Health literacy education programmes developed for qualified health professionals: a scoping review protocol

Introduction

The need for health literacy (HL) education, for qualified health professionals (QHPs), to improve patient outcomes has been identified¹, is supported by research literature^1–3 and is recognised in policy development in European countries⁴. This protocol is for a scoping review which aims to identify and map current educational interventions to improve HL competencies and communication skills of QHPs. Focus will be applied to diabetes care, as this study is a component of a larger research project entitled, Diabetic Foot Disease: from PRevention to treatment to IMproved patient Outcomes (DFD PRIMO).

HL has been described as an ‘evolving’ concept⁵, developing over time with multiple definitions identified in the literature^6,7. This is an identified limitation to research and can negatively impact the measurement of HL⁸. Nevertheless, there is increasing consistency in the use of a typology of HL comprising of three core domains: functional, communicative/interactive and critical⁵. At an individual level, functional HL leads to improved awareness of health risks, health services and treatment adherence; interactive HL, also referred to as communicative HL, leads to improved independence, motivation and self-confidence; whereas critical HL leads to better resilience to antecedents such as social adversity⁹.

A relational concept of HL will be used¹⁰, focusing on an organisational health literacy (OHL) approach which makes health services easier for patients and their families to access, navigate and engage with so that they can make informed decisions and take informed actions for their health¹¹. In this conceptualisation, emphasis is not on the individuals’ capabilities to manage their own health but on how their environment and the health services can play a central role in their successful application of their abilities to access and utilise services. This approach is informed by the identification of the ten attributes of a HL friendly organisation¹², specifically that the organisation ‘uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact’. By adopting this approach, educating QHPs on HL competencies, to optimise patient-practitioner communication^13,14, has the potential to strengthen the patient-healthcare professional dyad. Such competencies include the knowledge, attitudes and skills that professionals need to master in order to appropriately address limited HL levels presenting in their patients¹⁵. As a result health professional education in HL is often directed towards improving HL related communication skills by utilising a range of techniques such as teach-back¹⁶, minimising jargon¹⁷, Ask Me Three, which helps confirm patient understanding¹¹, and designing health literate reading materials to improve comprehensibility¹⁷.

For the purpose of this research, the relational characteristic of HL is recognised and informs the choice of definition used which is that HL is ‘People’s ability to find, understand, appraise and communicate information to engage with the demands of different health contexts to promote health across the lifecourse’¹⁰.

In Ireland, 1 in 7 adults have been found to have limited HL skills¹⁸, and at a European level almost every second respondent within the European health literacy survey (HLS-EU) had limited HL¹⁹, which is associated with increased hospitalization, higher all-cause mortality, poor health related knowledge, self-care behaviour and other outcomes²⁰. A social gradient can be seen with a higher proportion of those with limited HL experiencing lower socio-economic status, lower educational attendance and attainment, and are of older age which mirrors the pattern of inequality of those with chronic diseases^21,22.

For people with chronic disease, limited HL has been associated with lower health-related quality of life (HRQoL)²³, and poorer health outcomes²⁴. In chronic disease such as diabetes, demands on individuals are characterised by a high level of complexity²⁵, where self-management relies on patients’ having advanced HL skills, in order to utilise written education material and verbal instructions²⁶. Diabetes has a profound effect on individuals with varying complications: macrovascular complications such as cardiovascular disease, stroke, peripheral vascular disease; and microvascular complications such as nephropathy, retinopathy, peripheral neuropathy, and diabetic foot disease²⁷.

Inadequate HL has been shown to be an independent predictor of poor glycaemic control, being associated with a lower likelihood of achieving tight control²⁸. Also, it is suggested that when HL is considered in isolation it is associated with greater diabetes self-efficacy^29–31, where greater self-efficacy is associated with lower glycaemic levels. It is implied that a positive relationship between HL and improved diabetes control. Interactive and critical HL have been found to be more influential than functional HL in influencing self-efficacy in those with diabetes^32–34. In contrast, some studies have not found HL to have a statistically significant relationship with diabetes-related health outcomes such as wound healing²⁴ and other complications³⁵. But, when interactive HL or critical HL are considered some relationships have been found to be positive^32,33,36.

The majority of the literature focuses on functional HL, however, there has been increasing emphasis on the development of the interactive dimension of HL. This has been particularly evident within health professional education, where programmes have been developed to improve HL competencies and HL related communication skills^15,37. If the HL demand placed on individuals is reduced, by means of improved communication and health literate communication from the QHPs, patient outcomes have the potential to improve³⁸. Limited evidence has shown that confirming patient’s understanding of new concepts can increase glycaemic control in those with diabetes³⁹.

Although HL research has developed and grown since at least 1973⁴⁰, limited research has been undertaken on HL interventions and their effectiveness¹⁷, particularly in regards to qualified health professional education, despite the identification of such education programmes being relevant to mitigating potential health outcomes¹. More recently, some training programmes have been developed, for QHPs, to address HL competencies and Hl related communication skills^2,37,41,42. Although there is emerging evidence of these interventions, the extent and nature of programmes need to be collated in order to assess the potential of undertaking a full systematic review⁴³ and to inform future development of these complex interventions.

A HL education programme consists of a set of competencies to be addressed and achieved. Such competencies include the knowledge, attitudes and skills that professionals need to master in order to appropriately address limited HL levels presenting in their patients¹⁵. Although often recognized as a separate entity¹⁰, communication plays a significant role in the development of interactive and critical HL, whereby effective communication maintains the patient-practitioner relationship^13,14.

Interactive HL has been found to be the most important HL domain needed within diabetes self-management⁴⁴, where interactive HL consists of a higher level of communication (oral literacy) and socials skills needed to extract and discuss information with others⁵. Patients with these skills are characterized by the self-confidence to act independently on advice, and to interact effectively with the health system. Interactive/communicative HL takes place within the ‘oral exchange’ in the QHP and patient interaction^14,45. Oral literacy and social skills are integral to the interactive HL domain and in meeting patients’ health needs and understanding. An ‘interactive communication loop’ has been recommended, whereby the QHP assesses patient understanding and recall³⁹; an example of this is the ‘Teach-Back’ tool¹⁶. Other forms of communication within a health literate organisation include communicating: using social media and other digital forms, at an interprofessional level, with external stakeholders and at a community level.

Current educational health literacy interventions aimed at qualified health professionals need to be identified accordingly to collate the current evidence base and provide a comprehensive narrative pertaining to the characteristics, including their generic or any disease specific focus, methodologies and assessments used. Currently, there are no universally accepted guidelines in relation to development of HL curricula for qualified health professionals, although there are general outlines to help guide development such as the Calgary Charter on Health Literacy⁴⁶. Established HL competencies have been defined more recently for health professionals in areas such as general HL knowledge; HL related communication skills; and attitudes in practice^47,48.

Methods

The extent and nature of research in relation to health literacy education programmes for qualified health professions is currently unknown. A configurative scoping review was chosen as it aims to ‘seek concepts to provide enlightenment through new ways of understanding’⁴⁹. A preliminary review of research identified limited literature in the area. As a consequence, a scoping review design is appropriate to develop an overview of what is known⁵⁰ and to assess if a systematic review is possible³⁴. An iterative approach will be used in this study to allow authors to develop the inclusion and exclusion criteria while considering the presenting evidence^49,51. This scoping review will be conducted drawing on methods and guidance from the Joanna Briggs Institute⁵², which adds to earlier guidance on scoping review methodology³¹. It will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist⁵³. Protocol development started with preliminary research which did not identify current literature within the population pertaining to those with either diabetic foot disease (DFD) or those with a diabetes diagnosis, therefore it was decided to expand the review to capture all qualified health professionals (QHPs) practicing in primary, secondary and tertiary care settings.

The “PCC” framework was employed in this scoping review to determine the research question, whilst drawing on methods from Joanna Briggs Institute⁵² and Arksey and O’Malley's (2005) scoping review framework⁴³. The PCC framework, where PCC stands for Population, Concept and Context⁵², helps construct a title without the need for outcomes, interventions or phenomena of interest⁵². The PCC framework provides the core detail on the inclusion criteria related to the review topic, but acknowledges the need for more detail when planning the screening phases. In this scoping review the population is qualified health professionals of all backgrounds. Concept refers to education programmes for health literacy competencies and health literacy related communication skills. The context is in terms of qualified health professionals working clinically in primary, secondary and tertiary care settings.

Five stages of a six stage framework will be used to structure this review⁴³, the optional stage six which comprises stakeholder consultation will not be adopted in the context of this stage of this current study. Nevertheless, this research is the first stage of a three stage project with the results of this scoping review informing stakeholder engagement activities and further research.

Conclusions

Although some training programmes have been developed to address HL competencies and HL related communication skills^37,41,42, the extent and nature of programmes, needs identifying and collating to assess the potential of undertaking a full systematic review⁴³. This will inform future development of these complex interventions. Current educational health literacy interventions aimed at qualified health professionals need to be identified accordingly to collate the current evidence base and provide a comprehensive narrative pertaining to the characteristics, including their generic or any disease specific focus, methodologies and assessments used.

Data availability

No data are associated with this article.