Public health information has been an important part of government strategies for reducing the spread of the Covid-19 pandemic worldwide. In the UK, key public health messages have focused on the importance of regular hand washing, face coverings, social distancing and the self-isolation of positive cases. In addition, numerical information used for public health purposes has included data on hospital admissions, local cases and deaths per 100,000 people. This has also included the ‘reproduction number’, usually known as the ‘R number’, which is a measure of the average number of secondary infections produced by a single infected person.

While much information has been communicated in a simple-to-understand way, much has also required high levels of health literacy to fully understand and process. The more complex information has been particularly difficult for those with poor health literacy to access. As well as leading to poorer health outcomes generally, poor health literacy has therefore also risked exacerbating the pandemic’s impact.

What is health literacy?

Health literacy has been defined as:

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Examples include how people understand:

  • instructions on prescription medication;
  • information regarding healthy lifestyles and health behaviours; and
  • clinical information on medical education brochures and leaflets.

Research has shown that complex health materials can be a barrier to good health, with those most likely to benefit from health information being less likely to fully understand complex messaging. In one English observational study undertaken in 2015, for example, 43% of adults did not understand written health information above a sufficient level. This rose to 61% for health information that included both text and numbers. Taking the socioeconomic characteristics of participants into account, the researchers found that those more at risk of socioeconomic deprivation had higher odds of being below chosen literacy thresholds than those at lower risk of deprivation.

Health literacy and inequality

Levels of health literacy have been linked to a general health inequality gap in the UK, with those with limited financial and social resources being more likely to have limited health literacy.

This contributes to poorer average health outcomes in deprived areas. According to research from the King’s Fund, those in the least deprived areas of the UK can expect to live around 19 more years in good health than those in the most deprived areas. In addition, data from the Office of National Statistics has shown that people living in the poorest areas of England are twice as likely to die from Covid-19 as those living in the least deprived areas.

Other barriers to health literacy

Linguistic and cultural barriers

Linguistic and cultural barriers in healthcare settings can lead to poor patient experience. They can create significant communication problems between clinicians and patients, leading to poorer health outcomes as a result. Patients with high levels of health literacy in their own language can experience a sharp decline when presented with health information in an unfamiliar setting, particularly if translation services are inadequate.

Clinicians and healthcare staff have published guidance and resources aimed at reducing these barriers. For example, the Nursing and Midwifery Council’s Code of Practice states that nurses and midwives must:

  • take reasonable steps to meet people’s language and communication needs;
  • use a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to people’s personal and health needs; and
  • check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum.

Examples of resources for both the public and practitioners include the NHS ‘Health information in other languages’ website, and the health literacy toolkit. In addition, the Government’s coronavirus information hub includes a wide range of information with the public as the primary audience.

However, concern has been raised that public health information around the Covid-19 pandemic has not been published in enough languages. In July 2020, Doctors of the World UK published a letter addressed to the Secretary of State for Health and Social Care, Matt Hancock, and the Secretary of State for Housing, Communities and Local Government, Robert Jenrick, expressing concern about a:

[…] lack of availability of Covid-19 public health guidance in languages other than English, which is preventing people in England who do not speak or read English well from accessing essential public health information and limiting their ability to keep themselves, their families, and their communities safe.

The digital health divide

Research has shown that a digital divide exists in Britain. A 2019 study from the Office for National Statistics suggested that 7.5% of adults in the UK had never used the internet. Those less likely to use the internet include adults over the age of 75, and those who are economically inactive.

Researchers have suggested that this digital divide feeds into wider health inequality in the UK. For example, an article on the subject in The Lancet has noted that “many organisations, not least among them governments, still proceed as if access to the internet is already universal”.

The article also pointed to the closure of public libraries and online learning centres during lockdown measures as having affected those who require assistance and support to access online public health information.

What is the Government doing?

Public Health England (PHE) and Health Education England (HEE) lead on health literacy on the Government’s behalf. HEE, a non-departmental public body, works with national and local library and knowledge services across England to help improve levels of health literacy in the public. Schemes to improve levels of health literacy have included:

From August 2016, all organisations in England that provide NHS care or publicly-funded adult social care have been legally obliged to follow the AIS. Extensive guidance has also been published for primary care clinicians on interpretation and translation services available to all patients.

HEE have also published a bank of Covid-19 resources aimed at the public, with resources specifically targeted at those experiencing barriers to traditional public health information. These include:

In addition, PHE has published its latest updates to the guidance for households with possible coronavirus infection in 9 different languages, including Urdu, Punjabi, Portuguese, Polish and French.

Upcoming oral question

On 8 December 2020, Baroness Lawrence of Clarendon (Labour) will ask the Government “what plans they have to review public health information on the Covid-19 pandemic to ensure that any (1) linguistic, (2) cultural, and (3) digital issues with such information are addressed”.

Cover image by iMattSmart on Unsplash.