InnovAiT, 7(7), 437–440 DOI: 10.

1177/1755738014532627

.............................................................................................................................................................................................................

Health literacy

H
ealth literacy is the ability to absorb and use information relating to health.
Low levels of health literacy are associated with higher levels of hospital
admissions, emergency department attendances and reduced up-take of
screening and vaccinations. Additionally, low health literacy is linked to poorer
general health and increased mortality. All doctors, but especially GPs, need a
clear and sensitive approach to assess and adapt for low health literacy in the
consultation. As GPs play a vital role in health promotion, a good understanding
of health literacy is essential. This article aims to improve knowledge, awareness
and understanding of health literacy and suggests ideas for everyday practice.

The GP curriculum and health literacy

Contextual statement 2.01: The GP consultation in practice requires that GPs should understand that:
. Clear, sensitive and effective communication with your patient and their advocates is essential for a successful
consultation
. A non-judgemental attitude is necessary to promote equality and value diversity
. As a GP you must have a commitment to patient-centred medicine

Clinical example 3.01: Healthy people: Promoting health and preventing disease requires GPs to
understand that:
. Health inequalities are important determinants of health
. As a GP, you have a crucial role to play in promoting health and preventing disease
...................................................................................................

becomes unwell and has symptoms of DKA, with a

What is health literacy?
........................................................... good level of health literacy he will have an understand-
ing of DKA, relate it to his current experience and pro-
Health literacy is more than just the ability to read and actively prevent deterioration. This understanding is
write in the health care setting. Although there are vitally important for patient self-management and
numerous definitions, the most widely accepted is ‘the empowerment
motivation and ability to access, understand and use
information in ways which promote and maintain good Interestingly, health literacy is not fixed and can be mod-
health’ (Nutbeam, 2000). Health literacy heavily relies on ified. People who frequently use health care services may
language skills, vocabulary and reading ability; patients learn to recognise and understand medical terminology,
may find the language used in the health care environ- thus improving their health literacy. Research has demon-
ment particularly demanding as it tends to be more strated that various interventions can help people to
complex and the vocabulary different to everyday non- improve their health literacy, although whether this has
medical conversations. It is estimated that approximately an impact on health is yet to be established (Pignone,
43% of UK adults are unable to effectively understand 2004).
and use everyday health information (Protheroe and
Rowlands, 2013). Therefore, a significant part of the
population struggles to participate in shared, informed
decision-making. Why is health literacy
Health literacy is, also the ability to function within the important?
...........................................................
health care environment. This includes the ability to use
information previously learnt to have a positive impact on Health literacy has a huge part to play in health care,
health. For example, if a man who is diabetic and has both within the GP consultation and in the wider health
been educated about diabetic ketoacidosis (DKA) care environment (Box 1). A patient’s level of health

! The Author(s) 2014. Reprints and permissions:

sagepub.co.uk/journalsPermissions.nav
437.......................
...................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................
Box 1. Health literacy affects the following Use of health care
issues. With the increasing financial pressure on the NHS, there
has been increasing emphasis on reducing hospital
. The doctor/patient relationship
admissions by self-management and preventing acute
. Adherence to medications
exacerbations of chronic disease. In order to self-
. Implementation of the management plan
manage, patients need to understand health information
. Self-management of chronic illness
and have the confidence to act on their knowledge in an
. Hospital admissions
appropriate manner. People with lower health literacy
. Emergency department attendances
levels have been shown to have less knowledge about
. Health inequalities
their illness, more emergency care visits and hospital
. Lifestyle behaviours
admissions (Berkman et al., 2011). In fact, health literacy
has a direct effect on hospital admissions, those with a
low level of health literacy present late with more
advanced disease. Therefore, to help reduce hospital
literacy has been shown to have a direct impact on hos- admission, we should be targeting patient education
pital admission, emergency department attendance, and health literacy.
adherence and the doctor/patient relationship.
Furthermore, it is also thought health literacy has a role Low levels of health literacy are also associated with a
in reducing health inequalities. lower uptake of preventative health care, such as screen-
ing tests and vaccinations (Berkman et al., 2011). For
example, women are less likely to attend for smears or
In the consultation mammograms if they have low level of health literacy. In
All health care professionals have a responsibility to com- the UK, women receive a letter and information leaflet in
municate in a way that the patient understands. It is the post asking them to make an appointment for screen-
currently estimated that only a quarter of the information ing. The benefits and consequences of these tests cannot
given to a patient during a consultation is remembered be appraised if the information is not read or understood,
correctly (Protheroe and Rowlands, 2013). resulting in a poorly informed decision.
Understanding can worsen when the medical information
is too complex, which can have profound implications for
the patient and could result in safety issues.

It is very important for doctors to have an awareness of Health inequalities

the high prevalence of low levels of health literacy and Social and economic status is directly related to health in
adapt their consultation accordingly. Failure to recognise the UK, with those in lower socioeconomic groups more
poor health literacy can result in difficulties in the doctor/ likely to have poorer health. This relationship still exists
patient relationship and the doctor not realising when the despite taking age, educational status and lifestyle factors
patient has not understood the clinical discussion. If the such as smoking and alcohol into account. Although
patient does not understand and is not an active partici- inequalities in health are well documented, the causes
pant then the relationship becomes more paternalistic and solutions are less well understood. Health inequality
and doctor-centered. Subsequently, the patient is pas- is a result of complex multifactor interactions between:
sive and does not take responsibility for his or her own access to health care; behaviour; peer pressure; per-
medical management. Then adherence problems or ceived locus of control; living conditions; education;
errors in implementation of management plans may and income. Those in lower socioeconomic groups
occur. tend to have lower literacy levels, lower educational
achievement and more risky health behaviours such as
GPs often supplement their consultation with written smoking. Despite health inequality being a public health
information leaflets. Patients like to be given these leaf- priority, the gap is widening and it is thought health lit-
lets, however, with the average reading age required to eracy has a part to play in these inequalities.
read leaflets being 13–14 years old or higher, some con-
sideration is needed first. In the UK there are no regula- Those in non-skilled households are two times more
tions for leaflet production; anybody can produce a likely to: smoke; drink excessively; have a poor diet;
leaflet without proof-reading or assessing the document. and insufficient activity levels than those in professional
If leaflets are misinterpreted it could have the opposite households (Buck and Frosini, 2012). These health
intended effect, thus causing confusion and increasing behaviours have been estimated by the World Health
anxiety levels. It is important to read the information Organization to be associated with 29% of the disease
provided for patients to ensure it is appropriate, up to burden. This is a huge problem for the health care
date and easy to read. If leaflets are given it is good system, especially as much of it is potentially modifiable
practice to explain the leaflet during the consultation to and avoidable. There are ongoing health campaigns in
reduce the likelihood of misinterpretation. the UK targeting these health behaviours.

438
........................
.............................................................................................................................................................................................................
InnovAiT

....................................................................................................................................................................................................................................................
Between 2003 and 2008, the population as a whole: encouraging questions allows patients to be open if
reduced smoking and excessive alcohol consumption; they do not understand.
improved their diet; and their level of physical exercise.
However, on closer inspection only those in higher socio- Using a variety of different learning materials such as
economic groups had successfully modified their behav- three-dimensional models, internet images or diagrams
iours. The lower groups did not statistically change their reduces the reliance on literacy skills. Encouraging
behaviours, thus the divide widened further. In health patients to take responsibility and be an active participant
promotion, consideration should be given to how those ensures less of a passive role and will help to improve
in the lower socioeconomic groups are specifically tar- patient self-management.
geted, and health literacy and education may be part
of the solution. In order to empower patients to self-manage and change
potentially harmful behaviours, they need to be well
It is becoming commonplace for patients to present to informed and motivated. This is a particular challenge
the GP after researching symptoms on the internet. Some as those who are in low literacy and/or lower socioeco-
people may even self-manage from internet advice and nomic groups tend to be the hardest to reach.
choose not to visit their GP. To perform this process Government health strategies need to take this into con-
patients need a means to access the internet and must sideration when designing health promotion strategies
have a sufficient level of literacy to navigate around (Buck and Frosini, 2012). There is ongoing research
pages, read and appraise the advice given. Those with being performed on ways to improve health literacy
a low level of literacy are potentially less likely to have and subsequent self-management. The National
access to the internet and less able to find, read, under- Institute for Health and Care Excellence (NICE) offers
stand and act on the information given. There is a con- some recommendations for GPs to help patients initiate
cern that inequalities in health are set to widen given behaviour change (NICE, 2007). These principles can
increasing reliance on the internet. also be applied to patients to initiate management of
their chronic illnesses (See Box 2).
One of the predicting factors for low levels of health
literacy is older age. In an ageing population this is of
particular importance. An individual’s health literacy may Box 2. Concepts for behaviour change.
decrease as part of a general decline in cognitive func-
. Outcome expectations: Helping people to
tion; however, it does have the potential to increase from
develop knowledge about the health conse-
greater interactions with health professionals. Many eld-
quences of their behaviours/disease
erly people do not have access to the internet and have
. Personal relevance: Emphasising the points on
grown up in an age where the patient’s role in the
a personal note
doctor/patient relationship was passive. Effectively
. Positive attitude: Promoting positive feelings
empowering this specific patient group is a complex
towards behaviour change/self-management
and challenging problem.
. Self-efficacy: Enhancing people’s belief in their
ability to self-manage/change
. Social norms: Provide positive examples in peo-
ple’s reference groups with whom to compare
Practical suggestions for themselves or aspire to be like
. Personal and moral norms: Promoting per-
clinical practice
...........................................................
sonal and moral commitments to behaviour
change
Consider the patient’s level of literacy in all consultations. . Intention formation and concrete plans:
Asking the question: ‘How often do you need to have Helping people to form plans and goals to be
someone help you read written material from your doctor achieved over time and in specific contexts
or pharmacy?’ (Morris, McLean, Chew, & Littenberg, . Behavioural contracts: Asking people to share
2006) can be useful for highlighting those who struggle their plans and goals with others
with health information and can help the GP to adapt the . Relapse prevention: Helping people develop
consultation accordingly. skills to cope with difficult situations and conflicts

It is important to ensure the vocabulary used is not

unnecessarily complicated. This can be achieved by
using simple words and phrases rather than alternative Initiating a behaviour change, such as motivating a
complex words. Other techniques include: speaking patient to self-manage or stop smoking is a complex pro-
slowly; giving information in small chunks and checking cess and does not solely rely on health literacy. There are
understanding after each point (chunking and checking); other important factors that determine change: such as,
repeating key points; and checking understanding at the peer pressures; social norms; expectations; attitudes;
end of the consultation. Being approachable and self-efficacy; and setting plans. Having awareness of,

439.........................
...................................................................................................................................................................................................................................

...................................................................................................................................................................................................................
and accounting for, low levels of health literacy while . Coleman, M. P., Rachet, B., Woods, L. M., Mitry,
putting the key points in Box 2 in place will aid the GP E., Riga, M., Cooper, N.,. . . Esteve, J. (2004).
to successfully initiate behaviour change. NICE suggests Trends and socioeconomic inequalities in cancer
there are life circumstances where people are more sus- survival in England and Wales up to 2001. British
ceptible to behavioural intervention; for example, the Journal of Cancer, 90, 1367–1373. doi:10.1038/
time of diagnosis may be when patients are most likely sj.bjc.6601696
to be willing to learn about their illness and modify their . McFadden, E., Luben, R., Bingham, S., Wareham,
behaviours. Maybe more resources need to be put into N., Kinmonth, A. L., & Khaw, K. T. (2008). Social
patient education and behavioural interventions. The inequalities in self-reported health by age: Cross-
challenge then would be how to get patients more inter- sectional study of 22 457 middle-aged men and
ested and willing to learn about their health. women. BCM Public Health, 8, 230. doi:10.1186/
1471-2456-8-230
. Morris, N. S., MacLean, C. D., Chew, L. D., &
Littenberg, B. (2006). The single item literacy
Key points screener: Evaluation of a brief instrument to iden-
tify reading ability. BMC Family Practice, 7, 21.
. Health literacy is the ability of an individual to take doi:10.1186/1471-2296-7-21
in health information, process, understand and use . NICE. (2007). Behaviour change: The principles for
the information to promote health effective interventions. NICE public health guid-
. Low levels of health literacy can affect the doctor/ ance 6. Retrieved from www.nice.org.uk/niceme-
patient relationship and adherence to manage- dia/live/11868/37987/37987.pdf
ment of an illness . Nutbeam, D. (2000). Health literacy as a public
. People with low levels of health literacy are less health goal: A challenge for contemporary health
likely to self-manage chronic illness and more like education and communication strategies into the
to attend A&E and be admitted to hospital 21st century. Health Promotion International,
. Doctors should have an awareness of and screen 15(3), 259–267. doi: 10.1093/heapro/15.3.259
for limited health literacy . Pignone, M., DeWalt, D. A., Sheridan, S.,
. Thus, consultations should be tailored with an Berkman, N., & Lohr, K. N. (2004). Interventions
emphasis on patient understanding and to improve health outcomes for patients with low
empowerment literacy. Journal of General Internal Medicine, 20,
185–192. doi: 10.1111/j.1525-1497.2005.40208.x
References and further information . Protheroe, J. & Rowlands, G. (2013). Matching
clinical information with levels of patient health lit-
. Barnett, K., Mercer, S. W., Norbury, M., Watt, G.,
eracy. Nursing Management, 20(3), 20–21
Wyke, S., & Guthrie, B. (2012). Epidemiology of
. RCGP. Contextual statement 2.01: The GP consult-
multimorbidity and implications for health care,
ation in practice. Retrieved from www.rcgp.or-
research, and medical education: A cross-sectional
g.uk/gp-training-and-exams//media/Files/GP-
study. The Lancet, 380(9836), 37–43. doi:
training-and-exams/Curriculum-2012/RCGP-
10.1016/S0140-6736(12)60240-2
Curriculum-2-01-GP-Consultation-In-Practice.ashx
. Berkman, N. D., Sheridan, S. L., Donahue, K. E.,
. RCGP. Clinical example 3.01: Healthy people:
Halpern, D. J., Viera, A., Crotty, K.,. . .
Promoting health and preventing disease.
Viswanathan, M. (2011). Health literacy interven-
Retrieved from www.rcgp.org.uk/gp-training-and-
tions and outcomes: An updated systematic
exams//media/Files/GP-training-and-exams/
review. Evidence reports/technology assessments
Curriculum-2012/RCGP-Curriculum-3-01-Healthy-
no. 199. Rockville, MD: Agency for Healthcare
People.ashx
Research and Quality. Retrieved from
www.ncbi.nlm.nih.gov/books/NBK82434/
. Buck, D. & Frosini, F. (2012). Clustering of Acknowledgements
unhealthy behaviours over time. Implications for Professor Carolyn Chew-Graham (Professor of General
policy and practice. Retrieved from www.kingsfun- Practice Research, Keele University) and Dr Joanne
d.org.uk/publications/clustering-unhealthy-beha- Protheroe (Senior Lecturer in General Practice, Keele
viours-over-time University).

Dr Kay Benyon
Primary Care Academic Clinical Fellow, ST3, Keele University, Staffordshire
Email: kaybenyon@doctors.org.uk

440
........................