Seeking a deeper understanding of 'distributed health literacy': A systematic review

The role of health literacy in the association between social support and self-rated health: a Danish population-based study in 10,787 individuals with a long-term condition

BACKGROUND

Managing a long-term condition requires higher health literacy. Social networks may play a crucial role for self-management. However, the pathway is not entirely understood. This study aimed to examine whether the association between social support and self-rated health is mediated by health literacy among individuals with a long-term condition.

METHODS

This cross-sectional study used data from the "How are you?" 2021 survey in Central Denmark Region. Social support was assessed using a single question, health literacy with two dimensions from the Health Literacy Questionnaire (HLQ): 'Understanding health information' and 'Engaging with healthcare providers', and self-rated health with a single question from SF-36. Multiple logistic regression analyses were used to examine the associations, and multiple mediation analyses were performed using the Karlson-Holm-Breen method.

RESULTS

A total of 10,787 individuals with a long-term condition were included in the study, whereas 6% (n = 595) reported a low level of social support. Both health literacy scales mediated the association between social support and self-rated health, particularly the ability to engage with healthcare providers, accounting for 25% of the variance. After adjustment for sociodemographic factors, individuals with a low level of social support had significantly higher odds of reporting difficulties in understanding health information (OR 2.53 (95% CI: 1.84-3.48)) and engaging with healthcare providers (OR 3.77 (95% CI: 2.96-4.79)).

CONCLUSIONS

Health literacy, particularly the ability to engage with healthcare providers, was a mediator between social support and self-rated health. Additionally, a low level of social support was associated with higher odds of reporting lower health literacy. These findings suggest that strategies to enhance health literacy, improve health outcomes, and reduce health inequities may benefit from strengthening individuals' social network, particularly focusing on those with limited support.

Qualitative Evaluation of a Health Literacy Program for Older Adults Who Live in a Community Dwelling in Brazil

To address current gaps in health literacy research and practice in low-resource settings, the 'Alfa-Health Program' was designed to improve health literacy in older adults who live in a community dwelling in a socioeconomically disadvantaged community in North-East Brazil. In this longitudinal qualitative study, participants were interviewed before and after participating in the group-based program that was delivered November 2017 to December 2017 in the Primary Care Health Unit. Semi-structured interviews were guided by a previously validated health literacy instrument, translated and adapted for use in Brazil. Data was analyzed using Framework analysis. Of the 21 participants, the majority were age 60 to 69 years with a median of 4-years of school education. Our analysis identified self-reported improvements in health knowledge, behaviors, and skills that matched program content and indicated that participants were supported to manage their health conditions more autonomously. Other themes reflect the distributed nature of health literacy and the potential for group-based health literacy programs to facilitate feelings of social support and cohesion through co-learning. However, age-related deficits in memory and external and structural factors remained important barriers to program participation. This study provides insight into developing health literacy in low-resource settings with older adults, where health literacy is compounded by social determinants and cognitive and sensory changes that contribute to health disparities. Although the targeted Alfa Health Program addresses calls to ensure that priority is proportionate to need by reaching and engaging population groups who are disproportionately affected by low health literacy, further work is needed to adapt the program for people who are unable to read or write. [HLRP: Health Literacy Research and Practice. 2024;8(3):e140-e150.].

Acquisition, application, and distribution of health literacy from culturally sensitive type 2 diabetes education among Arabic-Speaking migrants in Denmark: A longitudinal qualitative analysis

BACKGROUND

Effective self-management of type 2 diabetes requires adequate health literacy (HL) and a supportive network. Diabetes self-management education and support programmes play a crucial role in improving these factors. However, limited research exists on how such programmes can support health literacy among migrants and facilitate the dissemination of knowledge within their social networks.

AIM

This study aimed to investigate the perspectives of Arabic-speaking informants with a migrant background in relation to how their type 2 diabetes-related health literacy was acquired, applied and distributed within social networks through participation in a culturally sensitive diabetes self-management education and support (DSMES) programme.

METHODS

Semi-structured interviews were conducted with 12 informants during the programme and three to 7 months later, from September 2019 to May 2020. Abductive analysis was applied using HL and distributed health literacy (DHL) theory as frameworks.

RESULTS

The analysis generated three themes: (1) sources of health information and the development of health literacy; (2) changes towards active self-management; and (3) distributed health literacy. Prior to programme participation, informants faced challenges in navigating conflicting information from family, friends and social media. After participating in the programme, they reported improvements in HL, particularly in knowledge acquisition. Many became more actively engaged in decision-making and exhibited improved health behaviours, such as dietary choices. Nonetheless, some informants continued to struggle with choosing appropriate prevention and treatment strategies. Notably, certain informants acted as HL mediators, sharing their newly acquired knowledge within their social networks in Denmark and abroad.

CONCLUSION

Culturally sensitive diabetes self-management education programmes have the potential to enhance HL among migrants, leading to the distribution of relevant diabetes knowledge within their social networks. Future studies should explore how members of migrants' social networks perceive their supportive role in type 2 diabetes management. Programmes can benefit from emphasising critical HL and exploring how participant-informants effectively communicate diabetes-related knowledge within their networks to address misinformation and conflicting information.

Narratives about distributed health literacy during the COVID-19 pandemic

The promotion of health literacy was a key public health strategy during the COVID-19 pandemic. However, the role of social networks and relationships for support with health literacy-related tasks in the context of the COVID-19 pandemic is scarcely understood. Moving beyond traditional notions of health literacy, which focus on individual skills and knowledge, this study uses the concept of distributed health literacy to explore how individuals make meaning of and respond to health literacy and make their literacy skills available to others through their relational and socially situated and lived experiences of the COVID-19 pandemic. Drawing on 89 semi-structured interviews conducted in three European countries (Italy, Portugal, and Switzerland) between October and December 2021, we found narratives of stabilization, hybridization, and disruption that show how health literacy concerning COVID-19 is a complex social construct intertwined with emotional, cognitive, and behavioral responses distributed among individuals, communities, and institutions within socioeconomic and political contexts that affect their existence. This paper opens new empirical directions to understand the critical engagement of individuals and communities toward health information aimed at making sense of a complex and prolonged situation of uncertainty in a pandemic.

Assessing perceived and functional health literacy among parents in Cyprus: A cross-sectional study

BACKGROUND

Parents often must take decisions regarding their children's health, which requires certain skills and competences. Parental health literacy (HL) is important in establishing positive health-promoting behaviours and better health outcomes to their children. Limited parental HL has been associated with various negative children's health outcomes. The aim of the study was to explore perceived and functional HL among parents in Cyprus.

METHOD

A cross-sectional study was conducted with a convenience sample of 416 parents of children, aged 6 months to 15 years old, presenting in pediatric outpatient departments across three Cypriot cities. Participants completed the HLS-EU-Q47, a self-reported measure of HL, and the NVS (Newest Vital Sign), a performance-based measure of HL. Associations with socio-demographic characteristics and health behaviors were explored.

RESULTS

Based on suggested ranges, among 416 parents, mostly mothers (83.2%), almost half of parents (42.6%) were classified as having inadequate or problematic perceived HL. Consistently, 62.8% showed high likelihood or significant possibility of limited functional HL, based on the NVS with a mean score of 2.73 out of 6 (SD = 2.02). Nevertheless, no correlation was observed between the two measures of HL. Limited parental perceived HL was statistically significantly associated with lower educational attainment, lower number of children in the family, increased self-assessed health status, and limited exercise habits. Limited parental functional HL was statistically significantly associated with female gender, younger age, lower educational attainment, receiving financial aid, lower family income, and lower alcohol consumption.

CONCLUSION

Even though there was lack of agreement in the classification according to the HLS-EU-Q47 and the NVS, moderate-to-low levels of perceived HL appear consistent with a performance-based measure of HL. As a high number of parents may face challenges in assessing and applying health information to improve outcomes for their children, with evidence of social gradient, healthcare services should be oriented towards identifying problematic HL while Public Health interventions are needed to enhance parental HL.

Relationship Between Health Literacy and Unhealthy Lifestyle Behaviours in Older Adults Living in Switzerland: Does Social Connectedness Matter?

Objectives: To investigate the association between health literacy (HL) and unhealthy lifestyle behaviours and to explore the moderating role of social connectedness in this relationship in older adults in Switzerland. Methods: We used data from 1,455 respondents to Wave 8 of the Survey of Health, Ageing, and Retirement in Europe (SHARE). Associations between the number of unhealthy lifestyle behaviours (smoking, risky alcohol consumption, suboptimal daily consumption of fruits/vegetables, lack of vigorous physical activity) and HL were examined using multivariable Poisson regression models, which allowed for interactions between HL and social connectedness to test the moderation hypothesis. Results: Respondents with inadequate HL were significantly more likely to have a higher number of unhealthy lifestyle behaviours than respondents with sufficient HL. We found a stronger positive association between inadequate HL and the number of unhealthy lifestyle behaviours among socially isolated individuals. Conclusion: Greater social connectedness seems to buffer the negative impact of inadequate HL on unhealthy lifestyle behaviours in older adults, highlighting the importance of good HL for healthy lifestyles, especially in individuals with low social reserve.

Bridging Inequity Gaps in Healthcare Systems While Educating Future Healthcare Professionals-The Social Health Bridge-Building Programme

Social inequity in healthcare persists even in countries with universal healthcare. The Social Health Bridge-Building Programme aims to reduce healthcare inequities. This paper provides a detailed description of the programme. The Template for Intervention Description and Replication (TIDieR) was used to structure the description. The programme theory was outlined using elements from the British Medical Research Council's framework, including identifying barriers to healthcare, synthesising evidence, describing the theoretical framework, creating a logic model, and engaging stakeholders. In the Social Health Bridge-Building Programme, student volunteers accompany individuals to healthcare appointments and provide social support before, during, and after the visit. The programme is rooted in a recovery-oriented approach, emphasising personal resources and hope. The programme finds support in constructs within the health literacy framework. Student volunteers serve as health literacy mediators, supporting individuals in navigating the healthcare system while gaining knowledge and skills. This equips students for their forthcoming roles as healthcare professionals, and potentially empowers them to develop and implement egalitarian initiatives within the healthcare system, including initiatives that promote organisational health literacy responsiveness. The Social Health Bridge-Building Programme is a promising initiative that aims to improve equity in healthcare by addressing individual, social, and systemic barriers to healthcare. The programme's description will guide forthcoming evaluations of its impact.

How socioeconomically disadvantaged people access, understand, appraise, and apply health information: A qualitative study exploring health literacy skills

OBJECTIVES

Health literacy, or a person's competence to access, understand, appraise and apply health information, can be considered a mediating factor between socioeconomic characteristics and health disparities. Socioeconomically disadvantaged people in particular present with less health literacy skills. To develop targeted interventions tailored to their real needs, it is important to understand how they function and what difficulties they encounter when dealing with health information. The purpose of this study was to explore their experiences when accessing, understanding, appraising, and applying health information in their everyday lives.

METHODS

Semi-structured face-to-face interviews were conducted with 12 socioeconomically disadvantaged adults living in the community in Switzerland (age range: 44-60 years old).

RESULTS

Thematic analysis of the interviews yielded four themes, describing the health literacy processes of participants, related barriers, and compensatory strategies used: Financial insecurity triggers the need for health information; Pathway 1: Physicians as ideal (but expensive) interlocutors; Pathway 2: The internet as a suboptimal alternative; and Pathway 3: Relatives as a default resource. The progression of socioeconomically disadvantaged people in the health literacy process is like an 'obstacle course', with numerous steps taken backwards before they can develop compensatory strategies to overcome the barriers to obtaining health information.

CONCLUSIONS

Financial deprivation seems to be the most important factor contributing to health literacy barriers. Appraising health information is the health literacy skill with which socioeconomically disadvantaged people struggle the most. Physician-based, individual skills-based, organizational, and policy-based interventions are needed to help them overcome their health literacy challenges.

Health literacy and musculoskeletal disorders in adolescents: a scoping review

OBJECTIVES

Health literacy (HL) related to musculoskeletal disorders (MSDs) in adolescents is a field with limited previous evidence. This study aimed to review and synthesise studies on MSDs and HL as well as various dimensions of HL in adolescents.

DESIGN

Scoping review in accordance with Arksey and O'Malleys framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

SEARCH STRATEGY

The search strategy was performed in the following databases in November 2021 (initial search) and December 2022 (updated search); Medline, EMBASE, PsychINFO, Cochrane, CINAHL, ERIC, Web of Science and Google Scholar. Eligible studies involving MSDs and HL or either of the HL dimensions related to finding, understanding, appraising or applying health information in adolescents were considered. Any dimension of HL studied, the outcome measure(s) used to assess HL and the type of MSD examined were charted, reviewed and synthesised. A directed content analysis was used for the subjective interpretation of text data.

RESULTS

A total of 16 841 studies were identified and 33 were eligible for inclusion. Ten articles presented HL with a definition or description in the theoretical background. The remaining 23 studies involved finding, understanding, appraising or applying health information, without using the term 'health literacy'. Most of the studies addressed how adolescents understand (n=32), and apply (n=23) health information, while few studies focused on how they find (n=11) and appraise (n=7) musculoskeletal health information.

CONCLUSION

Few studies have addressed HL and MSDs in adolescents explicitly, while most studies have considered dimensions of HL. Our findings suggest that there is important work to be done to align conceptual understandings with the measurement of HL in adolescents and that further research should be carried out to explore how HL is distributed among adolescents with MSDs and how adolescents living with MSDs report their HL.

Healthcare providers' support and outcomes in hemodialysis patients: The mediating effect of health literacy

OBJECTIVE

This study aimed to identify the mediating effect of health literacy (HL) on the relationship between healthcare providers' support and outcomes in patients on hemodialysis.

METHODS

A convenience sample of 149 hemodialysis patients participated in a cross-sectional survey. Mediation analysis with the percentile bootstrap method was used to identify the mediating effect of HL on the relationship between healthcare providers' support and patient outcomes.

RESULTS

Healthcare providers' support and HL were significant predictors of patient outcomes. HL mediated the relationship between healthcare providers' support and patient outcomes.

CONCLUSION

The HL of hemodialysis patients is essential in the relationship between healthcare providers' support and patient outcomes. Patient educators should implement a multifaceted HL-tailored intervention strategy to improve the HL of hemodialysis patients.

PRACTICE IMPLICATIONS

Hemodialysis patients' HL is a crucial mediating factor in the relationship between healthcare providers' support and patient outcomes. A multifaceted HL-tailored intervention strategy is needed to improve HL and, thus, health outcomes among hemodialysis patients.

Danish Women Want to Participate in a Hypothetical Breast Cancer Screening with Harms and No Reduction in Mortality: A Cross-Sectional Survey

INTRODUCTION

Informed decision making is recommended in breast cancer screening. Decision aids with balanced information on harms and benefits are recommended to support informed decision making. However, informed screening decision making may be challenged by overly positive attitudes toward cancer screening. We hypothesized that a substantial proportion of Danish women would want to participate in screening regardless of the presented information. Therefore, we aimed to estimate the prevalence of Danish women wanting to participate in a hypothetical breast cancer screening offering no reduction in breast cancer mortality but potential harms related to unnecessary treatment.

METHODS

In a cross-sectional study, we invited a random sample of 751 women in the nonscreening population aged 44 to 49 y in the Central Denmark Region to an online questionnaire using the official digital mailbox system. The questionnaire included a description of a hypothetical screening and questions about thoughts on breast cancer, health literacy, and questions on the assessment of the hypothetical screening including intended participation, understanding, and belief in information. Data were linked to register data on sociodemographic factors.

RESULTS

In total, 43.0% (323/751) responded to the questionnaire. Of these, 247 (82.3% [95% confidence interval: 77.5-86.5]) wanted to participate in the hypothetical breast cancer screening (participation group). More than two-thirds in both the participation group and nonparticipation group seemed to understand the presented information. Half of the women who understood the information disbelieved it.

CONCLUSIONS

Exceeding our expectations, a majority of women wanted to participate in a hypothetical screening with potential harms but no reduction in breast cancer mortality. A large proportion understood but disbelieved the screening information. This could indicate that Danish women make their screening decisions based on beliefs rather than presented screening information. This study was registered at ClinicalTrials.gov (Identifier: NCT04509063).

HIGHLIGHTS

The majority of Danish women wanted to participate in a hypothetical breast cancer screening with potential harms related to unnecessary treatment but no reduction in mortality.A large proportion of women understood but disbelieved the hypothetical screening information.Informed decision making may be challenging when women disbelieve the information they receive.Enthusiasm for cancer screening and potential disbelief in information are important factors when developing and improving screening information and invitation.

Health Literacy of People with Intellectual Disabilities: How Meaningful Is the Social Context for a Target Group-Oriented Model of Health Literacy?

Health literacy is primarily understood as an individual construct. People with intellectual disabilities still seem to be a "hidden" population in health literacy research. A target-orientated health literacy approach for this population is needed for developing precise and effective interventions that consider social context dimensions. Therefore, the following research question was answered: Which dimensions influence the health literacy of people with intellectual disabilities? A secondary data analysis containing 38 guided interviews with people with mild to moderate intellectual disabilities was conducted. The analysis followed the content analysis by Schreier (2012). Six main dimensions were inductively outlined, which are "interpersonal relationship", "organizations and communities", "healthcare system", "education", "digital interaction spaces", "politics", and "cultural contexts". All these dimensions influence people with intellectual disabilities on an individual level regarding their level of health literacy. The importance of these single dimensions becomes clear, although for now, the link between all these dimensions is not yet considered. In future research, the focus should be on how to develop interventions considering social context dimensions. Furthermore, analyzing the connection between those dimensions seems promising.