Health literacy assessment of primary care patients in a Lower Middle Income Country
1Pharmacology and Toxicology and Clinical Pharmacology Department, University of Prishtina, Prishtina, Kosovo
2Researcher, Department of Clinical Medicine, University of Business and Technology, Prishtina, Kosovo
3Nurse Department, University of Prishtina, Prishtina, Kosovo
4Infectious Diseases Department, University of Prishtina, Prishtina, Kosovo
*Corresponding author: Dardan Dreshaj, University for Business and Technology, Prishtine, Kosovo, Email: dardan.ayd@gmail.comAbstract
Background
Health literacy includes cognitive and social skills which help patients to access, understand and use medical information in ways that promote and maintain good health. Recently health literacy emerged as an important topic for public health and health policy makers.
Objectives
This study was designed to evaluate health literacy level among patients of primary care centers in Prishtina and its association with socioeconomic status, education level, hospitalization rates, self-perception on health and frequency of visits to the doctor.
Methods
Short Test of Functional Health Literacy in Adults was used to collect the data. S-TOFHLA administration criteria were strictly followed. 557 questionnaires were collected, filled by patients around Prishtina visiting primary healthcare centers, and further analyzed with SPSS.
Participants
Every third patient, older than 15 years old, who entered doctor’s office, was asked to fulfill the test totaling 557 patients.
Results
From 557 surveyed patients, according to S-TOFHLA scoring criteria, 79 % of patients are considered as health literate, 9 % have moderate knowledge and 12 % are health illiterate. Results revealed statistically significant differences in test performance between patients with different levels of education (p < .01), between males and females (p = .033), or between patients with different hospitalization rates (p < .05).
Conclusions
From results obtained, we can conclude there is an association between health literacy level and variables like gender, socioeconomic status, education level and hospitalization rates.
Introduction
For the past decade health literacy emerged as an important topic for public health and health policy makers [White, Chen and Atchison, 2008; Nielsen-Bohlman, Panzer and David 2004]. Health literacy includes cognitive and social skills which help patients to access, understand and use medical information in ways that promote and maintain good health [Berkman, et al, 2015]. Health literacy requires a complex skill-set, like reading, listening, analytical skills and navigation of healthcare system, that lead to a clear communication with healthcare providers and proper decision making [Berkman, et al 2015].
Recently health literacy is being recognized as a “system issue” [Kutner, et al, 2006], thus moving health literacy from an “under-recognized silent epidemic to an issue of health policy and reform” [Kutner, et al 2006; Aguirre, Ebrahim and Shea 2005; Baker, et al 1999; Howard, Sentell and Gazmararian, 2006].
Patients with limited health literacy skills, lack knowledge on medical topics, which leads to a lifestyle and decisions that may harm their wellbeing [Schillinger, 2002]
People with low health literacy use healthcare services more frequently [Bains and Egede, 2011], less likely use preventative care [Bennett, Chen and Soroui, 2009], have greater likelihood of taking medicines incorrectly [Weiss, 2007], have higher chances of hospitalization and bad disease outcomes [Baker, et al, 2002], have higher incidence and ineffective treatment of cancer and diabetes [Bennett,2009; Davis, et al 2002; Wolf, Gazmararian, Baker 2005; Parker, Ratzan, 2010; Schillinger, Grumbach and Piette, 2002], utilize expensive services, like emergency care and inpatient admissions, which increase expenses and impact economy in general [Parker, Ratzan, 2010; Eichler, Wieser and Brügger, 2009].
Rather than just being related with medicine, health literacy is a broader concept including also environmental, political and social factors that determine health [Berkman, et al 2015].
Thus, health literacy can be used as an empowering tool for achieving internationally agreed health and development goals, as well as to control the emerging threats such as pandemic influenza, climate change and non-communicable diseases. [Nielsen-Bohlman 2004; Paasche-Orlow, et al, 2005; Rudd, 2010]
We aimed to assess health literacy of primary care patients in Kosovo as LMIC (lower middle-income country) and to analyze the association between health literacy level and patient education level, socioeconomic status, presence of chronic diseases, self-perception of health, frequency of visits to the doctor and hospitalization rates.
Methodology
Population
Our study population consisted of 557 participants, 57.85% females and 42.15% males.
16-25 and 26-35 group-ages had the highest participation rate on survey, consisting of 29.69%, respectively 28.54%.
97.13% of the surveyed population was Albanians, and the rest were Bosnians, Roma-Egyptians and Turkish.
0.74% of the surveyed population was unschooled, 4.44% finished their primary school, around 29.94% had finished high school, 54.53% completed their university degree and 10.35% of them declared to have a post-university degree.
Including Criteria
Every third patient, older than 15 years old, who entered doctor’s office, was asked to fulfill the test. If the patient agreed, patient’s consent was read verbatim from the doctor and then was signed by patient. S-TOFHLA administration criteria were strictly followed. 7 minute time-limit S-TOFHLA test policy was rigorously respected, by using GP’s smartphone stopwatch.
Exclusion Criteria
Excluded were emergency cases, illiterate patients, or patients unable to perform the test due to mental or physical disabilities.
Data collection
Data were collected by using Short Test of Functional Health Literacy in Adults [Agiurre et al 2005,Baker et al 1999], as the most appropriate tool for this purpose [Collins, et al, 2012].
Aside from the health literacy test, we added another 14 general questions regarding gender, age, socioeconomic status, education, language, self-perception on health, number of visits to the doctor and hospitalization rates, which we considered to be of important association with health literacy level.
The testing process was approved and monitored by Family Medical Center’s Ethical Committee and Board of Directors in Municipality of Prishtina, Kosovo. Also patient consent was asked and signed before testing.
We handed out 560 tests in seven primary healthcare centers around Prishtina, and 557 out of 560 tests were completed.
The test was administered and monitored by randomly selected general practitioners. Each of the selected GP was given 20 tests, to complete in 20 working days.
Data analyses
Data collected from questionnaires were inputted and analyzed with SPSS software.
A one-way ANOVA test was used to measure differences between patient social status and their performance in health literacy test.
The ANOVA test was used to present the differences on test performance between diverse levels of educations among patients. A Chi-square test was used to perform the correlation of frequency of visits to the doctor among patients with or without chronic diseases.
Results
From the 557 surveyed patients, based on S-TOFHLA scoring criteria, 79 % are considered as health literate, 12 % of them are health illiterate, and 9% have moderate knowledge.
Categorization is done by S-TOFHLA score, as having adequate health literacy if the score is 23-36, as marginal health literacy if the score is 17-22, and inadequate health literacy if the score is 0-16.
The results reveal, there is statistically significant difference (p = .033) between females (M = 28.37, SD = 7.251) and males (M = 26.96, SD = 7.863) in terms of their performance in the health literacy test.
As depicted in the graph below, there are no statistically significant differences between patients of different age groups in regard to their performance in the health literacy test.
A one-way ANOVA test shows that there are significant differences (p < .01) in terms of health literacy test performance between the unemployed (M = 26.5, SD = 7.972) and students (M = 29.19, SD = 7.238), with the latter group performing better on average.
There are no other statistically significant differences between patients with diverse social statuses.
The ANOVA test also revealed differences (p < .01) in test performance between patients with different levels of completed education. Further exploration of results through Tukey’s HSD (honest significant difference) test showed that this difference is significant between those who are unschooled (M = 18.75, SD = 8.5) or with only a primary school education (M = 24.38, SD = 9.016) – who performed the worse in the health literacy test, and those with a Bachelor Degree (M = 28.69, SD = 7.309) or Masters/Doctoral degree (M = 29.63. SD = 6.571) – who performed the best in the test.
While there are no significant differences in test performance between patients who visit the doctor at different rates, there are statistically significant differences (p < .05) between those who have never been hospitalized (M = 29.43, 6.764) and those who have been hospitalized at least once in their life (M = 27.73, SD = 7.739), with the latter group of patients performing worse.
Aside from health literacy assessment, data analyses showed that patients who were never hospitalized were significantly more likely (p < .01) to perceive themselves as healthy people, compared to those who have been hospitalized once, twice or more times.
Similarly, those who visited doctor less often were again significantly more likely (p < .01) to report their health status as “healthy”.
Results revealed that there are statistically significant differences (p < .01) in frequency of doctor visits between patients with and without a chronic disease. As expected, those with a chronic disease are significantly more likely to pay more visits to the doctor within a year, when compared to those who do not suffer from a chronic disease.
Data analyses showed there are statistically significant differences (p < .01) in the opinion of the affordability of the therapy prices between patients with different levels of education. Students were the most likely group to say that they can afford therapy prices (58%), followed by the employed patients (52%). On the other hand, only 13 % of the patients that are dependent on social aid reported that they can afford therapy prices.
Discussion
Health literacy was firstly introduced in 1970s. Since then more than 3000 publications on health literacy are listed in PubMed and 75% of those have been published in the last five years, emphasizing thus the great importance health literacy plays on public health. [Stephan Van den Broucke, 2014]
The 2003 National Assessment of Adult Literacy (NAAL), showed that a majority of adults 53% had Intermediate health literacy level, 12 % had Proficient health literacy, 22 % had Basic health literacy and 14 % had Below Basic health literacy levels. [Rikard, et al, 2016]
International Adult Literacy Survey (IALS) results [Kirsch, 2001] showed that between 19 and 23 % of U.S. adults performed highest levels on the three literacy scales at levels 4 and 5. On all three scales, only Sweden had higher percentages of their adults at these levels. [Binkley, Matheson and Williams, 1997, p. 9].The United States performed better than German-speaking Switzerland and Poland on the prose scale, similarly as Australia, Belgium, Canada, Germany, Ireland, French-speaking Switzerland and United Kingdom and performed worse than Sweden, Netherlands and New Zealand. [Binkley, Matheson and Williams, 1997]
LMICs like Bangladesh, Mozambique, India, Zambia and sub-Saharan countries also researched the association of health literacy with oral health, child nutritional status, cardiovascular mortality and HIV infection. [McClintock, et al, 2017; Tique et al, 2017; Johri et al, 2016; Ramandeep, et al, 2014; Schrauben and Wiebe, 2017; Das, et al, 2017].
Our study is the first one to assess health literacy among primary care patients in Kosovo. According to the results, patients who frequent primary care services in Prishtina are mostly literate. Out of 557 surveyed patients, 79 % are considered as health literate, 12 % of them are health illiterate, and 9% have moderate knowledge.
Results revealed there are significant differences on patient’s health literacy level among gender, education, socioeconomic status and hospitalization rates.
Females performed better than males, students performed better than unemployed patients on health literacy test. Results revealed differences in test performance between patients with different levels of completed education. As well, at least once hospitalized patients performed worse on test than non-hospitalized ones.
An international systematic review which included 36 studies on health literacy also revealed that most of the studies investigated racial, ethnic and educational disparities. It has been stated a mediating effect of health literacy status, medication adherence and understanding of medication intake across racial, ethnic and educational disparities. [Mantwill, et al, 2015] Our study has some limitations. The study was only conveyed in municipality of Prishtina, the capital city of Kosovo, thus we lack information from other regions. Patients did not report data they considered sensitive, therefore we had some missing data. S-TOFHLA does not assess all health literacy aspects (ex. spoken health literacy). Therefore, external validity to some extent might be a concern.
To conclude, knowing that patients with low health literacy use healthcare services more [Bains and Egede, 2011], have higher chances of hospitalization and bad outcomes [Baker et al, 2002], utilize expensive health services, like emergency care and inpatient admissions, which increases healthcare system expenses and impacts economy in general [Eichler et al,2009; Paasche-Orlow et al, 2005], should arise the professional and public awareness on health literacy importance. [Clarke, et al, 2017; Brownlee et al, 2017].
We should be aware of the poor health literacy effect on patients’ ability to communicate their history and understand medical information, and then start improving patient-physician communication skills by avoiding medical jargon, breaking down the instructions or the information into small steps and limit the focus of a visit to three key points or tasks. These interventions would increase patient’s self-esteem, compliance, capacity to self-manage and most importantly improve safety patient and outcomes. [Williams, et al, 2002; Marshall, Sahm and McCarthy, 2012; Hersh, Salzman and Snyderman, 2015]
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.