Dr Jaap Koot from the Learning Community ‘Global Health’ in the University Medical Centre in Groningen talks about why it is important for medical workers to know how to deal with patients with low health literacy.

Understanding doctors

‘Doctor, you prescribed these pills twice daily. Should I take the two pills in the morning or in the evening?’

‘Nurse, I need to see a skin doctor, but at the reception they referred me to the dermatology department.’

Health professionals come across questions like this every day. Many patients have difficulties understanding medical terms, finding their way around health facilities or adhering to medical prescriptions. We call this ‘low health literacy’, or limited ability to understand and communicate about health issues, or take decisions about health-related problems. This is serious, because people with low health literacy often wait for too long before going to the doctor’s, by which time their illness has already worsened, they are hospitalised more often, and are more likely to have medical complications during treatment. They also have more health problems than people with higher health literacy.

People with low health literacy in general have lower education, lower socio-economic status and are older. There is a big overlap between health literacy and literacy in general, although even literate people can have low health literacy. A few years back, research in Europe estimated that around 50% percent of the population has insufficient levels of health literacy.

As medical professionals, we have the obligation to inform patients properly, and to verify that the patient has understood our explanation, and accepts the proposed treatment. In the Netherlands, it is even laid out in the legislation. And this topic is not to be taken lightly. In the UK and the Netherlands, more than three quarters of patients’ complaints in disciplinary courts for physicians are about problems in communication between the doctor and the patient. It is in the interest of the patient, the doctor and the hospital that we address health literacy issues seriously.

Created by Meghna Jadhav, EAEA

Dealing with low health literacy

More and more actions and interventions are being developed for dealing with low health literacy. We can divide them in two categories: empowering and mitigating.

Empowering interventions aim at making people more health literate and better capable of making decisions on health topics. Sometimes these approaches are linked to adult education and literacy training, but often they are disease specific (e.g., related to diabetes of high blood pressure). What works very well, is peer support. Diabetic patients help each other understand their disease, deal with the treatment and monitor their glucose level. These empowering interventions take time and are costly, and in general are applied when people have chronic medical conditions that need long-term follow-up. There is no time and money to apply them to simple conditions or acute care.

For non-chronic conditions, we need to use mitigating interventions, which means that the health professional helps the patient to deal with the condition. The professional communicates in a way that the patient can understand them. They take more time, use simple language, double check if the patient has understood the explanation. These interventions include brochures with simple language, videos and animations available on the internet, and smart phone apps. Medical workers also make use of modern technology, for example sensors, tele-messages and automated medicine dispensers. The latest invention is a pill with a microchip, that informs the pharmacist when the patient has swallowed it. This way adherence to treatment can be checked, with no effort from the patient.

Training health workers

Often health facilities are not health literacy-friendly – it is difficult for people who do not know medical terminology to find their way. Iinformation material is usually written in administrative or medical language and professionals do not communicate in plain language.

Universities in the Netherlands and Ireland have developed a training together, where health professionals first analyse the situation in their own facility: ‘how health literacy-friendly are we?’; then they address the weaknesses with the help of experienced trainers. This has been an eye-opener for many participants in the training, who discovered that they had overestimated their own performance. After realising their shortfalls, they were very motivated to learn more about health literacy and to assist people with low health literacy. They worked on concrete measures to make their health facility health literacy-friendly. After verifying the methodology and researching the impact of the training, it is now ready to be rolled out to other health facilities.

In the University Medical Centre in Groningen, we have now started training medical students in consultation skills with attention to patients with low health literacy. We teach them concepts and general communication principles and let them carry out consultations through role playing. Students discover how difficult it is to use plain language and to explain properly what they mean. Already at an early stage in medical school, they are conditioned to think in complicated terms. We now start early in the medical training programme – already in the second year – to make students aware of health literacy problems and their responsibility as future health professional to adequately deal with these issues.

Step by step, we are working towards better health care that is understandable for everyone. And, of course, we hope that in the meantime, people will continue to be empowered through adult education, peer support, and other methods, to make them health literate and capable of making the right decisions for their own health and wellbeing.

Jaap Koot is medical doctor, specialised in tropical medicine and global health, and is working as Dean of the Learning Community Global Health in the University Medical Centre in Groningen. He is staff member of the Department of Health Sciences in the Medical Faculty and works in a team, performing research into health literacy in Europe.