Health Literacy
Functional, communicative and critical health literacy of chronic disease patients and their importance for self-management

https://doi.org/10.1016/j.pec.2014.10.006Get rights and content

Highlights

  • 20% of chronic disease patients experiences difficulties with respect to functional or communicative health literacy; 50% reported problems with respect to critical health literacy.

  • A higher age, lower education level, lower income, multi-morbidity and/or more severe functional limitations were associated with lower levels of health literacy.

  • Functional, communicative and critical health literacy each impact in a unique way on (the abilities for) self-management, although in general communicative and critical health literacy are stronger predictors for successful self-management than functional health literacy.

Abstract

Objective

To provide insight into the level of health literacy among chronic disease patients in the Netherlands, to identify subgroups with low literacy and to examine the associations between health literacy and self-management.

Methods

Self-report questionnaires were sent to a nationwide sample of 1.341 chronic disease patients. The Dutch Functional Communicative and Critical Health Literacy scale (FCCHL), the Partners in Health scale (PIH) and Perceived Efficacy in Patient–Doctor Interactions (PEPPI-5) were used to assess health literacy and aspects of self-management.

Results

In general, health literacy skills were good. A higher age, lower education, lower income, multi-morbidity and/or functional limitations were associated with lower levels of health literacy. Communicative and critical health literacy were related to some aspects of self-management but not to all. Functional health literacy was less important.

Conclusion

Communicative and critical health literacy play a role in successful self-management of chronic disease but the impact differs by context. Health literacy levels vary according to socio-demographic and disease characteristics of patients.

Practice implications

Health care professionals should tailor their information and support to the health literacy skills and personal context of their patients.

Introduction

During the last decades there has been a growing interest in the concept of health literacy, together with an increased emphasis on individual responsibility for health and self-management of chronic illness [1], [2]. A number of reviews have pointed to the importance of health literacy as a factor to maintain or improve health [3], [4]. The specific relationship between health literacy and self-management of chronic illness has been studied less often. The aim of the present study is to contribute to the knowledge on health literacy and self-management by providing insight into the level of health literacy among chronic disease patients in the Netherlands, to identify subgroups that are less literate and by examining the association between health literacy and aspects of self-management.

Health literacy has been defined and conceptualized in many different ways [5], [6], and its nature and scope have been changed and widened during the last decade [7]. Early definitions focused on the ability to apply reading, writing and numeracy skills to health related materials such as prescriptions, appointment cards and medicine labels [7], [8], [9], while later conceptualizations encompassed a range of skills, including social and communication skills that enable people to obtain, understand and use health information in ways that enhance health, well-being and engagement in medical decision making [10], [11], [12]. More recent definitions also include the ability to apply these skills in various settings and across the life span [13].

Although definition and operationalization of health literacy vary, reviews have shown that lower levels of health literacy are consistently associated with a wide range of health related outcomes, including higher mortality, worse general health, poor healthcare access, more hospitalizations and greater use of emergency care, higher health care costs [14], greater difficulty participating in shared decision/making, and a worse medication adherence and self-management in general [3], [4], [15]. Moreover, low health literacy has been found to be especially prevalent in the elderly, those with low socio-economic status and minority groups [4], [16] and is recognized as a strong contributor to health inequalities [17].

A model of health literacy that is of specific interest in the context of self-management of chronic illness is the model proposed by Nutbeam [12]. This model distinguishes between three different types of health literacy: functional, communicative and critical health literacy. These types of health literacy each require different skills to obtain, understand and use information. The skills have an ascending order of difficulty that are supposed to progressively lead to greater autonomy and empowerment of patients and to a greater role in medical decision-making [18]. Functional literacy refers to the basic level of reading and writing skills to obtain, understand and use factual information on for example health risks, medication prescriptions or how to use the health care system. Communicative or interactive literacy refers to advanced skills that allow a person to extract information, derive meaning from different sources of communication, and apply new information to changing circumstances. Critical health literacy refers to more advanced skills for critically analyzing and reflecting on information or advice received and using information to exert greater control over life events and situations [12].

Studies exploring the specific relationships between functional, communicative and critical health and self-management are scarce. Most studies on health literacy and self-management focus on functional health literacy [3], [5], [19], [20]. Findings from these studies are inconsistent [21] and it is suggested that optimal self-management may not depend solely on a patient's ability to read health information [15], [21], [22]. Functional health literacy is important but greater value may be found in assessing health literacy beyond the functional level to explore barriers in self-management for chronic patients, including the ability to extract, compare, communicate and critically analyze information. There have been a few, small studies among diabetes patients [22], [23], [24] conducted in Japan, assessing all three types of health literacy, which all found that functional health literacy is less important than communicative and critical health literacy for diabetes self-management.

Most research on health literacy has been conducted in the United States and Japan. As a consequence, relatively little is known about the level of health literacy and its effects on outcome measures in European countries and more specifically, the Netherlands [20], [25]. Recent results from the European Health Literacy Survey showed that the percentage of the general Dutch population with limited health literacy skills is about 29% [26]. More specific insight into these skills is important however, as low health literacy may cause a gap between what is expected of chronic patients with respect to self-management and their actual skills. By identifying vulnerable groups with respect to health literacy, professionals can tailor their information and support to the health literacy skills of their patients.

The aims of the present study were threefold: (1) to provide insight into the functional, communicative and critical health literacy skills of chronic somatic disease patients in the Netherlands, (2) to identify groups that are less literate and (3) to examine the relationship between health literacy and aspects of self-management. Based on earlier findings [22], [23], [24], we hypothesize that communicative and critical health literacy contribute more to better self-management than functional health literacy of chronic patients.

Section snippets

Sample

We analyzed data from the ‘National Panel of people with Chronic illness or Disability’ (NPCD), a nationwide prospective panel-study on the consequences of chronic illness in the Netherlands [27]. Panel members were recruited from the patient files of general practices (national random samples of general practices, drawn from the Netherlands registration of General Practice [28]). Selection criteria for patients were: diagnosis of a somatic chronic disease by a certified medical practitioner,

Sample characteristics

In Table 1, sample characteristics are shown. Mean age was 62 years with 55% of the sample being female. Most patients had been diagnosed for quite a long time (M = 12 years) but with a large variation in illness duration (range 0–67 years). Half of the patients suffered from multi-morbidity, one-third experienced moderate to severe functional limitations. Mean scores on the PIH subscales and total scales and on the PEPPI were high indicating that patients perceived their abilities for

Discussion and conclusion

In this cross-sectional study among a large Dutch sample of chronic disease patients we investigated the level of functional, communicative and critical health literacy and their associations with chronic disease self-management. Results showed that patients in the Netherlands experience their health literacy as quite good, with patients scoring best on functional health literacy, followed by communicative and critical health literacy, providing support for Nutbeam's model that the three types

Acknowledgements

This study was based on data from the research program ‘National Panel of people with Chronic illness or Disability’, which is financed by the Netherlands Ministry of Public Health, Welfare and Sports and the Netherlands Ministry of Social Affairs and Employment. These ministries had no role in the design and execution of the study. The authors declare that they have no competing interests.

References (39)

  • I. Nielsen-Bohlman et al.

    A prescription to end confusion

    (2004)
  • K. Sørensen et al.

    Health literacy and public health: a systematic review and integration of definitions and models

    BMC Public Health

    (2012)
  • E.V. Estacio

    Health literacy and community empowerment: it is more than just reading, writing and counting

    J Health Psychol

    (2013)
  • I. Kirsch et al.

    Adult literacy in America: a first look at the results of the National Adult Literacy Survey

    (1993)
  • R.M. Parker et al.

    The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills

    J Gen Intern Med

    (1995)
  • Institute of Medicine

    Health Literacy: a prescription to end confusion

    (2004)
  • D. Nutbeam

    Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century

    Health Promotion Int

    (2000)
  • I. Rootman et al.

    A vision for a health literate Canada

    (2008)
  • K. Eichler et al.

    The costs of limited health literacy: a systematic review

    Int J Public Health

    (2009)
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