key: cord-0763779-5snrr38h
authors: Naughton, Joanne; Booth, Kerry; Elliott, Paula; Evans, Morag; Simões, Maria; Wilson, Suzanne
title: Health literacy: The role of NHS library and knowledge services
date: 2021-05-29
journal: Health Info Libr J
DOI: 10.1111/hir.12371
sha: cd919951227a7236cdb5184a818fa2bfe7a3e5b2
doc_id: 763779
cord_uid: 5snrr38h

Health literacy is key to person‐centred, preventative healthcare and is both a societal and individual responsibility. This feature describes work undertaken by Health Education England, the Community Health and Learning Foundation and NHS Library and Knowledge Services to raise awareness among NHS staff and other key partners of the impact of low health literacy. It highlights a range of health literacy resources and ideas for developing and adapting these tools for remote delivery during and post‐pandemic. D.I.

TEACHING AND LEARNING IN ACTION health information. However, a recent study showed that health information that combines words and numbers is too complex for 61% adults aged 16-65 in England (Rowlands et al., 2015) .

Health literacy is a societal responsibility and "effective responses to health literacy issues can improve health outcomes and reduce health inequities" (World Health Organization, 2015, p.15 ). The importance of high-quality, usable health information has never been more starkly apparent than during the COVID-19 pandemic (Paakkari & Okan, 2020) .

Health Education England (HEE) worked with the Community Health and Learning Foundation (CHLF) to develop and deliver a programme of health literacy training based on a national Health Literacy Toolkit (Health Education England, 2018) initially targeted at health library and knowledge specialists as part of implementing the Knowledge for Healthcare strategy (Health Education England, 2015) . The training drew on the extensive experience of the Community Health and Learning Foundation in working with people with low health literacy and was tailored to the needs of library and knowledge specialists. The Programme includes awareness training and more advanced "Train the trainer" sessions. The overall aim of the Programme was to upskill library and knowledge staff to raise awareness among frontline NHS staff and health information providers of the impact of low health literacy on the individual and the health care system.

The Health Literacy Awareness Training builds understanding of how effective health literacy approaches can support patient-centred care, positive lifestyle changes and enhance shared decision-making. Participants have an opportunity to practice some recognised, practical techniques to improve communication including Teach Back (Centrella-Nigro & Alexander, 2017) and Chunk and Check (NHS Education for Scotland). These two techniques can be used in tandem to check that communication is effective during a health consultation by breaking down information into small chunks and using an open question technique to check for understanding after each chunk. The aim of "Train the Trainer" is to help participants to transition into the role of trainer by reflecting in more depth on their learning and considering how they might adapt the materials to suit their local circumstances and different staff groups. This session also focuses on the role of library and knowledge services in promoting health literacy awareness.

An important performance indicator for Health Education England relates to the reach of the training across NHS Library and Knowledge Services. During 2018/19, 238 people participated in the training, and following the training evaluation, a condensed, one-hour training session has been developed which can be used as a bitesize introduction. Subsequently, an e-learning module (Health Education England, 2020) aimed primarily at health care professionals has been developed by HEE and NHS Education for Scotland. The tool, which can be used as part of a blended learning approach, has had 709 launches between April and July 2020.

In this article, NHS library and knowledge specialists who went through the train the trainer programme share how they have applied the learning from the Programme to develop initiatives within their organisations and with partners in the wider library and knowledge community.

Having attended the "train the trainer" workshops delivered by HEE and Community Health Learning Foundation in Spring 2019, I developed an initiative to embed health literacy champions at Dorset County Hospital NHS Foundation Trust. As a dementia champion at the Trust, I could see that this model was effective at promoting awareness of dementia and decided to do something similar for cascading the training I had received on health literacy.

I recruited a group of health literacy champions by advertising in the Trust's staff bulletin. Fifteen champions volunteered from a variety of specialties and backgrounds including dietitians, nursing staff, the hospital at home team lead and patient and public engagement lead. Motivations for becoming champions included wanting to empower patients in their use, to improve understanding of health information and to be better communicators.

Using the "Teach Back" and "Chunk and Check" methods, I was shown during the train the trainer sessions, I designed a workshop for the champions based on resources from a health literacy community of practice of which I am a member. Initial evaluations revealed how positive and enthusiastic the champions are about improving health literacy in their own departments/teams. For example, one champion has started using the techniques to improve her departmental patient information leaflets. There is potential for redesigning patient appointment letters to make them more readily understandable. During COVID-19, the group have met virtually to promote the new e-learning module on health literacy to all staff.

I plan to produce a quarterly health literacy bulletin for staff and embed a health literacy champion in each department. I have recently met with the Trust's Director of Strategy, Transformation and Partnerships in order to prioritise health literacy in the organisation's health inequalities programme. Potentially, this could include health literacy awareness training during Trust induction and a call for more champions.

As a large mental health care provider, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust has approximately 7000 staff spread across the north of England.

We are a small library working across multiple sites and community settings. We arranged for Health Education England to deliver two bespoke health literacy training sessions. One was an health literacy awareness session, the other was a train the trainer session. We chose a collaborative, multidisciplinary effort to increase awareness across the Trust.

The aim was to create a group to act as advocates for health literacy, working together to deliver training and support a social movement of change, that is informal, collective action to fuel a shift in how staff communicate, with each other and patients. We hoped that the training would empower staff to challenge practice and suggest and lead improvements locally.

We gained support from senior Speech and Language Therapists working in learning disability and secure services. We also used personal invitations and discussions with existing networks and attracted an enthusiastic cohort of 15 staff from across the Trust. This group included representatives from service user groups, communications, corporate services, allied health professionals, inpatient and community staff.

The group met bimonthly and members have delivered awareness sessions at local conferences, events and to groups of staff. Where possible, the group have connected with existing work programmes to ensure health literacy has maximum exposure across the Trust. The work has been supported by the Executive Team, reinforcing the importance on patient outcomes.

This approach has enabled us to collaborate with staff from across disciplines, giving greater visibility to our work and further emphasised the importance of improving awareness and skills in health literacy. Collaborating with speech and language therapists has offered real life scenarios of the struggles people have with language, communication and understanding information about their health, improving our own understanding of health literacy.

By adopting the concept of a social movement to raise awareness, rather than a formal programme of work, we hoped that staff feel empowered to change behaviours and organisational culture around communication and literacy at all levels of the Trust.

To improve literacy among some inpatient groups, the library is supporting the development of patient collections. Fiction and self-management materials are being provided to encourage patients to read more and support their own literacy and self-care. This is an example of where a health library is directly supporting patients.

There is still a considerable amount of work to do to realise the impact of improving health literacy awareness and skills in staff. Early indications are encouraging and senior leaders are asking for the work to be recognised in formal strategies and aligned to the long-term plan to ensure it is sustained.

After completing the Heath Literacy Awareness training sessions, I co-presented an awareness session for library professionals from health, academic and public libraries in June 2019.

This training highlighted that many other professionals working within the NHS organisation could benefit from attending similar sessions. Based on this, I developed a session for incoming, recently qualified doctors. The original training session was adapted and shortened to a one-hour session, including various examples of low health literacy that junior doctors may have witnessed in their roles. I included the Dr Jargon game within this session. It is designed for health professionals to develop their communication skills with patients, by challenging players to describe a health term without using jargon. This technique demonstrates that some terms familiar to clinicians can be considered jargon.

The session also covered what health literacy is, its impact and a variety of examples. There were opportunities for discussion, sharing experience and a couple of practical activities. I created an exercise which required participants to crack a code, in order to give them a sense of how it feels to be out of your depth and to not fully understand the information in front of you. This gave participants four sentences written entirely with symbols, each accompanied with an image to give clues to participants as they attempt to break the code.

The sessions received positive feedback and will now continue annually with Foundation Year doctors. Some of the key learning noted by participants included a new awareness of how information is presented to patients, taking time to check patient understanding and to offer additional explanations. Other key learning included not making assumptions about patient understanding, to try and tailor information and reduce jargon.

To further develop the sessions, additional strategies will be used to improve communication and health literacy. These will include the "Teach Back" and the "Chunk and Check" methods. These two strategies can be highly efficient in assessing and assuring patient understanding.

Bolton Health Information Partnership (BHIP) brings together representatives from health information providers around two common aims:

• Promoting the importance of health literacy, including functional personalised information, which all people can make sense of and act on, to assist them to make To promote the importance of health literacy, members of the Partnership attended an introductory health literacy session followed by a discussion.

Two online resources were created to share and communicate good practice: a resource page for health literacy appears on the BHIP blog, and content from the Health Education England one-hour e-learning has been adapted to create an introductory HL section for the University of Bolton online skills portal. This is designed to support students on their university journey at Bolton, both academically and from a personal development perspective. The module will be promoted for use with university students and members of the public. BHIP members had planned to launch both resources during Health Information Week, with face to face events; these plans are being revised as we come to terms with new ways of working and learning during the COVID pandemic.

Becoming more aware of health literacy highlighted the shorthand and jargon we use. Simple explanations for a selection of terms were user tested, amended based on feedback and published as posters. So far, we have "published" eight Jargon Busters starting with "What is OpenAthens?" They generate interest on Twitter and are embedded on the homepage for the service on the Trust intranet.

Participants fed back that they valued the opportunity to refresh their knowledge of health literacy and being able to discuss options for embedding it into their service.

Leeds Libraries for Health, a partnership of NHS and academic libraries as well as the Council's Public Health Resource Centre, held an Away Day in 2019 to which public health library colleagues were also invited. The theme for the day was improving the health and well-being of the citizens of Leeds: strengthening links between libraries. Working with the Leeds Teaching Hospitals' Corporate Support Librarian, we delivered a health literacy "taster" session. It included an introduction to the concept of health literacy, its impact on public health, some national and regional statistics, as well as examples of techniques health care staff can use to communicate information to patients effectively.

Our aim was to kick start a city-wide conversation. Colleagues from public libraries ran a session on developing the public's digital and health literacy skills, and the tools and techniques that they use to promote these skills. We focused on the role of NHS librarians in raising awareness among health care staff. We talked about how our different roles and audiences were complementary, and how we could achieve maximum impact by working in partnership.

The participants openly shared stories, illustrating how people can struggle to understand health messages. We also had time to reflect and list key actions in group discussions. Some practical key actions and techniques identified and discussed were: responsible signposting, clarifying needs, use of plain English, active listening, approachability, asking questions, targeting, using visual messages, using "Teach Back" techniques, providing information in a range of languages, being aware of average reading age and examining the contents of patient leaflets.

Future plans were developed for NHS and public libraries to work together on delivering health literacy sessions for both staff and patients. Those plans include organising joint Patient Information events at the Central Library as well as health centres, although COVID-19 has put them on hold. Plans were also made to share stands at events and to support Patient Participation Groups. All the services highlighted the importance of health literacy during their Health Information Week activities in July.

As we see through these case studies, librarians are ideally placed to raise awareness of the impact of low health literacy and to work with health professionals to embed the use of tools and techniques to improve health literacy into their daily practice. The authors have applied the learning from the Programme to their own organisations and tailored their delivery to meet local needs. Through these initiatives, they have not only raised awareness of health literacy issues but also raised the profile of their services and the highlighted the contribution that Library and Knowledge Services can make to improving the quality and accessibility of health care information for patients and the public.

Reviewing these case studies provides an opportunity to reflect on progress to date. One important output from the training has been the development of relationships and regional communities of practice. In the North, this has led to buddying up to deliver cascade training and in the South West, shared health literacy resources are made freely available to all (NHS Library & Knowledge Services in the South West, Thames Valley & Wessex). NHS Library and Knowledge Specialists are playing their part in raising awareness of the impact of low health literacy and of key tools and techniques to improve communication. Looking to the future, alongside maintaining the scale and spread of health literacy awareness training in the health sector, Health Education England will work with a wide range of information providers to improve health and digital literacy skills, including digital navigation,

Using the teach-back method in patient education to improve patient satisfaction

Knowledge for healthcare: A development framework for NHS library and knowledge services in England

NHS Education for Scotland. The health literacy place: Tools and techniques

Retrieved from https:// www.longt ermpl an.nhs.uk/ NHS Library and Knowledge Services in the South West, Thames Valley and Wessex Community of Practice

COVID-19: Health literacy is an underestimated problem

A mismatch between population health literacy and the complexity of health information: An observational study

Health literacy toolkit for low-and middle-income countries. A series of information sheets to empower communities and strengthen health systems

Health literacy: The role of NHS library and knowledge services

in community settings such as public libraries, prisons and schools.

@JoanneStemp Kerry Booth @kerry_booth73 Paula Elliott @paulaedwiott Morag Evans @MoragEvans Maria Simões @MariaJSimoes Suzanne Wilson @suzwilson