Health Literacy in An Otolaryngology Patient Population

Abstract

Objective

Health literacy is defined as the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. This study aimed to assess the health literacy of patients seeking care at an adult tertiary care Otolaryngology-Head and Neck Surgery (OHNS) clinic and its correlation with sociodemographic information.

Study Design

Prospective cross-sectional study.

Setting

Tertiary care OHNS clinic.

Participants

New adult patients who presented to a tertiary OHNS clinic from July 2022 to March 2023.

Interventions

Patients were asked to complete a sociodemographic questionnaire and the BRIEF Health Literacy Screening Tool. The BRIEF is scored out of 20 with scores of 17 and higher showing adequate health literacy.

Main Outcome Measures

Bivariate and multivariate analyses were performed to determine whether sociodemographic variables were associated with health literacy.

Results

Two hundred eighteen patients were recruited (59% females, 32% were above age 65). Although the average score on the BRIEF was 17.0 ± 3.6, about 33% of participants were found to have inadequate health literacy. Non-native English speakers, racial minorities, immigrants, and those with a lower income were more likely to have poor health literacy.

Conclusion

This study highlights that a significant number of patients presenting to a tertiary OHNS clinic have inadequate health literacy, with certain socioeconomic factors serving as predictors. Future research is needed to evaluate targeted interventions aimed at improving and advocating for health literacy among OHNS patients.

Keywords

health literacy socioeconomic status equity otolaryngology

Graphical Abstract

Background

As healthcare providers shift from the historically paternalistic relationship with patients, there is greater emphasis on involving and encouraging patients to actively make decisions regarding their medical care. This paradigm shift underscores the imperative for active patient engagement and empowering individuals to play a central role in shaping their medical journeys. Central to this empowerment is the cultivation of robust health literacy skills, enabling patients to navigate the complex realm of medical information and arrive at decisions that resonate with their personal values and aspirations.

Sixty percent of Canadians are estimated to be health illiterate and poor health literacy is linked to worse outcomes across various patient populations.¹ It has been associated with increased mortality in patients with heart failure, higher hospital admission rates in those with asthma, and poorer glycemic control in individuals with diabetes.^2-4

There are only a few studies examining the health literacy of Otolaryngology-Head and Neck Surgery (OHNS) patients.^5-9 A study by Megwalu and Lee reported that 10% of patients in a tertiary care Otolaryngology clinic in the United States had inadequate health literacy, which was associated with having English as a second language and being a racial minority.⁵ Other studies have suggested that patients with lower health literacy were more likely to present with higher degrees of hearing loss, as well as lower quality of life.⁹ Thus far, very few studies have formally assessed the health literacy of patients using validated tools. The BRIEF Health Literacy screen tool (BRIEF) is a self-administrated 4-item questionnaire tool that only takes about 1 minute to complete. It has been validated to assess health literacy, capturing patients’ perception of their ability to independently read hospital materials, comprehend information communicated about their health, and complete medical forms.^10-12 The objective of this study was to examine the health literacy of patients presenting to a tertiary OHNS clinic using the BRIEF and correlate the findings with their sociodemographic characteristics.

Methods

This was a prospective, cross-sectional study, which included all adult patients presenting for an initial consultation at the OHNS clinic at Unity Health Toronto–St. Michael’s Hospital between August 2022 and May 2023. This study was approved by the Unity Health Research Ethics Board (REB #22-112). Patients were excluded if they were younger than 18 years of age. Eligible patients were invited to complete an anonymous, voluntary, one-time survey after their clinic visit with an Otolaryngologist. The survey included both the Standardized Patient Demographic Data Collection and the BRIEF, taking approximately 5 minutes to complete (Supplemental Materials A and B). A research assistant provided patients with a Quick Response (QR) code linking to the online survey, which was hosted on a Research Electronic Data Capture (RedCap^®) database through the University of Toronto. For patients who did not have mobile devices or felt more comfortable completing the questions on paper, physical copies of the questionnaires were also available. The demographic questionnaire was available in multiple languages, including Arabic, Mandarin, English, French, Hungarian, Italian, Korean, Portuguese, Russian, Spanish, Tamil, and Vietnamese. Furthermore, a translator was made available through the hospital virtual translator service if required for the BRIEF or any language that the demographic survey had not been translated into.

Data Collection

All participants completed 2 questionnaires. The first was the Standardized Patient Demographic Data Collection, which had been implemented in downtown Toronto hospitals as a part of the standard of care since 2013 to promote a system-level approach to health equity (Supplemental Material A).¹³ This set of standardized demographic questions focused on 8 demographic variables: spoken language, birthplace, ethnicity/race, disability, gender, sexual orientation, income, and the number of people the income supports.¹³ The second questionnaire was BRIEF, which is a 4-item survey that uses a 5-point Likert scale for responses (Supplemental Material B).^14-16 Total scores range from 4 to 20, with scores of 17 to 20 indicating adequate health literacy, 13 to 15 indicating marginal health literacy, and 4 to 12 indicating inadequate health literacy.¹⁷ Lastly, we recorded the specific OHNS concern that prompted each participant’s clinic visit (e.g., voice, nasal/sinus, ear-related issues).

Statistical Analysis

Demographic data were summarized using descriptive statistics. Bivariate analysis was performed using chi-square or Fisher’s exact test to assess the association between sociodemographic factors and adequate health literacy scores (BRIEF ≥17). Multivariate analysis was used to examine the impact age, gender, race, English as a primary language, and other sociodemographic variables have on health literacy. Statistical significance was reached if the P value was less than .05. All analyses were conducted in SPSS (Chicago, IL, USA).

Results

Two hundred eighteen patients participated in the study. The study population reflected a broad spectrum of otolaryngologic concerns, including ear-related issues (43%), nasal problems (23%), breathing difficulties (20%), throat symptoms (18%), voice disorders (18%), swallowing difficulties (13%), balance concerns (9%), and thyroid conditions (8%). Demographic information of the included patients is displayed in Table 1. The majority of patients spoke English as a primary language (88%) and self-identified as white (56%) and an interpreter was only required for a small proportion of patients (2.8%).

Table 1.

Participant Demographic Information.

Participant demographic information	Number (%)
Total number of participants	218 (100)
Age
18-24	10 (5)
25-34	24 (11)
35-44	46 (21)
45-54	41 (19)
55-64	26 (12)
Above 65	60 (32)
Gender
Male	85 (39)
Female	128 (59)
Other	3 (1)
Preferred not to answer/did not know	2 (1)
Primary language
English	192 (88)
Other	26 (12)
Not born in Canada	98 (45)
Race
White	122 (56)
Asian	42 (19)
Black	15 (7)
Other	31 (14)
Preferred not to answer/did not know	8 (4)
Sexual orientation
Heterosexual	159 (73)
Homosexual	7 (3)
Bisexual	13 (6)
Other	13 (6)
Preferred not to answer/did not know	28 (13)
Total income
$0-$19,999	23 (11)
$20,000-$29,999	8 (4)
$30,000-$39,999	13 (6)
$40,000-$59,999	19 (9)
$60,000 or more	103 (50)
Preferred not to answer/did not know	52 (23)

The mean total BRIEF score was 17 ± 3.6. The mean score for each BRIEF question is displayed in Table 2. The mean BRIEF score by otolaryngologic concern is displayed in Table 3. Sixty-six percent (145/218) of patients had adequate health literacy scores (≥17 on the BRIEF) and the remaining 33% had inadequate or marginal health literacy. Ten percent of patients had inadequate health literacy (scores of BRIEF 4-12). Bivariate analysis evaluated the association between sociodemographic factors and having adequate health literacy scores (≥17). This found that birthplace being in Canada [χ² (1, N = 216) = 16.09, P < .0001], English speaking [χ² (1, N = 218) = 25.72, P < .0001], white race [χ² (3, N = 210) = 19.57, P = .0002], and an annual income of $60,000 or more [χ² (4, N = 166) = 19.63, P = .0006] were all significantly associated with adequate health literacy. Although older age (>65) and gender were not found to be significant factors, heterosexual orientation was found to be associated with adequate health literacy (P = .0027). However, this finding should be interpreted with caution as about 13% of participants were uncomfortable answering the question regarding their sexual orientation.

Table 2.

Average BRIEF Health Literacy Screen Scores.

BRIEF: Health literacy screening tool	Mean score ± standard deviation	Percentage of patients who scored “inadequate” (scores of 1 or 2) on individual questions (n = 218)
How often do you have someone help you read hospital materials?	4.4 ± 1.1	7.8%
How often do you have problems learning about your medical condition because of difficulty understanding written information?	4.3 ± 1.0	6.9%
How often do you have a problem understanding what is told to you about your medical condition?	4.2 ± 1.0	7.8%
How confident are you in filling out medical forms by yourself?	4.2 ± 1.2	11.9%
Average total Brief Health Literacy screen scores	17.0 ± 3.6

Table 3.

BRIEF Score by Otolaryngologic Concern.

Otolaryngologic concern	Average total BRIEF score ± SD
Ear	17.3 (3.6)
Balance	16.8 (3.9)
Swallowing	16.3 (4.6)
Throat	16.9 (4.0)
Breathing	16.0 (3.5)
Nose	16.9 (3.0)
Thyroid	16.8 (4.1)
Voice	17.0 (3.7)

Abbreviations: BRIEF, Brief Health Literacy screen; SD, standard deviation.

On multivariate analysis, English-speaking and White participants were more likely to have adequate health literacy [odds ratio (OR) 0.183; 95% confidence interval (CI) 0.06, 0.56; P = .0027; and OR 0.318; 95% CI 0.12, 0.84; P = .039, respectively].

Discussion

The current study showed that 33% of an OHNS patient population at a single tertiary institution had inadequate or marginal health literacy, as measured by the BRIEF health literacy screening tool. Patients who were non-White, non-English speaking, non-Canadian born, and had a low household income were more likely to exhibit inadequate health literacy. Similarly, Megwalu et al conducted a study in a U.S. patient population using the same tool and found that 10% of patients had inadequate health literacy. Although this rate is lower than the 33% observed in the current study, the authors noted that their research was conducted in Silicon Valley, a region with a highly educated population. In contrast, the present study was conducted in Downtown Toronto, where the hospital serves a more inner-city population. Despite potential differences in demographics, both studies found that being a racial minority and not having English as a primary language were strongly associated with inadequate health literacy. Similarly, Koay et al identified older age and lower education levels as factors linked to low health literacy.¹⁸ Hearn et al examined health literacy in an academic Otolaryngology population and found that 12% had inadequate health literacy with male gender and race as significant predictors.¹⁹ Notably, the current study is among the few to include income data, highlighting its relevance.^20,21 Research suggests that lower health literacy is associated with increased hospitalizations, greater use of emergency care, poorer medication adherence, and higher mortality rates.²¹ Therefore, the identified predictors of health literacy are critical in clinical care, enabling clinicians to recognize patients who may face worse treatment outcomes.

The findings of this study underscore the importance of screening for and identifying patients who may have inadequate health literacy when presenting with otolaryngologic complaints. This is crucial to better understanding and addressing the needs of our patient population. As medical knowledge and treatment options rapidly evolve, the information our patients are expected to understand has become increasingly complex. This is particularly true for the field of OHNS, where advancements in both surgical and medical treatments, such as biologic therapy for chronic rhinosinusitis and in-office laser treatments for voice disorders, are continuously emerging. Routine screening for health literacy in both academic and community-based practice settings is not only feasible but also effective in identifying at-risk patients and enhancing patient satisfaction.^22,23 The BRIEF, utilized in the current study, is a short and user-friendly tool that is both reliable and valid, and previous studies have demonstrated its feasibility for routine screening.^16,22,23

Once at-risk individuals have been identified, it is important to develop and implement interventions to mitigate the impact of low health literacy on health decision-making and outcomes. A scoping review of health literacy in pediatric OHNS suggested 3 main categories of interventions.⁶ These strategies included improving the readability of patient education materials, assessing patient recall after informed consent, and using audiovisual and hands-on training to enhance patient comprehension.⁶ This review found that verbal information was often forgotten, and much of the existing written content was too complex for most patients. Several studies have shown that patient education materials often exceed the recommended sixth-grade reading level.²⁴ Conversely, interactive tools and hands-on training have been proven to effectively modify patient behavior, improve adherence to treatment regimens, and enhance patient understanding of their condition. Additionally, providing patients with written materials that feature diagrams, simple words with fewer than three syllables, and concise sentences has been shown to improve effectiveness.²⁵ Furthermore, leveraging artificial intelligence holds considerable promise for improving health literacy. Emerging literature suggests that natural language processing technologies and large language models can enhance patients’ understanding of their radiology reports and improve the readability of patient education materials.^26,27

This study has several notable limitations. First, the BRIEF is a self-reported measure of health literacy, which may be subject to reporting bias. However, to minimize this, we administered the survey anonymously. In addition, the clinical significance of marginal health literacy versus inadequate health literacy remains unclear and warrants further investigation. The authors acknowledge the complex relationship between health literacy and language barriers. Although a virtual translator was available and the demographic surveys were provided in multiple languages, cultural interpretations and language barriers may still have influenced survey responses and patients’ self-perception of health literacy. It is also important to recognize that, while large academic centers often have access to translator services and virtual translation tools, smaller clinics and hospitals may face limitations in this regard. Furthermore, our study results may have been confounded by missing data, as many patients selected “preferred not to answer” for some of the sociodemographic categories. For example, almost 13% of the participants chose not to answer the question regarding sexual orientation, which limits our ability to draw definitive conclusions about certain variables. Lastly, the sociodemographic characteristics of the patient population are influenced by the city where the study was conducted, and as such, our findings may not be generalizable to other OHNS practices in different regions of the world. Nonetheless, findings from this study can raise awareness of the risk factors associated with inadequate health literacy in the OHNS population, helping Otolaryngologists identify and advocate for patient who may require additional support in understand their health information.

Conclusion

Thirty-three percent of OHNS patients in a tertiary institution were found to have inadequate or marginal health literacy, as measured by the BRIEF. Sociodemographic factors associated with lower health literacy included non-English speaking, non-White, being born outside of Canada, and having a low annual household income. This study underscores the importance of screening for inadequate health literacy in the OHNS setting and implementing interventions to enhance patient’s ability to navigate their health care.

Supplemental Material

sj-pdf-1-ohn-10.1177_19160216251330630 – Supplemental material for Health Literacy in An Otolaryngology Patient Population

Supplemental material, sj-pdf-1-ohn-10.1177_19160216251330630 for Health Literacy in An Otolaryngology Patient Population by Elysia Grose, Silkan Bains, Yvonne Chan, Jessica Trac, Jennifer Anderson, John M. Lee, Molly Zirkle and R. Jun Lin in Journal of Otolaryngology - Head & Neck Surgery

Supplemental Material

sj-pdf-2-ohn-10.1177_19160216251330630 – Supplemental material for Health Literacy in An Otolaryngology Patient Population

Supplemental material, sj-pdf-2-ohn-10.1177_19160216251330630 for Health Literacy in An Otolaryngology Patient Population by Elysia Grose, Silkan Bains, Yvonne Chan, Jessica Trac, Jennifer Anderson, John M. Lee, Molly Zirkle and R. Jun Lin in Journal of Otolaryngology - Head & Neck Surgery

Footnotes

Author Contributions

Dr. R. Jun Lin, Dr. Elysia Grose, Ms. Silkan Bains, Dr. Rosane Nisenbaum, and Dr. Yvonne Chan conceptualized and designed the study, carried out the initial analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript.

Dr. R. Jun Lin, Dr. Elysia Grose, Ms. Silkan Bains, Dr. John M. Lee, Dr. Jennifer Anderson, Dr. Molly Zirkle, and Dr. Yvonne Chan collected data, critically reviewed, and revised the manuscript.

All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.M.L. has received research grants and honoraria from Baxter Corporation. All other authors declare no potential conflicts of interest.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Meeting Information

This paper was presented as an Oral presentation at the Canadian Society of Otolaryngology Conference in Toronto, Ontario, Canada on September 12, 2023.

ORCID iDs

Elysia Grose

R. Jun Lin

Supplemental Material

Additional supporting information is available in the online version of the article.

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Supplementary Material

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