Abstract
Aim:
Health literacy (HL) is a multifaceted concept, thus understanding the perspective of healthcare providers, patients, and the system is vital. This systematic review examines and synthesises the available studies on HL-related knowledge, attitude, practice, and perceived barriers.
Methods:
CINAHL and Medline (via EBSCOhost), Google Scholar, PubMed, ProQuest, Sage Journals, and Science Direct were searched. Both quantitative and/or qualitative studies in the English language were included. Intervention studies and studies focusing on HL assessment tools and prevalence of low HL were excluded. The risk of biasness reduced with the involvement of two reviewers independently assessing study eligibility and quality.
Results:
A total of 30 studies were included, which consist of 19 quantitative, 9 qualitative, and 2 mixed-method studies. Out of 17 studies, 13 reported deficiency of HL-related knowledge among healthcare providers and 1 among patients. Three studies showed a positive attitude of healthcare providers towards learning about HL. Another three studies demonstrated patients feel shame exposing their literacy and undergoing HL assessment. Common HL communication techniques reported practiced by healthcare providers were the use of everyday language, teach-back method, and providing patients with reading materials and aids, while time constraint was the most reported HL perceived barriers by both healthcare providers and patients.
Conclusion:
Significant gaps exists in HL knowledge among healthcare providers and patients that needs immediate intervention. Such as, greater effort placed in creating a health system that provides an opportunity for healthcare providers to learn about HL and patients to access health information with taking consideration of their perceived barriers.
Introduction
Health literacy (HL), commonly cited as individuals’ ability to read, understand, and apply health information to make healthcare-related decisions, 1 is increasingly gaining recognition as a critical determinant of patients’ health outcomes. Patients with limited health literacy (LHL) were often linked with difficulty in managing chronic diseases, 2 lower rate of medication adherences,3,4 increased emergency care use, and risk of hospitalisation.3,5,6
Prevalence of LHL is considerably high in developed countries like the United States, Europe, and Australia.7–9 In the United States, 26% of the population has difficulty with common health tasks such as complying with directions of medication administration and appointment dates, filling out forms, and understanding health information. 7 The European Health Literacy Survey (HLS-EU) reports the prevalence of LHL between 29% and 62% among eight European countries, 8 whereas the Australian adult literacy and life skills survey shows more than half of the respondents have less than minimum life skill. 9
Many countries have recognised the impact of HL on the health system, and considerable efforts are made to address this silent epidemic. International collaboration, national policy, and legal regulations are some steps taken to reduce the risk of LHL (European Commission 2013; World Health Organization 2011). HL is multifaceted, involving participation of not only the healthcare providers (HCPs) or the healthcare system but also patients and other supporting organisations. Therefore, the key to effectively address issues of HL is through an overall understanding of HL from the perspective of HCPs and patients, which this article aims to provide. A systematic review was conducted on available studies that report on HL-related knowledge, attitude, practice, and perceived barriers. Insight into this valuable information will be an important step to help policy makers and stakeholders to take active measures to address HL issues, which will subsequently optimise patient care and health outcomes.
Methods
Search protocol
This systematic review was developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. 10 An extensive search of literature published from 1990 to February 2016 was undertaken using electronic databases: CINAHL and Medline (via EBSCOhost), Google Scholar, PubMed, ProQuest, Sage Journals, and Science Direct. Some of the keywords used were ‘health literacy’ and ‘low health literacy’ combined with other terms such as ‘practice’, ‘knowledge’, ‘attitude’, ‘barriers’, ‘communication’, ‘techniques’, ‘perception’, ‘perspective’, ‘understanding’, ‘health system’, and ‘impact’. In addition, the bibliography of retrieved articles was screened for relevant titles.
Study selection
All studies were screened initially for title and abstract by the main reviewer (R.R.) for any duplication. The reviewer further assessed publication titles and abstracts against pre-determined inclusion and exclusion criteria. A second reviewer (M.K.K.) independently assessed the included abstracts for eligibility, and any disagreements were discussed until consensuses were reached.
Inclusion criteria comprised the following: (1) articles published in the English language; (2) studies that contained both qualitative and/or quantitative descriptions of HL-related knowledge, attitude, practice, and perceived barriers. No restriction was placed to include only those studies reporting all our outcomes, but studies that provide useful data for any of these findings were included.
Exclusion criteria comprised the following: (1) interventional studies on HL and health HL outcome studies; (2) studies investigating HL assessment tools and prevalence of LHL; and (3) editorials, reviews, notes, comments, conference proceedings, and letters.
The main focus of this systematic review was on functional HL, which is defined as a skill to read, understand, and comprehend medical information and instructions. 11
Quality assessment
Quality assessment of eligible studies was performed independently using a set of quality criteria by two reviewers (R.R. and L.C.J.). 12 Discussion resolved disagreements between the reviewers, and the third reviewer (M.A.A.H.) was involved when necessary. A total of 16 items for qualitative studies which include 8 items for each section of reporting clarity and robustness of the study methods, respectively; meanwhile, 13 items for quantitative studies with 8 items for reporting clarity and 5 items for robustness of the study methods were determined. A score of 1 is given if the specific criteria are met and 0 if not met. Items that are not applicable were excluded from the final score. Qualitative studies were categorised as high quality if they met 13 or more criteria and medium quality if met between 10 and 12 criteria. Quantitative studies were categorised as high quality if they met 11 or more criteria and medium quality if they met 10 criteria. Mixed-method studies were assessed by quantitative and qualitative study items separately and then determined whether both aspects of qualitative and quantitative studies are met.
Synthesis of results
A narrative synthesis was adapted to analyse the studies due to their methodology heterogeneity, which includes study types, population, and research questions. The data extracted were categorised into four outcomes addressing our research questions: HL knowledge, attitude, practice, and perceived barriers. HL knowledge was further classified into basic facts of HL, consequences of HL, and HL screening knowledge. For this review purpose, attitude towards HL was defined as the opinion of HCPs or patients about HL screening and intervention. HL practice was classified as a screening of HL and application of HL strategies or communication in the LHL population. Perceived barriers were defined as factors hindering HL screening and implementation of HL strategies from the perspective of HCPs and patients.
Results
The initial database search yielded 307 studies, of which 30 studies consisting of 19 quantitative studies, 9 qualitative studies, and 2 mixed-method studies met the selection criteria and were included in the final analysis. Figure 1 describes the flow of studies through searching and screening for inclusion by the PRISMA guideline.
Flow chart for study screening and selection according to PRISMA guidelines.
Study characteristics
Of the reviewed 19 quantitative studies, 11 were rated as high quality, and 8 studies were rated as medium quality. Of the nine qualitative studies, four studies were rated as high-quality and five studies were categorised as medium quality. Both the mixed-method studies fulfilled the criteria for high-quality studies for both the qualitative and quantitative aspects. Table 1 provides a summary of included studies characteristics and quality assessment.
Summary of included studies and quality assessment
HL: health literacy; REALM: Rapid Estimate of Adult Literacy in Medicine; TOFHLA: Test of Functional Health Literacy; COPD: chronic obstructive pulmonary disease; CKD:Chronic Kidney Disease; ED:Emergency Department.
HL-related knowledge
The review identified and categorised HL-related knowledge into basic facts of HL, knowledge of HL or LHL consequences, and knowledge of HL screening. As for the basic fact of HL, the majority of studies reported that HCPs had inadequate knowledge and understanding of HL definition,22,23,34,37,41 and only qualitative study results support that HCPs demonstrated adequate knowledge in defining HL. 35 The prevalence of LHL was mostly responded incorrectly by HCP.14,16,18,22 Overall, the major factors perceived by HCPs to determine patients’ HL were socioeconomic characteristics,21–23 age,22,23 and education level.14,18,22,23 As for knowledge about consequences of HL and LHL, both patients and HCPs agreed upon the impact of HL on disease management, improving patient outcomes, and delivery of health information. 21 Besides studies reviewed reported the majority of HCPs acknowledging the consequences of LHL.14,15,28,29,37,38,42,43 These comprise the ability to understand information, obtain appropriate health services, follow through with recommended treatments, adhere to medication instructions, manage treatment adverse events, and assess preventive health screening. Contrary to this finding, two quantitative studies have found that a relatively lower percentage of HCPs believed HL interferes with patients’ ability to obtain health information (48%) 23 and as an obstacle in their practice (32%). 27 For the category of knowledge on HL screening, two quantitative studies reported a lack of HCPs’ familiarity with the HL assessment tools of the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy (TOFHLA).15,28 However, HCPs were reported adequately knowledgeable of recognition of low HL behaviour and higher risk groups.16,18,41,42 High awareness about HL screening improving healthcare teaching to patients was demonstrated by one quantitative study conducted among 360 senior nursing students, 16 and the majority of the same population showed a sound knowledge of the effective HL screening approach. 28
Attitude towards HL
Generally, positive attitudes were demonstrated by HCPs in learning more about HL and training to provide effective communication to LHL patients.21,27,29 As for screening of patients’ HL using an objective HL assessment tool, a mixed attitude was reported. A study found that the majority (92%) of respondents were interested in conducting formal HL assessment, 21 whereas overestimation of patients’ HL due to the use of subjective assessment was reported in another study among nurses. 19 Only one study reported on HCPs attitude towards HL intervention that is low percentage (14%) of HCPs believed HL intervention programme was beneficial. 23
A qualitative study exploring difficulties faced by patients dealing with the healthcare system identified patients’ deep sense of shame and embarrassment upon the need to reveal their reading problems to HCPs. 32 Similarly, a quantitative study reported that almost half (47.8%) of the patient population reading at or below third-grade level admitted feeling shame and embarrassment about their reading difficulties. 31 Over two-thirds (67.2%) of these patients never even told their spouse. Negative attitudes like anxiety and stress were also shown by patients towards HL screening, even though the majority of patients acknowledge the importance of HCPs being aware of their reading abilities and having their literacy documented in their medical records. 20
The practice of HL
The practice of HL was categorised into HL communication techniques and HL screening. Table 2 summarises the HL communication techniques used by HCPs in the reviewed studies.
A summary of health literacy communication reported in the studies
HL: health literacy.
As for HL screening, HCPs were reported not utilising HL assessment tools to determine patients’ HL.21,23,27,43 Several studies reported that HCPs often depend on their gut feelings to determine patients’ HL.23,27,43 The majority of the HCPs claimed to have not received any formal training about HL13,43 and less than 10% felt confident about their HL knowledge or skills to identify LHL patients. 13
Perceived barriers towards HL
HCPs’ perspective
Three main categories of perceived barriers identified from the perspective of HCPs were healthcare system barriers, patient-related barriers, and HCP-related barriers. At the top of the list of healthcare system–related perceived barriers was time constraint. Four quantitative studies and three qualitative studies have highlighted this barrier.18,21,23,29,35,39,40 This is followed by the lack of educational materials or resources to address patients with LHL, as reported by two quantitative and four qualitative studies, respectively.21,29,34,37,39,40 Only one quantitative and three qualitative studies showed a lack of organisational/leadership support.23,35,37–39 As for patient-related factors, their language especially non-English-speaking patients were HCPs’ main perceived barriers towards improving patients’ HL, besides patients’ culture and socioeconomic status.18,34,39,40 Patients’ characteristics, such as their education level, 35 age, 34 and attitudes like self-consciousness and feeling shame,35,42 are some other perceived barriers raised by HCPs.34,39,40 In the category of HCP-related barriers, almost 50% of HCPs agreed on the lack of commitment to enhance HL. 18 Three quantitative studies reported their lack of knowledge and skills as barriers towards HL.18,21,23 Two qualitative studies have identified a lack of trust and rapport between HCPs and patients as a barrier to good health information delivery to patients.34,40 Besides, three other studies supported the claim by HCPs on the lack of reliable and flexible HL assessment tools.17,21,23
Patients’ perspective
Only three qualitative studies have explored perceived barriers towards HL from patients’ perspective.33,35,36 Some of the findings by Jordan et al. 33 are lifestyle commitment, education, and socioeconomic background and family support. 33 The use of medical jargon by HCPs and time constraints were reported in all the three studies.33,35,36 Table 3 provides a detailed summary of the perceived barriers from HCPs’ and patients’ perspective.
A summary of the perceived barriers from healthcare providers’ and patients’ perspective
HL: health literacy.
Discussion
This study is the first of its kind to synthesise the available literature on HL-related knowledge, attitudes, practice, and perceived barriers to provide an overview of HL from all aspects, especially the main players in the system, HCPs, and patients.
Quality assessment revealed the majority (60%) of the studies fulfilled the determined quality criteria. This suggests that the overall quality of the studies included in this review was at an acceptable level. However, there were some weaknesses identified, especially regarding the robustness of both the qualitative and quantitative studies. Most of the qualitative studies failed to provide information relating to the comprehensiveness of sampling strategy and the reliability of the data collection methods. While for quantitative studies, the majority failed to provide data on the sufficiency of the sample size and response rate, undermining the representability of the study findings. In the aspect of clarity, two criteria were not fulfilled by some of the qualitative studies. These include insufficient data provided to describe the design of the study to achieve the study goals and strategies involved to recruit the sample. Assessment of the quantitative studies showed that some failed to provide an adequate description of the study population and lacked clarity in the data analysis method. Future research in the same field should take measures to address the aspect highlighted in the studies.
HCPs’ lack of awareness of HL definition and understanding of the concept presents a huge deterrent towards establishing HL in the healthcare system. Clearly, HCPs must be trained in HL, and there is no better way than integrating a HL course in their curriculum and/or during residency. Numerous studies have shown the positive outcome of such exposure to HCPs.44–46 Apart from HCPs, a great knowledge deficiency on the definition of HL was demonstrated by patients. 35 This study finding was not surprising because the term and concept are jargon to them since they had no previous knowledge or exposure to it. Importantly, evidence from the studies showed both HCPs and patients acknowledge the consequences of HL or LHL. This awareness is important because it will create a learning interest about HL. Objectively assessing patients’ HL using validated and established tools earlier can help HCPs to recognise patients with LHL and deliver the appropriate intervention. However, this cannot be achieved if HCPs themselves are not well versed with available HL tool.15,28 Although studies have shown that HCPs are knowledgeable on subjective assessment such as body gesture, language, socioeconomic status, and education level, it can be misleading at times.
It is evident that HCPs were keen on learning about HL and conducting HL assessment to deliver health information effectively to their patients.21,27,29 There is plenty of room for health institutes to start HL training to equip their staff to handle the needy population in the sense of HL.However, it is important to ensure the designed training or programme is substantial and impactful to both HCPs and patients considering feedback that reported existing programmes were perceived as not beneficial.23,25 On the contrary, negative attitudes were shown by patients towards HL and HL screening.20,31,32 It is important to point out that patients’ negative feeling will affect their acceptances of HL intervention. Thus, efforts should aim to create a more sensitive and conducive environment that provides patients with equitable access to health information. HCPs should adopt a more impartial and less judgemental manner which will not embarrass or discourage patients from revealing their HL or seek assistances.
Several studies highlighted that HCPs do not regularly use formal HL assessment tools in their practice.21,23,27,43 Lack of knowledge and skills on existing HL tools can be one of the factors leading to the lack of practice. Two studies reported that HCPs claimed to have not received any formal training on HL.13,43 There is currently no best practice established to indicate the frequency of assessing patients’ HL level. However, it is unfair to pinpoint that HCPs do not practice HL screening at all because studies reported they use other assessments such as the verbal cues, non-verbal cues, and their gut feelings.16,18,22,27,38 Although this evaluation can serve as a quick and convenient way to assess HL; it may result in different and variable interpretation according to the individual HCPs’ subjective perception of the patients. The study by Dickens et al. 19 revealed nurses overestimating patients’ HL level without using a validated HL tool. Various HL communication techniques utilised by HCPs have been identified in this study. However, the rationale of the communication techniques adapted and any studies did not evaluate the effectiveness of each strategy. Studies have suggested that reimbursement or appreciation to healthcare HCPs are some of the strategies to encourage them to implement HL screening or communication techniques in healthcare settings.29,47
There were many perceived barriers mentioned by HCPs and patients across the studies, but one that concerned both was time constraints. It is a known fact that the work burden is tremendous in busy clinical settings, and the number of patients waiting will restrict HCPs from spending sufficient time to cater to LHL patients. Thus, the best coping strategy is involving other supporting team members or referring to other recourses, such as local support teams and specific education classes. Moreover, as mentioned by previous studies,25–27,30,37,38 patients are encouraged to bring family members or friends. This will provide extra help to explain information imparted by HCPs to patients, especially those with language barriers. Assigning an interpreter or certified navigators is another option that needs serious consideration in identified clinical settings. Effective communication with adequately knowledgeable and skilled HCPs on HL is considered paramount in building trust in patients. Strong organisational support with sufficient staff to carry out HL intervention is also equally important.
Strengths and limitations
The strengths of this review include the multi-database search strategy, inclusion of both quantitative and qualitative studies and involvement of dual reviewers at every phase that includes screening of articles, assessing eligibility and quality of included articles. However, few limitations need to be acknowledged in this review. First, it only included articles published in the English language, so some relevant studies in other languages may have been missed. Furthermore, the study specifically focused on functional H. which may affect the generalisability of the study findings. Another limitation is the challenge to extract study findings according to the established definition of little bias. Finally, the heterogeneous nature of the included studies also reduces the ability to summarise the key trends of the HL-related knowledge, attitudes, practice, and perceived barriers.
Conclusions
It is evident from the findings of this systematic review that there is a lack of knowledge among both HCPs and patients that needs to be addressed immediately. Emphasis should be placed on educating and training the HCPs to improve the practice of HL screening and communication. Fundamentally, it is important to ensure that all materials and communications with patients are tailored in a way that is easy to be administered and at a level that everybody can benefit. It is equally critical to create a positive attitude among patients towards HL screening and strategies to promote HL interventions. The findings of perceived barriers from the perspective of HCPs and patients will be valuable insights to stakeholders to implement policies and guidelines to encourage HL practices in future.
Footnotes
Acknowledgements
We wish to thank Ministry of Health, Malaysia and Universiti Sains Malaysia for the support.
Conflict Of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Review
The protocol of this study was registered with the Malaysian Medical Research Register (NMRR-15-2208-28623) and approved by the Medical Research Ethics Committee.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.