Do rehabilitation professionals need to consider their clients’ health literary for effective practice?

Abstract

Objective

To discuss the importance of integrating health literacy into rehabilitation practice.

Background

The effectiveness of rehabilitation interventions and clients’ long-term health might depend on various factors, including health literacy. Health literacy is defined as the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings over the life-course. Rehabilitation professionals are often uniformed about and neglect health literacy in their interventions.

Method

The scientific and grey literature on health and, more specifically, rehabilitation and health promotion was reviewed. The Medline, OTDBASE, CINAHL, AMED and MANTIS databases were searched by combining the key word 1) “health literacy” with the key words 2) “rehabilitation”, “physical therapy”, “occupational therapy” or “health promotion”.

Results

Health literacy is one of the foundations of individual health and might have an impact on interventions, the individual and society. All papers addressing both health literacy and rehabilitation (n=10) specifically mentioned that rehabilitation professionals need to consider their clients’ health literacy. Rehabilitation is particularly linked to health literacy because both stress the importance of 1) capacities, functioning, participation and empowerment of clients; 2) holistic approach; 3) client-centred practice; 4) teaching of information and methods; and 5) access to services and equity issues.

Conclusions

Based on these results, we think it is important that rehabilitation professionals be aware of the importance of health literacy and intervene to improve it. The challenge is now to better understand how health literacy influences the effectiveness of rehabilitation and health outcomes.

Introduction

The effectiveness of rehabilitation interventions depends on various factors related to 1) the intervention, 2) the environment (intervention place, time and context, environmental resources of the professional and client, etc.), 3) the rehabilitation professional, 4) the client, and 5) interactions between the professional and client [1]. Even the most relevant intervention based on solid science and a good assessment and having very specific targets and objectives (factors related to the intervention) could have poor results if other factors are ignored. The effectiveness of rehabilitation interventions is highly compromised if professionals have difficulty communicating [2, 3], an essential competency for their practice [4, 5]; if clients have limited ability to understand, evaluate and communicate information [6]; or if interactions between the professional and the client are not optimal. Improving these competencies, abilities or interactions could be more effective [2, 3, 7–9] than any new biomedical advance [10, 11].

Rehabilitation professionals’ communication competencies, clients’ communication abilities, and interactions between the professional and the client are among the core determinants of health literacy. “Literacy is the ability to understand and use reading, writing, speaking and other forms of communication as ways to participate in society and achieve one’s goals and potential.” (p. 10) [12]. More specifically, health literacy is “[t]he ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course.” (p. 11) [12]. This definition of health literacy indicates what influences the health choices that individuals make for themselves and others in their everyday lives [3, 13]. It goes beyond individual abilities and considers the context and interactions in which these abilities are needed [14, 15].

Specifically in the context of the health system, health literacy refers to 1) expressing one’s needs, signs and symptoms [16], 2) the identification of health services and when to seek them, 3) the means used to navigate through the complex health system, 4) how to act in partnership with health professionals [13], 5) the ability to understand the health professionals’ recommendations and one’s rights and responsibilities, and 6) the ability to take action to improve one’s health [16] and safety [7], including doing what is necessary for one’s treatment and the optimal use of equipment or medication [17]. Health literacy highlights the importance of individuals developing more control over their health and its determinants [9, 13] to improve their health-related living conditions [18]. By emphasising greater individual control, the concept of health literacy [9, 19] underlies the emergence of more sophisticated approaches to health education that have broader objectives [19] and can produce significantly different results [20].

There is growing evidence that health professionals need to consider their clients’ level of health literacy in order to tailor their interventions accordingly and optimise their impact [2, 3, 7–9]. The relevance of health literacy to practice has been discussed in relation to various health professionals (physicians [21–34], nurses [7, 35], dentists [36], social workers [37], pharmacists [38]). However, to date, there are few such discussions in the scientific literature on rehabilitation, with the result that the majority of rehabilitation professionals do not know enough about health literacy and rarely integrate it into their practice. This opinion paper presents a review of the scientific and grey literature on rehabilitation, health promotion and health literacy, and discusses the importance of integrating health literacy into rehabilitation practice. This paper will help rehabilitation professionals gain a better understanding of health literacy, identify the clinical implications and find ways to actively contribute to improving it. The underlying premises are: 1) health literacy is relevant to rehabilitation practice; 2) current requirements with regard to essential rehabilitation professional competencies do not put enough emphasis on the role rehabilitation professionals should play in this regard, and 3) to optimise their interventions and collaborate in health promotion initiatives, rehabilitation professionals must receive health literacy training and tailor their interventions accordingly [12].

Method

To discuss the importance of integrating health literacy into rehabilitation practice, we reviewed the scientific and grey literature. In addition to the rehabilitation literature, we looked specifically at the health promotion literature. Derived from an area still generally underutilised by health professionals [39], the vision of health literacy in health promotion is more complete, holistic and proactive than that found in other health fields [9]. The methodology of scoping studies [40] was followed to carry out the literature review. Scoping studies are used to examine the extent, range and nature of publications in a particular field. Their aim is to quickly identify research gaps in the existing literature [40]. The Medline, OTDBASE, CINAHL, Allied & Complementary Medicine Database (AMED) and MANTIS databases were searched by combining the key word 1) “health literacy” with the key words 2) “rehabilitation”, “physical therapy”, “occupational therapy” or “health promotion” for the period from 1980 to December 2008. An extensive review of the titles and available abstracts identified all types of articles (empirical studies, conceptual articles, etc.) that could contribute to the debate on the importance of health literacy in rehabilitation. The key authors on health literacy in the health promotion field (Kickbusch, Rootman and Nutbeam), bibliographies and Websites were also included in the search strategy. Elements supporting the importance of health literacy in general and also for rehabilitation professionals were extracted, based on a discussion between the authors, from selected papers.

Results

Of the 1079 articles found using the key word “health literacy”, 147 (14%) also included the key word “health promotion” and 17 (1%) the key words “rehabilitation”, “physical therapy” or “occupational therapy”. Five articles [6, 41–44] (0.5%) included both categories of key words, only two of which [42, 43] were empirical articles. Of these five articles, only one focused on written material [44]. Two others [6, 41] discussed the importance of integrating health literacy into practice, physiotherapy in the first case and occupational therapy in the second. With 9 and 11 references respectively, however, these two articles were not based on a comprehensive review of the scientific literature.

Of the twelve other references that also included the rehabilitation key words, seven articles [45–51] were not primarily concerned with rehabilitation, one [52] only touched on health literacy, one [53] was a position paper by the Canadian Association of Occupational Therapy, and the last [54] was an unpublished doctoral dissertation. In addition, two articles [55, 56] not identified in the rehabilitation category also dealt with health literacy and rehabilitation, but without specifically discussing its importance in rehabilitation. All told, ten articles addressed health literacy and rehabilitation in sufficient detail but none provided a detailed discussion about the importance of integrating health literacy into rehabilitation practice. The research on health literacy is thus undoubtedly in its early days, and the literature needs to be enhanced in both quantity and quality. Nevertheless, the articles found, including those on health promotion, 1) indicate the importance of health literacy in general, 2) present factors associated with low health literacy levels, and 3) provide information that links health literacy to rehabilitation, emphasizing its importance for rehabilitation professionals. These elements, in addition to the study’s strengths and limitations, are discussed below.

Importance of health literacy

Health literacy is one of the priorities of health promotion initiatives [3, 9], a pillar of modern life [13, 57, 58] and one of the foundations of individual health [12]. Because it affects everyday tasks (Table 1), low levels of health literacy have varied and serious consequences (Table 2). Poor health literacy impacts not only individual health and development, but also has enormous economic, social and cultural consequences [13, 16, 19]. This is especially true since low levels of health literacy are a problem in many countries [12, 13]. In Canada, for example, an estimated 60% of the population has a low level of health literacy [16]. Finally, health literacy might explain diverging results from educational intervention studies (e.g. [59, 60]).

Table 1.

Examples of tasks affected by the level of health literacy [16]

Health Activities	Focus	Example of materials	Examples of tasks
Health Promotion	Enhance and maintain health	Articles in newspapers and magazines, booklets, brochures; Charts, graphs, lists; Food and product labels	Purchase food; Plan exercise regimen
Health Protection	Safeguard health of individuals and communities	Articles in newspapers and magazines; Postings for health and safety warning; Air and water quality reports; Referenda	Decide among product options; Use/avoid products; Vote
Disease Prevention	Take preventive measures and engage in early detection	News alerts: TV, radio, newspapers; Posting for inoculations and screening; Letters related to test results; Graph, charts	Determine risk; Engage in screening or diagnostic tests; Follow up
Health Care and Maintenance	Seek care and form a partnership with health-care providers	Health history forms; Medicine labels; Discharge instructions; Education booklets and brochures, health information on the Internet	Describe and measure symptoms; Follow directions on medicine labels; Calculate timing for medicine; Collect information on merits of various treatment regimes for discussion with health professionals
Systems Navigation	Access needed services; Understand rights	Maps; Application forms; Statements of rights and responsibilities, informed consent; Health-benefit packages	Locate facilities Apply for benefits; Offer informed consent

Table 2.

Possible consequences of a low level of health literacy [12, 13]

Poorer self-perceived health Situations and behaviours that could jeopardise safety and health Less participation and social support Lower income Low level of empowerment, dependence on the environment and maladaptive skills Reduced likelihood of achieving life goals and poorer quality of life ↑ use of health services including hospitalization Other negative clinical outcomes such as underutilisation of some health or information services, less participation in interventions and non-compliance with recommendations ↑ morbidity and health inequities ↑ premature mortality

Factors associated with low health literacy levels

By knowing the factors associated with low health literacy levels, we have a better understanding of what can influence health and intervention outcomes. A few studies have documented the factors associated with a low level of health literacy, which limits the ability to access, understand and use information [9]. These factors include personal limiting factors, environmental obstacles [12] and the interaction between individual and environment [12, 15]. Personal limiting factors include: advanced age (over 65), low levels of formal education, different mother tongue or culture (recent immigrant), being unemployed or having a low income, lack of daily reading and learning disorders [12]. Some of these factors require public health initiatives that should start in the early school years and are long-term investments [3]. However, rehabilitation professionals can intervene in the short and medium term by taking action to optimise their clients’ abilities and reduce environmental obstacles.

These environmental obstacles include: demands of modern life and self-management of health requiring an understanding of the information; the complexity of the health system that is spawning a large and ever-increasing number of partners [12, 13]; social stigma; a context that offers few health support measures or measures not adapted to the person and his/her environment; complex documents and messages; lack of health literacy awareness and knowledge; and health professionals’ limited communication skills [12]. Thus the health system is one of the prime sectors that must assume their responsibilities in order to improve health literacy [15].

Finally and more specifically related to interventions, health literacy is linked to certain factors arising out of the interaction between the individual and his/her environment, namely: motivation; compliance; self-management of chronic disease; participation in preventive and health programs; social participation and skills; and, as already mentioned, treatment effectiveness [9]. Health literacy enables clients and health professionals to engage in a true dialogue fostering: 1) a common perspective on how to address the situation, 2) listening, 3) mutual learning, and 4) a climate of trust and partnership [3]. To be effective, clinical practice must consider health literacy [2, 3, 7–9]. Other factors also support its importance specifically in rehabilitation.

Importance of health literacy in rehabilitation practice

Among the 17 papers including rehabilitation key words, ten [6, 41–44, 48, 53, 54, 56, 61] addressed both health literacy and rehabilitation in sufficient detail. All of these ten papers specifically mentioned that rehabilitation professionals need to consider their clients’ health literacy. No paper presented a contrary opinion. To highlight the importance of health literacy for rehabilitation practice, links between health literacy and rehabilitation will be discussed first. Other factors that might be conducive to rehabilitation professionals’ involvement in improving health literacy will then be presented.

Rehabilitation is linked to health literacy because of the importance of 1) capacities, functioning, participation and empowerment of clients; 2) holistic approach; 3) client-centred practice; 4) teaching of information and methods; and 5) access to services and equity issues. Rehabilitation professionals’ main focus is on the capacities, functioning, participation and empowerment of clients in their everyday lives [42, 62, 63], which is clearly consistent with health literacy [53, 58] and an idea reinforced in five of the ten papers [41, 42, 44, 53, 56]. The European Union of Medical Specialists [64] defines rehabilitation as “an independent medical specialty concerned with the promotion of physical and cognitive functioning, activities (including behaviour), participation (including quality of life) and modifying personal and environmental factors.” (p. 6) According to the same source [64], rehabilitation has a significant contribution to make in the reduction of the burden of disease and to the empowerment of people with disabilities to help them achieve optimal participation in all aspects of life [63, 65]. Rehabilitation professionals use intervention methods that foster individuals’ empowerment [62, 66] and can improve their health literacy [52].

These intervention methods require rehabilitation professionals to consider not only the client’s literacy skills but also the context of the intervention and the strategies used to convey the information. This consideration of the individual’s capacities and situation (environment) is a holistic approach, which is precisely one of the strengths of rehabilitation interventions and one of the characteristics of a competent rehabilitation professional [67]. The aim of rehabilitation is to support individual autonomy using a holistic approach [63]. Surprisingly, links between the holistic approach, rehabilitation and health literacy were not emphasized in the papers consulted. However, links between the holistic approach, rehabilitation and health promotion were found [68]. Also, rehabilitation professionals frequently and typically use a client-centred approach [42, 62, 66, 69] that encourages individuals to manage the core aspects of their care and monitor their own health [12]. Three papers [42, 44, 53] specifically supported the link between rehabilitation and health literacy because of a client-centred approach. Moreover, rehabilitation professionals teach clients information and new methods to increase their abilities (e.g. exercise program) or adapt their daily activities [41, 63]. Teaching of information and methods was the most frequent link between health literacy and rehabilitation, supported by nine [6, 41–44, 48, 53, 54, 56] of the ten papers.

Finally, as mentioned in six papers [41, 43, 44, 53, 56, 61], health literacy raises access to services and equity issues [16]. Rehabilitation professionals are aware of the pressures on individuals due to their racial, cultural or religious differences or sexual orientation. Access to rehabilitation services [61] and social participation without discrimination are fundamental values of rehabilitation [64].

In addition to its many links with health literacy, rehabilitation practice might be conducive to improving clients’ health literacy because of the following factors: 1) timing issues, 2) professional knowledge, and 3) work in interdisciplinary teams and with the community. Rehabilitation professionals often meet their clients at a time when the adaptation process has begun and they are ready to listen to an explanation of the implications of their health problems. They sometimes follow their clients over long periods of time, creating situations conducive to improving health literacy.

Moreover, rehabilitation professionals know about health and its determinants, increasingly act as health educators, and must seize every opportunity to stress disease prevention and health promotion messages [6, 42, 70, 71]. For example, rehabilitation professionals can talk about the importance of daily exercise, a healthy and balanced diet containing at least five portions of fruits and vegetables, and not smoking [72]. However, the availability of information is not enough [12]. Because of their knowledge and special relationship with clients, rehabilitation professionals can and must intervene to i) clear up confusion, ii) ensure that the health messages in health promotion efforts reach the people who need them most [3], iii) not only reinforce them, iv) but also personalise them to show that the messages are relevant and to increase clients’ motivation. Rehabilitation professionals are in a privileged position to foster not only their clients’ understanding of health information [73], but also to translate this information into behaviours optimising their health [3].

Finally, since they often deal with individuals who have complex and multiple needs and a low literacy level, rehabilitation professionals regularly work in interdisciplinary teams and with the community. The health literacy issue requires a public health effort requiring the close collaboration of various disciplines and the inclusion of families and even communities [74]. These particular aspects of rehabilitation might make it easier to integrate health literacy into rehabilitation practice on a daily basis. However, given the paucity of level of evidence in this field, specific actions that rehabilitation professionals can take have not, for the most part, been evaluated. Nevertheless, rehabilitation professionals must be informed about the issue of health literacy and its impact on interventions, the individual and society. They must also make their knowledge and services accessible. To do so, it is important to verify what clients retain of the information taught and identify obstacles to implementing the recommendations. Further research is unquestionably needed on health literacy issues. It is important to know more about the determinants of health literacy, people’s habits with regard to accessing health information, and the effectiveness of innovative interventions to improve health literacy. We also need a better understanding of gender differences, and the relationship between health literacy and 1) chronic diseases requiring lifestyle changes, and 2) some clinical outcomes. It is also important to improve the operationalisation of the concept for both research and clinical purposes [75]. Lastly, there is still a lot of work to be done to develop a more comprehensive measure to evaluate people’s level of health literacy in terms of their ability to access, understand and use health information in a way that promotes and maintains good health [9].

Strengths and limitations

In this opinion paper, we systematically considered and reviewed health literacy articles from the rehabilitation and health promotion literature. Using the rigorous procedures of scoping studies, the importance of integrating health literacy into rehabilitation practice was discussed. However, the opinion of the authors was based on premises which might have influenced the review. Moreover, the electronic search did not specifically include other potentially interesting concepts such as “literacy” and “illiteracy” per se and, contrary to physical and occupational therapy, did not specifically target other rehabilitation specialties. Finally, the number of rehabilitation papers on health literacy is small and further research is needed to confirm the importance of health literacy for rehabilitation professionals.

Conclusion

The low level of health literacy in the population is a serious problem requiring innovative and proactive initiatives. Health professionals in general, and rehabilitation professionals in particular, because of their specific competencies, must take appropriate action. Health literacy enables clients and rehabilitation professionals to engage in a true dialogue fostering: 1) a common perspective on how to address the situation, 2) listening, 3) mutual learning, and 4) a climate of trust and partnership [3]. Given the impact of health literacy on interventions, the individual and society, rehabilitation professionals must seize every opportunity to improve it. It is important to avoid certain mistakes made in health education: taking a reductionist approach to health literacy, limited development of personal competencies, and investing only in information, education and communication [20].

Research must continue so that rehabilitation professionals: 1) better understand how health literacy influences the effectiveness of rehabilitation interventions and health outcomes, and 2) base their actions on the best possible evidence. It is also essential to make a concerted effort to improve the health literacy of individuals and communities. Improving health literacy could lead not only to personal benefits but also to social benefits, for example, the development of social capital [14]. The potential impacts of improving the health literacy of the population are wide-ranging and substantial: increase in general population health; decline in the use of health services; reduction in average costs of treatment including shorter treatment times and fewer errors; decline in work accidents; increased productivity; growth in the country’s economy; and reduction in health inequities [16]. Therefore it is important for rehabilitation professionals to integrate health literacy into their practice.

Key Clinical Messages.

• Low levels of health literacy are a widespread problem that has an impact on the effectiveness of rehabilitation professionals’ interventions, and on individual and population health.

• Health literacy must be considered by rehabilitation professionals because of its links with 1) capacities, functioning, participation and empowerment of clients; 2) holistic approach; 3) client-centred practice; 4) teaching of information and methods; and 5) access to services and equity issues.