Recognizing Low Health Literacy

How to recognise low health literacy?

Some social characteristics are linked to a high risk of poor health literacy:

  • Low socio-economic status, as determined by occupation, income or social exclusion
  • Low education
  • Loneliness
  • Poor language skills or illiteracy (analphabetism)
  • Disadvantaged ethnic minority status
  • Prevalence of low or inadequate health literacy increases steadily from about age 50, and the majority of people age 75+ have been found to have low health literacy
  • Any group that is probably underserved by preventative health care services, such as migrant workers or illegal drug users

The most vulnerable individuals often will have many of these risk factors. In a clinical environment, individuals with low health literacy may become apparent from chronic poor adherence to medication or healthcare regimes, in spite of apparent willingness to follow health care advice. Also, A European survey found that people who perceive themselves to have poor health are also most likely to have relatively poor health literacy.

It is important to recognise the impacts of these social and cultural traits, and to identify appropriate support when helping patients to overcome limited health literacy. Being part of a social or cultural minority often creates both barriers and opportunities for individuals when accessing or acting upon health information. Health promotion programmes may for instance be more successful if delivered by peer educators from the same ethnic minority, who are sensitive to specific cultural habits or expectations. Indeed, many risk factors are relative to the community and country norms where people live.

Nevertheless, people from any background can have inadequate health literacy. It is not a problem confined to or determined by any particular characteristic, such as ethnic background, overall intelligence, disability, age, income level or even reading skills.

Because many patients are

  • unaware of their low health literacy, and/or
  • are ashamed of their difficulties in understanding health information or following medical advice

Poor health literacy can be a very hidden problem.

What can health professionals do?

  • Ask patients directly about any difficulties they may have. The simple question “How well do you understand medical forms?” is often very revealing and can initiate open dialogue without embarrassment.
  • Use short and simple instructions and descriptions, in oral, visual and written information.
  • Recognise that often patients are given information exactly when they are least able to understand and remember it (due to physical illness or emotional stress). Therefore, multiple methods of delivering information are best, including information that patients are able to access independently (leaflets to look at later, helpful websites, etc)
  • Consider using the TeachBack technique in consultations: Ask the patient how they would explain their problem or most recent consultation to their spouse, a friend or neighbour. This creates an opportunity to identify and correct misunderstanding.
  • Encourage questions from patients about their condition or treatment.

What can Policy Makers do?

  • Encourage health systems to make it easier for patients: Encourage simple presentation of information to patients and adequate communication skills among health staff.
  • Review the knowledge and skill burdens placed on vulnerable patients when managing their own health, and encourage research that can recommend how these burdens can be minimised by better service delivery.

There is more information on how to recognize low health literacy and on effective interventions in these links: Understanding health literacyLow health literacy in EuropeMeasuring health literacy and Patient centeredness

References

Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. Bmj 2012; 344: e1602.

Sørensen K, Pelikan JM, Röthlin F, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). The European Journal of Public Health 2015: ckv043.

Nierkens V, Hartman MA, Nicolaou M, et al. Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. A systematic review. PloS one 2013; 8(10): e73373.

Organization WH. Health literacy. The solid facts. 2013. WHO Regional Office for Europe: Copenhagen 2014.

King A. Poor health literacy: a’hidden’risk factor. Nature Reviews Cardiology 2010; 7(9): 473-4.

Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. health 2004; 11: 12.

Jain D, Sheth H, Bender F, Weisbord S, Green J. Evaluation of a single-item screening question to detect limited health literacy in peritoneal dialysis patients. Advances in peritoneal dialysis Conference on Peritoneal Dialysis; 2013; 2013. p. 27-30.

Kripalani S, Bengtzen R, Henderson LE, Jacobson TA. Clinical research in low-literacy populations: using teach-back to assess comprehension of informed consent and privacy information. IRB: Ethics & Human Research 2008: 13-9.

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