Health literacy and the role of therapeutic professionals: A scoping review / Gesundheitskompetenz und die Rolle der Therapieberufe: Ein scoping Review

A total of 1380 records were identified through our search. After removing duplicates, 1310 titles were screened for potential inclusion. After 1103 records were removed based on screening titles, 207 abstracts and/or full texts were checked for inclusion. After excluding 168 records, a total of 39 articles were included in the review. A PRISMA flow chart of the search and inclusion process is shown in Figure 2.

Figure 2:

Included articles were published between 2006 and 2022 and derived from 14 countries (USA [17], Australia [3], Germany [4], Ireland [5], Netherlands [3], UK [2], Canada [1], Denmark [1], Italy [2], Malaysia [1], New Zealand [1], Poland [1], Portugal [1], Spain [1]). There were 8 non-research articles, which generally discussed HL for therapeutic professionals (including position papers, unsystematic literature overviews, editorials). Of the 31 research articles 2 were systematic (scoping) reviews, 15 quantitative research studies, 6 qualitative research studies, and 8 mixed methods studies. Most of the articles were related to mixed populations of health care practitioners including therapists (n=17), followed by OT only (n=14), and PT only (n=8). In only 2 studies SLT were included in mixed professional populations.

Type of articles, year of publication, country, methods of data acquisition, details of participants, thematic contents, and results are summarized in Appendix 1 and 2 in the (Supplementary File 1).

The content analysis revealed the following 5 themes: (1) HL related knowledge and skills, (2) education and training regarding HL, (3) assessment of HL in clients, (4) prepare and communicate health-related information, and (5) HL in organizations.

We identified seven studies addressing results on the HL of therapeutic professionals. Four stated that 60% to 80% of the therapeutic professionals were familiar with the term HL itself (Billek-Sawhney et al., 2012; Galati et al., 2018; Rajah et al., 2018; Wirner et al., 2022). Galati et al. (2018) showed that 64% of the OTs agreed that they understand the difference between HL and literacy and those who were familiar with the term could quickly grapple with the idea of HL and what it meant in their work (Salter et al., 2014). However, fewer therapists had knowledge of the deeper construct of HL (Brown, 2016). For OTs, a qualitative study described that there is a lack of comprehensive understanding of HL (LeQuieu, 2016). Furthermore, OTs with low knowledge about HL were less likely to determine if health-related information they present to their clients is accessible and comprehensible (Attard et al., 2021).

Simon et al. (2021) presented results of therapeutic and medical students, showing that 70% have low levels of HL. Additionally, health care professional students in medicine or dietetics scored higher in HL than PT students (Chawłowska et al., 2022). In Spain health science students (including OT and PT) showed sufficient HL levels, with 30% showing low levels of HL. Students that had low literacy levels were 7% in OT and 32% in PT (Rueda-Medina et al., 2020). Simon et al. (2021) described that the different elements of HL – finding, judging and applying health information – are challenging for those therapeutic professionals with low levels of HL. Chawłowska et al. (2022) highlighted that especially the ability to apply knowledge gained during their studies to everyday life was challenging and must be supported.

Overall, 12 studies reported issues regarding the topic of education and training. First, the current integration of HL in the vocational training of therapeutic professionals was analyzed. Galati et al. (2018) examined OT practitioners (n=80) in the USA and described that half of them learned about HL in school, but also that 36% had no education on this topic. Furthermore, 14% received education in one or more places (Galati et al., 2018). 61% of German PTs (n=419) thought it is important to learn about HL in school (Wirner et al., 2022). Overall, 88% of PTs in Germany wanted to learn more about HL, especially methods to build up HL in their clients (Wirner et al., 2022). There was a need to train therapeutic professionals in identifying HL needs and to evaluate these trainings (Koenig & Provident, 2019; LeQuieu, 2016). OTs highlighted a lack of strategies for treating patients identified as having low literacy (Brown, 2016).

Secondly, we summarized the current practices and important contents in the education of therapeutic professionals in HL advanced training. A review of Kaper et al. (2018) described the main themes that should be addressed in HL interventions: raising the awareness of HL, addressing patient-centered communication, applying HL adapted communication, and using educational techniques. Overall, eight studies provided training programs for therapeutic professionals. The content of the trainings is listed for each article in Appendix 3 provided in (Supplementary File 2). The results of the included studies showed, in all cases, that training leads to a broader understanding of HL as a concept in therapeutic professionals. Especially the identification of HL needs, the use of less jargon, raising self-efficacy, and the awareness of adaptations in patient interaction were influenced (Attard et al., 2021; Bird et al., 2022; Finlay et al., 2019; Kaper et al., 2018; Kaper et al., 2019; Koenig & Provident, 2019; Lubasch et al., 2021; Miller-Scott, 2014; Muscat et al., 2021; Toibin et al., 2017).

Educational programs should feature general information about HL, techniques to modify therapy for patients with low HL, and giving practical examples (Brown, 2016). They should focus on identifying the needs of patients with low HL and include strategies to promote communication between therapeutic professionals and patients (see Appendix 4 in (Supplementary File 2) for recommended contents of trainings; Attard et al., 2021; Brown et al., 2012; Kaper et al., 2018; Levasseur & Carrier, 2012; Pizur-Barnekow et al., 2017; Toibin et al., 2017). In addition, it is recommended that assessment of future PTs’ abilities to promote health education and teach self-management strategies take place in PT education programs. HL training that encompasses recognition of “red flags,” administration of screening tests, and incorporation of intervention strategies, including how to create patient education materials, will enhance holistic management of patients, including older adults and those with multiple chronic conditions (Ennis et al., 2012).

Armstrong-Heimsoth et al. (2019) claimed it is necessary to teach OTs how to identify, gain access to, and apply reliable online health information for use with clients. Furthermore, it is essential that there are train-the-trainer approaches in which OTs learn skills on how to best educate their clients on how to find reliable health care information independently. For example, a 1-hour training on “how to find health-related information online” is effective in promoting clients’ participation in health management and self-efficacy as health care consumers (Armstrong-Heimsoth et al., 2019).

Four studies reported that the therapeutic professionals did not use any standardized screening instrument to identify patient HL levels. Some used their own definitions of HL (Billek-Sawhney et al., 2012; Brooks et al., 2020; Brown et al., 2012; Rajah et al., 2018). PTs and OTs had difficulties in identifying patients with low HL (Koenig, 2018; Koenig & Provident, 2019; Murugesu et al., 2022). Salter et al. (2014) described that professionals (and patients) agreed that the best way to identify patient HL needs was by spending enough time talking to patients. It is presented that therapeutic professionals rated patient HL levels higher than did patients themselves (Rajah et al., 2018; Voigt-Barbarowicz et al., 2022). LeQuieu (2016) stated that OTs did not intentionally address HL in their practice. There are also efforts to integrate HL as an addition to existing models in, for example, OT (Smith & Hudson, 2012).

One study reported a systematic approach to implementing an HL assessment in practice. Jensen et al. (2021) in Denmark used focus groups to test the Conversational Health Literacy Assessment Tool (CHAT). CHAT seemed to be a feasible and efficient tool for assessing HL needs among individuals with different socio-demographic characteristics and diagnoses. They stated that the implementation was easy when health care providers were familiar with the concept of HL. Koenig (2018) stated that therapists should focus on the individuals instead of using assessments.

Differences in HL estimation in patients and therapeutic professionals may lead to communication problems (Voigt-Barbarowicz et al., 2022). Barriers in identifying HL levels included embarrassment and stigma, “gauging” (but not directly asking about) patients’ understanding and need for information (Salter et al., 2014). When communicating with culturally and linguistically diverse women there were communication difficulties, cultural differences, and inadequate comprehension (Hughson et al., 2018). Half of the PTs knew that low patient HL is linked to overutilization of the health care system and poor health status (Billek-Sawhney et al., 2012). They reported that clients had poor compliance (Finlay et al., 2019; Murugesu et al., 2022) and, for example, 20% of clients missed their appointments because of problems understanding why to go to, for example, PT (Hughson et al., 2018). Individuals who lack HL may feel neither comfortable nor capable of engaging in a discussion, and they probably feel overwhelmed by the information (LeDoux & Mann, 2019; Murugesu et al., 2022).

Professionals who were familiar with HL found HL to be very relevant when working with clients (Wirner et al., 2022). Some of the health care providers felt frustrated when they got to know the concept of HL and a tool to identify HL needs, as they did not have the opportunities and strategies to meet the needs of their clients (Jensen et al., 2021). The main identified barriers were lack of time to spend with a client with low HL and difficulties in providing the information needed (Finlay et al., 2019; Hughson et al., 2018; Murugesu et al., 2022; Rajah et al., 2018; Wirner et al., 2022). Communication with clients with low HL and communication problems took twice as long because the information must, for example, be translated. Therefore, the conversation time window was halved (Brooks et al., 2020; Hughson et al., 2018).

In the following we present the results regarding communication with clients with low HL and the design of health-related information materials.

Therapeutic professionals can play a key role in enhancing HL, for example, when ensuring that clients understand their diagnoses and treatments or using communication strategies at a level where clients can understand the information (Koenig, 2018; Smith & Gutman, 2011). Eight articles mentioned strategies to improve communication with clients with low levels of HL. Appendix 5 in (Supplementary File 2) lists these strategies. Key elements of communication strategies are: client-centered communication through using less medical jargon, understanding that head nodding does not always indicate comprehension, scheduling enough time to discuss information, and providing information in the client’s native language. Furthermore, the use of, for example, teach-back methods or “ask me three” to ensure understanding was recommended. Even case-based simulation and examples may be supportive to enable understanding of the information (Denysiuk, 2016; Ennis et al., 2012; Galati et al., 2018; Koenig, 2018; LeDoux & Mann, 2019; Levasseur & Carrier, 2012; Miller-Scott, 2014; Smith & Gutman, 2011; Toibin et al., 2017).

We identified two studies that described the current communication practices illustrating very different perspectives. Galati et al. (2018) described that over 80% of American therapeutic professionals interviewed did review information with their clients verbally, and almost all used simple terms instead of jargon. In contrast, Murugesu et al. (2022) found that nearly 40% of the health care professionals they interviewed didn’t react to low HL levels in communication with their clients and furthermore didn’t use special information materials. This was due to a lack of knowledge about HL-oriented information materials. Galati et al. (2018) showed that 76% of therapeutic professionals used handouts with pictures and 82% illustrated these by using examples. 33% used teach-back methods to evaluate if clients understood what they had been told.

Studies reported different challenges in preparing adequate information materials: for example, heeding adequate reading levels

When preparing health-care information material the appropriate readability should be provided. This is also described as using easy or plain language, i.e., Centers for Disease Control and Prevention (2023); Netzwerk Leichte Sprache (2022). To assess readability of written materials the Flesch formula is mostly used. Its calculation is based on two variables: the average sentence length and word length. An online calculator uses grade levels to interpret the scores. Very easy texts are estimated to be at US Grade 5 (11-year old pupils). Fairly difficult texts are estimated to be at US Grade 10–12, see Jindal & MacDermid (2017).

In theory, a majority of therapists knew that patient materials should be provided at 5^th grade (very easy) reading level (Billek-Sawhney et al., 2012), but creating patient materials with the appropriate reading level was challenging (Doyle et al., 2013). Galati et al. (2018) described that 51% of therapeutic professionals assessed the readability of client materials. Some prepared information materials in easy language and used illustrative pictures (Brooks et al., 2020). When designing home programs, 70% of the PTs took patients who are illiterate into consideration (Billek-Sawhney et al., 2012). In physical rehabilitation the patient materials Dignan und Hunter (2015) screened were designed using Flesch Scale reading level 16 (difficult) instead of reading level 5 (very easy). Brown (2016) examined the patient education forms in OT practice and noted that 90% were written at a level above the 8^th grade Flesch Scale (standard reading difficulty). Written information materials were handouts for home education, precautions, or educational material (Galati et al., 2018). Therapeutic professionals were keen to provide healthcare information at the appropriate reading level but there were challenges when evaluating if patients understand the materials. For example, they noted that patients might not be willing to answer questions on whether they can read the materials (Salter et al., 2014).

Appendix 6 in (Supplementary File 2) shows the list of the key elements to consider when designing patient materials. They should be written in an adequate reading level (5^th grade; very easy), avoiding medical jargon, using plain language and integrating pictograms, diagrams, and examples (Billek-Sawhney et al., 2012; Brooks et al., 2020; Denysiuk, 2016; Doyle et al., 2013; Ennis et al., 2012; Galati et al., 2018; Miller-Scott, 2014; Smith & Gutman, 2011). Written materials can be revised using plain language, and staff can be trained in oral plain language using case-based simulations (Smith & Gutman, 2011). Furthermore, therapists should ensure that the assessment of health information is easy for clients (Ennis et al., 2012). Therapists could help to ensure that information fits to patients’ HL levels, cultural characteristics, and verbal, cognitive, and social skills (Pizur-Barnekow et al., 2017; Pizur-Barnekow & Darragh, 2011; Sørensen et al., 2012).

Integrating HL into practice should focus on clients and their HL needs. To enhance patients’ disease knowledge, their ability to self-manage, and adherence to health care recommendations, awareness of the importance of HL may be integrated into clinical practice by the whole healthcare rehabilitation team (Voigt-Barbarowicz et al., 2022) and health organizations. Furthermore, not only do the clients have to be addressed but also their carers. OTs who work with children with chronic pain reported that 15% of their HL activities were related to the children themselves and 57% interacted with parents or carers (Brown et al., 2012). Integrating HL skills training into routine practice of OT is critical to health care professionals engaged with clients in improving health management (Armstrong-Heimsoth et al., 2019). For example, in a Portuguese school setting, a physiotherapy training to learn about back care was implemented and positively evaluated. Children gained practical and theoretical knowledge after the training (Minghelli, 2020).

HL is not an individual attribute or skill but rather a result of interaction between patients and the healthcare system (Salter et al., 2014). The key role of organizations in supporting HL was stated. Governance and responsibility for HL means: interpersonal and intra-organizational communication, continuity of care, information management, and responsibility for HL (Salter et al., 2014). A systematic approach to address factors on an organizational level is needed, providing culturally appropriate patient care, resources that are accessible to vulnerable groups, communication with patients in ways they understand and are comfortable with, maximizing HL, and knowledge about the health system (Hughson et al., 2018).

Enablers to promote HL in persons with cultural and linguistic problems are bilingual or bicultural HCPs, and persons who have a high awareness of cultural and linguistic factors and are motivated to bridge the gap (Hughson et al., 2018). Major barriers to supporting HL were organizational issues. The existing systems do not adequately accommodate the needs of patients (Hughson et al., 2018). Therapeutic professionals can participate in the creation of an HL-sensitive environment (Pizur-Barnekow et al., 2017; Smith & Gutman, 2011).

There is a lack of a systematic approach to address HL in practice, as there were no instruments systematically used to screen clients for HL. Additionally, there is some evidence that therapeutic professionals are critically facing screening instruments. They are facing challenges of clients with low HL in practice and wish to improve their ability to address these. Therefore, it is necessary to identify relevant short screening instruments that are easy to administer in daily practice. Furthermore, studies are needed to evaluate the usefulness and practicability of screening instruments. Empirical studies about HL in the therapeutic professions themselves are missing. Therefore, more research should generally focus on the different aspects of HL in the therapeutic professions. Since key elements for creating training programs and adapting practice already exist, the implementation of training programs should be accompanied by evaluation studies.

Studies reported that therapeutic professionals are familiar with the term HL, but they identified a lack of broad knowledge. One study of the USA tells, that 50% of the therapeutic professionals learned about HL in school. For Germany the PTs express this desire (Galati et al., 2018; Wirner et al., 2022).They are aware of the importance of addressing the needs of clients with low HL and of gaining knowledge and skills regarding HL. There is some evidence, that training in HL related knowledge and skills are positively evaluated. We found no description of a systematic approach in inclusion of HL in the professional training of therapeutic professionals. Most learn about the concept in advanced training courses. However, ideas and projects where systematic training is implemented in practice do exist and all evaluations of these trainings present positive results. They should therefore be widely implemented to improve the practice of HL screening and communication and further evaluated regarding their impact. We could identify key elements that should be addressed in trainings on HL of therapeutic professionals. Interventions to enhance clear communication are needed and especially their implementation in practice should be integrated in a multidisciplinary and organization specific way. Preparing and communicating with clients with low HL is throughout the literature a challenge for therapeutic professionals and organizations. Policies and guidelines to encourage HL practices should be implemented (Mackey et al., 2019; Murugesu et al., 2022; Rajah et al., 2018). On the one hand, the curricula of all therapeutic professionals should integrate HL as an important educational theme in the vocational training and academic studies of therapeutic professionals (Ennis et al., 2012; Rueda-Medina et al., 2020; Wirner et al., 2022). On the other hand, there is a need for formal training on HL beyond institutional education to acquire knowledge about HL and furthermore keep professionals up-to-date (Galati et al., 2018; Hamel, 2006). Especially therapeutic professionals have a key role in facilitating HL due to the strong therapeutic alliance between therapists and clients and their profession’s unparalleled assessment and intervention of the person, environment, and occupation (Perez et al., 2020; Smith & Gutman, 2011). More efforts should focus on revising the existing educational curricula, professional laws, and HL adapted practice in therapeutic professionals. To create health literate organizations, it is necessary to enhance clients’ abilities to gain access to, understand, and use health related information, therapeutic professionals in particular can play a key role. Systematic approaches by therapeutic professionals to measure client HL and instruments to adapt information and communication to low HL should be conducted and implemented in organizations.