How do cognitive tests and health equity connect? By implementing accessible testing protocols, providing multilingual support, and tailoring assessments to diverse patient preferences, clinicians can better serve marginalized populations.
Social and environmental factors impact brain health, a fact that is increasingly being recognized by healthcare professionals and their patients. With this awareness comes the need to address and improve access to brain health care.
While an individual’s lifestyle choices, such as exercise, nutrition, sleep quality, and stress management, certainly influence brain health, systemic factors also contribute to brain health challenges at a population level, according to The Lancet. These include unequal access to healthcare resources, education, housing, and other social services, as noted in Nature Aging.
Improving health equity requires more than just the choices of individual patients and clinicians. Public policy, private sector innovations, and technology must also play a role, according to the Global Council on Brain Health.
In the face of healthcare worker shortages and intense administrative demands, closing the gap in health equity may seem like an uphill battle. However, a concerted effort, including tools designed to address accessibility needs, can help start the process.
Health systems can begin by introducing technology and improved workflows to make brain healthcare more accessible. This means considering patients' varying learning styles, languages, abilities, mobility, and other factors that shape how they access care.
In this article, we explore the design features that make cognitive testing more accessible to patients with diverse needs.
Article Highlights
Addressing health equity in cognitive and mental health assessments is essential for ensuring that all patients receive the care they need.
- By 2050, an estimated 22% of the global population will be over 60 years old, and one survey found that about 13% of seniors were very worried about developing Alzheimer’s disease or dementia.
- One study found that less than 12% of U.S. doctors practice in rural communities, even though around 20% of the population resides there.
- A 2021 study by researchers at UNSW Sydney’s Centre for Healthy Brain Ageing found that standard cognitive tests frequently misclassified diverse, non-English speaking patients as having more advanced dementia.
- Features of accessible cognitive tests include visual instructions, audio instructions, improved reading levels for written instructions, correcting for color blindness, dark mode, and reduced administration time.
Cognitive tests and health equity in primary care
Primary care physicians (PCPs) are often the first point of contact for patients with brain health concerns, as well as for routine check-ups. In recent years, more patients are seeking behavioral health care from their PCPs, according to Health Affairs.
This means PCPs need to be well-versed in both cognitive and mental health, and they must also be knowledgeable about social services that can support patients in maintaining good brain health.
However, physician shortages are currently making brain health challenges worse. The number of U.S. adults with a primary care doctor fell by 2% within a 13-year period, with a more significant decline among younger adults, particularly those in their 30s, according to JAMA Internal Medicine.
Due to this shortage, patients are increasingly turning to emergency rooms, urgent care, or walk-in clinics for routine health needs, often seeking faster access to care, as reported in Cureus.
Below, we explore some of the patient groups most affected by health inequities and what PCPs can do to help close the gaps in care.
Meeting the needs of older patients
By 2050, an estimated 22% of the global population will be over 60 years old, according to the World Health Organization. Brain health concerns are particularly high among seniors. One survey found that about 13% of seniors were very worried about developing Alzheimer’s disease or dementia, as reported in Archives of Gerontology and Geriatrics.
Achieving health equity requires making healthcare more accessible for older patients with chronic and cognitive health conditions.
When it comes to routine brain healthcare tasks, such as taking cognitive function tests or filling out a digital mental health questionnaire, older patients may face a few barriers.
Challenges that seniors face when completing cognitive assessments can include:
- Anxiety about using technology
- Reduced hearing or vision
- Limited mobility or motor skills
- Memory or attention problems
- Difficulty remembering instructions
This highlights the importance of designing cognitive assessments that are user-friendly and adaptable. They should be able to be administered in a clinic or at home, with assistance from a doctor, technician, or caregiver when necessary.
Reaching rural populations
Another important focus of health equity is improving access to healthcare for people living in rural areas. One study found that less than 12% of U.S. doctors practice in rural communities, even though around 20% of the population resides there, according to the Department of Veterans Affairs.
To improve access in these areas, the U.S. would need an estimated 202,800 more doctors, according to the Association of American Medical Colleges.
Patients in these areas face multiple challenges, including:
- Fewer clinicians
- Longer distances to travel for in-person appointments
- Limited social services or emergency care centers
One proposed solution focused on health equity is expanding virtual primary care. By offering cognitive and mental health assessments online, doctors can reach more patients, improve overall health, and reduce the need for long trips.
Overcoming education and literacy barriers
Socioeconomic factors contribute to dementia risk, including education, which is one of the keys to lifelong brain health, according to the Lancet Commission on dementia. Research in PNAS shows that having at least a high school education in young adulthood reduces the risk of cognitive decline.
However, significant inequities exist in the U.S. regarding access to education, particularly for marginalized populations, as noted in Nature Aging.
As a result, it’s crucial for doctors to make dementia screening accessible to patients with varying levels of education and literacy. This includes providing health education and instructions in ways that everyone can understand.
Features of accessible cognitive tests and digital mental health questionnaires include:
- Providing both spoken and written instructions
- Using simple language in health education and medical instructions
- Offering a user-friendly digital experience
- Having a technician or caregiver available to answer questions
Making cognitive testing available in multiple languages
The U.S. boasts incredible ethnic, racial, and language diversity. It’s estimated that the percentage of the U.S. population identifying as a minority group will grow from 41.1% in 2022 to 55.1% by 2060, according to the United States Census Bureau.
However, current cognitive testing protocols often fail to account for this diversity. A 2021 study by researchers at UNSW Sydney’s Centre for Healthy Brain Ageing found that standard cognitive tests frequently misclassified diverse, non-English speaking patients as having more advanced dementia.
To address these disparities, it is crucial to provide health education in patients' primary languages as a fundamental aspect of patient-centered care. This approach not only increases access and improves compliance with cognitive testing but also enhances overall population health, according to America’s Essential Hospitals.
Clinics and health systems can bridge this care gap by hiring multilingual staff and utilizing cognitive assessments available in various languages, thereby making these services more accessible.
With these patient groups in mind, let’s explore specific design features that enhance the accessibility of cognitive and mental health assessments.
What are 6 features of accessible cognitive tests?
Understanding the needs of diverse patient groups is a starting place for clinicians to evaluate the accessibility features that they need in digitized cognitive assessments.
One effective way to enhance access to brain health care is to deliver instructions through multiple mediums. In a healthcare context, having multiple modes of instruction (visual, audio, written) can significantly affect retention, compliance, and overall health outcomes over time.
Research indicates that providing these instructions collectively (rather than focusing solely on reading, for example) results in a 90% retention rate when learning something new, according to Principles of Adult Learning.
Below, we outline 6 relevant features to look out for when evaluating the accessibility of various cognitive assessment solutions.
Visual instructions
Visual instructions are essential for supporting people who prefer reading at their own pace, whose first language is not English, and who need additional context for the information presented. Enhanced visual instructions can include:
- User-friendly avatars: Avatars can provide a cohesive and friendly way to guide patients through the assessment process.
- Screenshots and practice rounds: Visual aids can help set clear expectations and improve how patients retain information.
- Clear navigation: Icons and animations can help patients navigate from one step to the next, ensuring they are never confused about how to continue the assessment.
Audio instructions
Audio instructions can benefit patients who prefer to have instructions read to them out loud, patients with limited sight, and those who may struggle with written language. Key considerations include:
- Supplement technician oversight: Audio instructions can supplement communication that would typically be provided by a supervising technician or caregiver.
- Multilingual support: Multilingual instructions streamline assessment and reduce reliance on translators, allowing patients to complete assessments more easily in clinic or from home.
Improved reading levels for written instructions
Cognitive and mental health assessments need to cater to a broad demographic, including very young and older patients. A key accessibility feature is:
- Simplified language: Clear, straightforward language in written instructions improves how approachable assessments are for all ages and all education levels.
Correcting for color blindness
In gamified cognitive tests, having appropriate color contrasts supports patients with color blindness. Without these features, testing results might misrepresent the abilities and cognitive performance of a patient with color blindness. Considerations include:
- Color contrast: Ensure that cognitive assessments include color choices that are distinct and accessible to individuals with various types of color blindness to minimize errors and improve compliance.
Dark mode
For patients experiencing post-concussion symptoms or photosensitivity due to neurological conditions, dark mode can significantly improve accessibility:
- Adjustable brightness: Allow patients to alter brightness levels or switch to “dark mode” to reduce discomfort, especially for patients with traumatic brain injury (TBI) or concussion.
Reducing administration time
Time with a primary care physician is often limited, with many physicians spending only 17 to 24 minutes per patient during consultations, according to a Medscape physician survey.
While digitized cognitive tests and mental health questionnaires can streamline the assessment process and optimize the use of this limited time, it is essential to continuously improve the user experience.
Enhancing usability can significantly reduce the amount of time patients spend navigating through complex instructions or multiple windows. Features such as intuitive interfaces, clear navigation pathways, and consolidated information can lead to quicker completion times for assessments, ultimately maximizing the effectiveness of each patient visit.
What does the future of equitable cognitive assessment look like?
Addressing health equity in cognitive and mental health assessments is essential for ensuring that all patients receive the care they need. Accessible testing protocols, multilingual support, and assessments tailored to diverse patient preferences help clinicians better serve marginalized populations. These efforts not only enhance patient experience and compliance but also contribute to improved health outcomes across communities.
As we strive for a more equitable healthcare system, prioritizing inclusivity in cognitive assessments will empower patients and promote better brain health for everyone, regardless of their background.