The concept of ‘literacy’ as a person’s ability to understand written and numerical information is well understood but not everyone is so familiar with the term ‘health literacy’. Health literacy refers to the skills that people need to be able to navigate, and function effectively within, the healthcare environment (Berkman, 2011).
It is easy to take for granted the literacy levels required to understand a patient information leaflet or follow the instructions on a packet of medication but these tasks can require a relatively high level of health literacy. It has been shown that, despite an effort to avoid jargon and use plain English, health materials are written at levels that require reading skills that exceed the average reading level of the public (Rowlands, 2015).
Low health literacy levels are associated with poorer health outcomes and poorer use of health resources. A 2011 systematic review of health literacy and health outcomes (Berkman, 2011) found that low health literacy was associated with:
- Poorer health related knowledge and comprehension
- Increased hospitalisation
- Increased use of emergency care
- Decreased uptake of screening and immunisation opportunities
- Poorer abilities to demonstrate taking medications properly
- Poorer skills at interpreting medication labels and health messages
- In the elderly population, poorer overall health status and higher mortality
The 2009 Scottish Survey of Adult Literacies revealed that just over a quarter of the Scottish adult population (26.7%) have literacy levels that mean they “may face occasional challenges and constrained opportunities due to their skills but will generally cope with their everyday lives” (Scottish Government, 2009). Even more concerningly, this survey also revealed that 1 in 28 people (3.6%) have literacy levels that are so limited they will be faced with serious challenges in their daily lives. Similar figures were found across 8 EU member states when health literacy was specifically investigated with approximately 12% of adults being shown to have inadequate health literacy and 35% had ‘problematic’ health literacy.
This means that adults living with low health literacy are not uncommon but they can be part of a hidden population (Easton, Health in the 'hidden population' of people with low literacy. A systemic review of the literature, 2010). Many people will not volunteer that they struggle with literacy problems for fear of stigma, being thought stupid or in case it will have a detrimental effect on their relationship with healthcare professionals (Easton, How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation, 2013). One small study showed that within a group of 58 patients with low literacy, two thirds reported in a structured survey that they had not told their spouses and one fifth had never told anyone (Parikh, 1996).
To address these issues, the Scottish Government has published two health literacy action plans: Making It Easy in 2014 and Making It Easier in 2017. The aim of these reports is to raise awareness of health literacy and help the NHS workforce respond to the problem. One outcome of the first report was the creation in 2015 of The Health Literacy Place website by NHS Education for Scotland Knowledge Services. This website is the home for numerous tools and resources that can be used by healthcare professionals to help their patients overcome any health literacy barriers they may face. These include communication tools that can be very useful as part of the consent journey, such as:
These include communication tools that can be very useful as part of the consent journey, such as:
- Teach back
- A method for confirming that a patient has understood the information being presented to them
- Ask the patient to describe back to you, in their own words, what has been discussed or the plan/treatment instructions that have been given
- This can identify whether a patient has truly understood whereas the closed question ‘do you understand’ may not as a patient can say ‘yes’ even when the real answer is ‘no’ to avoid potential embarrassment
- Chunk and check
- An approach where you break down information into small chunks with breaks to check understanding in between
- Aims to avoid overloading the patient with too much detailed information in one go
- The checking process allows for identification of anything the patient has not understood or that they would like further information on
- Combine with the teach back method to ensure understanding
Further resources can be found at Health Literacy, the website of a special interest group within the Society of Academic Primary Care.
Berkman, N. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of Internal Medicine, 97-107.
Easton, P. (2010). Health in the 'hidden population' of people with low literacy. A systemic review of the literature. BMC Health Services Research, 459.
Easton, P. (2013). How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation. BMC Health Services Research, 319-330.
Parikh, N. (1996). Shame and health literacy: the unspoken connection. Patient Educ Couns, 33-39.
Rowlands, G. (2015). A mismatch between population health literacy and the complexity of health information. British Journal of General Practice, e379-e386.
Scottish Government. (2009). Scottish Survey of Adult Literacies 2009: Report of Findings. Edinburgh: Scottish Government.