A mismatch between population health literacy and the complexity of health information: an observational study

Gillian Rowlands; Joanne Protheroe; John Winkley; Marty Richardson; Paul T Seed; Rima Rudd

doi:10.3399/bjgp15X685285

Article Figures & Data

Tables

Health activities	Focus	Examples of materials	Examples of tasks	Subject areas
Health Promotion	Enhance and maintain health	Charts, graphs, lists Food and product labels	Purchase food Plan exercise regimen	Healthy weight
Protecting personal and public safety	Safeguard health of individuals and communities	Health and safety warnings Air and water quality reports	Decide between product options Use/avoid products	Road safety Home safety
Disease prevention	Take preventive measures and engage in early detection	Postings for inoculations and screening Letters related to test results Graphs, charts	Determine risk Engage in screening or diagnostic tests Follow-up	Men’s health Cancer screening Reduction in harmful lifestyle activities Vaccination
Managing illness	Seek care and form a partnership with healthcare providers	Health history forms Medicine labels Discharge instructions Education booklets and brochures	Describe and measure symptoms Follow directions on medicine labels Collect information on merits of various treatment regimens for discussion with health professionals	Diabetes mellitus Medication instructions
Systems navigation	Access needed services	Maps Application forms Statements of rights and responsibilities Informed consent	Locate facilities Apply for benefits Offer informed consent	Which services to access when acutely unwell, and how to access them

Level	English NQF age equivalent	Literacy An adult classified at the level understands	Numeracy An adult classified at the level understands	Examples of typical skills
Entry 1	5–7 years	Short texts with repeated language patterns on familiar topics Information from common signs and symbols	Information given by numbers and symbols in simple graphical, numerical, and written material	Write short messages Select floor numbers in lifts
Entry 2	7–9 years	Short straightforward texts on familiar topics Information from short documents, familiar sources, signs, and symbols	Information given by numbers, symbols, simple diagrams, and charts in graphical, numerical, and written material	Describe health symptoms Use a cashpoint machine
Entry 3	9–11 years	Short straightforward texts on familiar topics accurately and independently Information from everyday sources	Information given by numbers, symbols, diagrams, and charts used for different purposes and in different ways in graphical, numerical, and written material	Understand price labels Pay household bills
Level 1	Matriculation examinations (GSCE) grade D–G	Short straightforward texts of varying length on a variety of topics accurately and independently Information from different sources	Straightforward mathematical information used for different purposes. Independently select relevant information from given graphical, numerical, and written material	GCSE grades D–G
Level 2 or above	GCSE grades A* to C or higher qualifications	A range of texts of varying complexity accurately and independently Can obtain information of varying length and detail from different sources	Mathematical information used for different purposes and can independently select and compare relevant information from a variety of graphical, numerical, and written material	5 grades A* to C GCSE

Variable	Categories
Sex	Male, female
Age	16–44 years, ≥45 years and over
Ethnicity	White, black and minority ethnic
Nativity (Place of birth)	UK, outside of UK
First language	English, other
Qualification level	National Qualification Framework (NQF) at or above the level expected by age 16 years (level 2), NQF below level 2
Employment status	Employed, not employed
Job status	National Statistics Socioeconomic Classification 3 bands
Gross individual income	≥£10 000, <£10 000
Home ownership	Owns or part-owns home, does not own home
Area deprivation (Index of Multiple Deprivation score)	Quintiles

View popup

Table 1.

Health materials sampled

Health activities	Material type			Are these materials representative of those in everyday use?	How many patients would be exposed to this material?	What is the potential impact of failure to understand this material	Weight (frequency of exposure x potential impact)
Health activities	Text only	Text + numeracy	Total	Mean score^{^a}	Mean score^{^b}	Mean score^{^c}	Range 0–9^d
Health promotion	0	13	13	1.8	1.8	2.0	3.6
Protecting personal and public safety	4	10	14	2.0	1.9	2.6	4.9
Disease prevention	2	10	12	2.1	2.0	2.0	4.0
Managing illness	3	12	15	2.2	2.0	2.4	4.8
Systems navigation	5	5	10	2.1	2.1	2.2	4.6
Total	14	50	64

↵a 0= not at all; 1 = slightly; 2 = moderately; 3 = highly.
↵b 1= a few; 2 = many; 3 = most.
↵c 1 = low; 2 = medium; 3 = high.

View popup

Table 2.

Literacy competency descriptive analyses

Category	Below competency threshold % (n below/n total)	Skills test not completed/not recorded, n
All	43 (2515/5795)	255

Sex^{^a}
Female	41 (1197/2907)	137
Male	45 (1317/2887)	118

Age, years^{^a}
16–44	57 (1439/3500)	149
45–65	43 (1074/2292)	106

Ethnicity^{^a}
White	41 (2032/4996)	206
Black and minority ethnic	61 (481/795)	49

Nativity^{^a}
Born in UK	41 (2010/4953)	189
Not born in UK	60 (504/842)	66

First language^{^a}
English	40 (2102/5200)	203
Other than English	69 (412/594)	52

Qualification level^{^a}
5 grade A–C GCSE or above	25 (569/2306)	199
Below 5 grade A–C GCSE	56 (1945 /3488)	56

Employment^{^a}
In work	39 (1582/4061)	184
Not in work	54 (932/1733)	71

Job grade^{^a}
Managerial/professional	28 (602/2158)	95
Intermediate	43 (438/1014)	18
Routine/manual/students/unemployed	56 (1474/2622)	142

Income^{^b}
≥£10 000	20 (806/4015)	94
<£10 000	96 (1708/1779)	161

Home ownership^{^b}
Owns or part-owns home	35 (1251/3593)	155
Does not own home	57 (1263/2202)	100

Area deprivation^{^a}
0–9 (least deprived)	29 (362/1233)	44
10–19	38 (733/1906)	87
20–29	44 (460/1036)	42
30–39	55 (406/737)	30
≥40 (most deprived)	64 (553/862)	52

Access to information score^{^a}
≥9 (high access)	27 (499/1881)	72
5–8	44 (1208/2725)	119
<5 (low access)	68 (807/1187)	64

Variable data missing (not entered or declined):
↵a = n 0–10,
↵b n = 10 to 20.

View popup

Table 3.

Literacy competency univariable and multivariable analyses

Category	Unadjusted odds ratio	95% CI	P-value	Adjusted odds ratio	95% CI	P-value
Sex
Female (ref)
Male	1.20	1.08 to 1.33	<0.001	1.25	1.09 to 1.43	0.001

Age, years
16–44 (ref)
45–65	1.26	1.14 to 1.40	<0.001	1.44	1.25 to 1.67	<0.001

Ethnicity
White (ref)
Black minority ethnic	2.23	1.92 to 2.60	<0.001	1.43	1.09 to 1.87	0.008

Nativity
Born in UK (ref)
Not born in UK	2.18	1.88 to 2.53	<0.001	1.07	0.75 to 1.51	0.719

First language
English (ref)
Other than English	3.34	2.78 to 4.00	<0.001	2.03	1.39 to 2.97	<0.001

Qualification level
≥2 (ref)
<2	3.85	3.43 to 4.32	<0.001	2.38	2.04 to 2.77	<0.001

Employment
Employed (ref)
Not employed	1.82	1.63 to 2.04	<0.001	1.05	0.88 to 1.25	0.551

Job grade
Managerial/ professional Intermediate (ref)	1.97	1.68 to 2.30	<0.001	1.40	1.18 to 1.71	<0.001
Routine/manual/ students/unemployed	3.32	2.94 to 3.75	<0.001	1.88	1.60 to 2.22	<0.001

Income
≥£10 000 (ref)
<£10 000	1.91	1.71 to 2.12	<0.001	1.41	1.19 to 1.67	<0.001

Home ownership
Owns/part-owns home (ref)
Does not own home	2.04	1.83 to 2.27	<0.001	1.32	1.13 to 1.60	<0.001

Area deprivation
0–9 (ref)
10–19	1.50	1.29 to 1.75	<0.001	1.25	0.97 to 1.60	0.075
20–29	1.92	1.61 to 2.28	<0.001	1.46	1.16 to 1.83	0.001
30–39	2.95	2.44 to 3.57	<0.001	1.58	1.28 to 1.96	<0.001
≥40	4.04	3.37 to 4.85	<0.001	1.94	1.54 to 2.46	<0.001

Access to information score
≥9 (ref)
5–8	2.21	1.94 to 2.51	<0.001	1.78	1.51 to 2.11	<0.001
<5	5.89	5.02 to 6.90	<0.001	3.11	2.56 to 3.79	<0.001