Health Literacy In Canada

Health literacy as a determinant of health, and health equity is seldom discussed. Since, it significantly impacts patient outcomes, health literacy warrants our attention now more than ever. Specifically in Canada, immigrants, a fast growing population falls below the national average health literacy level (Rootman & Bihnety, 2008). Client health literacy significantly impacts their ability to cope with chronic illness. In order to help clients cope with chronic illness, nurses face the challenge of educating clients, especially those with low literacy. As healthcare technology progresses, personal health care records (PHRs) are more accessible than ever. However, most healthcare professionals in Canada, especially nurses, are not using them

to improve client health literacy (Curtis, Cheng, Rose & Tsai, 2011). PHRs hold significant potential to help us track, and supplement healthcare related education, and we as nurses, and nurse leaders possess the skills to use them to improve client health literacy, and client health related outcomes. Through this paper we hope to highlight the crucial concepts, links and methods required to improve client health literacy, and chronic illness management through the use of PHRs.
Understanding Literacy, and Health Literacy
An understanding of literacy, and health literacy is crucial to understand their impact on client health outcomes. Further, a nurse’s ability to better educate clients lies in his or her understanding of these terms. Literacy is a multilayered, dynamic and complex topic; however, for our purposes it can be defined as a set of skills including reading, writing & oral skills, numeracy skills, and skills that enable us to acquire knowledge and information (Keefe & Copeland, 2011). Literacy can be understood through various theoretical lenses. Keefe & Copeland also highlight five principles we must keep in mind when thinking about literacy (2011). Firstly, all people are capable of acquiring literacy, however methods of acquiring literacy vary greatly. Literacy is also a human right, given its ability to shape human experience. Further, there is a social component to literacy, and it is linked to the human relationship ability. Literacy also serves as a crucial empowerment tool. Lastly, literacy is not the responsibility of an individual alone; community, and human interaction help nurture literacy.
All clients possess a degree of health literacy, and like literacy, it is a human right. It is a client's ability to understand written, spoken or numerical information, and make healthcare related decisions based on the information (Eadie, 2014). A client’s health literacy also has a social component, often being influenced by their socioeconomic status, immigration status and language (Eadie, 2014). For example, literacy, and health literacy scores both tend to be lower for immigrants, especially new immigrants, and for clients who do not fluently speak one of the official languages (Rootman & Bihbety, 2008). Given that health literacy can empower clients to improve their health care outcomes, we as nurses have the ability to influence, and facilitate this process. Health literacy is a nurse's responsibility as much as clients.
Client Education, and Chronic Illness – A Challenge
Client education is one of the many responsibilities of nurse, and one that is relevant to health literacy.

In order to empower our clients to make appropriate health care related decisions we must educate them. However, prior to educating clients, it is a nurse's responsibility to assess client health literacy status. Further, it is important that assessment is an ongoing process, and not limited to clients with low health literacy.

In order to ensure accurate assessment of health literacy, and effective patient education nurses can use the ACTS method during each patient interaction (French, 2015). ACTS method encompasses assessment, collaboration and comparison, teaching/teaching back, and survey of the client. Using this 4 step processes nurses can effectively educate, and empower clients. The ACTS methods allows nurses to adapt to all clients, including those with varying levels of health literacy, with varying degrees of experience with their chronic illness, and with various socioeconomic backgrounds (French 2015). Further, additional components that help make the ACTS method effective include the opportunity to seek support from other healthcare professionals, and the opportunity of ongoing process. Client education needs are dynamic, and variable, and even more so in the case of chronic

illnesses.
Chronic illnesses present a unique challenge to patient education. Not only do chronic illnesses require long-term complex health related decision making, but clients with low literacy rates are more likely to have chronic illnesses as well. Numerous reasons could potentially contribute to this link. Chronic illnesses such as Diabetes Mellitus, and Coronary Heart Disease (CHD) have high prevalence in disadvantaged groups such as immigrants, ethnic minorities, and those who belong to lower socioeconomic classes. The same groups tend to also have low literacy, and/or low health literacy rates. The complexity of education for chronic illness is further increased when clients have low health literacy. Evidence indicates that such clients tend to have a higher non-compliance rate attributed to knowledge deficits regarding their illness, medication regimen or necessary lifestyle changes (Ozok, Wu, Garrido, Pronovost & Gurses, 2013). Therefore, clients with chronic illness require a significant amount of education to manage their complex disease processes, making effective educational techniques crucial. For example, a client with CHD requires education on the disease process, on the complex medication regimen associated with CHD, and on the numerous secondary prevention activities such as exercise, diet, smoking cessation, and lifestyle change. Often a language barrier between the nurse and client makes patient education more challenging. Given the complex link between chronic illness, health literacy, and the need for patient education, we as nurses face a challenging task.
Personal Health Records – Overcoming Challenges
In order to overcome challenges presented by patient education for clients with chronic illnesses, and low health literacy, Personal Health Records (PHRs) can serve as a valuable resource.

PHRs are a type of record accessible to healthcare workers that contain health related information such a diagnoses (Curtis et al., 2011). The records effectively and efficiently organize patient information in order to help healthcare workers and the patient manage their health. Information found on PHRs helps healthcare professionals provide better care; they can relate how past and current conditions will affect client treatments, education and outcomes. In contrast to the States, Canadian institutions are slow to effectively utilizing PHRs primarily based on the belief that they are not considered crucial to client centered care (Curtis et al., 2011). PHRs sole purpose is often thought of as only keeping a record of all relevant health information; however, the primary purpose of the PHR is to improve clients’ health care outcomes (Ozok et al.,

2013).
Uniform adoption of PHRs can allow nurse to promote client centered care and empower clients (Curtis et al., 2011). When used effectively, PHRs can help nurses assess, and educate clients, while also monitoring their progress. Further, facilitating client access to personal health records can serve as an effective teaching tool. PHRs are valuable in not only acute settings but also community settings because they can address primary health care principles through focusing on preventative health (Ozok et al, 2013). For example, PHRs, especially electronic versions can allow patients to update their health history and it can provide information on recommended screening tests and relevant educational resources and support circles (Curtis et al., 2011). PHRs have significant potential to improve patient outcomes, however limitations exist as well.
PHRs present security and privacy issues; challenges related to ownership & policy further precipitate barriers. As the number of healthcare professionals with access to PHRs increases, the opportunity for privacy breaches, and security violations increases as well (Curtis et al., 2011). This can be understood simply through the possibility that the more healthcare professionals with access to a PHR the more opportunities for those with malicious intent to hack one of the many accounts. An additional challenge related to ownership and policy prevents clients from having easy access to their own health records, which hinders their ability to use information on their PHR to improve their health literacy (Curtis et al., 2011). Overcoming these challenges can only begin through change in perspective towards electronic PHRs in Canada.
In order to change these perspectives health care needs to utilize PHRs as a means to assess health literacy and empower and educate patients to become more actively involved in their own care. Instead of viewing PHRs as allowing only short term benefits term, such as easier access, and easier record tracking, the benefits of PHRs should be seen for their potential to improve patient centered care and increase patient’s autonomy over their own health (Curtis 2011). The first steps taken by nurses can help steer Canadian healthcare professionals in the right direction. Nurses can and must use their access to PHRs to educate clients on their disease processes, track client progress, and empower clients by sharing PHR information.
Nurses Role in Promoting Health Literacy and PHRs
Statistically speaking, understanding health information is difficult for majority of the population; however, health education becomes even more complex with immigrants who possess cultural or language barriers. Based on nursing standards of practice, nurses must ensure that their clients have access to their healthcare information and must effectively communicate in order to improve patient care, which can be done by using PHRs (College and Association of Registered Nurses of Alberta, 2013). Firstly, nurses should assess the client’s baseline knowledge and what domains of learning (cognitive, psychomotor and affective) need to be included in order to tailor the PHR and education to the patient's preferences (French, 2015). This intervention reduces the patient's stress, increases their motivation to learn and improves knowledge retention (Potter & Perry, 2010). Then the nurse can begin teaching by providing key points to the patient from their PHR through reinforcing key concepts while avoiding medical jargon and technical terms (Mitty & Flores, 2008). For example, a nurse can apply this technique when providing dietary or medical instructions. Through keeping education simple, it increases clarity and allows the patient to ask questions. Along with this technique, the teach back method is also commonly utilized.
Especially, those with cultural or language barriers the nurse can use the teach back method to assesses if the patient understands. If the patient does not understand, then the nurse can assess whether they need an interpreter or can utilize any family. Involving the family in education can help reduce the patient's stress because they may feel less isolated and instead more supported and therefore more motivated to learn (Day et al., 2010). These techniques allow nurses to effectively and efficiently integrate PHRs into health promotion in order to actively involve the client in their care.