Selected socio-economic factors of health literacy of the poor

Introduction

The article focuses on selected socio-economic aspects of the health literacy of people living below the poverty line, and the opportunities they have to access health care. Our research is using Health Literacy questionnaire and article is trying to determine the level of health literacy of the people living below poverty line. Obtaining adequate health care when needed is considered a basic human right; nevertheless, studies show that some population groups do not always do so and that right is often not upheld (WHO, 2015). Health literacy deserves greater attention and efforts should be made to improve it, as low health literacy can lead to poor self-care and is generally related to a riskier life style, which is associated with higher hospitalization and sickness rates and increased mortality levels (Kickbusch et al., 2013)

Health literacy of low-income groups

The literature contains many definitions of health literacy, as it is a complex and changing concept. With some simplification, we can quote Holčík (2017, p. 9):

Health literacy refers to people’s knowledge and to their ability to obtain, understand, assess and make use of health-related information and understand the healthcare and social system. Health literacy is improved by a caring health service, the availability of the necessary health and social services and by the efforts of social organizations (schools, workplaces, institutions, organizations, public administration) to create an environment favourable to health.

Some scholars also include motivation to become politically engaged in health issues or having knowledge of pathological processes and the ability to use modern technologies and communicate with others using networks (Berkman et al., 2011). As Smith et al. (2015) state, being health-literate means having sufficient skills and knowledge on health and health care, including the ability to find, understand, interpret and communicate health information, seek out adequate care and be able to make important decisions regarding health. The WHO defines health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (Kickbusch et al., 2013). The most up-to-date and comprehensive definition of health literacy comes from the 2011 European Health Literacy Consortium, which states that health literacy is related to current literacy levels and that it includes people’s motivation and ability to understand, assess and apply health information, make judgments and decisions in everyday life regarding health care, disease prevention and health promotion to maintain or improve the quality of life over the life cycle (Vogt et al., 2016).

We can also define health literacy using three models. The first model is functional health literacy, which Holčík (2009) states is passing information on health risks and making use of health services (including information leaflets, booklets and patient health education) to people. The second model—interactive health literacy—concerns the personal communication skills needed to cooperate effectively with health care professionals. The third model is critical health literacy, and it follows on from functional to interactive health literacy. It is the ability to critically analyse and use and obtain information to acquire better control over life events and situations (Mullen, 2013).

As Watkins and Xie (2014) note, health literacy is viewed from two different perspectives: clinical care and public health. The clinical care perspective views health literacy in terms of impact on health outcomes. From this perspective, low health literacy affects observance of clinical recommendations, which affects clinical health outcomes (in clinical practice the focus in health literacy is on skills such as knowing how to choose a health care provider, ability to understand and complete consent forms, ability to understand medicine package inserts and physicians’ instructions on how to take medicines and disease management). From the public health perspective, health literacy is seen in terms of the person’s interest. It is a tool or means whereby individuals can exert better control over the personal, social and environmental factors affecting their health.

Having an adequate level of health literacy has been shown to improve people’s confidence in their abilities to engage in preventive care. While low health literacy is associated with low engagement in self health care, more risky health choices (increased likelihood of smoking), and with a higher number of work-related accidents, worse chronic disease management (diabetes, HIV, asthma), errors in taking medicines, increased hospitalization rates and multiple hospitalizations, higher sickness rates and even premature death (Kickbusch et al., 2013). Low health literacy means higher health care costs (Kučera, 2015). This is because prevention costs less than intervention (Prevence je levnější než léčba, 2006). People with low health literacy often rely far more on emergency medical services than on preventive ones (Nutbeam, 2008). Low levels of adult health literacy are associated with difficulties in understanding and using basic health resources, prescriptions, food labels, articles, booklets and health insurance, which may affect their ability to obtain adequate health care.

In 2014, the Czech Republic participated in the European Health Literacy Survey and 1,037 respondents in the Czech Republic completed the survey. A total of 59.4% adult participants had inadequate and problematic levels of health literacy. The Czech Republic came second last in health literacy, followed only by Bulgaria. The Netherlands came first, followed by Ireland, Germany and Poland (Šimůnková & Vojtíšková, 2015).

According to Nutbeam (2000), transmission health information is fundamental to improving health literacy, but on top of that, we have to raise people’s confidence in their ability to make use of the information, through more personal forms of communication and educational activities. Health education is a basic step in promoting health literacy. Health education features in everyone’s education, and thanks to modern medicine, health education has become more widespread, which has helped to improve the general health care of the population. Health literacy should play a role in all kinds of education and training, not only in school but as part of lifelong education, professional training of health care workers, journalists, politicians and other target groups (Zdraví, 2020, 2015).

However, many health education programmes have proved successful with more educated sections of society, but not with socially disadvantaged groups (Vogt et al., 2016). As Parnell (2015) states, the relationship between the skills of the recipient of the care or treatment and the professionals or systems providing the care or treatment is crucial. Parnell explains that many adults have problems finding their way around health care systems due to low health literacy. The latter is a stronger predictor of a person‘s health than age, income, professional status, education level or race. Low health literacy results in economic losses, increased health risks and great health differences between social groups (Vogt et al., 2016).

Health literacy is a multi-faceted issue, affected by income level, profession, education, housing and access to medical care. As Higgins et al. (2008) state, it is mainly related to the individual‘s education and health. Educated people tend to be more interested in their health and are also more likely to be employed, which is more beneficial to health than being unemployed. They may also have a higher income and be prepared to invest in their health and a healthy life style. Higgins et al. (2008) also point out that those with higher education are also more likely to work in a safer environment, which is more beneficial to health.

Vulnerable populations include older adults, immigrant populations, minority populations and low-income populations (Health Literacy). Berens et al. (2016) confirm this and state that level of health literacy is affected by education and social status. Moreover, low health literacy tends to be found among those on low incomes, with lower education levels and who find themselves in poor social situations, preventing them from modifying their life styles. Evidence for this also comes, for example, from a comparative study of 11 European Union countries that surveyed high-income countries (Albert & Davia, 2011). The HLS-EU Consortium (2012) obtained similar findings and found that level of health literacy is affected by several factors. These include education, age, gender, socio-economic status and employment. Research suggests that education is the most important determinant of health literacy (Matsuyama et al., 2011).

The European Health Literacy Survey administered in the Czech Republic also showed that level of health literacy decreases with age and increases with education level and subjective social status (Kučera, 2015). The results also showed that health literacy is strongly affected by financial deprivation, by the ability to pay bills, purchase medicines, health devices and visit a physician.

As Nutbeam (2008) states, low health literacy affects health both indirectly, through restricted job choices and potential income, and directly, for example, through the ability to adopt preventive measures, when detecting the early stages of disease, when accessing health services and in the treatment of chronic disease.

Scott et al. (2002) describes how those with fewer health literacy skills skip important preventive examinations like mammograms or cervical smears or do not seek vaccination against influenza and enter the health care system only when they become ill. Therefore, as Baker et al. (2002) state, low health literacy is related to more frequent visits to health care facilities, to the use of emergency services and to hospitalizations. This is associated with higher health care costs (Howard, Gazmararian, & Parker, 2005).

Many studies show a correlation between low health literacy and poor health. According to Berkman et al. (2004), low health literacy results in reduced take up of preventive health care such as vaccinations and routine examinations. It has an impact on the patient’s understanding of the physician’s instructions on medicines and may affect the treatment of chronic conditions like diabetes, asthma or high blood pressure. Where adults are concerned, there is a direct connection between low health literacy and poor understanding of the information on preventive care and access to preventive care (Sanders et al., 2009). Holčík (2009) also states, based on international and national studies, that adults with low health literacy more frequently:

• fail to understand oral and written information provided by health care workers,

• fail to follow instructions and the prescribed treatment,

• have less knowledge of the health care system and do not access the appropriate health services,

• use emergency services, they often come to the doctor when it`s to late, and therefore require hospitalization,

• underestimate preventive care and fail to follow a healthy regime,

• report worse health.

Methods

This study uses the short form of the standardized Health Literacy Questionnaire (Osborne et al., 2013), containing 16 items. The questions ask, for example, how easy it is to find information on treatment, disease prevention, and how easy it is to understand advice provided by a physician, pharmacist, the media or a friend. Respondents provide their answers on a scale of 1 to 5, depending on whether it is very easy or very difficult for them (1 means “very easy”, 2 = “quite easy”, 3 = “quite difficult”, 4 = “very difficult” and 5 means “I don’t know”).

The data were recoded according to the standardized 16-item abbreviated scale used to measure health literacy. This meant the value scale of the answers changed. The answer “I don’t know” was coded as a missing answer and was therefore eliminated from subsequent processing. The other values were re-coded on a 2-point scale with a range of 0 to 1, where 0 means “difficult” (including the values of “very difficult” and “quite difficult”) and 1 means “easy” (including the values of “very easy” and “quite easy”). The health literacy index (HL score) is the total of points assigned to responses indicating how the respective activity was easy. The resulting scale for the short questionnaire therefore has 16 points, ranging from 0 to 16. Based on that scale, three basic levels of health literacy were defined: inadequate health literacy (0–8 points); problematic health literacy (9–12 points) and sufficient health literacy (13–16 points).

The questionnaire was administered in the form of a structured interview conducted by trained interviewers. Several additional questions were included, some were sociodemographic in nature, while others concerned health. There was also a question on income, including state benefits. For example, respondents had to state whether they had any health problems, what their general state of health was, whether they smoked cigarettes or drank alcohol. We were interested in who they shared a home with, whether they had children and their marital status. These questions were 24. So together the questionnaire has 40 question. The research sample consisted of inhabitants in the South Bohemian Region living below the poverty line, defined in this case as entitlement to the state material poverty benefits. In total 320 respondents were approached, but only 254 of them were willing to be interviewed. Altogether 204 respondents answered all the questions. A combination of purposive and snowballing sampling was used to obtain the research sample. Potential respondents were targeted from low-income population groups identified with the help of contacts at employment offices and in social services. The South Bohemian Region was selected because of the good availability of respondents, 320 respondents were approached, but only 254 of them were interested in being interviewed. The data were statistically processed using SPSS.

Results

On average those living below the poverty line obtained 10.16 points on the HL score. The sample was divided approximately into thirds—inadequate (insufficient) health literacy was found in 31.9% of respondents, problematic health literacy in 34.3% of respondents, and enough health literacy was found in 33.8% respondents living below the poverty line.

Levels of health literacy in the research sample

Inadequate health literacy was found in 31.9% of respondents, while 34.3% had problematic health literacy and 33.8% had sufficient health literacy.

The respondents answered questions relating to socio-economic status and were asked to specify whether they were employed, unemployed, retired, retired due to disability, independent earners and so forth. It was found that 50.8% were unemployed, while 16.4% stated they had some form of employment (the so-called working poor). The relationship between socio-economic status and HL score was not statistically significant (p=0.27). Respondents were also asked about their total family income. There were three main categories. Incomes of below 5000 CZK were reported by 17.6% of households, usually single person households, while incomes ranging from 5001 CZK to 7000 CZK were reported by 15.3% of households and incomes from 7001 CZK to 10,000 CZK was reported by 19.7% of households. No statistically significant relationship was found between health literacy and net monthly income of all persons in the household living below the poverty line (p = 0.08). We also asked the respondents how difficult it was for them to pay for any medicines needed. Table 2 shows that 34.2% found this difficult and almost 21% of respondents found it very difficult. Statistical significance tests showed that difficulty paying for medicines decreased, the higher the level of education (p=0.001, Pearson correlation coefficient = -0.19).

Question “Are you able to pay for medicines required for your health? Do you find this...?” The responses were: 8.1% - very easy, 32.2% - easy, 34.2 %- difficult, and 20.7% - very difficult. Some (3.4%) responded “I don’t know” and some “I don’t want to answer” (1.4%).

The respondents’ financial situations were also addressed in a question asking whether they could afford to visit their physician. As the answer shows, 23.3% consider it difficult, and 9.7% very difficult. Can you afford to visit your physician? Is it ...? 16.7% responded that it was very easy, while 47.7% thought it was easy, 23.3% thought it was difficult, and 9.7% very difficult. Some (2.3%) responded “I don’t know” and some “I don’t want to answer” (0.3%)

The respondents gave the following main reasons for finding it difficult to visit their physician: cost of transport (36.5%), lack of time (13.2%) and being unable to access transport from home (10.8%). 2.4% respondents reported not having health insurance. Statistical significance tests showed that difficulty visiting a physician decreased the higher the level of education (p=0.003, Pearson correlation coefficient = -0.21). We found a correlation between education level and household income (p< 0.001, Pearson correlation coefficient = 0.27); we also know that money is the main factor behind the poor use of health care services. The relationship between HL score and education level is statistically significant (p< 0.001, X2= 33.04).

Discussion

Our findings are similar to the results of the 2015 European Health Literacy Survey in the Czech Republic. That survey showed that 59.4% of adult participants from the Czech Republic had inadequate and problematic levels of health literacy (Šimůnková & Vojtíšková, 2015). Although our study was restricted to the South Bohemian Region, the results reflect those of the European Survey. We found that 66.2% respondents had insufficient or problematic levels of health literacy.

Kučera (2015) states that health literacy strongly affects people’s ability to visit their physician. Our study shows that 23.3% find it difficult to travel to their physician, and 9.7% find it very difficult. Although the Czech Republic has an extensive network of health service providers and health insurance companies have to ensure those with insurance receive health care provision, taking account of availability and time, some respondents may live in localities where access to transport, including public transport is poor, and so they find it difficult to travel to their physician (Růžička, 2010). Czech law determines the availability of health care services, stating that the health care provider must be a reasonable distance from the insured person’s permanent residence and can be accessed within a specific travel time by transport while adhering to road traffic laws. Similar laws apply to the provision of services with respect to time and to urgent and acute services depending on the nature of the urgency (Act on public health insurance 48/1997 Coll.). The specific travel times are defined in the annex to government decree 307/2012 Coll., and are the same all over the Czech Republic.

However, as Helšusová (2014) states, there are regional differences. In the South Bohemian Region, the accessibility of health care is close to the Czech average. But in the Vysočina Region, for example, it is below the Czech average.

Another part of our study focused on the relationship between health literacy and difficulty paying for medicines. As Kučera (2015) states, health literacy has a strong effect on ability to pay for medicines, but it has also been shown that health literacy increases with education level. As the statistical significance tests in our study showed, difficulty paying for medicines decreases as education level increases. There is a close connection here, as health literacy increases with education level and health education includes developing an awareness that some medicines do not require additional payment. Those with insurance are entitled to such medicines, and information about these can be requested from the pharmacist as an alternative to a prescribed medicine with a substantial additional payment. Our study showed that education level and ability to pay for medicines is linked and that a high proportion of poor persons find paying for medicines very difficult.

Act No. 48/1997 Coll. on public health insurance makes the possession of health insurance obligatory, except in some specific cases. Nonetheless, our study showed that some respondents (2.4%) had no insurance. We put this down to ignorance, also related to health literacy. The employment office pays health insurance on behalf of those who meet the material poverty criteria (and) or are registered unemployed, and the insured person probably doesn’t care about his or her insurance.

Our study also showed that some respondents receive state benefits, despite having different jobs. Specifically, 16.4% reported having some form of employment (the so called working poor). This is becoming increasingly familiar, as with decreasing unemployment levels, there is an increasing number of people who are in work but are close to the poverty line (Antošová, Birčiaková, & Stávková, 2015). The main reason they remain employed despite the low wages and insecurity is out of an effort not to fall into social exclusion (Sirovátka & Mareš, 2006).

Conclusion

Our study confirms some of the findings from European and international studies on the insufficient health literacy of low-income groups and low-education groups. Unfortunately, our study also confirmed that the Czech Republic is one of the countries with the lowest health literacy in Europe. It is followed only by Bulgaria (Šimůnková & Vojtíšková, 2015). We can speculate about the causes, but as our study and that by Růžička (2010) show, it may be caused by inequalities in health care access, affecting the poor and low-income groups in particular. Some of the findings, such as the existence of respondents without insurance or ignorance of insurance, were almost shocking, and we suggest more attention should be paid to this issue and interventions in health literacy considered. Ignorance about the fact physicians can be accessed free of charge and medicines can be obtained without additional payment is also related to insufficient levels of information about health insurance and its advantages. We believe the solution to this lies in health literacy interventions.