Health literacy – a public health priority
Health literacy has been described as ‘a more powerful predictor of health inequalities than age, income, employment status, educational attainment or ethnic group’ . In Scotland 40% of adults have trouble understanding information about their health and finding their way around the health service. Put simply, they have difficulty knowing what is wrong with them and how to treat it. This is what is known as poor health literacy. Unless something is done to help address the gaps in understanding the full potential of our health services is unlikely to be realised. This is all the more important at a time when the NHS expects patients to play a more active role in decision making about their health and healthcare.
What is health literacy?
Health literacy – “put simply people have difficulty knowing what is wrong with them and how to treat it.”
The term health literacy was first defined in 1974 as the ability to read and comprehend written medical information and instructions . Today the definition has broadened and recognises that health literacy is the ability to obtain, process and understand health information and services in order to make appropriate health decisions and follow instructions for the treatment and prevention of ill-health .
How bad is the problem?
Widespread low health literacy in Scotland exists not just because some people have difficulty reading, but because much health communication routinely contains jargon and unfamiliar phrases. The problem appears worse amongst lower socioeconomic groups, ethnic minorities, elderly people and those with chronic or disabling conditions . Low health literacy invariably results in poorer health .
Specifically patients with low health literacy:
- Are at greater risk of hospitalisation and have longer hospital visits;
- Have higher rates of admission to emergency services;
- Make more mistakes with their medication and treatment plans;
- Have less knowledge of disease management and healthy behaviour;
- Are less able to make decisions with healthcare professionals; and
- Make less use of preventative services.
Engaging patients in a shared approach to their healthcare and treatment is a major objective of current health policy in Scotland. The Scottish Government is committed to a patient centred healthcare system, delivered by a well-prepared workforce, effective at preventing disease and tackling health inequalities . Yet without addressing low health literacy such efforts may result in those who need healthcare not being able to fully access and engage with the services they need. It is against this backdrop that the Scottish Government commissioned a scoping report on health literacy in 2009  and is now preparing the Strategic Framework for Health Literacy for consultation in spring 2011.
Improving health literacy
Internationally, and in Scotland, various initiatives have sought to tackle low health literacy, but the evidence base remains patchy. Two of the best known and effective interventions are the ‘teach-back’ technique and ‘Ask Me 3’. Both these American techniques relate to improving interpersonal communication with patients and are simple and easy to adapt to a Scottish context.
Teach-back involves asking patients to demonstrate or explain in their own words what they have just been told by the clinician, nurse or pharmacist. It is not a test for the patient but rather a chance to check their understanding and teach again if necessary. For example, the patient could be asked ‘I’d like you to explain how you will take your medication, so that I can be sure I have explained everything correctly’. In using teach-back if the patient cannot explain or demonstrate what they should do then the health professional must assume responsibility for having not provided their patients with an adequate explanation or understandable instructions. Research indicates that ‘teach-back’ is effective in improving patients’ understanding and health outcomes. For example, patients with diabetes where clinicians assess their comprehension and recall with the ‘teachback’ technique have significantly better diabetes control than patients whose clinicians do not use the technique .
‘Ask Me 3’ encourages patients to ask, and health professionals to answer, three basic questions during every consultation:
- What is my main problem?
- What do I need to do about it?
- Why is it important for me to do this?
A recent study in the USA  measured the results of implementing ‘Ask Me 3’ in a paediatric health centre. Of the 393 parents surveyed all “liked” the technique and found the questions “helped them get more information about their child's health”. Interestingly the parents also felt that the clinician spent more time with them, even though the study did not show any increase in the consultation time.
Ready Steady Baby
Ready Steady Baby is a health literacy intervention for pregnant women in deprived communities in north Edinburgh. The project aims to improve the health literacy of pregnant women to increase their control over their lives, their health, their ability to seek out information and their ability to take responsibility. It is being piloted for 12 months, and has been developed in partnership with midwives, health visitors, GPs and the voluntary sector. The project is delivered by adult literacy workers from Edinburgh’s Health & Literacy project* and is funded by NHS Lothian. The local area faces many of the problems associated with poverty and disadvantage, including low uptake of antenatal care.
* The project is a key partner in the Edinburgh City Literacy and Numeracy Partnership (CLAN)
Ready Steady Baby is based on the Baby Basics programme developed in the USA  and works with women on a one to one and group basis. The workers assess the health literacy needs of pregnant women at booking clinics by discussing the Ready Steady Baby book; this publication is produced by NHS Health Scotland and is distributed to all pregnant women. At antenatal clinics and classes, staff use specially developed antenatal health education materials and literacy support to enable women to be involved in their healthcare during their pregnancy. The project also provides 1:1 literacy support for those women with very low literacy. The project also seeks to raise health professionals’ awareness of literacy problems and introduce the ‘teach-back’ and ‘Ask Me 3’ techniques. The project works in a dynamic way, developing and adapting approaches to suit local circumstances and will be evaluated using an action research process.
- Health literacy is not just about being able to read and understand health information.
- It is an ability which enables individuals to make informed health decisions in the context of every day life, empowering people to take more responsibility for their health and wellbeing and that of families and communities.
- NHS Lothian is learning from other healthcare systems and adapting existing techniques to the particular Scottish and Lothian context.
- Health literacy involves both the public and healthcare professionals, working together to ensure information is delivered in the most appropriate way.
- Low health literacy is a major public health problem and further research is required to identify effective ways of getting patients better informed about their own health and actively involved in their healthcare.
- Health literacy improvement needs to be integrated and incorporated into all national, regional and local health programmes and services.
- Teach-back and ‘Ask Me 3’ techniques are simple tools for improving interpersonal communication with patients and should be implemented across NHS Lothian.
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