Health Literacy: the forgotten social determinant of health? Save

Nine out of ten adults in the USA struggle to understand basic health-related information (1). Across the pond, in the UK, 7.1 million adults read at, or below, the level of a nine-year-old, with 60% unable to understand health information (2). There is a health literacy crisis globally, yet, relatively little research and relatively few interventions have been implemented in order to address this.

With an increasing prevalence of multimorbidity and chronic conditions, it is more important than ever to ensure patients have access to appropriate, clear and understandable health information. This is especially true for rheumatic diseases, which are not only chronic conditions with complex pathology, but are also treated with complex medications with aspects such as the requirement for regular monitoring and often tailored dosing regimens.

Health literacy is the “the ability of individuals to ‘gain access to, understand and use information in ways which promote and maintain good health’ for themselves, their families and their communities” (3, 4). Thus, health literacy refers to a concept which transcends simply being able to read medical information or make and attend clinic appointments, for example. Additionally, while it is related to an individual’s educational level, health literacy is a distinct entity (5).

An increasing body of research in rheumatic diseases has sought to understand the impact of health literacy, long neglected as a social determinant of health, on clinical and non-clinical outcomes over the last decade. Several abstracts at this year’s ACR Convergence focus on this topic.

One such work is abstract 1913, a systematic literature review assessing the association between health literacy and outcomes in people with inflammatory arthritis. The team identified 3087 articles from their initial search, of which 29 were ultimately included. A striking finding was the vast heterogeneity with which health literacy was measured across the studies. The most frequent were the Test of Functional Health Literacy in Adults (short and long form; n=13); Single Item Literacy Screener (n=10); and Rapid Estimate of Adult Literacy in Medicine (n=6). Interestingly, the longer questionnaires featured in noticeably fewer articles, such as the 44-question Health Literacy Questionnaire which was used in just two.

Outcomes were also, as expected, markedly varied, covering a range of clinical and non-clinical aspects, ranging from disease activity, quality of life and pain, to medication adherence and use of the Internet and telehealth. Outcomes were determined using a vote-counting exercise, and ultimately six associations were identified. Low health literacy was associated with greater disease activity; greater disability and lower function; greater mental health symptoms (including depression and anxiety); greater healthcare and medication use; lower medication adherence; lower use of the Internet, telehealth and technology.

So, why does this matter?

Let us return to the start of this article. 90% of adults in the USA cannot understand basic healthcare information. We, as health professionals, can and must do better to ensure our patients have the tools and knowledge they require to make good healthcare decisions, especially given the chronic nature of rheumatic diseases.

Providing reliable health information in accessible formats for patients, carers and their families can help people make better decisions about their health and take an active part in planning their own care.  An increased knowledge of their conditions can also have a huge impact on how patients accept and respond to treatment, as well as manage their long-term condition. This will require many initiatives, including radical changes in current healthcare policy and attempts to address health literacy in healthcare systems which are already stretched and under significant pressure.

Nonetheless, increased awareness of health literacy can go one step further to ensuring we can overcome this crisis, and ensure it is not left behind in our efforts to address social determinants of health.

References

1. Health Literacy Fact Sheets Center for Health Care Strategies2024 [Available from: https://www.chcs.org/resource/health-literacy-fact-sheets/.

2. Local action on health inequalities: Improving health literacy to reduce

health inequalities. Public Health England; 2015.

3. Health Literacy World Health Organization [Available from: https://www.who.int/teams/health-promotion/enhanced-wellbeing/ninth-global-conference/health-literacy.

4. Nutbeam D. Health Promotion Glossary. Health Promotion International. 1998;13(4):349-64.

5. Jansen T, Rademakers J, Waverijn G, Verheij R, Osborne R, Heijmans M. The role of health literacy in explaining the association between educational attainment and the use of out-of-hours primary care services in chronically ill people: a survey study. BMC Health Services Research. 2018;18(1).