve better HF self-care and clinical outcomes.60,61

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What’s New and Important

* Nurses and advanced practice nurses are in a pivotal position to assess patients and intervene to improve access to and understanding of health information.

* Identification of logistic barriers confirms the need to alter research protocols to allow older adults more time with HL testing or to ensure the availability of any necessary assistive devices.

* The medical complexity of ethnic minority patients with limited HL, the limited HL of the elderly, and the relationship of HL and HF knowledge clearly identify the need to examine HL in elderly Latinos with heart failure in more detail.

* In culturally diverse populations, HL levels alone may not be reliable predictors of people’s ability to maintain their health, as they also need enough knowledge to self-manage, recognize symptoms, and develop, implement, and revise a self-care action plan.

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aged; aging; chronic disease; comorbidity; congestive heart failure; diastolic heart failure; disease management; frail elderly; geriatrics; healthcare disparities; health status disparities; heart failure; heart failure (congestive); heart failure (diastolic); heart failure (systolic); Hispanic Americans; intervention studies; Mexican Americans; minority health; review literature as topic; review (systematic); self care; systolic heart failure (health literacy)

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