Health literacy: Do we have effective interventions to enhance it in socially disadvantaged people?

According to a comprehensive definition by the European Health Literacy Survey (HLS-EU), the concept of health literacy (HL) refers to the knowledge, motivation and competencies to assess, understand, appraise and apply health-related information within healthcare, disease prevention and health promoting settings. HL is recognised as a key determinant of health at both the society and individual level, in healthy people and with diverse communicable and non-communicable diseases. In healthy people and patients with coronary artery disease, low HL is significantly associated with smoking, unhealthy food choices, less physical activity and low adherence to medication. Thus, efforts to enhance HL are also highly relevant for cardiovascular disease (CVD) prevention. How can we improve HL? Are there any specific conditions that have to be taken into account in order to develop effective interventions? In fact, according to a recent systematic review, there is evidence that low HL in patients with coronary artery disease is more prominent in patients of higher age, male sex, non-white ethnic groups, lower educational level, lower income and lower social support. A recent multinational study on patients with familial hypercholesterolemia, published in this journal, has shown that HL was strongly associated with higher age and low education or income, and the latter was an independent predictor for low HL, even when adjusted for age. However, studies on how to enhance HL in specific groups (e.g. ethnic minorities, higher age, male gender, low income and/or educational level) of patients at risk and with manifest CVD are scarce. In principle, the current European Society of Cardiology (ESC) guidelines on CVD prevention recommend a broad range of different approaches, ranging from regulatory policies such as banning tobacco use, media-based interventions, optimised caregiver–patient interaction, to group-based, multimodal interventions in patients at very high risk. However, based on the aforementioned data on HL, one could suggest that it may need tailored interventions for specific subgroups in order to gain optimal effects. In this issue of the European Journal of Preventive Cardiology, Greenberg et al. present data on a prospective cohort trial on the efficacy of a ‘skills-based intervention’ on knowledge of CVD risk factors and CVD symptoms (as important parts of HL as defined above) in 407 socially disadvantaged, middle-aged women in Jerusalem. The intervention consisted of three 2-hour workshop sessions with a nurse or nutritionist, embedded in 20 pre-existing municipality-run groups on a weekly basis with 15–20 women. One prominent aim of the intervention was to teach participants how to prepare effectively for doctors’ visits in order to maximise their chances of gaining as much information and instruction as needed. Another aim was to teach participants how to interpret their physical and blood test measurements, to inform about women’s CVD risks and to instruct on preventive health behaviours and heart attack symptoms. After 3 months, more women prepared for doctors’ visits and knowledge of several CVD risk factors increased. Interestingly, women with low perceived efficacy of the patient– physician interaction (PEPPI) at baseline reported a significant increase in PEPPI, while women with initially high PEPPI showed decreased values, indicating that socially disadvantaged women with high PEPPI at baseline might have overestimated their HL at baseline. Hence there is evidence that community-based group interventions are able to increase HL in socially deprived women. In contrast, according to a recent systematic review, available evidence does not support the assumption that mass media interventions targeted towards ethnic minorities effectively improve health