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Issue: 2019, December, Volume 13, No 4
issue id: 2019_12_13_4
article id: 2019_12_13_4_1

Letter to the Editor

Why considering “health literacy” level is important for Family Physicians?

Why considering “health literacy” level is important for Family Physicians?

Sağlık okuryazarlığı seviyesini göz önünde bulundurmak Aile Hekimleri için neden önemlidir?

Candan Kendir1 *, Isabella V. Vega2, Mehtap Kartal3




Family physicians are challenged with complicated cases every day, on some occasions; these circumstances get more difficult as a result of lack of compliance or poor communication between the patients and health care providers. Today, it is know that health literacy level of the individuals affect how patients interact with their care provider and their compliance to the treatment.Low health literacy levels are not exclusive to a particular region on the globe; reports show that 30% of the European has inadequate literacy level, and 64.6% in Turkey have low or problematic health literacy.  Family physicians have a crucial role in identifying patients with low health literacy level and improve it to adequate level. Even though the limited time, work overload are some possible barriers for family physicians, a number of easy-to-use methods are developed to overcome some of these problems in primary care. Red flags have been identified to help family physicians to quickly identify the patients with low health literacy level. After that, in order to provide better communication, following strategies can be used are use of plain language, teach-back, ask me three questions, chunk and check, visual aids & written materials. Increasing health literacy can improve the health and well-being of the population and can also decrease the necessary time with patients to solve problems and prevent unnecessary repetitive attendance to primary health care services.


Keywords: health literacy, primary care, family medicine




Aile hekimleri her gün karmaşık olgular ile karşılaşmakta olup, bazı durumlarda, hasta uyumsuzluğu veya hasta-hekim iletişim yetersizliği nedeniyle bu durum daha da zorlaşmaktadır. Bugün, sağlık okuryazarlığının hastaların hekimleri ile iletişimlerini ve tedaviye uyumlarını nasıl etkilediği bilinmektedir. Düşük sağlıkokuryazarlığı herhangi bir bölgeyle sınırlı olmamakla birlikte, raporlar Avrupa halkının %30’unun yetersiz seviyeye sahip olduğunu, Türk halkının da %64,6’sının düşük veya sınırlı sağlık okuryazarlığı düzeyine sahip olduğunu göstermektedir.

Aile hekimler sağlık okuryazarlık düzeyi düşük hastaları belirlemede ve düşük düzeyleri yeterli sağlık okuryazarlık seviyesine taşımada önemli bir role sahiptir. Kısıtlı zaman ve yoğun iş yükü aile hekimleri için olası engeller olsa da bazı kullanımı kolay teknikler bu sorunların üstesinden gelmek üzere birinci basamak için geliştirilmiştir. Kırmızı bayrak işaretleri hekimlerin sağlık okuryazarlığı düşük hastaları hızlıca belirlemeleri için tanımlanmıştır. Bunun ardından, daha sağlıklı bir iletişim için, yalın dil kullanımı, öğrenileni geri anlatma metodu, bana üç soru sor yöntemi, bilgiyi ver ve kontrol et metodu ve görsel ve yazılı materyal kullanımı gibi stratejiler uygulanabilir. Sağlık okuryazarlığı toplumun sağlık ve iyilik halini geliştirdiği gibi, hastanın problemini çözmekiçin gereken süreyi kısaltıp, gereksiz tekrarlayan birinci basamak başvurularını da önleyebilir.


Anahtar kelimeler: sağlık okur yazarlığı; birinci basamak; aile hekimliği


Received Date: 07.03-2019, Accepted Date: 16.07-2019

*1 Ecole des hautes etudes en sante publique, EHESP, Saint Denis, France

*2Ecole des hautes etudes en sante publique, EHESP, Saint Denis, France

*3Department of Family Medicine, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey

*Address for Correspondence / Yazışma Adresi: Candan Kendir, Ecole des hautes etudes en sante publique, EHESP, Saint Denis, France

E-mail: candankendir@hotmail.com

Kendir C., Vega V.I., Kartal M. Why considering “health literacy” level is important for Family Physicians? TJFMPC, 2019;13 (4): 402-406.

DOI: 10.21763/tjfmpc.651477


“The case example: A 49-year-old male, working at the automobile industry. He is obese, smoker and he was diagnosed with diabetes mellitus type 2 in 2013. He is under treatment but has not been using his treatment regularly and not following the recommendations of his family doctor especially on lifestyle modification activities. He sometimes searches on the internet for health information and sporadically receives brochures at the medical center or the hospital. Occasionally, his wife insists to measure the finger-tip blood glucose level and he complies; she keeps a record of this measurements, the physician recognizes that they are usually high. You are planning to meet and talk to him about healthy eating for better control of his blood glucose.”



Family physicians (FP) face everyday patients like this case who are not compliant to treatment or lifestyle modifications. Even though an extra effort is made to educate with patient education materials, usually it doesn’t seem to be working.

In Europe, it was found that 30% of adults have inadequate health literacy (HL) level and in a study in Turkey, it was shown that 64.6% of the Turkish population have inadequate or problematic HL level.1,2 Low health literacy level is not only a barrier to healthy behavior of the individuals, it also has negative impact on patient compliance to treatment and disrupts communication between health care providers and patients.3–6 It was found that low HL level results in less participation to health promotion and disease prevention activities (e.g. cancer screening participation), more frequent risky health behaviors such as smoking, poor management of chronic diseases, more accidents, increased hospitalization and readmission rates, increased mortality especially premature death.7–9 It also follows social gradient and reinforces existing inequalities in the society.10

In the literature, it is reported that people with low education levels, low income, ethnic minorities and vulnerable populations such as migrant groups are at risk of low HL.11,12 Since its first introduction by Simonds in 1970s, the concept HL has been defined in many ways.13 In 2012, Sorenson et al reviewed the definitions of HL in the literature and concluded with a definition.14

“Health literacy entails people’s knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgments and make decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course”.

The ultimate goal of health care practitioners including family physicians is to improve health implementing science, research and technology so that achieve better health outcomes in the last century but if the patients are unable to understand or apply the recommendations evidence has to offer it won’t matter how much science advances.

With the intention of understanding HL and possible dimensions Nutbeam described different groups of HL4:

1) Functional HL; basic reading comprehension and writing skills to understand basic health information, health condition, services and systems. The case patient can read and understand some information online, with help of his wife he can measure glycemic levels. Is this enough for him to have a better health status?

2) Communicative/ interactive HL; in order to be able to discuss the information with others, higher level of communicative and social skills. The patient is receiving information using the hospital brochures but the information exchange between the health care professionals and the patient is unilateral. Is there a space and time for a better health- related communication for the patient to ask you about his disease and its management?

3) Critical HL; an advanced level of HL that includes cognitive and social skills to analyze information and making informed decisions. In the case example there seems to be a lack of awareness on the consequences of hyperglycemia, does the patient have all the knowledge to make the healthy choices for his health and manage his disease?

Measures of Health Literacy

Following the evolution of the definitions of HL, the different measures have been also developed.1,15–21 Some of them focused on the use in the primary care, clinical settings, and others focused on public health and community evaluations.21,22

The most popular ones are the European HL Survey, TOFHLA, REALM, NVS and all of them were translated into Turkish.23–25However, almost all of them take more than 5 minutes of time to apply and in daily practice, family physicians usually do not have that much time to spare for application of the scales. Considering this, in the USA, some practical tools were developed for primary care physcians in order to identify the low HL level of the patients and to intervene them in the clinical settings (Figure 1. Red flags of low HL level). 26

Also, single item question is a very common quick assessment method for the physicians:

“How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”




What can you do as a family physician?

Family physicians have a privileged position, they are the reference for patients seeking healthcare. However, if a physician has limited time, attending trainings to improve HL level might not be on the top of his or her agenda. In this case, speaking clearly and limiting the content of the information could be time-effective both for the patient and the physician. Additionally, some of the tips to improve health literacy found in the evidence are easily applicable during the patient -doctor communication.26,27

1. Always use a plain language: In the case patient it will be more effective to explain what to change in his diet than talking about a reducing calorie intake.

“Instead of recommending lifestyle modifications, clearly mention healthy eating behavior”

2. Teach back: When indicating treatment or recommendations as your patient to explain back the instructions you will identify if the information is clear for the patient and solve any misunderstanding.

“I reviewed the options to keep your blood glucose level low today. To make sure that I explained these options clearly, can you tell me in your own words the options?”

3. Ask me three questions: This statement encourages patients to engage during the medical recommendations clarifies questions and aids with patient empowerment.

“Can you tell me what the main problem we talked about, why is it important to eat healthy and what you plan to do for it?”

4. Chunk and check method: After giving each key point, the physician asks the patient to repeat it and encourages to ask questions about it.

“Eating healthy is important for you to keep your blood glucose level low. What do you understand from this? Do you have any question about it?”

5. Visual aids & written materials: Using visual materials while explaining things were also found to be useful for patient understanding. Additionally, written information summarizing the key points will be complementary.

“Showing a 1-2 minutes online video on how to do physical activity”

Outside consultation, health practitioners can improve health literacy by creating community centered strategies: encourage patient screening, workshops for public education on health promotion tailored to the community needs, create support groups, identify community leaders and assign roles in the protection of the community health and in the communication of healthy practice.22,28Ensure that your community is in a healthy environment and that the healthcare system is accessible and well understood by the users. Brochures that are prepared with less written and more visual can be used as a mean to communicate about the health care systems, healthy behaviors and pathologies that concert the member of the community.


Family physicians have continuous relationship with their patients, and this serves as an opportunity to educate their patients and increase their health literacy level. Increasing HL level will eventually decrease the necessary time with patients to solve the problems. Additionally, the unnecessary admissions of patients that result in patient overload will decrease in time. Eventually, improving HL will reduce the health inequalities and improve health of all.



1. Sørensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013;13(1).

2. Tanrıöver Durusu M, Yıldırım H, Ready Demiray F, Çakır B, Akalın E. Türkiye Sağlık Okuryazarlığı Araştırması. Sağlık ve Sosyal Hizmet Çalışanları Sendikası Sağlık-Sen Yayınları-25, Ankara. 2014:14-26.

3. Nouri SS, Rudd RE. Health literacy in the “oral exchange”: An important element of patient–provider communication. Patient Education and Counseling. 2015;98(5):565-571.

4. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2000;15(3):259-267.

5. McNeil A, Arena R. The Evolution of Health Literacy and Communication: Introducing Health Harmonics. Progress in Cardiovascular Diseases. 2017;59(5):463-470.

6. Ngoh LN. Health literacy: a barrier to pharmacist–patient communication and medication adherence. Journal of the American Pharmacists Association. 2009;49(5):e132-e149.

7. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Annals of internal medicine. 2011;155(2):97-107.

8. Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA. Health Literacy and Health Outcomes in Diabetes: A Systematic Review. J Gen Intern Med. 2013;28(3):444-452.

9. DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and Health Outcomes. J Gen Intern Med. 2004;19(12):1228-1239.

10. Batterham R, Hawkins M, Collins P, Buchbinder R, Osborne R. Health literacy: applying current concepts to improve health services and reduce health inequalities. Public Health. 2016;132:3-12.

11. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD, World Health Organization, eds. Health Literacy: The Solid Facts. Copenhagen: World Health Organization Regional Office for Europe; 2013. Accessed January 5,2018.

12. National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Roundtable on Health Literacy. Facilitating Health Communication with Immigrant, Refugee, and Migrant Populations Through the Use of Health Literacy and Community Engagement Strategies: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2017. http://www.ncbi.nlm.nih.gov/books/NBK464589/. Accessed May 3, 2018.

13. Simonds SK. Health Education as Social Policy. Health Education Monographs. 1974;2(1_suppl):1-10.

14. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC public health. 2012;12(1):80.

15. Kiechle ES, Bailey SC, Hedlund LA, Viera AJ, Sheridan SL. Different Measures, Different Outcomes? A Systematic Review of Performance-Based versus Self-Reported Measures of Health Literacy and Numeracy. J Gen Intern Med. 2015;30(10):1538-1546.

16. O’Connor M, Casey L, Clough B. Measuring mental health literacy – a review of scale-based measures. Journal of Mental Health. 2014;23(4):197-204.

17. Doustmohammadian A, Omidvar N, Keshavarz-Mohammadi N, Abdollahi M, Amini M, Eini-Zinab H. Developing and validating a scale to measure Food and Nutrition Literacy (FNLIT) in elementary school children in Iran. PLoS One. 2017;12(6).

18. Chinn D, McCarthy C. All Aspects of Health Literacy Scale (AAHLS): Developing a tool to measure functional, communicative and critical health literacy in primary healthcare settings. Patient Education and Counseling. 2013;90(2):247-253.

19. Rowlands G, Khazaezadeh N, Oteng-Ntim E, Seed P, Barr S, Weiss BD. Development and validation of a measure of health literacy in the UK: the newest vital sign. BMC Public Health. 2013;13:116.

20. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: A new instrument for measuring patients’ literacy skills. Journal of General Internal Medicine. 1995;10(10):537-541.

21. Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP et al. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Ann Fam Med. 2005;3(6):514-522.

22. Batterham RW, Buchbinder R, Beauchamp A, Dodson S, Elsworth GR, Osborne RH. The OPtimising HEalth LIterAcy (Ophelia) process: study protocol for using health literacy profiling and community engagement to create and implement health reform. BMC public health. 2014;14(1):694.

23. Abacigil F, Harlak H, Okyay P, Kiraz DE, Gursoy Turan S, Saruhan G et al. Validity and reliability of the Turkish version of the European Health Literacy Survey Questionnaire. Health promotion international. 2018:1-10.

24. Bilgel N, Sarkut P, Bilgel H, Ozcakir A. Functional health literacy in a group of Turkish patients: A pilot study. Cogent Social Sciences. 2017;3(1):1287832.

25. Ozdemir H, Alper Z, Uncu Y, Bilgel N. Health literacy among adults: a study from Turkey. Health education research. 2010;25(3):464-477.

26. Brega A, Barnard J, Mabachi N, Weiss BD, DeWalt DA, Brach C et al. AHRQ health literacy universal precautions toolkit. Rockville, MD: Agency for Healthcare Research and Quality. 2015. Accessed March 15, 2018

27. Taggart J, Williams A, Dennis S, Newall A, Shortus T, Zwar N et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract. 2012;13:49.

28. McGill B, Nutbeam D, Premkumar P. Improving health literacy in community populations: a review of progress. Health Promotion International. 2017;33(5):901-911.

Table 1. Red flags for low health literacy level

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