By Dr Laura Mackey, Post Doctoral Researcher, ARCH

As a physiotherapist, I have encountered many patients who have been largely unaware of processes involved in managing their condition, let alone how they developed it in the first place. A particular experience that stuck with me, and ultimately motivated me to pursue a PhD was a patient with a 20+ year history of chronic low back pain. Despite years of quality care from various healthcare professionals, this patient continued to believe that ‘hurt equaled harm’, and as a result, developed a range of maladaptive beliefs regarding their ability to exercise and engage in normal activities of daily living. To put this in context, chronic pain is defined as pain that has persisted beyond normal healing time1, and while it may originate from an initial trauma, the symptom itself serves no purpose and is no longer indicative of any tissue damage – in other words, ‘hurt does not equal harm’ in the case of chronic pain2. Furthermore, best practice guidelines for chronic pain management recommend graded physical activity programmes, education regarding the mechanisms behind chronic pain development, and continuing with normal activities as able3. Unfortunately, for this patient (and likely for many others), these approaches were unsuccessful as their overall understanding of their condition remained poor.

This led me to consider how we as healthcare professionals impart information to our patients, and the skills or characteristics required by our patients to take on board recommendations provided by us. A concept known as ‘health literacy’ provides a framework to explore this further, which formed the basis of my own PhD. Health literacy is defined as ‘the cognitive and social skills, which the determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’ 4. The research community has become increasingly interested in the role of health literacy in chronic disease outcomes, reporting associations between low health literacy and increased hospitalisations and mortality rates, and poorer development of self-management skills, to name a few. More recently, health literacy has been further expanded upon, described from both the health services perspective and the patient’s perspective as either a ‘clinical risk factor’ or  ‘personal asset’ respectively5, thus recognising the combined involvement of all stakeholders in the healthcare process.

So, what does this mean for connected health?

Connected health also supports an integrated model of care, working most efficiently when all stakeholders are adequately engaged6. For the patient, inherent to this engagement is their ability to understand how to utilise the technology, and how to use the resources provided to self-manage outside of the clinical setting. However, a patient with low health literacy will have difficulty with all of these tasks, which is likely to disrupt the cycle of integrated care proposed in the connected health model. Low health literacy will impede the patient’s ability to find, understand and use information to make informed health choices, and they will often become passive in their healthcare. As a result of low health literacy, a vital link in the connected health process is lost.

The next questions is what can done to address this?

As part of the user-friendly design process, it is crucial to consider health literacy in the development stages. In the traditional health environment, services have encountered numerous difficulties when attempting to address health literacy7. Most notably, the persistence of the biomedical approach, which only considers the disease or condition, and not the patient’s background, has hindered progression in creating more health literacy-friendly environments in health settings. Given that connected health is an emerging area in healthcare, and lends well to a biopsychosocial model of care (i.e. considers the biological as well as the psychosocial), those involved in developing these technologies have the potential to avoid the difficulties observed in the traditional health setting. Moreover, there is potential to start as you mean to go on, and maximizing patient adoption of connected health technologies using health literacy-friendly strategies. Avoiding situations such as the patient described above in connected health will not only reduce a waste of  limited resources, but may further endorse the important role that connected health has in improving care and health outcomes for our patients.

For further information on health literacy-friendly approaches see:

Reference List

  1. Merskey, H. & Bogduk, N. 1994. Classification on Chronic Pain, Seattle, IASP-Press.
  2. Hylands-White N., Duarte, R. V. & Raphael, J. H. 2016. An overview of treatment approaches for chronic pain management. Rheumatol Int.
  3. Scottish Intercollegiate Guidelines Network. 2013. Management of chronic pain: SIGN publication no.136 [Online]. Edinburgh.
  4. Nutbeam, D: Health Promotion Glossary. Health Prmot Int, 1998;
  5. Nutbeam, D. 2008. The evolving concept of health literacy. Soc Sci Med.
  6. Caulfield, B.M, Donnelly, S.C. 2013. What is connected health and why will it change your practice? Q J Med.
  7. Mackert, M., Ball, J. & Lopez, N. 2011. Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques. Patient Educ Couns.

You can contact Laura on Check out our website for more information about Laura’s research interests.

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