Gillian Rowlands

A mismatch between population health literacy and the complexity of health information: an observational study

BACKGROUNDnLow health literacy is associated with poorer health and higher mortality. Complex health materials are a barrier to health.nnnAIMnTo assess the literacy and numeracy skills required to understand and use commonly used English health information materials, and to describe population skills in relation to these.nnnDESIGN AND SETTINGnAn English observational study comparing health materials with national working-age population skills.nnnMETHODnHealth materials were sampled using a health literacy framework. Competency thresholds to understand and use the materials were identified. The proportion of the population above and below these thresholds, and the sociodemographic variables associated with a greater risk of being below the thresholds, were described.nnnRESULTSnSixty-four health materials were sampled. Two competency thresholds were identified: text (literacy) only, and text + numeracy; 2515/5795 participants (43%) were below the text-only threshold, while 2905/4767 (61%) were below the text + numeracy threshold. Univariable analyses of social determinants of health showed that those groups more at risk of socioeconomic deprivation had higher odds of being below the health literacy competency threshold than those at lower risk of deprivation. Multivariable analysis resulted in some variables becoming non-significant or reduced in effect.nnnCONCLUSIONnLevels of low health literacy mirror those found in other industrialised countries, with a mismatch between the complexity of health materials and the skills of the English adult working-age population. Those most in need of health information have the least access to it. Efficacious strategies are building population skills, improving health professionals communication, and improving written health information.

Health literacy and the social determinants of health: a qualitative model from adult learners

SummarynHealth literacy, ‘the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health’, is key to improving peoples’ control over modifiable social determinants of health (SDH). This study listened to adult learners to understand their perspectives on gathering, understanding and using information for health. This qualitative project recruited participants from community skills courses to identify relevant ‘health information’ factors. Subsequently different learners put these together to develop a model of their ‘Journey to health’. Twenty-seven participants were recruited; twenty from community health literacy courses and seven from an adult basic literacy and numeracy course. Participants described health as a ‘journey’ starting from an individuals family, ethnicity and culture. Basic (functional) health literacy skills were needed to gather and understand information. More complex interactive health literacy skills were needed to evaluate the importance and relevance of information in context, and make health decisions. Critical health literacy skills could be used to adapt negative external factors that might inhibit health-promotion. Our model is an iterative linear one moving from ethnicity, community and culture, through lifestyle, to health, with learning revisited in the context of different sources of support. It builds on existing models by highlighting the importance of SDH in the translation of new health knowledge into healthy behaviours, and the importance of health literacy in enabling people to overcome barriers to health.

Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England

BACKGROUNDnDemand for Englands accident and emergency (A&E) services is increasing and is particularly concentrated in areas of high deprivation. The extent to which primary care services, relative to population characteristics, can impact on A&E is not fully understood.nnnAIMnTo conduct a detailed analysis to identify population and primary care characteristics associated with A&E attendance rates, particularly those that may be amenable to change by primary care services.nnnDESIGN AND SETTINGnThis study used a cross-sectional population-based design. The setting was general practices in England, in the year 2011-2012.nnnMETHODnMultivariate linear regression analysis was used to create a model to explain the variability in practice A&E attendance rates. Predictor variables included population demographics, practice characteristics, and measures of patient experiences of primary care.nnnRESULTSnThe strongest predictor of general practice A&E attendance rates was social deprivation: the Index of Multiple Deprivation (IMD-2010) (β = 0.3. B = 1.4 [95% CI =1.3 to 1.6]), followed by population morbidity (GPPS responders reporting a long-standing health condition) (β = 0.2, B = 231.5 [95% CI = 202.1 to 260.8]), and knowledge of how to contact an out-of-hours GP (GPPS question 36) (β = -0.2, B = -128.7 [95% CI =149.3 to -108.2]). Other significant predictors included the practice list size (β = -0.1, B = -0.002 [95% CI = -0.003 to -0.002]) and the proportion of patients aged 0-4 years (β = 0.1, B = 547.3 [95% CI = 418.6 to 676.0]). The final model explained 34.4% of the variation in A&E attendance rates, mostly due to factors that could not be modified by primary care services.nnnCONCLUSIONnDemographic characteristics were the strongest predictors of A&E attendance rates. Primary care variables that may be amenable to change only made a small contribution to higher A&E attendance rates.

Lay Health Trainers Supporting Self-Management amongst Those with Low Heath Literacy and Diabetes: Lessons from a Mixed Methods Pilot, Feasibility Study

This article reports a mixed methods process evaluation of a pilot feasibility randomised controlled trial comparing a Lay Health Trainer (LHT) intervention and usual care for those with poorly controlled Type 2 Diabetes Melitus (T2DM). Set in a deprived area in the UK, this research explores patient and health care practitioner (HCP) views on whether a structured interview between a patient and a Lay Health Trainer (LHT), for the purpose of developing a tailored self-management plan for patients, is acceptable and likely to change health behaviours. In doing so, it considers the implications for a future, randomised controlled trial (RCT). Participants were patients, LHTs delivering the intervention, service managers, and practice nurses recruiting patients to the study. Patients were purposively sampled on their responses to a baseline survey, and semistructured interviews were conducted within an exploratory thematic analysis framework. Findings indicate that the intervention is acceptable to patients and HCPs. However, LHTs found it challenging to work with older patients with long-term and/or complex conditions. In order to address this, given an ageing population and concomitant increases in those with such health needs, LHT training should develop skills working with these populations. The design of any future RCT intervention should take account of this.

Health literacy in selected populations: Individuals, families, and communities from the international and cultural perspective

International and cultural perspectives of health literacy help deepen the understanding of the global context within which health literacy plays an important role. Throughout this chapter, we explore the significance of health literacy initiatives, interventions, practices, and research for addressing health challenges on a variety of levels in the international and global context. More specifically, in this chapter, the notion of health literacy as a dynamic construct is introduced, after which we examine health literacy throughout the life course, emphasizing the impact of health literacy among children and the elderly in their families and in the community. Cultural norms and family interpersonal relations, and values influence health literacy and need to be considered when closing the health literacy disparities. Global trends of migration and immigration bring to the forefront the need for unravelling the complexity of health systems, for which health literacy plays a central role; health literacy initiatives address cultural differences between providers and patients to help narrow the communication gap. The importance of cultural competency among health care providers exemplifies how capacity building in health literacy is critical for maximizing the benefits to the public of the health care system. Health literacy provides a conceptual foundation for community participatory research, involving members of the public to take part in the planning, execution and evaluation of health education interventions. Throughout the chapter, selected case studies and picture boxes from around the globe, exemplify aforementioned topics of interest, showcased in the chapter. Practical recommendations for policy makers, practitioners and research are offered based on the studies conducted in the international context.

Global health systems and policy development: implications for health literacy research, theory and practice

Accessible and responsive health systems are critical to population health and human development. While progress has been made toward global health and development targets, significant inequities remain within and between countries. Expanding health inequities suggest a widespread and systemic neglect of vulnerable citizens, and a failure to enshrine within policies a responsibility to tailor care to the variable capabilities of citizens. Implementation of health and social policies that drive the design of accessible health systems, services, products and infrastructure represents the next frontier for health reform. Within this chapter we argue the need to consider health and health literacy across policy domains, to operationalize the intent to address inequities in health in meaningful and pragmatic ways, and to actively monitor progress and impact within the context of the Sustainable Development Goals (SDGs). We contend that viewing and developing policies and systems within a health literacy framework will assist in placing citizens and equity considerations at the center of development efforts. In this chapter, we explore the relationship between health literacy and equitable access to health care, and the role of health system and policy reform. We first explore international policies, health literacy, and the SDGs. We then explore national policies and the role that national and local services and systems play in building health literacy, and responding to the health literacy challenges of citizens. We discuss the World Health Organizations (WHO) Framework for Integrated People-Centered Health Services and the way in which health services are being encouraged to understand and respond to citizen health literacy needs. Each section of the chapter ends with a summary and a review of health literacy research and practice. Throughout, we illustrate our points through vignettes from around the world.

The Feasibility of Health Trainer Improved Patient Self-Management in Patients with Low Health Literacy and Poorly Controlled Diabetes: A Pilot Randomised Controlled Trial

Type 2 diabetes mellitus is most prevalent in deprived communities and patients with low health literacy have worse glycaemic control and higher rates of diabetic complications. However, recruitment from this patient population into intervention trials is highly challenging. We conducted a study to explore the feasibility of recruitment and to assess the effect of a lay health trainer intervention, in patients with low health literacy and poorly controlled diabetes from a socioeconomically disadvantaged population, compared with usual care. Methods. A pilot RCT comparing the LHT intervention with usual care. Patients with HbA1c > 7.5 (58u2009mmol/mol) were recruited. Baseline and 7-month outcome data were entered directly onto a laptop to reduce patient burden. Results. 76 patients were recruited; 60.5% had low health literacy and 75% were from the most deprived areas of England. Participants in the LHT arm had significantly improved mental health (p = 0.049) and illness perception (p = 0.040). The intervention was associated with lower resource use, better patient self-care management, and better QALY profile at 7-month follow-up. Conclusion. This study describes successful recruitment strategies for hard-to-reach populations. Further research is warranted for this cost-effective, relatively low-cost intervention for a population currently suffering a disproportionate burden of diabetes, to demonstrate its sustained impact on treatment effects, health, and health inequalities.

How is health literacy addressed in primary care? Strategies that general practitioners use to support patients

ABSTRACT Background: Low health literacy is associated with adverse health outcomes and raises healthcare costs. General practitioners (GPs) are the first point of access to health care services and play a key role in building patients’ health literacy level. This study aimed to explore: (1) GPs’ understanding of health literacy, (2) their perceived challenges to addressing health literacy, and (3) the strategies they used to support patients with health literacy difficulties. Method: This qualitative study was conducted in South Western Sydney, New South Wales, Australia. Semi-structured interviews were audio-recorded and transcribed verbatim. Interview data were analyzed using the Framework method, a matrix-based approach to thematic analysis. Results: Eighteen participants took part in the study. Four key themes were identified: (1) identifying patients with health literacy difficulties; (2) perceived consequences of low health literacy; (3) being sensitive to developing health literacy skills; and (4) strategies used to build health literacy. Intuitive skills were used to identify the patient’s health literacy skills through recurring encounters with patients over time. A range of communication techniques were used to build health literacy. The value of a long-term relationship with patients and support from relatives were reported (Please eliminate this comma and the one right before this) to be important in helping patients build their health literacy skills. Conclusions: A number of challenges in health literacy exist in general practice. General practitioners can play a role in overcoming these challenges by placing an increased focus on health literacy, including self-education on this topic, identification of patients with low health literacy skills and helping build patients level of health literacy.