Health literacy continues to be a significant problem with a majority of women in Kenya having difficulties accessing, understanding and using health information to improve their health. Health literacy is now the bedrock of an individual’s ability to access health care and achieve an improved level of health and wellness. Women are the main decision makers in terms of medical decisions and health information seeking in the family. When a woman has low health literacy it affects not only her health knowledge, her ability to navigate the health care system but also her ability to care for her children. Women are gatekeepers to health for their families so health literacy has implications beyond the woman herself. The article outlines the concept of health literacy and how it is critical in the optimization of health information by women. The paper outlines the different sources of health information accessed by women, the challenges facing promotion of health literacy among women in the country and the possible interventions in promoting health literacy. The paper concludes by emphasizing the importance of health literacy to women.
**Keywords: **Constraints, Health literacy, Health information, Low health literacy, Promotion, Women.
In Kenya women form the most underprivileged group in society. A majority are denied education as a result of backward cultural practices that encourage the boy child to access education. This leaves them vulnerable to exploitation without skills in reading and writing which contribute greatly to how they access health information. Women who are literate can better understand and interpret health information. Access to appropriate and relevant health information is critical in the lives of every individual. Health care has changed significantly over the past few years with an emphasis on personal responsibility for maintaining good health. Health literacy is now the bedrock of an individual’s ability to access health care and achieve an improved level of health and wellness. Evidence has shown that access to the right information, by the right person at the right time can have a very significant impact on their wellbeing and also on their health outcomes. (Smith, 2009) Health literacy is important to women since it affects their capacity to make decisions and manage their health. It influences their lifestyle choices, the type of preventive health actions they get involved in and how they maintain health regimens. (ACSQHC, 2014)
Smith (2009) defines health literacy as “the personal, cognitive and social skills which determine the ability of individuals to gain access to, understand, and use information to promote and maintain good health”. Access is concerned with the ability to seek and obtain health information, understand refers to the ability to comprehend the information, appraise means to filter, judge and evaluate the health information, while use/apply is the ability to use the information to make an informed decision.
Health literacy is a complex phenomenon involving individuals, families and communities. Improving health literacy is critical in tackling health inequalities. Women with low health literacy have poorer health status and higher rates of hospital admission, are less likely to follow prescribed treatment plans and experience more drug errors. Women experience unique health care challenges and are more likely to be diagnosed with certain diseases than men. These include chronic diseases and conditions like cancer, diabetes and heart conditions which are leading causes of death for women (Wheeler, 2013). Wheeler adds that 38% of women suffer from one or more chronic disease as compared to 30% of men.
Health literacy plays a crucial role in chronic diseaseself-management.To manage chronic and long term disease on a daily basis, a woman must be able to understand and assess health information, plan and make lifestyle adjustments, make informed decisions and even visit the health center or hospital when necessary.
Consumers are at the center of the health system. The way they make decisions and take action about health and health care is driven by their own skill, capacities, knowledge and environment (ACSQHC, 2013).A woman’s health literacy determines how they engage with the health care system and also their likelihood of accessing disease prevention services such as screening for various diseases.
A common misconception is that low health literacy is only associated with the illiterate, unskilled or even unemployed. This is not true after all one would not expect lawyer to understand medical jargon any more than a doctor should understand legal terminology. Health literacy is the bridge between the literacy and other skills and abilities of the individual and the health context. Health literacy affects an individual’s ability to:
Read, understand and act on preventive health messages, healthcare plans, medication instructions and other health information.
Navigate the healthcare system, fill out complex forms and locate providers and services.
Share personal information including health history with health providers.
Effective management of chronic diseases and self-care instructions.
Act upon necessary procedures and direction such as medication and appointment schedules.
Understand mathematical concepts such as probability and risk.
Health literacy includes numeracy skills e.g. calculating cholesterol levels, measuring medications, understanding nutrition or even what to do when one misses a dose.
Women are the main decision makers in terms of medical decisions and health information seeking in the family. When a woman has low health literacy it affects not only her health knowledge, her ability to navigate the health care system but also her ability to care of her children. Women are gatekeepers to health for their families so health literacy has implications beyond the woman herself. Women with high health literacy are more aware of prenatal healthcare, nutrition and hygiene.
According to ACSQHC (2013) lower levels of individual health literacy have been associated with increased hospitalization rates and use of emergency care, poorer knowledge among consumers of their own medical conditions, poor ability to take prescribed medications appropriately, and to interpret labels and health messages, poor overall health status among the elderly and a higher risk of death among the elderly. It results in women having difficulties in accessing health care, following instructions from a physician and even taking medication as prescribed e.g. for women living with HIV limited health literacy can be associated with severity of illness due to poor medical adherence.
Decreased health literacy results in misuse of medication, repeated and serious medical errors, inability to manage multiple medications, and a disinclination to read extra labeling on prescription medication such as safety warnings and drug interaction warnings (Berkman et al, 2011).With low health literacy women exhibit an impaired ability when it comes to recalling health information, unwillingness to ask health providers for assistance in managing health conditions, difficulties in dealing with post discharge medical adherence, and inability understanding one’s health conditions, illness and treatment (Palumbo, 2015)
Liechty, (2011) posits that inadequate health literacy causes individuals not to seek help in a timely manner due to fear or embarrassment, resulting in increased emergency room usage, longer hospital stays, and increased self-reporting of poor health. For example a woman may be embarrassed to go for screening for diseases such as cancer which means the disease may not be detected early enough when it can be treated.
According to Bosworth, (2010) individuals with lower health literacy have a nearly two fold higher mortality rate. Women with low health literacy are unable to manage their children’s nutrition, and even hygiene. For example a woman may not understand why the doctor insists that a baby should be breastfed exclusively for six months and out of ignorance the woman may introduce other foods which may be detrimental to the health of the child. Even for the older children the woman may not understand the importance of a balanced diet thereby leading to children suffering from malnutrition.
Generally low health literacy has a negative effect on doctor patient communication. Women with low health literacy find it difficult to explain their medical conditions to the health care provider which makes it difficult for the health provider to assist the patient.
The social ecological model is the primary theoretical framework for this study. This model considers the complex interplay between individuals, relationship, and community and society factors. Health literacy is a product of individual, social and environmental factors that are mediated by education, culture and language. An individual improves his or her health literacy as a result of interactions with other individuals, the community and society where he gets health information from. The way in which people make decisions about health care is influenced by their capacities, skills and knowledge, and also by the environments in which these decisions and actions are taken.
The paper seeks to look into four objectives in an aim to bring out the constraints facing the promotion of health literacy among women in Kenya, which are:
· Identify the sources of consumer health information for women in Kenya
· Establish the constraints facing promotion of health literacy to women in Kenya.
· Identify the possible interventions in promotion of health literacy to women in Kenya.
The paper used the desk research approach where secondary data was gathered and literature reviewed from various published sources. The author mainly concentrated on peer reviewed journal articles and articles drawn from the website on health information. The author reviewed current articles with the oldest one being from the year 2000. A total of 18 articles were used in coming up with the article.
Sources of consumer health information for women
Women gain great deal of health information from informal networks particularly female family members and friends, coworkers, peer-networks and women-groups. Other sources of information include seminars and workshops, church and religious organizations, community barazas, and social workers. Younger women obtain a larger proportion of their health information informally through peers especially for sensitive issues like sexuality and sexual health (Murphy, 2003)
Also included as sources of information are brochures, pamphlets and newsletters containing health information. Other upcoming sources of health information include electronic resources, websites, and blogs, listening to podcasts and sharing information in social networking sites. (Smith, 2009)
Jones (2000) in his paper on the “development in consumer health informatics in the next decade” cited the following as places where individuals access health information; use of telephones, worldwide web,emails,public access touch screen kiosks, libraries or health shop based health points, hospitals and health care patient workstations, schools and the community and patient records.
Kutner (2006) in a research carried out by the national center for educational statistics (NCES) stated that individuals revealed that they received information about health issues from traditional sources such as newspapers, magazines, books, brochures, internet, televisions, conversations with family,friends,coworkers or conversations with health care professionals.
ACSQHC (2013) indicates that with changes in technology increasing amounts of information are available to consumers through sources such as social community-including parents, family and friends; educational systems including primary, secondary and university; health systems; including health care provides, health care organizations, government and non-governmental health organizations; mass media, internet and health promotion campaigns.
Wasike & Tenya (2013) in their study in Kenya covering a medical training college and hospital established that majority of the students obtained health information from books, followed by journals, the internet and finally newspapers. A look at local residents in the region established that most of them accessed information from the internet, others from lectures and other means. When the respondents were asked where they accessed the information they indicated from their homes, offices, cybercafés, libraries and information centers and even friends. Physicians, nurses and medical practitioners were also quoted as the best sources of health information especially for their patients.
Khayesi (2009) in a study on the elderly people in Kenya included women groups, religious organizations, and agricultural shows as sources of health information.
Constraints facing promotion of health literacy to women
Kenya has numerous problems that have compromised the quality of health care service delivery. Some of the issues include lack of infrastructure, poor management of healthcare facilities, lack of equipment, drug shortages, issues of affordability and accessibility and unqualified staff among others. High levels of poverty and illiteracy and ignorance have led to escalating mortality rates due to preventable diseases.
Over the past decade there have been improvements in the health profile for Kenya. The population rate has remained high at 2.4% per annum including a large and dependent population that is increasingly urbanized. Absolute poverty levels remain high at 46% and literacy levels at 78.1% although inequalities in age and geographical distributions persist. Gender disparities also remain significant. (MOH, 2014)
The readability and comprehension of health information is a major constraint. It applies to both the internet and written resources. Majority of health promotions and patient education has traditionally used printed materials. Such materials are not accessible to the millions of women in Kenya with inadequate literacy levels. Older individuals are more affected due to their poor comprehension influenced by their cognition, vision and hearing status (Afya Daily, 2016). Numerous studies document how many health materials, including patient education brochures, discharge sheets, contraception instructions and informed consent documents are often written at levels far exceeding abilities of patients. The language of the internet is mainly English and in Kenya the levels of literacy are still low in some regions.
The social stigma associated with illiteracy compounds the health literacy issue. People who have difficulty reading hide their illiteracy from health providers, friends, and close family members. As it is a majority of women in Kenya have difficulties accessing, understanding and using health information to improve their health outcomes.
Osborne (2004) interviewed healthcare professionals from a few countries and received this from Kenya. In the Kenyan situation the following issues apply to all parts of the country;
There are languages and communications breakdowns because doctors are trained in English yet the majority of their clients do not know English.
Medicine labels are in foreign languages and not in any of the national languages, Kiswahili or vernaculars.
Illiteracy levels among women are high necessitating need to communicate health information in vernaculars or folk media.
Access to the internet is growing fast in Kenya, due to laptops, desktop computers and also cell phones (Wasike & Tenya 2013) Although health information is now widely available via the internet, women who have less education, less money, and marginalized are more likely to have low health literacy. This is because acquiring information from the internet, includes requirements for infrastructure such as a laptop, desktop computer, cell phone, availability of bandwidth and electricity which a majority of women in Kenya do not have. This can be associated with low incomes and economic abilities of a majority of Kenyan women.
Internet information and structure also pose an obstacle to female internet users with low health literacy. Most health websites are known to use overly complex medical language that makes content difficult to understand. Navigation of the website is also a challenge for most people since using a website correctly requires computer literacy skills, information literacy skills among others (Egbert & Nanna 2009). The internet has a lot of information and it becomes difficult for users to determine which sites are relevant and useful.
Most patients do not have an idea about the reliability of the information they access since no one evaluates the internet and they end up with unauthoritative and inaccurate information (Wasike, 2013). Some internet sites promote health care products in which developers have a commercial interest in and this ends up being an advertising site for the organization or company.
Egbert &Nanna (2009) in their paper indicated that when the health provider is different from the patient in terms of age, gender, ethnic background, education and social economic status it becomes difficult for the patient to feel comfortable asking questions and disclosing personal health information.
There is also the issue of confidentiality. This is particularly relevant in regards to sensitive issues such as drug abuse, reproductive health, pregnancy, contraception and even sexual health. This is a barrier in information seeking especially for young women. Lack of anonymity may prevent these women from seeking health information due to fear that their friends or even parents will know especially relating to sensitive personal issues (Murphy, 2003). Other groups that may fall into this category are female sexual workers, women suffering for HIV/AIDS who may fear to be stigmatized.
Other challenges relate to cultural influences where some women believe in the use of herbal medicine and therefore will not go to seek information from any other source.
There is also the issue of quacks who pretend to be doctors. These people operate by marketing unreliable and inaccurate health information to women consumers in a bid to make money. Women consumers with medical conditions that do not seem to respond to medicine are easily convinced by the quacks. (Wasike, 2013)
There is also the issue of competition between the conventional medicine and alternative medicine providers e.g. the ayuverdic.All these provide information to female consumers, which at times is very conflicting. This disharmony causes confusion to women looking for health information since they are not sure what to make out of all the information they have received and which one to use.
According to Wasike, (2013) language is also an issue since the majority of the available print information on health is written for a level above the ordinary individual. Medical terminologies are complex and most times the consumers are not able to understand. When physicians communicate to the female patients using medical jargons they are not able to understand. These women struggle with health literacy demands and few claim adequate skills for communicating with their physicians and following up with self-care instructions due to limited background of health knowledge. Most health workers in Kenya are not aware of the magnitude of the problem.
Rural and marginalized women living in remote areas face barriers in accessing quality health information. Transport issues, lack of access to health services from which they may access health information.
Stigma is also a problem among women with low health literacy who face conditions such as HIV, fistula etc. They experience feelings of anger and fear of disclosure which becomes a barrier to accessing health information thus leading to worse health conditions (Palumbo 2015).
Possible interventions in promotion of health literacy to women
There is a need to address the gap between health information currently available and the skills women have to understand the information to make life altering decisions. For Kenya the success of the health system will depend largely in the capacity of women, families and communities to make informed decisions.
The most obvious approach to addressing low health literacy is making health information more accessible. Since without this information there is no basis through which women can improve health outcomes. Health care institutions, public health systems and the government should play a critical role in health literacy since they can make it easier or difficult for women to find and use health resources. The mandate to promote accurate and authentic health information squarely rests on them.
It is important to note however that information consumers with high information literacy can have low health literacy and a compromised understanding of health care information because the information is outside their field of specialization or they are challenged by age or serious illness. (Wasike & Tenya, 2013)
A culture should be created where help is routinely offered in completing important documents and where surrogate readers or translators for patients with limited health literacy are included when health education is taking place.
Healthcare givers need to learn to pay attention to signs that a woman has inadequate health literacy skills or is illiterate, this may include: incompletely filled forms, patients who are unable to assume the self-management role successfully; statements such as “I will read this at home or I forgot my glasses “patients who do not read any printed material during their interaction with the physician (Egbert, 2009). Women who say they want their family members more so spouses to fill out medical forms for them because they do not have the needed information.
Redesign Health education resources, letters and forms so as to make them easier to understand.
Nurses and other health care providers can assist women find resources such as local support groups, health education classes and community services.
Librarians can also assist by guiding women or consumers to authoritative health websites, electronic databases, blogs, list serves that will reinforce the information further.
Patient centered communication is also key as it helps women understand medical information within the context of their lives. When it comes to communication skills, in talking to patients, health care providers should: slow down when they speak to ensure the patient internalizes, emphasize important concepts, use the lay language which is easy to understand, read instructions out loud to patients.
Family members who understand the patient better can also be involved so that they are able to explain medical information to the female patient in a way she can understand. The medical practitioner can also use the teach-back method to check understanding of the instructions.
The use of non-written material should also be considered e.g. picture books, video and audio tapes (Parker, 2000) pictures increase patients attention to health information as well as aid in recall and comprehension. User of multimedia is also important as a strategy. Health care providers can employ use of visuals, graphics and also posters. For example to explain a concept on the importance of pregnant women attending antenatal clinics, a video can be shown to a group of pregnant women to pass on the intended information.
Education interventions are also important. Schools and universities should also take it upon themselves to ensure female students are health literate early enough. This can be done by conducting lectures covering different health topics. Also health communications can be tailored to specific needs and there can be use of community self-help and social support groups for women e.g. HIV awareness groups, breastfeeding groups etc.
Including health literacy into the curricula of professional nursing or medical schools is also important. This helps nurses and doctors to be easily able to identify patients with low health literacy and thus come up with ways in which they can be assisted (Shich& Halstead, 2009)
Support and expand local efforts in the provision of adult education and literacy, English language instruction and appropriate health information services in the communities (ACSQHC, 2014)
Health care administrators, educators, policy makers and public health professionals should strive to create a society that is sensitive to the health literacy needs of its women and provide access to health information that matches the health literacy skills of women in Kenya.
Scholars and practitioners have presented inadequate health literacy as a silent epidemic which is affecting most of the world population. Women have a role to play in promoting their health status. Health literacy is an important determinant of healthy life styles and health status among women. Women have the right to access health information that helps them to make informed decisions concerning their health, and the health of the members of their family. Health information should be delivered in ways that women can understand and interpret so as to enhance their quality of life and that of their households.
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