General practitioners' predictions of their own patients' health literacy: a cross-sectional study in Belgium

Disagreement between patients' and general practitioners' estimates of patient health literacy increases from the top to the bottom of the social ladder: a cross-sectional study in the Paris area

BACKGROUND

Associated with both socioeconomic position and health outcomes, health literacy (HL) may be a mechanism contributing to social disparities. However, it is often difficult for general practitioners (GPs) to assess their patients' HL level.

OBJECTIVE

To analyse disagreements about patient HL between GPs and their patients according to the patient's socioeconomic position.

METHODS

For each of the 15 participating GPs (from the Paris-Saclay University network), every adult consulting at the practice on a single day was recruited. Patients completed the European HL Survey questionnaire and provided socio-demographic information. For each patient, doctors answered 4 questions from the HL questionnaire with their opinion of the patient's HL. The doctor-patient disagreement about each patient's HL was analysed with mixed logistic models to study its associations with patients' occupational, educational, and financial characteristics.

RESULTS

The analysis covered the 292 patients (88.2% of the 331 included patients) for whom both patients and GPs responded. The overall disagreement was 23.9%. In all, 71.8% of patients estimated their own HL as higher than their doctors did, and the gap between doctors' answers and those of their patients widened from the top to the bottom of the social ladder. The odd ratio for the 'synthetic disagreement' variable for workers versus managers was 3.48 (95% CI: 1.46-8.26).

CONCLUSIONS

The lower the patient's place on the social ladder, the greater the gap between the patient's and doctor's opinion of the patient's HL. This greater gap may contribute to the reproduction or maintenance of social disparities in care and health.

Physicians are Unable to Consistently Predict Patient Health Literacy in a Breast Clinic

INTRODUCTION

Health literacy (HL) is a patient's capacity to understand health information. Low HL is associated with worse cancer outcomes and adherence to treatment regimens. This study aimed to test physicians' ability to predict their patients' HL after an initial consultation to determine if routine HL screening is valuable.

METHODS

From February 2023 through June 2023, patients seen at an academic breast clinic completed a validated, self-reported HL assessment. Surgical and medical oncologists estimated their patients' HL by answering the same HL questionnaire based on their perception of the patient visit. Patient and physician scores were compared using an intraclass correlation coefficient. Linear regression was used to evaluate associations between physicians' ability to predict HL and other variables.

RESULTS

The cohort included 210 patient HL scores with corresponding physician scores for each. Most patients (75.7%) had adequate HL. There was moderate agreement between the patient and physician HL scores (intraclass correlation coefficient = 0.677, P < 0.01), meaning physicians could somewhat predict their patient's HL. Physicians were worse at predicting HL when patients had low HL. There was no difference in physicians' ability to predict HL based on patient age (P = 0.09) or race (P = 0.29). Additionally, we found no difference in the ability to predict HL based on the physician's specialty (P = 0.25).

CONCLUSIONS

After an initial consultation, physicians cannot accurately predict patient HL, particularly in patients with lower HL. Given the impact of low HL on a patient's ability to make treatment decisions and adhere to treatment plans, using a validated tool to measure HL is necessary.

Exploring Work Absences and Return to Work During Social Transition and Following Gender-Affirming Care, a Mixed-Methods Approach: 'Bridging Support Actors Through Literacy'

PURPOSE

Research on return to work (RTW) following transition-related gender-affirming care (GAC) is lacking. We aim to study the RTW outcomes and experiences of transgender and gender diverse (TGD) people during social and medical transition to understand their needs better and provide tailored support.

METHODS

In this convergent mixed-methods study, the questionnaires of 125 employed TGD people, who took steps in transition (social and GAC), were analyzed for personal- and work characteristics, medical work absences, RTW, support at work, and health literacy. In-depth interviews were held with twenty TGD people to explore perceived facilitators and barriers to RTW.

RESULTS

One hundred and nine participants reported an average of 38 sick days after GAC. The majority (90.2%) resumed their job at the same employer. Although TGD workers felt supported, their health literacy (55.1%) was lower compared to the general population. The qualitative data analysis revealed four major themes: (1) the need and access to information; (2) having multidisciplinary TGD allies; (3) the influence of the occupational position; (4) the precarious balance between work, life, and GAC. Especially participants with a low health literacy level experienced RTW barriers by struggling: (1) to find and/or apply information; (2) to navigate (occupational) health and insurance services.

CONCLUSION

Our research has shown that RTW for TGD individuals is a multifaceted process, affected by personal factors, work-related elements, and the characteristics of the healthcare and social insurance system. Enhancing support for TGD people at work and their RTW requires a high need for centralized information and promoting health literacy while engaging relevant stakeholders, such as prevention services and employers.

Health Literacy in Pediatric Consultations on Allergy Prevention

BACKGROUND

The first 3 years of life offer an opportunity to prevent allergic diseases. Pediatricians are an important source of health information for parents. However, a certain degree of health literacy is necessary to understand, appraise, and apply preventive behavior, which can be supported by health literacy (HL) sensitive consultations and a HL friendly environment.

OBJECTIVE

In this study, we want to shed light on how pediatricians in outpatient care in Germany advise on early childhood allergy prevention (ECAP) and how they consider parental HL.

METHODS

We conducted 19 semi-standardized telephone interviews with pediatricians from North-Rhine-Westphalia and Bavaria. The interviews were audio-recorded, transcribed, pseudonymized, and subjected to content analysis.

KEY RESULTS

Current ECAP recommendations were well known among our sample. Despite the shift of evidence from avoidance of allergens toward early exposure, providing advice on ECAP was considered non-controversial and it was widely assumed that recommendations were easy to understand and apply for parents. However, ECAP was treated as an implicit topic resonating among others like infant nutrition and hygiene. Regarding HL, our interview partners were not aware of HL as a concept. However, they deemed it necessary to somehow assess parental information level and ability to understand provided information. Formal HL screening was not applied, but implicit strategies based on intuition and experience. Concerning effective HL-sensitive communication techniques, interviewees named the adaptation of language and visual support of explanations. More advanced techniques like Teach Back were considered too time-consuming. Medical assistants were considered important in providing an HL-sensitive environment. Time constraints and the high amount of information were considered major barriers regarding HL-sensitive ECAP counseling.

CONCLUSION

It seems warranted to enhance professional education and training for pediatricians in HL and HL-sensitive communication, to reach all parents with HL-sensitive ECAP counseling. [HLRP: Health Literacy Research and Practice. 2024;8(2):e47-e61.].

Development of the Conversational Health Literacy Assessment Tool for maternity care (CHAT-maternity-care): participatory action research

BACKGROUND

Limited health literacy in (expectant) parents is associated with adverse health outcomes. Maternity care providers often experience difficulties assessing (expectant) parents' level of health literacy. The aim was to develop, evaluate, and iteratively adapt a conversational tool that supports maternity care providers in estimating (expectant) parents' health literacy.

METHODS

In this participatory action research study, we developed a conversational tool for estimating the health literacy of (expectant) parents based on the Conversational Health Literacy Assessment Tool for general care, which in turn was based on the Health Literacy Questionnaire. We used a thorough iterative process including different maternity care providers, (expectant) parents, and a panel of experts. This expert panel comprised representatives from knowledge institutions, professional associations, and care providers with whom midwives and maternity care assistants work closely. Testing, evaluation and adjustment took place in consecutive rounds and was conducted in the Netherlands between 2019 and 2022.

RESULTS

The conversational tool 'CHAT-maternity-care' covers four key domains: (1) supportive relationship with care providers; (2) supportive relationship within parents' personal network; (3) health information access and comprehension; (4) current health behaviour and health promotion. Each domain contains multiple example questions and example observations. Participants contributed to make the example questions and example observations accessible and usable for daily practice. The CHAT-maternity-care supports maternity care providers in estimating (expectant) parents' health literacy during routine conversations with them, increased maternity care providers' awareness of health literacy and helped them to identify where attention is necessary regarding (expectant) parents' health literacy.

CONCLUSIONS

The CHAT-maternity-care is a promising conversational tool to estimate (expectant) parents' health literacy. It covers the relevant constructs of health literacy from both the Conversational Health Literacy Assessment Tool and Health Literacy Questionnaire, applied to maternity care. A preliminary evaluation of the use revealed positive feedback. Further testing and evaluation of the CHAT-maternity-care is required with a larger and more diverse population, including more (expectant) parents, to determine the effectiveness, perceived barriers, and perceived facilitators for implementation.

Medical Doctors Approaches and Understanding of Health Literacy: A Systematic Literature Review

A physician's role is critical in fostering patient health literacy (HL) and influencing various aspects, including patient-physician communication and treatment effectiveness. The purpose of this systematic literature review is to analyze physicians' perspectives, comprehension, and management of HL. The focus of this review is on physicians' views, opinions, experiences, and strategies related to HL. We conducted comprehensive searches across seven databases, including PubMed, Scopus, ProQuest, Science Direct, Web of Science, The Cochrane Library, and Google Scholar. Original research articles published between January 1, 2009, and July 31, 2020, were considered for inclusion. This literature review incorporates qualitative studies and mixed-methods studies, with a focus on extracting qualitative data. Among the 22 articles included in our review, we employed the method of inductive thematic analysis for data analysis. A detailed description of the review methodology can be found in a previously published protocol available through PROSPERO (CRD42020212599). The themes that emerged from the thematic analysis include: (a) physicians' perception and management of HL; and (b) barriers. The results of the systematic review reveal that healthcare professionals exhibit varying perceptions of patients' HL levels and ascribe different meanings to it. However, none of them employ a specific measuring tool. While there appears to be no uniform approach to managing patients with low HL, some prioritize certain communication strategies, such as repetition, simplified language, and providing written instructions, among others. Most physicians cited multiple barriers that impede the development of patients' HL, including dysfunctions within the healthcare system, staff shortages, managing a large number of patients, limited time, work-related stress, cultural and socio-economic barriers, medical jargon, and language barriers. Considering the pivotal role of physicians in fostering patient HL, it is crucial to enhance medical education in addressing and managing HL, both within academic curricula and through continuing education seminars. Furthermore, there is a pressing need to improve healthcare professionals' working conditions, ensuring that each physician can allocate the necessary time to each patient based on their individual needs, without being hindered by stress-inducing work environments.

Greek medical professionals approaches and understanding of health literacy: a qualitative study

BACKGROUND

Health literacy holds significant importance for medical professionals, as it is widely acknowledged as a key element in enhancing health promotion and overall well-being. The primary objective of this study is to explore Greek physicians' comprehension of health literacy, the significance they attribute to it, their strategies for addressing patients with low health literacy, and the potential barriers they face while striving to enhance a patient's health literacy. In this context, we examine the communication methods employed by physicians as an integral part of their approach to improving a patient's health literacy.

METHODS

A qualitative study was conducted between April 29, 2021, and February 17, 2022, utilizing in-depth, semi-structured interviews with 30 Greek medical professionals, of whom 15 were university professors. The research sample selection methodology employed in this study was purposive sampling. Data analysis was conducted using inductive thematic analysis.

RESULTS

The majority of physicians were not familiar with the concept of health literacy. The most significant barriers to the development of health literacy among physicians are a lack of time, issues within the healthcare system, and interference from third parties, although they acknowledge that a significant portion of the responsibility lies with them. Effective communication with patients is important for all physicians, as it plays a crucial role in the therapeutic process. When they realize that their patients are not understanding them, they employ communication methods such as using plain language, providing numerous examples, incorporating visuals like pictures and even using drawings.

CONCLUSIONS

The findings of this study underscore the importance of implementing targeted initiatives to promote health literacy within the Greek medical and academic community. Integrating health literacy training for physicians into the educational and training curriculum is essential. To accomplish this goal, it is imperative to first address the shortcomings within the healthcare system and improve the working conditions for physicians.

Exploring discordance between Health Literacy Questionnaire scores of people with RMDs and assessment by treating health professionals

OBJECTIVES

We studied discordance between health literacy of people with rheumatic and musculoskeletal diseases (RMDs) and assessment of health literacy by their treating health professionals, and explored whether discordance is associated with the patients' socioeconomic background.

METHODS

Patients with RA, spondyloarthritis (SpA) or gout from three Dutch outpatient rheumatology clinics completed the nine-domain Health Literacy Questionnaire (HLQ). Treating health professionals assessed their patients on each HLQ domain. Discordance per domain was defined as a ≥2-point difference on a 0-10 scale (except if both scores were below three or above seven), leading to three categories: 'negative discordance' (i.e. professional scored lower), 'probably the same' or 'positive discordance' (i.e. professional scored higher). We used multivariable multilevel multinomial regression models with patients clustered by health professionals to test associations with socioeconomic factors (age, gender, education level, migration background, employment, disability for work, living alone).

RESULTS

We observed considerable discordance (21-40% of patients) across HLQ domains. Most discordance occurred for 'Critically appraising information' (40.5%, domain 5). Comparatively, positive discordance occurred more frequently. Negative discordance was more frequently and strongly associated with socioeconomic factors, specifically lower education level and non-Western migration background (for five HLQ domains). Associations between socioeconomic factors and positive discordance were less consistent.

CONCLUSION

Frequent discordance between patients' scores and professionals' estimations indicates there may be hidden challenges in communication and care, which differ between socioeconomic groups. Successfully addressing patients' health literacy needs cannot solely depend on health professionals' estimations but will require measurement and dialogue.

VIDEO ABSTRACT

A video abstract of this article can be found at https://www.youtube.com/watch?v=ggnB1rATdQ4.

Implementation of health literacy training for clinicians in a federally qualified health center

Objective

The objective of this quality improvement project was to evaluate the effectiveness of a succinct health literacy training for providers at a demanding federally qualified health center.

Methods

One group, pretest-posttest design was used to measure for a change in knowledge regarding the effects of limited health literacy, a change in self-reported measure of routine screening for limited health literacy and a change in self-reported utilization of patient-centered communication techniques.

Results

The average percentage of correct responses on the Health Literacy Knowledge Check showed significant improvement from 23.6% (SD = 18.1%) to 63.9% (SD = 25.3%), p < .001. There were no significant changes in median responses at pre- and post-intervention for self-reported use of screening and communication techniques (all p > .05).

Conclusion

This brief training was effective at improving participants' knowledge of health literacy but did not improve use of recommended communication techniques or screening for health literacy. The results suggest that emphasizing a universal precautions approach to health literacy may be more effective with participants who work in high-volume clinics.

Practice implications

For high-volume clinics, a brief training may improve participants' knowledge but does not increase use of actual communication techniques based on self-report.

Health Literacy Development among People with Chronic Diseases: Advancing the State of the Art and Learning from International Practices

Chronic diseases account for a considerable part of the strain on health care systems [...].

Challenges and solutions in communication with patients with low health literacy: Perspectives of healthcare providers

Insights in the challenges that healthcare providers encounter in serving low health literate patients is lagging behind. This study explored challenges perceived by healthcare providers and provides strategies in communication with low health literate patients. Primary and secondary healthcare providers (N = 396) filled in an online survey. We assessed the frequency of challenges prior to, during and following a consultation, and which strategies were used and recommended. Survey outcomes were validated in in-depth interviews with healthcare providers (N = 7). Providers (76%) reported one or more challenges that were subscribed to patients’ difficulties in comprehending or applying health-related information, in communicating with professionals, or in taking responsibility for their health. Providers (31%) perceived difficulties in recognizing low health literate patients, and 50% rarely used health literacy specific materials. Providers expressed needs for support to recognize and discuss low health literacy, to adapt communication and to assess patient’s comprehension. Future research should focus on developing strategies for providers to ensure patients’ understanding (e.g. applying teach-back method), to recognize low health literate patients, and to support patients’ in taking responsibility for their health (e.g. motivational interviewing).

Patients' Health Literacy in Rehabilitation: Comparison between the Estimation of Patients and Health Care Professionals

The term health literacy (HL) comprises the handling of health information and disease-specific and generic self-management skills, especially relevant for patients with chronic conditions. Health care professionals (HCPs) should correctly identify patients' communication needs and their HL levels. Therefore, the aims of the study were (1) to determine inpatient medical rehabilitation patients' HL based on self-assessment, (2) to evaluate changes from admission to discharge, (3) to identify HCPs estimation of patients' HL, and (4) to compare the estimated patient HL by patients and HCPs. A combined cross-sectional and longitudinal study was conducted in an orthopedic rehabilitation center in Germany. The multidimensional Health Literacy Questionnaire (HLQ) was filled in by patients (admission, discharge). An adapted version was administered to HCPs (n = 32) in order to assess HL of individual patients. Data from 287 patients were used for the longitudinal analysis, and comparison was based on n = 278 cases with at least two HL estimations. The results showed a significant increase in HL in five of nine scales with small effect sizes. Moreover, HCPs mostly provided higher scores than patients, and agreement was poor to fair. Differences between the HL estimation might lead to communication problems, and communication training could be useful.

Use of the pictorial Sleepiness and Sleep Apnoea Scale in Chinese patients with suspected obstructive sleep apnoea syndrome

Background

Sleep related breathing disorders represent a significant health burden. Being able to stratify patients according to their need for differing types of investigation and predicting the likelihood of obstructive sleep apnoea syndrome (OSAS) is helpful. This study attempts to assess the value of a pictorial Sleepiness and Sleep Apnoea Scale (pSSAS) in this process.

Methods

A total of 126 sequential patients attending a sleep service with suspected OSAS completed the pSSAS, the Epworth Sleepiness Score (ESS), and the Berlin Questionnaire (BQ) prior to full polysomnography.

Results

With Apnoea-hypopnea index (AHI) >15 as the positive diagnostic criterion, the area under the receiver operating characteristic curve (AUC) of the BQ was the highest (0.683), followed by pSSAS and ESS (AUC 0.648 and 0.516, respectively). With AHI >30 as the positive diagnostic criterion, the AUC of pSSAS was the highest (0.696), followed by BQ and ESS (AUC 0.653 and 0.510, respectively). With MiniSO₂ <80% as the positive diagnostic criterion, the AUC of pSSAS was the highest (0.736), followed by BQ and ESS (AUC 0.634 and 0.516, respectively).

Conclusions

This study shows that the pSSAS which was first tested in a European population performs equally well amongst a Chinese population. The pSSAS performed in a similar fashion to the BQ in predicting those likely to have OSAS and was superior at predicting those who have severe OSAS. Because it is a pictorial questionnaire, it has advantages for those who may have reduced health literacy, a problem which is under-recognized in most healthcare systems.

A cross-sectional analysis of health literacy: patient- versus family doctor-reported and associations with self-efficacy and chronic disease

BACKGROUND

Adequate health literacy (HL) levels contribute to good health outcomes and successful disease self-management in patients with chronic disease. Hence, it is essential that family doctors recognize patients with inadequate HL in need of additional support. This study had two aims: (1) to assess and compare patient self-reported versus family doctor-rated HL estimates, and (2) to explore associations between patient-reported HL, self-efficacy and chronic diseases.

METHODS

Participants in this cross-sectional survey were recruited through general practices in North Rhine-Westphalia, Germany. Patient self-reported HL was measured using the European Health Literacy Survey-16. Family doctor-rated HL was measured with an adapted version of this instrument. Using crosstabulations patient-reported and family doctor-rated HL estimates were compared for 346 patient-family doctor pairs. Associations between HL, self-efficacy and chronic disease were investigated using regression analyses.

RESULTS

Patient-reported and family doctor-rated HL estimates were concordant in 38% of all cases. On average family doctors rated their patients' HL lower than patients rated their own HL. The lower average family doctor ratings were more pronounced when patients were older, male and had more than one chronic disease. Female family doctors rated HL of male patients lower than their male colleagues. Patient reported HL had a significant positive association with self-efficacy. Mediation analysis provided support that self-efficacy acts as mediator between HL and the number of chronic diseases.

CONCLUSIONS

Our study findings indicate a significant discrepancy between patients' self-reported HL and externally rated HL by family doctors. A more systematic utilization of HL screeners might help reduce this discrepancy. At the same time, consideration should be given to enhancing communication training for family doctors and addressing critical HL skills in patient education.

The Prevalence of Limited Health Literacy and Its Associated Factors among Elderly Patients Attending an Urban Academic Primary Care Clinic in Malaysia

Limited health literacy (HL) is linked to many negative health outcomes, including poor self-management of chronic diseases and medication adherence among patients. There are a lack of data regarding HL in the elderly population in Malaysia. This study aimed to determine the prevalence of limited HL levels and its associated factors among elderly patients in an urban academic primary care clinic in Selangor, Malaysia. A cross-sectional study was conducted among 413 elderly patients (≥60 years old) who attended this academic primary care clinic between January 2020 and January 2021. Sociodemographic data, clinical characteristics, and health literacy scores were collected. Descriptive statistics (median with interquartile ranges (IQR), frequency, and percentages) and multiple logistic regression were utilized. The prevalence of limited HL in our population was 19.1% (95% CI: 15.3, 23). The middle-old (70–79 years) and very-old (≥80 years) age groups were more likely to have limited HL (aOR 4.05; 95% CI: 2.19, 7.52 and aOR 4.36; 95% CI: 1.02, 18.63, respectively). Those with at least secondary school education (aOR 0.06; 95% CI: 0.02, 0.24) and those who found medical information via the internet/television (aOR 0.21; 95% CI: 0.05, 0.93) had lower odds of having limited HL. In conclusion, having limited HL levels was not common among elderly patients in this primary care clinic. Further studies involving rural and larger primary care clinics in Malaysia are required to support these findings.

The Agreement between Patients' and Healthcare Professionals' Assessment of Patients' Health Literacy-A Systematic Review

Healthcare professionals (HCPs) can play a key role in promoting health literacy (HL) in patients to help them navigate the healthcare system effectively. This involves assisting patients to locate, comprehend and evaluate health information. HCPs should assess patients’ health literacy needs and check the patient´s understanding to communicate adequate health information. This review investigates the agreement between the patients’ and HCPs assessment of patients’ HL. A systematic literature search in PubMed, Scopus, PsycINFO, CINAHL and the Cochrane Library was performed in November 2019. The search yielded 6762 citations, seven studies met the inclusion criteria. The following HL measurement instruments were completed by the patients in the included studies: REALM (n = 2), REALM-R (n = 1), S-TOFHLA (n = 1), NVS (n = 1), SILS (n = 1), HLSI-SF (n = 1) and HLS-EU-Q16 (n = 1). The HCPs assessed patients’ HL by answering questions that reflect the content of standardized tools. Six studies reported that a high proportion of patients assigned to have HL needs based on their self-report were overestimated by their HCPs in terms of the HL level. The results demonstrated that HCPs had difficulty determining patients’ HL adequately. Differences between the HL estimation of HCPs and the actual HL skills of patients might lead to communication problems.