Supporting the people of Scotland to be "sufficiently on their guard"

Scotland’s earliest champion of health literacy was probably a physician working in Roxburghshire, William Buchan, who wrote:

“Medical authors have generally written in a foreign language; and those who were unequal to the task, have even valued themselves upon couching .. their prescriptions, in terms and characters unintelligible to the rest of mankind.  It is not to be supposed that men can be sufficiently upon their guard against diseases, who are totally ignorant of their causes.”

This was written in his best-selling “Domestic Medicine”  in 1784 at a time when Scotland was one of the most well read nations on earth.  An estimated 75% of the population had adequate reading and writing skills. Buchan understood that for mankind to thrive and be “upon their guard against diseases”, medical authors must “de-medicalise” information and use words and letters which people could understand.  He eloquently made the link between literacy and living well. This may be one of Scotland’s first references to “health literacy” and “self management”, and although these terms are contentious, there is seldom any doubt about their relevance to health and wellbeing.

For many years, health literacy, however defined, was a specialist interest of professionals who focussed on children and adult literacy and people with communication difficulties; areas which demanded particular skills to ensure information is communicated in simple terms. However, the benefits of giving and receiving information in an easy to understand format became clear as evidence gathered about the importance of communicating safely in the health environment and the significance of differing levels of understanding.

In the early 2000’s, there was a flurry of activity worldwide as papers were published about the benefits of checking understanding and using approaches such as Ask Me 3  and Teach Back .

In 2003, the Institute of Medicine’s report, “Priority Action for National Action in Quality Improvement” , part of the Quality Chasm Series, recommended a set of 20 priority areas for the US Department of Health and Human Services.  One of the 20, described as “cross cutting”, was health literacy and self management.

The key link between health literacy and control of conditions such as diabetes was also being made. Clinicians, such as Professor Dean Schillinger, provided evidence that people with inadequate health literacy and type 2 diabetes had worse glycaemic control and higher rates of retinopathy than their peers with adequate literacy.

Interest remained scattered and unconnected across Scotland, as it was in most countries, and activities were not necessarily labelled “health literacy”.  However, many adult literacy initiatives, such as The Big Plus, a National Adult Literacy and Numeracy campaign, and Adult Literacies Online , made numerous references to health in their campaigns.

Keep Well, a national plan to address health inequalities in Scotland, contributed useful research about health care staff’s approach to literacy and health in “Exploring Primary Care Responses to Adult Literacy Issues”  in NHS Greater Glasgow and Clyde (2008).  Conclusions were that some staff were reluctant to raise the issue of literacy and questioned whether they should be addressing literacy issues, which could result in a lost opportunity to signpost people to support.

An important contribution to knowledge about health literacy was made in the UK when Coulter and Ellins’ published a Review of Patient-Focussed interventions (2006)  , which included a very useful section on health literacy.  This provided an excellent reference when, in 2008, the Health Improvement Strategy division of the Scottish Government commissioned a Health Literacy Scoping Study . This was a major step forward, as this represented an opportunity to gather intelligence and start planning a national approach. The Health Literacy Scoping Study explored the concept of health literacy, its application to policy and practice in Scotland and identified options for further development.

Another impetus was a key finding in the Scottish Survey of Adult Literacies in 2009, which was that: “26.7 per cent of the population may face occasional challenges and constrained opportunities due to their literacy skills. Within this quarter, 3.6 per cent face serious challenges in their literacy practices.”  “People with occasional difficulties” referred to the huge number of the citizens of Scotland who manage well in an unchanging environment, but struggle to make sense of an unexpected change in their health, such as being given a diagnosis of a long term condition, being prescribed medicines or being admitted to hospital. This survey confirmed that the unfamiliar health environment remained “unintelligible to the rest of mankind”.

Further momentum was gained when the Scottish Government produced strategic guidance in 2010 in Adult Literacies in Scotland 2020 , which stated ‘Making sense of complex health environments and information can be challenging for us all; however, poor “health literacy” affects a large part of the population.”  The guidance recommended that there should be a focus on literacies and health and well-being, and made clear that poor health literacy had equal importance for people working in the health services; “complex health information can also be challenging for some health care staff, who may have to deal with dosage, report writing and communicating with patients in a variety of ways”.

Meantime, directorates in Scottish Government were collaborating to develop the connections between health improvement, self management of long term conditions, functional literacy and patient safety. One outcome of this collaboration was a lively event in March 2010, “Mrs Dalrymple’s Toe” – examining the link between poor literacy and poor health outcomes” when adult learners, professionals from the world of education, literacy, third sector, health and social care and policy makers, gathered to discuss whether there should be a national focus on health literacy, the answer was a resounding “Yes”.

A significant advance was made later in the year, when health literacy was identified as a key component of the person centred ambition in Scottish Government’s Healthcare Quality Strategy for NHSScotland. This focus was provided in 2011, when the Scottish Government appointed a Policy Lead for Health Literacy and a National Clinical Lead for Health Literacy and Self Management. The following year, the National Health Literacy Action Group (NHLAG)  was established, chaired by the Chief Executive of the Health and Social Care Alliance Scotland (the ALLIANCE), the national third sector intermediary for a range of health and social care organisations.  The remit of the NHLAG was to “provide a national narrative, vision, direction and support to raise awareness and reduce the negative impact of poor health literacy.”

And so now, two hundred and thirty years after William Buchan’s far sighted reflections, Scotland’s first Health Literacy Action Plan is being launched with an ambition to ensure that the people of Scotland have the opportunity to live well and “be sufficiently upon their guard”.

Christine Hoy, Primary Care Development Manager, Health and Social Care Alliance Scotland

Christine has spent much of her career in practice nursing in NHS Lothian. Following a scholarship to study health literacy and self-management internationally, she was seconded to Scottish Government to establish a self-management programme, and retains a keen interest in health literacy.