Describing concept of health literacy
Health literacy is defined as ‘achievement of a level of knowledge, personal skills, and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions’ (WHO, n.d.). The other definition is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decision (Ratzan & Parker, 2006). It is considered that from patient perspective, it is the ability to obtain, understand and act on health information. Meanwhile, for healthcare facilities, it is capacity to communicate clearly, educate about health, and empower their patients.
The Paache-Orlow & Wolf’s theory indicates that a person’s medical knowledge is distributed by individual (age, education, sight, hearing, speech, memory, and analytic factors) and sociocultural factors (occupation, income, social support, culture, language). Medical knowledge is the personal property of the patient, the knowledge that the patient acquires over time, and through which the patient also reflects the policies and practices of the health operating system. Medical literacy influences patient health outcomes through access to and use of services, provider-patient interaction, and self-care. (Paasche-Orlow & Wolf, 2007.)
Current evidence indicates that although they are correlated, health literacy (HL) and patient activation (PA) are distinct. HL, PA, and their determinants intersect and diverge and how these concepts might inform the development of self-management interventions were investigated based on reviewing relevant literature (Yadav et al., 2019). Previous researchers have identified determinants of low HL including age, educational attainment and socioeconomic status, culture beliefs and practices, and communication skills (including language barriers) between professionals and patients. This directly affects individual decisions, actions and their lifestyle behaviours and plays a key role in the prevention and management of chronic illness. PA refers to the knowledge, skills, and confidence a person has in managing their own health and care. Activation involves four stages (1) believing in the patient role, (2) building patient confidence and knowledge for self-care, (3) taking action to maintain and improve one’s health and (4) staying the course even under stress. Measurement of PA informs how tailoring confidence building strategies have succeeded. Previous research has reported that symptom burden, illness perception, presence of comorbidities, age, body mass index, physical health status, depression, social support, financial distress, and lack of understanding their role in care process were independently associated with lower PA in e.g., COPD patients. (Yadav et al., 2019.)
The concepts of HL and PA contribute to self-management interventions in different ways. HL includes the skills and confidence required for self-management while PA focuses more on motivation and ability to act. In this light, communication of concepts on HL and PA needs to be more widely understood by academics, researchers, and policy experts as each of them plays a unique role in promoting self-management for chronic conditions. Both PA and HL are necessary in self-management intervention as each of them has unique roles in improving the patients’ behaviour for management of their chronic conditions. (Yadav et al., 2019.)
Influence of health literacy on self-management of non-communicable diseases
Conceptual framework on HL of diabetes self-management describes HL affecting sociocognitive determinants: knowledge, understanding, beliefs and attitude within motivational phase and self-efficacy as well as social support within action control. System factors, such as healthcare costs and accessibility to information affect other sociocognitive determinants together with the HL. The sociocognitive determinants in turn affect the diabetes self-management and further the glycaemic control (von Wagner et al., 2009.) Yadav et al. (2019) have distinct perception, seeing the sociodemographic variables, including skills, culture, belief, and practices as factors affecting person’s HL. They also separated skills construction under domain of HL, and mindset of construction with motivation and care-confidence under influence of PA rather than HL. Both aspects affect the self-management of COPD. (Yadav et al., 2019.)
Koh, Brach, Harris and Parchman (2013) proposed a HL care model that would constitute a systems approach to improve patients’ engagement in their care. This 20-item Health Literate Care Model (HLCM) begins with team formation, practice assessment and awareness raising. It contains interaction methods such as communicating clearly, the teach-back method, encouragement for questions, follow-up with patients and culture as well as language difference considerations. Also, it includes easy-to-read material design, effective use of health education materials and materials on how to improve medication adherence and review of brown bag medication (reviewing patients’ use of medication and identifying medicine errors and misunderstandings). In addition, model ensures making of action plans, using health and literacy resources in the community, linking patients to nonmedical support, and getting patients’ feedback. (Koh et al., 2013.)
Studies on how HL affects to self-management among NCD patients reveal association between HL level and level of self-management, health, and wellbeing. The results with diabetic patients suggest that HL may be indirectly related to patient health and well-being outcomes through psychosocial factors, communication with doctors, and self-management behaviour. Higher HL had significant positive effects on understanding of diabetes care, self-efficacy, communication with doctors, and medication adherence. In addition, HL might have a positive influence on exercise and diet through self-efficacy. Improving HL may lead to better self-management and improved health and well-being outcomes, although the impact of improvements in HL may be determined by the relationship between a patient’s HL level and the understandability of the information provided. (Ueno et al., 2019.)
African American asthma patients with poor HL had also poor medication recall and knowledge of co-pay requirements. They had less ability to provide information needed for a medical visit about a persistent cough unresponsive to medication. Patients with poor HL had a poor inhaler technique and limited understanding of inhaled corticosteroid function, as well as limited numeracy and print literacy. (Perez et al., 2016.) However, association of HL level and health behavior is not straight forward. In a cross-sectional study in an urban community in Thailand, one-quarter of the patients with poorly controlled blood pressure had good levels of health knowledge and HL and nearly half had good health self-care literacy but only 13% exhibited adequate self-management behaviors (Visanuyothin et al., 2019a).
HL affects in individual, family, and community level and therefore, it is essential to provide multi-dimension and multidisciplinary interventions to improve HL. Facilitators and barriers affecting COPD self-management in Nepal existed at the patient-family, community, and service provider levels. At the community level, widespread use of complementary and alternative treatment was found to be driven by social networks and was used instead of western medicine. Also, limited primary level healthcare providers’ skills and lack of educational materials for COPD to promote HL and self-management affected at the community levels. (Uday Narayan et al., 2020).
Self-management interventions in low income or low HL populations with chronic illness were found to be most effective when three to four self-management skills are utilized, particularly when problem-solving is targeted (Schaffler et al., 2018). Similarly, an integrated intervention program for primary care patients with e.g., poorly controlled hypertension residing in an urban community of Thailand, resulted to be significantly effective in increasing knowledge and self-management behaviours (Visanuyothin et al., 2019b). Also, the results in the study on barriers of diabetes self-management support health education on lifestyle modifications to be tailor made taking into consideration family and social background and self-management among people with NCD (Anitha & Vanishree, 2019.)
Anitha, R. M., & Vanishree, S. (2019). Are Patients With Type 2 Diabetes Not Aware or Are They Unable to Practice Self-Care? A Qualitative Study in Rural South India. Journal of Primary Care & Community Health, 10. http://dx.doi.org/10.1177/2150132719865820
Koh HK, Brach C, Harris LM, Parchman ML. (2013). A proposed ‘health literate care model’ would constitute a systems approach to improving patients’ engagement in care. Health Aff (Millwood). Feb;32(2):357-67. doi: 10.1377/hlthaff.2012.1205. PMID: 23381529; PMCID: PMC5102011
Paasche-Orlow, M., & Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes. American Journal of Health Behavior, 31, S19-26. https://doi.org/10.5993/AJHB.31.s1.4
Perez, L., Morales, K. H., Klusaritz, H., Han, X., Huang, J., Rogers, M., . . . Apter, A. J. (2016). A health care navigation tool assesses asthma self-management and health literacy. Journal of Allergy and Clinical Immunology, 138(6), 1593-1599. http://dx.doi.org/10.1016/j.jaci.2016.08.043
Ratzan SC, Parker RM. (2006). Health literacy – identification and response. J Health Commun.11(8):713-5. doi: 10.1080/10810730601031090. PMID: 17190778.
Schaffler, J., Leung, K., Tremblay, S., Merdsoy, L., Belzile, E., Lambrou, A., & Lambert, S. D. (2018). The Effectiveness of Self-Management Interventions for Individuals with Low Health Literacy and/or Low Income: A Descriptive Systematic Review. Journal of General Internal Medicine, 33(4), 510-523. http://dx.doi.org/10.1007/s11606-017-4265-x
Uday Narayan, Y., Lloyd, J., Hosseinzadeh, H., Kedar Prasad, B., Dahal, S., Bhatta, N., & Mark Fort, H. (2020). Facilitators and barriers to the self-management of COPD: a qualitative study from rural Nepal. BMJ Open, 10(3). http://dx.doi.org/10.1136/bmjopen-2019-035700
Ueno, H., Ishikawa, H., Suzuki, R., Izumida, Y., Ohashi, Y., Yamauchi, T., . . . Kiuchi, T. (2019). The association between health literacy levels and patient-reported outcomes in Japanese type 2 diabetic patients. Sage Open Medicine, 7. http://dx.doi.org/10.1177/2050312119865647
Visanuyothin, S., Plianbangchang, S., & Somrongthong, R. (2018a). Appearance and potential predictors of poorly controlled hypertension at the primary care level in an urban community. Journal of Multidisciplinary Healthcare, 11, 131-138. http://dx.doi.org/10.2147/JMDH.S156518
Visanuyothin, S., Plianbangchang, S., & Somrongthong, R. (2018b). An integrated program with home blood-pressure monitoring and village health volunteers for treating poorly controlled hypertension at the primary care level in an urban community of Thailand. Integrated Blood Pressure Control, 11, 25-35. http://dx.doi.org/10.2147/IBPC.S160548
von Wagner, C., PhD, Steptoe, A., D.Sc, Wolf, M. S., PhD., & Wardle, J., PhD. (2009). Health literacy and health actions: A review and a framework from health psychology. Health Education and Behavior, 36(5), 860. http://dx.doi.org/10.1177/1090198108322819
WHO, World Health organization. (n.d.). Improving health literacy. Retrieved 22.4.2022 from https://www.who.int/activities/improving-health-literacy/improving-health-literacy
Yadav, U. N., Hosseinzadeh, H., Lloyd, J., & Harris Mark, F. (2019). How health literacy and patient activation play their own unique role in self-management of chronic obstructive pulmonary disease (COPD)? Chronic Respiratory Disease, 16. http://dx.doi.org/10.1177/1479973118816418