3.1. Quantitative Analysis
The complete scores of the participants in GHL, healthcare, disease prevention, and health promotion domains, as well as the individual scores in the four competencies of health literacy, are shown in Table 2
Overall, the woman and man with adequate health literacy achieved 42 and 43 points (out of 50) indicating sufficient and excellent general health literacy, respectively. The woman with adequate health literacy reached an excellent level in the healthcare domain but she scored one level lower (sufficient) in the other two domains. The man with adequate health literacy achieved more stable results with the lowest score in the healthcare domain. The woman and man with limited health literacy achieved 20 and 23 points indicating inadequate general health literacy. The woman with limited health literacy scored low in all three domains. The man with limited health literacy achieved borderline scores in healthcare and health promotion domains but his score was much lower in the disease prevention domain.
With regards to health-related competencies, the participants with adequate health literacy reached at least a sufficient level in all health-related competencies and achieved the highest scores in understanding health information. The woman with adequate health literacy achieved the lowest score in accessing health information while the man with adequate health literacy achieved the lowest score in appraising health information. The participants with limited health literacy mostly reached inadequate levels in health-related competencies. Both achieved the highest scores in understanding health information and the lowest scores in appraising health information.
From the participants’ point of view, the most difficult health-related tasks were to “find information on how to manage mental health problems like stress or depression” (no. 18) in accessing health information, to “understand information on how to keep their mind healthy” (no. 40) in understanding health information, to “judge when they may need to get a second opinion from another doctor” (no. 11) in appraising health information, and to “decide how they can protect themselves from illness based on information in the media” (no. 31) in applying health information.
The overall results of the questionnaire survey of health literacy in people who are undergoing treatment of alcohol disorder are presented in the original article of Rolová et al. [8
3.2. Qualitative Analysis
3.2.1. Circumstances of Alcohol Abuse
To provide the context for further results, the participants’ description of their alcohol problems is introduced.
The participants with adequate health literacy had started to use alcohol during their secondary education. What was initially social drinking turned into alcohol abuse during their adulthood due to long-term stress exposure and occurrence of anxiety spectrum disorders. The woman with adequate health literacy (Participant 1) reported that her alcohol drinking peaked in her forties due to mental issues arising from partnership issues which she tried to alleviate with the combination of alcohol and sedatives. She was undergoing her second long-term institutional treatment after almost 20 years of remission at the time of the study. The man with adequate health literacy (Participant 2) stated that his alcohol drinking turned into abuse due to anxiety associated with his work responsibilities. He was undergoing his first long-term institutional treatment at the time of the study. Both participants agreed that alcohol drinking provided them with relief and helped them to alleviate anxiety, which indicates that they were unable to cope with stress exposure effectively. They both stated that they prefer low-alcohol beverages.
The participants with limited health literacy started to abuse alcohol soon after their first experiences. The woman with limited health literacy (Participant 3) stated that she started drinking larger doses of alcohol in response to a lack of energy caused by anorexia and bulimia from the age of 17. Later, she developed alcohol dependence due to stress exposure associated with childcare responsibilities. At the time of the study, she was undergoing her second long-term institutional treatment. The man with limited health literacy (Participant 4) reported frequent drinking because he was enjoying the state of altered consciousness associated with alcohol intoxication. He was undergoing his fourth long-term institutional treatment at the time of the study due to repeated relapses. Both participants stated that they prefer liquors and spirits and felt more relaxed after alcohol drinking.
3.2.2. Understanding of the HLS-EU-Q47
In general, all participants reported a good understanding of the individual items in the HLS-EU-Q47. However, limitations related to the utilization of the questionnaire in clinical practice were found. In particular, the participants discussed the length of the questionnaire, the context of the questions and the general focus.
The woman with adequate health literacy expressed her concerns about the length of the questionnaire in connection with her feeling of fatigue and exhaustion stemming from a demanding therapeutic program, as she was at the very beginning of the addiction treatment:
“...as I did not get familiarized with the atmosphere yet. It seemed long to me (the questionnaire) because I was scared of adhering to the demands of the program.” [Participant 1]
The woman with limited health literacy pointed out that it was difficult for her to evaluate the perceived difficulty of many of the health-related tasks in the questionnaire as she did not encounter those situations in practice:
“Well, I did not encounter some questions in practice. I could have rated them, but they were not from practice. It was more theorizing... They were very hypothetical (the health-related tasks), and I had a lot to guess what my reaction might be” [Participant 3]
The man with limited health literacy also reported a good understanding of the questionnaire but was puzzled by its general focus, which made it difficult for him to answer the individual questions:
“There were no problems at all. What seems strange to me was that the questionnaire had nothing to do with my illness (alcohol dependence). It (the questionnaire) was general. So, it seems strange to me. I asked if I should answer the questions in connection with my disease or in general. Because obviously there is a difference whether one should seek medical help due to flu or because he is an alcoholic. So, this was not clear to me.” [Participant 4]
3.2.3. Accessing Health Information
All participants answered positively to the question asking if they knew how to access health information and where to find medical help. However, important differences between both groups were found in terms of preferred sources of information and efforts to access information.
The participants with adequate health literacy reported actively seeking information about their health problems in various sources including the medical literature and via web search. However, despite their active approach to accessing health information, they still rely on healthcare providers as the main sources of health information. Furthermore, they were confident in discussing health-related questions with healthcare providers and participating in their treatment:
“I trust doctors because they are experts. I am still just a layman, even if I can get some information by myself. In case, it is something extra serious, one is eagerly trying to get some information about it. For example, in the case of life-threatening surgery, if I presented it as a model situation, I would be probably consulting it with more than one doctor.” [Participant 2]
The participants with limited health literacy, on the other hand, reported usually relying on healthcare providers as sole source of information. They were rather passive recipients of health information as they did not actively seek it in other relevant sources. However, the statement given by the man with limited health literacy about his interest in acquiring health information suggests that they might not know where to look for such information:
“Did you yourself were looking for information about your illness (alcohol dependence) in other sources? Somewhere outside of healthcare providers, medical professionals, nurses?” [Interviewer] “Not exactly, but I would definitely want to, and if there are any publications, I would like to learn something.” [Participant 4]
Interestingly, except for the woman with medical education (Participant 1), the participants had a critical attitude towards seeking health information on the web:
Well, I am definitely not one of those who determine the diagnosis themselves because of the Internet... Well, either there might be nonsense, but there might be also the things that might be true. But if it was that simple, the medical professionals would not have to study for six years and then make the specialization.” [Participant 2]
The differences observed between both groups of participants also applied in the case of accessing information about alcohol and dependence. Whereas the participants with adequate health literacy actively sought alcohol-related information from various sources during the treatment process, the participants with limited health literacy relied on information given by healthcare providers only:
“When I am sick, I go to see an expert and wait for what they tell me. I do not understand it at all, I will not make up things that are not what they say. When they say it is like that, it is just like that.” [Participant 4]
3.2.4. Understanding Health Information
Overall, all participants claimed to understand health information at least well enough to manage their health problems. However, when they were further questioned, we found that the level of understanding varied between the groups.
The participants with adequate health literacy reported a good understanding of health information including the information provided by healthcare providers, written materials for the general public, and books popularizing medicine. Moreover, the participants with adequate health literacy frequently used various medical terms (e.g. dehydration, serotonin, lymphatic) during the interviewing, whose meaning they seemed to understand.
“Do you understand the provided information (by the healthcare providers)?” [Interviewer] “Yes I most certainly do, and in case I had not understood something, I have asked, and it was explained to me.” [Participant 2]
The participants with limited health literacy also stated that they understood various common forms of health information such as that provided by their healthcare providers, patient information leaflets, and prevention materials. However, as the man with limited health literacy stated, he often does not understand the context as he has no medical background, which does not allow him to fully cooperate with healthcare providers:
“I take it like it is their job and these people are experts who know what they are doing. I do not try to say to them that they do not know something or that they do it wrong, because nobody will tell me such a thing in my work. I am not an expert and I do not understand it, so I take it as it is, and it should be always like that. I will trust them (the healthcare providers). What should I say to them when I do not know anything about it?” [Participant 4]
Interestingly though, all participants reported that they usually ask healthcare providers for further explanation if they have difficulty understanding the provided health information, suggesting that they have strategies for how to cope with gaps in their competencies:
“So, you usually consult it (use of medication) with the healthcare provider.” [Interviewer] “Yes, I do. I always ask if there is any chance of intolerance, if I can take it with my other medication, before or after a meal and so on.” [Participant 3]
When questioned about their understanding of alcohol-related information, all participants reported a good understanding of information concerning the health consequences of excessive alcohol drinking, the nature of alcohol dependence, and the principles of the addiction treatment process. However, as the man with limited health literacy described, his knowledge and understanding of alcohol-related information evolved over time with a significant contribution from addiction treatment programs, suggesting their important educational component.
“I know a lot about it (alcohol addiction) because I have been an alcoholic for a long time. I did not even know what being an alcoholic means... in my youth.” [Participant 4]
3.2.5. Appraising Health Information
In general, all participants reported being able to assess their health condition and the severity of disease symptoms. Moreover, the participants were aware that their lifestyle affected their health outcomes. However, both groups differed significantly in the amount of confidence in their ability to appraise health information and the extent to which they were able to use their knowledge and experiences to appraise health information.
The participants with adequate health literacy showed higher confidence in their ability to appraise health information. They also reported being able to use their knowledge to appraise health information such as the severity of acute health problems:
“One has some general knowledge about common illnesses like flu, virus-like diseases or rhinitis, headache... So, in my years, when I am already 35 years old, one has some awareness of what he can do alone and what he cannot solve. Of course, if I had some abdominal pain, I would seek medical attention. Nevertheless, at that moment when I have a temperature of 38.5 degrees Celsius, at this moment, I do not seek information, I will attribute it to the flu, go to the pharmacy and buy myself the Paralen or Brufen. Of course, at a time when it would not improve for a long time, I would probably find out that it is not the flu, and then I would deal with it.” [Participant 2]
Furthermore, the participants with adequate health literacy stated that they are usually cautious concerning any health information from the media as they are aware that the information might not be credible. They were also able to evaluate living and environmental conditions affecting their health outcomes:
“We live in a relatively small village... Those conditions are probably not ideal, because it is still relatively close to Prague. I must admit that I do not monitor any concentrations that occur there, whether allergens or toxic compounds, but I think that as for the Czech Republic, it is above standard...” [Participant 2]
In addition, the participants with adequate health literacy were also able to evaluate the benefits and negatives of different types of treatment facility:
“I have a comparison with another treatment facility. I have to say that there is the more individual approach here and what is very different is that here you have a responsibility both for yourself and for the team, which is not the case in the other treatment facility.” [Participant 1]
In contrast, the participants with limited health literacy showed low confidence in their ability to appraise health information as they were aware of their inadequate health-related knowledge and experiences. Therefore, as the participants reported, they usually rely on the judgement of others such as healthcare providers or more knowledgeable acquaintances, as concerns the appraisal of health information:
“When the children were small and when I did not want to annoy my pediatrician anymore, I used to call one of our family acquaintances several times to make sure that something was good or bad.” [Participant 3]
Furthermore, participants with limited health literacy seemed to have trouble evaluating health information in a broader context. For example, the man with limited health literacy was aware that his lifestyle and living conditions might affect his health outcomes, but he evaluated their effect at a very basic level, not considering the complexity of this issue.
“I lived in the fodder rack in the woods for one time and it was cold, and these things are not good. But because I was that old as I was then, I survived. Anyway, a one needs to have warmth, dryness and a place to wash. This is important to me in terms of health.” [Participant 4]
Regarding the appraisal of alcohol-related information, all participants were able to assess the health risks of alcohol drinking in general and in connection with their health condition:
“What I am saying, and what really bothers me is that it is so terribly benevolent here. It is dangerous when alcohol can be bought 24/7. It is dangerous and for me for sure.” [Participant 4]
However, the participants with adequate health literacy seemed to have more comprehensive knowledge about this issue as they specified concrete health problems and used more expert terms:
“What about that brain... I definitely have worse memory, but it should be reversible. Well, we will see, it is still a short time. Certainly, it (alcohol drinking) can negatively affect the pancreas, digestive tract... And the body, of course: I was dehydrated, demineralized, so it definitely has an impact on joints and teeth... It affects the whole organism.” [Participant 2]
Interestingly, both groups expressed their concerns about the benevolent alcohol policy of the Czech Republic:
“I just say that on every single cigarette pack is written that smoking kills, but they will not write on alcohol bottle what are the consequences of booze. It is because we are a pro-alcoholic government.” [Participant 3]
3.2.6. Applying Health Information
Overall, all participants reported being able to apply the health information given by their healthcare provider in order to improve their health when they have any problems. However, a difference concerning compliance and adherence with treatment recommendations was found between the groups. Moreover, gender-specific differences were found in terms of applying health information in order to improve lifestyle.
The participants with adequate health literacy seemed to be able to use health information to make decisions, based on their ability to appraise health information in order to improve their health condition. They claimed they usually have no trouble in following health recommendation to reduce the risk of developing health problems:
“...I have always read the patient information leaflets and tried to follow them. In particular, I pay attention to how much it affects concentration while driving, to be sure not to produce an accident. And I look at the counter-indications, of course, especially so that the drugs do not cross each other, so I pay a lot of attention to that.” [Participant 2]
The participants with limited health literacy described some experience of non-compliance with the treatment process, as they sometimes purposely did not follow the instructions of the healthcare providers:
“You suffer from neuropathy, for example. Is he (medical professional) able to explain to you in a way you understand what you are suffering from and what is the cause?” [Interviewer] “I understood this very well. Another question is if I follow it then.” [Participant 4]
The woman with limited health literacy admitted that she does not read patient information leaflets, suggesting the possible risk of medication misapplication. However, she also described an alternative strategy:
“I do not read them (patient information leaflets), but if I must take something, I ask him (healthcare provider) directly about what I am interested in.” [Participant 3]
Furthermore, as the participants described, the men were not interested in healthy eating and smoked cigarettes daily even though they were aware of the impact of lifestyle on health. The women, on the other hand, were aware of the principles of a healthy lifestyle especially regarding a healthy diet and its impact on health and avoidance of cigarette smoking, and they tried to adhere to those principles daily:
“...I try to eat adequately with my age because you do not eat as 20-year-old when you are older, and I think I have the ideal weight.” [Participant 2]
However, both men and women agreed on the important role of sports and exercises for health and claimed to participate in sport regularly:
“I currently smoke and undergo addiction treatment for alcohol addiction. This means that I am the very last person that would say that he is striving for a healthy lifestyle... So, I smoke, that is true, but I do a lot of sports and this extremely helps the body.” [Participant 2]
Concerning the application of alcohol-related information, all participants claimed that they were determined to abstain from alcohol, based on their knowledge and experience acquired during the addiction treatment. The participants also reported being able to adhere to the addiction treatment program and to apply the acquired experience in order to prevent relapse. However, as the addiction treatment history of the participants with limited health literacy showed, even though they were equipped with knowledge and strategies on how to prevent relapse, they failed several times to do so.
“I entered (the addiction treatment) with some expectations. Firstly, I would fix the mess I did, secondly, find the reason why the relapse actually happened to me and what I actually had in my head, and thirdly, why the crisis plan did not work. The one when he is out (of treatment) and drinking alcohol, should be back in here very fast. But I, for my sake of stubbornness, made it all more complicated for me...” [Participant 3]