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Review

Health literacy

Ways to maximise the impact and effectiveness of vaccination information

Pages 2130-2135 | Published online: 11 Jul 2014

Abstract

Health literacy skills are cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health’. Patients use these literacy skills to critically analyze information; to allow them to exert greater control over life events and situations. An understanding of health literacy is also important for those developing and delivering healthcare programmes, especially vaccination programmes, as both the information and the actions required to use the information are complex requiring sophisticated health literacy skills beyond the capacity of a significant proportion of the population. There are simple steps which can be taken to make the information in vaccination materials easier to understand and use. The complex concepts of reading and numeracy skills in relation to health will be discussed and strategies described which can improve access to healthcare information for all patients, whatever their literacy level.

Introduction

Health literacy skills are ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health’Citation1. Health literacy skills can be conceptualized at various levels of complexity; however the most fundamental skills can be defined as ‘those basic skills in reading needed to be able to function in everyday (health) situations to access and use information’ i.e., functional health literacy.Citation1 To become and remain healthy citizens need a wide range of literacy and numeracy skills to promote health, protect personal and public safety, prevent disease, manage illness and navigate the health service.Citation2

Low health literacy is a public health problem; it reduces health and/or increases the levels and impact of illness while simultaneously affecting a significant proportion of the population. Lower functional health literacy skills are associated with lower levels of self-reported healthCitation3 and higher prevalence of long-term health conditions,Citation3 higher mortality in older people,Citation4-Citation6 greater use of medical services such as increased hospitalization and greater emergency care use,Citation7 poorer ability to interpret labels and health messages and demonstrate taking medications appropriately,Citation6,Citation8 and poorer ability to manage long-term illnesses such as heart failure and asthma.Citation9,Citation10 Health literacy also impacts on a persons’ ability to engage in preventative activities; there is evidence of lower involvement in cancer screening (colorectal,Citation11,Citation12 cervicalCitation13 and breast screeningCitation12,Citation14 and reduced uptake of influenza vaccination.Citation12,Citation14 Low health literacy is known to be a problem for a large proportion of the population. Reported levels of low health literacy vary according to the measures used, but in industrialized nations reported prevalence of low or ‘problematic’ health literacy is around 50%.Citation3,Citation15-Citation17 The situation is similar in England; when a range of health materials in common circulation were rated for the level of literacy and numeracy skills required to fully understand and use them, the literacy (text) component difficulty of the majority of materials was at the skills level expected to be achieved by English school students at age 14–16 y (National Qualifications Framework level 2: see ), while the numeracy component was at the skills level expected to be achieved by English school students at age 11–14 y (National Qualifications Framework level 1, ). Analysis of the most recent English national skills survey, undertaken on the English working age (16 – 65 y) population,Citation18 shows that 43% of working age adults do not have the literacy skills to fully understand and use the written (text) element of health materials in common circulation, this figure rises to 61% when text is combined with numerical concepts or calculations.Citation19 There is significant regional variation in the proportion of the population below these ‘health literacy thresholds’, with those in London and the North-East being at higher risk of low health literacy. Health literacy is associated with other social determinants of health; in particular older people and those from Black and Minority Ethnic Groups (with a first language other than English), in low grade employment (with low income) and living in more socio-economically deprived areas are at higher risk of being below the ‘health literacy threshold’Citation19. These groups are already at higher risk of poor healthCitation20 therefore understanding the issues raised by low health literacy can help to reduce health inequalities.

Table 1. English National Qualifications Framework (NQF)Citation18

Why health literacy is important in vaccination programmes

The complexity of vaccine information

Information about vaccination is inherently complex and consequently challenging to communicate to patients, particularly those with low literacy and numeracy. Patients need to have information about the disease or illness, the risks of contracting the condition, the risks of having the vaccination, and the potential risk of vaccination failure resulting in the patient contracting the condition anyway. There are three important elements to consider as vaccination information is developed and communicated; what are the overall literacy and numeracy skills of the patient, do they have marked variation in literacy and numeracy sub-skills (known as ‘spiky profiles’) and what cognitive skills are required for the patient to respond to the information?

Targeting resources toward patients with low health literacy and numeracy

When thinking about approaches to tailoring health information to patient health literacy and numeracy skills there are several approaches. The strongest predictor of functional health literacy and numeracy skills is the patient education level (in England this has a sensitivity of 59% and a specificity of 78%.Citation21 One option is thus to routinely collect data on qualification level at patient registration and tailor information to health literacy levels. Such questions are routinely asked for and so this approach is likely to be acceptable to patients. A second option is to ‘test’ patient health literacy levels, either before or during consultation. The Newest Vital SignCitation22 and the REALMCitation23 are quick measures which can be applied in clinical settings and have been validated for use in the UK.Citation24,Citation25 However, such an approach has the potential to distress patients particularly those with low literacy and numeracy due to the stigma attached.Citation26 Such approaches place the onus for successful communication of information on the patient rather than on the doctor or nurse. A better more inclusive approach is that of universal precautions, where information and services are developed to be accessible and understandable by people with low health literacy and numeracy.Citation27 shows the proportion of the English working age population at or above different literacy and numeracy levels; from this table it can be seen that producing information presented more simply greatly increases the proportion of the population able to understand and use it. Obviously a proportion of the population have more sophisticated language and numeracy skills, therefore simple and accessible materials can be supported by more complex information available to those who request it.

Table 2. Percentage of the English working age population at or above different literacy and numeracy skills levels

‘Spiky profiles’ and learning preferences

Literacy and numeracy skills are made up of ‘sub-skills’ using different cognitive processes. For literacy the sub-skills are reading comprehension, vocabulary, word recognition, comprehension and writing. For numeracy the sub-skills are numbers, shapes and space and data handling. Everyone has skills that are better in some areas than others and corresponding learning preferences (’spiky profiles’Citation18, for people at lower skill levels these are more marked. People with higher skills levels will generally be able to adapt to understand and use information presented in a non-preferred format, whereas people with lower skills will find this difficult or impossible to do.

Cognitive processing of information

Skills levels also impact on the extent of cognitive processing applied to information, as shown in Bloom’s Taxonomy of LearningCitation28 (). At the lowest skill level people may know, but not understand information. More sophisticated skills are required to apply knowledge in various settings and to be able to analyze the information ‘de novo’ rather than having to rely on pre-analyzed data. Being able to deconstruct and reconstruct information and to evaluate the relevance of information to oneself, one’s life and work environments requires the highest level cognitive skills. This is of importance in vaccination information, which requires cognitive processing at all these levels as patients must not just understand but evaluate and act upon vaccination information.

Figure 1. Bloom’s taxonomy of learningCitation28

Figure 1. Bloom’s taxonomy of learningCitation28

Making vaccine information easier to understand

For vaccine information to be accessible and useful for as many people as possible those producing vaccine information should take account of the literacy and numeracy level required to understand and use the materials. This should include the design and layout of the material, whether materials can be produced in varying formats to suit learning preferences and whether additional support is required in understanding and applying the information thus enabling patients to make decisions that are right for them.

Simple steps can be taken to reduce the literacy and numeracy difficulty of vaccine information. For text (literacy) information, the SMOG (simplified measure of gobbledygook) is a useful tool. Developed in the US.Citation29 It has now been applied to UK English.Citation30 The two major factors impacting on the readability are the number of syllables in each word, specifically the number of words with three or more syllables, and the sentence length. Short sentences and short words greatly increase the accessibility of information to people with lower skills levels. The SMOG test is available online (http://www.niace.org.uk/misc/SMOG-calculator/smogcalc.php#top) meaning that documents can be written, rewritten and simplified easily. The SMOG is however only a tool; it does not analyze the quality of the content - completely incorrect information can be written at a highly accessible level – but it is helpful when used well. In addition factors such as document layout, font size and word spacing can have a large impact on readability.Citation30 Communicating complex medical information in mono- and bi-syllabic words can be very challenging; how can one explain about illnesses such as meningococcal septicaemia without using these very complex words? Such ‘medical metalanguage’ is best managed by using the term once or twice early in a text, next to a simplified explanation, then referring back to the term with simpler language. In longer texts this can be repeated to refresh recognition of essential medical terms. (.)

Table 3. Making the literacy (text) element of materials easier to read

Unfortunately, no tools like the SMOG exist to assess and simplify the numeracy content of materials. There are, however, simple steps that can be taken to make the numeracy content of materials easier to understand. This is particularly important for vaccine information because of the need to convey complex numerical constructs such as risk. These difficulties are augmented by the fact that for 60% of people numeracy skills levels are lower than literacy skills.Citation18 Generally an individual’s numeracy skills decline faster than literacy skills as many people do not routinely use numeracy skills in everyday life. Finally, large numbers (over 1,000) are difficult for people to conceptualize. Steps to increasing the accessibility of the numeracy components of materials are shown in . Key points are to avoid numbers wherever possible, to reduce the number of calculations required to zero or 1 by using absolute values (i.e., avoiding decimals and fractions) and giving real-life examples rather than abstract concepts. As with the text component of materials, using larger clearer fonts, spacing and increasing the amount of white space may help to keep numerical information clear. Following these suggestions will mean that understanding will be improved for many people, enabling them to undertake more sophisticated cognitive processing such as applying the information to their situation and evaluating different sources and types of information. Having information available in different formats (such as graphs, pictographs, video and audio formats) may be helpful for people with lower numeracy skills, who can then choose the format they find most helpful.

Table 4. Making the numeracy element of materials easier to understand

Finally, written information should always be supported by the practitioner checking the patients’ understanding. The ‘teach back’ technique is a good exampleCitation31; the practitioner uses a phrase such as ‘let me see if I’ve explained this clearly enough. Can you tell me the benefits to you if you have this injection?’ The emphasis should always be that teach back tests the practitioner communication skills, not the patient health literacy skills.

Building public health literacy skills

Teaching basic skills to adults is a highly specialized field outside both the skill-sets and time constraints of health professionals. However health professionals aware of the issues of health literacy may, through their clinical work, be able to identify patients with low literacy and numeracy skills who would benefit from opportunities to build their health literacy skills. Good health is important to everyone and thus is an excellent ‘hook’ to get people engaged in learning literacy and numeracy. Furthermore, the skills learned are likely to be highly transferable to other areas of life such as management of personal finances. Learning outcomes from such programmes include increased health knowledge, improved health behaviors, and engagement in further learning, including studying for qualifications.Citation32 In vaccination clinics, sensitivity to the issues involved, and engagement with local education services, means that patients who might benefit from developing health, and wider, literacy and numeracy skills can be supportively referred to appropriate education courses.

Potential impact on participation in vaccination programmes

The known association between low health literacy and low rates of involvement in vaccination programmes implies that simplifying vaccine information and building patient health literacy skills should lead to higher vaccination rates, but such interventions may have unexpected outcomes. There has been little high quality research published in this area,Citation6 however a well-designed Australian randomized controlled trial looked at the effect of a carefully designed decision aid focusing on the benefits and risks of Colorectal Cancer (CRC) Screening, when this was sent out with the CRC screening kit it increased knowledge and informed choice but decreased participation in screening.Citation33 Decisions about participation in preventative health actions are complex and will reflect not only the extent to which individuals can understand the information, but also issues of self-efficacy, locus of control, previous experiences (personally or of family and friends) and cultural influences. Interventions designed to improve participation may need to look different to interventions designed to improve knowledge and inform choice. A potential solution to this could be the theoretical construct ‘critical health literacy’, defined by Nutbeam as ’more advanced cognitive skills that, together with social skills, can be applied to critically analyze information, and to use this information to exert greater control over life events and situations’Citation34. Nutbeam goes on to postulate that developing higher-level health literacy skills will have social benefits and the development of social capital. It could be that by clearly outlining the benefits and risks to the individual, their friends, families and communities (i.e., the risk of infectious disease outbreaks if immunization rates (herd immunity) drop below critical levels) about the benefits of immunization, may lead to more informed decisions, resulting in higher participation rates.

Conclusion

Health literacy is a complex concept, ranging from basic skills in reading and numeracy through to advanced cognitive skills needed to critically analyze information, and to use this to exert greater control over life events and situations. Health literacy is important for those developing and delivering vaccination programmes, as both the information and the actions required to use the information are complex requiring sophisticated health literacy skills beyond the capacity of a significant proportion of the population. However, simple steps can be taken to make the information in vaccination materials easier to understand and use. Materials should be produced at as simple literacy and numeracy level as possible, with more detailed and sophisticated material available for those wanting more detailed information. Those with lower skills should be offered alternative information formats or longer 1:1 consultation time. Techniques such as ‘teach-back’ can be used to check that information has been successfully communicated and understood.

In the course of their work, those administering vaccines will identify patients with low health literacy skills. Such health professionals are in an ideal position to inform patients about local opportunities to develop literacy and numeracy skills for health and multiple other areas in life. Developing partnerships between health professionals and adult learning tutors can lead to fruitful partnerships for both.

Finally, while developing and using health information which is easier to use and understand must be best for patients, and will improve informed consent, it may have unintended consequences on participation rates. Widening information and discussions beyond individual benefits and risks, to include consequences to families, communities and the wider society may help to redress this.

Abbreviations:
CRC=

Colorectal Cancer

NQF=

National Qualifications Framework

SMOG=

simplified measure of gobbledygook

AUTHOR PLEASE PROVIDE SUBMITTED/ACCEPTED DATES

10.4161/hv.29603

References

  • Nutbeam D. Health Promotion Glossary. Health Promot Int 1999; 13:349 - 64
  • Rudd R, Kirsch I, Yamamoto K. Literacy and Health in America. Princeton, NJ: Education Testing Service 2004. Accessed at: http://www.ets.org/Media/Research/pdf/PICHEATH.pdf
  • HLS-EU Consortium. Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012. Accessed at: http://ec.europa.eu/eahc/documents/news/Comparative_report_on_health_literacy_in_eight_EU_member_states.pdf
  • Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ 2012; 344:e1602; http://dx.doi.org/10.1136/bmj.e1602; PMID: 22422872
  • Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med 2007; 167:1503 - 9; http://dx.doi.org/10.1001/archinte.167.14.1503; PMID: 17646604
  • Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Mar. (Evidence Reports/Technology Assessments, No. 199.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK82434/
  • Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005; 118:371 - 7; http://dx.doi.org/10.1016/j.amjmed.2005.01.010; PMID: 15808134
  • Zhang NJ, Terry A, McHorney CA. Impact of health literacy on medication adherence: a systematic review and meta-analysis. Ann Pharmacother 2014; 48:741 - 51; http://dx.doi.org/10.1177/1060028014526562; PMID: 24619949
  • Murray MD, Tu W, Wu J, Morrow D, Smith F, Brater DC. Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clin Pharmacol Ther 2009; 85:651 - 8; http://dx.doi.org/10.1038/clpt.2009.7; PMID: 19262464
  • DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr 2007; 7:25 - 31; http://dx.doi.org/10.1016/j.ambp.2006.10.001; PMID: 17261479
  • Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med 2008; 66:1809 - 16; http://dx.doi.org/10.1016/j.socscimed.2008.01.003; PMID: 18295949
  • White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: a national study. Am J Health Behav 2008; 32:227 - 42; http://dx.doi.org/10.5993/AJHB.32.3.1; PMID: 18067463
  • Garbers S, Chiasson MA. Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City. Prev Chronic Dis 2004; 1:A07; PMID: 15670438
  • Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med 2009; 7:204 - 11; http://dx.doi.org/10.1370/afm.940; PMID: 19433837
  • Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav 2007; 31:Suppl 1 S8 - 18; http://dx.doi.org/10.5993/AJHB.31.s1.3; PMID: 17931141
  • Health Literacy in Canada. A Healthy Understanding. Canadian Council on Learning, 2008. Accessed at: http://www.ccl-cca.ca/pdfs/HealthLiteracy/HealthLiteracyReportFeb2008E.pdf
  • Literacy H. Australia. Canberra: Australian Bureau of Statistics, 2006. Accessed at: http://www.abs.gov.au/AUSSTATS/[email protected]/Latestproducts/4233.0Main%20Features22006
  • The 2011 Skills for Life Survey: A Survey of Literacy, Numeracy and ICT Levels in England. London: Department for Business Innovation and Skills 2012. BIS Research paper number 81. Accessed at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/36000/12-p168-2011-skills-for-life-survey.pdf
  • Rowlands G, Protheroe J, Richardson M, Seed P, Winkley J, Rudd R. Defining and describing the mismatch between population health literacy and numeracy and health system complexity. In progress; data on file at King's College London.
  • Fair Society. Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010 (The Marmot Review), February 2010. Accessed at: http://www.ncb.org.uk/media/42195/marmotreview_vssbriefing.pdf
  • Rosenkilde KL, Protheroe J, Seed P, Wolf MS, Rowlands G. Estimating Health Literacy levels from National Surveys. In progress. 2014.
  • Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005; 3:514 - 22; http://dx.doi.org/10.1370/afm.405; PMID: 16338915
  • Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, Crouch MA. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med 1993; 25:391 - 5; PMID: 8349060
  • Rowlands G, Khazaezadeh N, Oteng-Ntim E, Seed P, Barr S, Weiss BD. Development and validation of a measure of health literacy in the UK: the newest vital sign. BMC Public Health 2013; 13:116; http://dx.doi.org/10.1186/1471-2458-13-116; PMID: 23391329
  • Ibrahim SY, Reid F, Shaw A, Rowlands G, Gomez GB, Chesnokov M, Ussher M. Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease. J Public Health (Oxf) 2008; 30:449 - 55; http://dx.doi.org/10.1093/pubmed/fdn059; PMID: 18660507
  • Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Couns 1996; 27:33 - 9; http://dx.doi.org/10.1016/0738-3991(95)00787-3; PMID: 8788747
  • DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, et al. Health Literacy Universal Precautions Toolkit. Rockville MD: Agency for Healthcare Research and Quality, 2010.
  • Bloom B. Taxonomy of Educational Objectives: Cognitive and Affective Domains. New York: David McKay Company Inc; 1956 & 1964.
  • McLaughlin GH. SMOG Grading–a New Readability Formula. J Read 1969; 12:639 - 46
  • Readability: how to produce clear written materials for a range of readers. Leicester, UK: NIACE; 2009.
  • Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman AB. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003; 163:83 - 90; http://dx.doi.org/10.1001/archinte.163.1.83; PMID: 12523921
  • Evaluation of the second phase of the Skilled for Health Programme. London: The Tavistock Institute and Shared Intelligence, 2009. Accessed at: http://www.chlfoundation.org.uk/pdf/Skilled_for_health_evaluation.pdf.
  • Smith SK, Trevena L, Simpson JM, Barratt A, Nutbeam D, McCaffery KJ. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. BMJ 2010; 341:c5370; http://dx.doi.org/10.1136/bmj.c5370; PMID: 20978060
  • Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000; 15:259 - 67; http://dx.doi.org/10.1093/heapro/15.3.259

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