Solving the health literacy equation

I’ve lost count of the number of times my friends have asked me what R means since April.

These are individuals who, pre-pandemic, barely took an interest in my profession. Now they apparently see me as a mystical decoder of Boris Johnson’s deepest thoughts.

Given my enquirers are from a broad range of occupations – corporate lawyer, plumber, graphic designer – I assumed that one of them must surely have solved this algebraic mystery. But no, not even an inkling.

They are not alone. Among the many trends and hugely significant issues accelerated or exposed by Coronavirus is the matter of health literacy. Even in the UK, a developed country with high levels of general education, there is marked variability in the understanding of health information.

The WHO has a quite wordy definition for health literacy, so it’s perhaps most succinctly described as a person’s ability to access, understand and use information to be healthy. That ability is influenced by a range of personal characteristics and social resources.

Don Nutbeam, the University of Sydney professor who has probably done more than anyone to academically advance and promote the concept of health literacy over the last 20 years, landed on three ‘types’ or levels of health literacy: functional, interactive and critical.

Functional health literacy is about the basic understanding of information in everyday situations, while interactive relates to ‘participation’ and an ability to apply information from different places. But while practical access to basic health information has become easier in recent years, filtering and applying the right advice is now much, much harder.

The possession of critical health literacy skills is today more of a gift than ever. In an era of information overload, the ability to analyse information and know which content to trust can be a significant challenge for even the most literate – especially during a fast-moving pandemic.

The relationship between health literacy and a range of health outcomes is well established. There is a clear correlation between low levels of health literacy, socioeconomic disadvantage and chronic illness. This means that those who could most benefit from the right health information can be the least likely to find and understand it. And understanding is rarely more vital than during a public health emergency.

Sometimes, lack of understanding is the result of broad-brush health communications. In a quest to quickly explain a complex concept and bridge as many educational, social and language differences as possible – as in Boris Johnson’s now infamous R-based national address – the meaning and purpose of a message can disappear almost entirely.

But while, in Johnson’s instance, it could be argued that the government didn’t have time to base its communication on audience insights and tailor its message accordingly, most of the time, we do. To ensure our campaigns genuinely engage those we need to help, we must take the time to truly understand people and their needs. We may be surprised by what we find.

Work undertaken by Stoke-on-Trent City Council, as a member of the WHO European Healthy Cities movement, revealed that 49% of the city’s adult population has inadequate health literacy. The finding is representative of Europe on average, with data suggesting around 47% of the European population has a level of health literacy that is inadequate or problematic.

This means that when we’re designing patient support materials, creating interactive resources or communicating with non-health professionals in any way, we must assume that around half the people seeing that content will struggle to understand it.

Otherwise there’s likely to be zero chance those people will take the intended positive action to benefit their health – which is, after all, the objective of almost every campaign or item of health communication.

Far from being able to navigate infographics or interpret the self-diagnostic online tools that often form part of pharma’s patient materials, the Stoke-On-Trent initiative confirmed that some members of the population can find it difficult to understand medicine labelling.

Never mind decoding the meaning of R, those below the ‘functional’ health literacy level can struggle to absorb and act on instructions about risk – for example, blanket guidance about social distancing.

In a Catch-22, this group are more likely to suffer from a chronic condition and engage in unhealthy behaviours like excess alcohol consumption, but less likely to engage with screening or vaccination programmes. They need the most support, but find it difficult to understand the information intended to help.

One of the recommendations from the work undertaken in Stoke was to ensure a ‘multi-agency’ approach to health engagement, including working with patient groups and advocates – something that’s often the hallmark of pharma-coordinated campaigns that make a real difference to people. A collaborative approach has also been put forward by Professor Don Nutbeam, who advocates community-based educational outreach to help people make better health decisions.

It’s no accident that an award-winning public campaign for NHS Sussex helped reduce unwanted teenage pregnancies in East Sussex by 11% – over twice the anticipated KPI – in a single year. The messaging and visual language was co-created with youth club members and pupils in school PSHE lessons.

It simply featured the headline, ‘Which one is easier to carry?’ Below were two icons: a baby and a condom.

To positively influence health outcomes, people need to quickly understand the ‘what’ and – vitally – the ‘why’ in a way that engages and means something, personally, to them. Only then can they be persuaded to act on a message and positively adapt their health behaviours.

Unlike anything else, the pandemic has brought the role of pharma and healthcare communicators into sharp focus. Even before a second wave and local lockdowns, it’s clear that many people’s long-term well-being has been significantly affected by Coronavirus.

Worsened economic circumstances, deteriorated mental health and reduced access to secondary care services all disproportionately affect those who most need clearer, more meaningful information to help them manage and improve their health.

Now is the moment for us to check. Check that the information and resources created before the pandemic truly resonate and are helping people as intended. It’s also a chance for us to do some things differently from this point on, ensuring that we never assume the information we provide will be understood. Co-creation or genuine, robust consultation with target audiences at the programme and message development stage will almost always be to the significant benefit of those who need the most help.

By keeping health literacy front of mind, we have a real opportunity to help tackle health inequality across populations. We can give individuals – regardless of geography, social background, age or profession – the trustworthy tools and support needed to help improve their understanding, health outcomes and well-being. If ever there was an opportunity for pharma and healthcare communicators to truly make a difference to people’s lives, it’s now.

And now I’d better try explaining that to my friends.

‘There is a clear correlation between low levels of health literacy, socioeconomic disadvantage and chronic illness’