Clinical Features

Plain Talking: The European Pain Federation EFIC’S Health Literacy Campaign

Written by Brona Fullen, PhD, MSc, BSc, Associate Professor, UCD School of Public Health, Physiotherapy and Sports Science, Director, MSc Advanced Physiotherapy Studies programme, Belfield Campus, Dublin

The European Pain Federation EFIC is a multi professional organisation in the field of pain science representing 20,000 doctors, physiotherapists, nurses, psychologists and researchers across Europe who are involved in pain management and pain research. Its overarching vision and mission are to advance education, research, and the clinical management of pain, serving as an authorative science based resource on issues related to pain.

EFIC President Brona Fullen (Associate Professor, UCD School of Public Health, Physiotherapy and Sports Science) chose the theme of health literacy (HL) for her term in office with the ‘Plain Talking’ campaign

Health literacy is an individual’s capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions 1 .

The World Health Organisation has declared HL a global health concern and state that efforts to raise HL will be vital in realising the social and economic ambitions described in their 2030 Agenda for Sustainable Development 2 .

A pan European study found that 47% of respondents had limited HL 3 , with certain populations (e.g., older people, those with lower social status and education) more likely to be affected. Similar levels of limited HL have been reported in people living with chronic pain 4,5,6 .

Active self-management is key to the long term management plans of pain conditions 1 . For this to be effective patient education is key 7 . However, limited HL can be a barrier as it impacts on disease related knowledge 8 – a vital component for developing effective self management skills 9 .

Limited HL results in poorer health outcomes for those with chronic diseases; worse symptom control, an increase in healthcare utilisation, lower adherence to treatment and inadequate communication between the patient and clinician 10 . The economic cost has been estimated to account for 3–5% of total healthcare costs at health system levels 11 due to medical errors, increased illness and disability, loss of wages and compromised public health 12 .

Identifying People with limited Health Literacy

Patients with lower levels of HL tend not to ask questions and engage less with their clinicians, frequently miss appointments, and show poor adherence to treatment.

Whilst questionnaires 13,14, 15 and scales offer a method to potentially identify those with limited HL, healthcare professionals should assume that all patients, regardless of their educational or socioeconomic background may struggle to understand and absorb health-related information.

Health Literacy Interventions

To support patient self management education HL- sensitive approaches should be implemented by all healthcare professionals to enable patients develop and improve their levels of HL 16 . The following tools can be successfully integrated into everyday clinical practice:

Plain Language

• Use lay language and explain complex medical terminology when it is used.

• Provide written information in a style that is accessible to all, by considering the average reading level, the language used, and the design of the leaflet 17 .

• Include diagrams to help explain.

• is a useful online website to gauge reading level difficulty 18 .

Teach Back Method 19

• Ask your patients to repeat back what you have said to them in their own words.

• This allows you to gauge your patient’s understanding of the information you have given them.

• If necessary rephrase the information until the patient understands.

Ask Me 3 ®20

• Empower your patients by encouraging them to ask these three questions during all healthcare consultations:

• What is my main problem?

• What do I need to do?

• Why is important for me to do this?

Limit information given in a consultation to 3 to 5 messages per session

Implementing the Teach Back Method and Plain English strategies lead to greater improvements in treatment adherence 21 , and increased engagement in self-management practices and disease-related knowledge 22 , regardless of prior HL levels. Similarly, Ask Me 3 ® encourages patients to be more engaged while attending physiotherapy sessions 23 .

Health services also have a role in supporting patients to separate evidence-based information from false or misleading information, to provide new information that is accessible, and to deliver it at a pace that suits the patient. 24 This will ultimately allow patients to make informed decisions and become actively engaged in their own healthcare.

Limited HL is a global health issue with social and economic implications. Increasing HL sensitive interventions in existing health services have the potential to improve health outcome for those living with pain. Health services need to consider their role in, and develop strategies for improving the public’s levels of HL and accessibility to evidence based health information.

For further information on EFIC and the health literacy campaign please see

Authors: The EFIC Health literacy Working Group Dr Laura Mackey (Chair, Working Group on Health literacy), Professor Harriet Wittink, Dr Magdalena Kocot-Kępska, Dr Brona Fullen, Dr Nadja Nestler

References available on request

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