Celiac disease classification and clinical forms.
\r\n\tThis book aims to introduce general concepts about clock synchronization describing clock generation techniques and the properties of oscillators, phase-locked loops and in general of frequency synthesizers. Also welcome are topics that describe clock synchronization for digital ICs and the pertaining low-latency clock domain crossing techniques based on clock phase adjustment and standards for clock synchronization, such as the IEEE1588 and the Precision Time Protocol. Moreover, the book aims to describe the issues of sub-nanosecond synchronization in distributed systems on scales from a few tens of meters to a few tens of kilometers.
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He has spent most of his scientific career in the field of research and development of electronics for data acquisition and processing in Nuclear and Subnuclear Physics experiments, including ATLAS, RD51, Belle2 and SuperB. He is the author of 371 papers on well-recognized scientific international peer-reviewed journals, including IEEE TNS, NIM-A, and JINST. His H-index is higher than 63 and the total number of citations is around 20k. He gave numerous contributions to international conferences (including 15 oral, 2 invited oral). 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"63217",title:"Genotype DQ2.5/DQ2.2 (ββ2/ββ2) and High Celiac Disease Risk Development",doi:"10.5772/intechopen.80578",slug:"genotype-dq2-5-dq2-2-2-2-and-high-celiac-disease-risk-development",body:'Celiac disease (CD) is a genetically determined immune-mediated disease, and individuals with CD have specific HLA haplotypes (DQ2 and/or DQ8) that trigger an immune response to gluten intake, leading to intestinal and clinical signs and symptoms [1, 2], besides other autoimmune-associated CD diseases, such as dermatitis herpetiformis [3], type 1 diabetes mellitus, Hashimoto’s thyroiditis, and Sjögren syndrome [4]. Also, there are some genetic syndromes that may be CD associated such as Down syndrome [5, 6], Turner syndrome [7], and Williams syndrome [8].
As CD is one of the most well-elicited autoimmune diseases and one of the most common permanent food intolerances among humans [9], its prevalence in the general population from Europe, USA, and countries where the population is predominantly of European origin is approximately 1% [2]. Prevalence is lower, ranging from 0.15 to 0.84%, in Latin American countries such as Brazil [10, 11, 12, 13, 14]. When Brasília city (Brazilian capital and population representation) is considered, since it is a city formed by people from all regions of the country, the prevalence found in the general population is 0.34%, considering 0.21% in adults and 0.54% in children [11].
The CD prevalence can still be related to the cereal consumption that contains gluten (mainly wheat) and to the distribution of predisposing HLA alleles in the population [15, 16]. Besides, the existence of genetic and environmental factors may influence the CD prevalence rate in a region [15]. Last but not least, we highlight the microbiota variability, the existence of intestinal infections, and socioeconomic conditions, which are also factors that may influence the CD development and prevalence [17, 63].
According to clinical signs and symptoms, laboratory and histopathological findings, which together have been called “clinical forms,” CD can be classified into five distinct forms (Table 1).
Classification | Clinical forms |
---|---|
Classic or typical | Frequently in children, characterized by gastrointestinal manifestations that can arise after the introduction of gluten foods (weeks, months, or even years). Patients have positive serology for CD and HLA compatible; and, in intestinal biopsy, there are usually lesions of variable severity, but they are frequently characterized by hypotrophy or atrophy of intestinal villi and varying degree of intestinal cryptic hyperplasia. |
Atypical or nonclassical | Minimal or no gastrointestinal manifestations and recurrent extraintestinal manifestations. It can appear at any age (but commonly in teenagers and adults). It presents positive serology, HLA, and CD-compatible biopsy. |
Silent or asymptomatic (subclinical) | Signs and manifestations commonly associated to CD are nonexistent. Patients are diagnosed occasionally in screening programs or because they are in risk CD groups (carriers of autoimmune diseases or celiac relatives), by positive serology, HLA, and CD compatible biopsy. |
Potential | Patient may or may not present manifestations, as well as may not develop mucosal lesions in the future. CD-positive serology, CD-compatible HLA typing, normal intestinal mucosa, or with subtle abnormalities (increase of intraepithelial lymphocytes) and absence of significant enteropathy. |
Latent (controversy) | Characterized by the presence or absence of antibodies in the normal intestinal mucosa, HLA typing is CD compatible, but for being defined as having CD, there must be a prior diagnosis of at least the presence of an enteropathy associated to gluten consumption. |
CD pathogenesis, which is an inflammatory enteropathy with autoimmune characteristics, is triggered by gluten ingestion [17]. In nonceliac individuals, gluten is cleaved by digestive enzymes into small fragments for eliciting an immunogenic response and is digested by gastrointestinal system without causing damages. In CD patients, the gluten digestion induces gliadin fragments initiating an innate and adaptive immune response resulting in tissue damage of the intestinal mucosa and clinical CD manifestations [24].
Gluten is the energy storage protein found in wheat, rye, barley, and oat grains, which has a large amount of prolamins (glutamine and proline) in its primary structure. Proline-rich peptides are resistant to gastrointestinal digestion [25].
Specifically in wheat, gluten proteins are divided into gliadins and glutenins [25], according to the solubility of the prolamins present. Gliadin is soluble in alcohol, while glutenin is soluble in acidic and basic dilutions [26]. Gliadin is an alcohol-soluble, 30 kDa protein, particularly rich in glutamine and proline residues, which are contained in polyglutamine sequences, represented as a single chain of polypeptides, which can be divided in four different groups: α-, β-, γ-, and Ω-gliadin [26]. The N-terminal domain of α-gliadin contains the most immunogenic fragment, which has the peptide 31–43 and the 33-mer fragment, which contains six significant epitopes for CD pathogenesis [27, 28].
The presence of gliadin and its peptides is the external factor triggering the immune response in CD, which implies the need for its entry through the mucosa and presence in the lamina propria with consequent obligatory passage through the cells of the intestinal epithelium. This epithelium entry occurs by three mechanisms: (1) through the transcellular route, where gluten is endocytosed in lysosomes, which degrade it in small nonimmunogenic peptides [29]; (2) via the paracellular route, by regulating the TJ junctions responsible for the union of the epithelial cells, promoting a change in cellular permeability and, consequently, the entry of gliadin peptides into the mucosa, such as regulation through zonulin produced by epithelial cells of celiac patients that alter the permeability between epithelial cells [29, 30]; (3) by transepithelial transport in cells of celiac patients, where there is an increase in CD71 (transferrin receptor) expression. This receptor recognizes IgA complexed with gliadin through the Fc portion of the immunoglobulin, and releases this association without processing in the lamina propria [31].
Although these mechanisms of entry and processing by digestive enzymes are described in the literature, it is believed that these peptides interact with the intestinal epithelial cells and produce an inflammatory response before presenting themselves in the lamina propria, promoting gene alterations in this cell by mechanisms not yet fully elucidated [24].
In an in vitro cellular CD model by using CaCo2 cells, intact gliadin and its immunogenic peptides from the 33-mer fragment (nondeaminated—P56-88, P57-68, P69-82, P31-43, and deaminated P57-68 E65 and P69-82 E72) were used for understanding this interaction mechanism in the first 24 and 48 h. Results showed that following interaction with CaCo2 cells, these peptides modulated receptor gene transcripts such as TLR-4, cell permeability altering protein genes such as zonulin and occludin, as well as inflammatory cytokines (IL-1, IL-6, IL-8, and IL-15) very important for CD pathogenesis, besides increasing the production mediators of oxidative stress such as nitric oxide. Afterward, IL-6 and TNF-α levels revealed the secretion of these cytokines in culture supernatant, confirming the inflammatory process initiated in the first 24 and 48 h after interaction with these human epithelial cells when culture (unpublished data) [32]. Earlier data had previously confirmed that the peptide p31-43 activates the innate immune response through the activation of proinflammatory cytokines, while the p57-68 peptide has been identified as immunodominant and capable of activating the adaptive immune response through recognition by T cells-CD4 [33].
When gliadin peptides reach the lamina propria, they are modified by the action of the tissue transglutaminase 2 (tTG2) enzyme, which in the presence of calcium, converts glutamine residues to glutamic acid, the negative charge of glutamic acid increases the affinity of tTG2 for gliadin and the gliadin-tTG2 complex also increases the affinity of the gliadin-tTG2 complex and the gliadin peptides with the MHC class II molecules HLA-DQ2/DQ8 [15, 34, 35, 36].
These gliadin peptides are recognized and processed by the HLA-DQ2/DQ8 MHC class II antigen presenting cells (APCs) and are presented to CD4 T cells, which become active and begin to produce IFN-γ and IL-15. T-CD4 lymphocytes, activated by APCs on the lamina propria, differentiate into intraepithelial lymphocytes (IELTs) and infiltrate epithelial cells in response to IL-15 stimuli produced by enterocytes. Also, in response to IL-15, IELTs display cell membrane receptors for natural killers (NK), which promotes the cascade recruitment of new NK cells, which promote destruction of the epithelial barrier, cryptic hyperplasia, and atrophy of the intestinal villi [25, 37, 38].
APCs migrate to the mesenteric lymph node and display the gliadin peptides complexed with tTG2 to immature CD4 T cells. In mesenteric nodules, T-CD4 cells differentiate into effector T-CD4 cells (T-CD4+), which increases the proliferation of reactive B cells to the gliadin-tTG2 complex. Reactive B cells differentiate into plasma cells and produce IgA and IgG antibodies, not only against glutamine residues modified to glutamic acid, but also against tTG2, which may still be complexed with these peptides [39, 40].
The continuous recognition by APCs of the gliadin-tTG2 complex as an immunogenic stimulus accentuates the immunological and proinflammatory response, triggering the autoimmune response found on CD [8]. However, in healthy individuals, the recognition of these peptides when presented by MHC of class II originated of HLA DQ2/DQ8 [41] also occurs.
The entire inflammatory process induced by gliadin and its peptides on CD is a result from the synergism between the innate and adaptive immune response that occurs in two distinct sites in the small intestine, that is, in the epithelium and in the intestinal lamina propria [31, 42].
Studies suggest that CD is primarily mediated by adaptive immunity, where CD4 T cells recognize gliadin peptides through MHC II molecules, which are encoded by the HLA (Human Leukocyte Antigen) DQ2 and DQ8 genes present in celiac patients, which confirms the strong genetic basis [15, 31, 42].
For all these reasons, CD is an excellent model for studying the genetic factors that contribute to the development of immune-mediated disorders. Among these reasons, we can highlight the fact that it has a well-known environmental triggering factor—gluten, an autoimmune disease with a well-described genetic predisposition associated to the MHC HLA DQ2/DQ8 alleles, the involvement existence of other non-MHC genes, and the high incidence of other immunological diseases reported in both celiac and familial patients, in which the innate and adaptive response plays a key role [43]. CD is also considered a multifactorial disease caused by the interaction of different genetic factors that act in consonance with nongenetic effects, since nonceliac individuals also have such alleles, suggesting that additional complementary mechanisms are necessary for the disease development [39].
Similar to other autoimmune diseases, CD is a polygenic disorder and the MHC gene is the most important genetic factor. Most celiac patients carry a specific genetic variance of HLA-DQ2 (DQA1 * 05: 01, DQB1 * 02: 01, known as DQ2.5), and those who are not HLA-DQ2.5 almost always carry the HLA variance -DQ8 (DQA1 * 03, DQB1 * 03: 02) or another variant of HLA-DQ2 (DQA1 * 02: 01, DQB1 * 02: 02), known as DQ2.2 [9]. Since all celiac patients carry specific HLA variations, this factor may be considered necessary for CD diagnosis, but alone it is not sufficient for CD development [25].
Recently, studies based on Genome Wide Association Studies (GWAS) has been allowing the identification of single-nucleotide polymorphisms (SNPs) in each gene in the human genome associated to a cell metabolic pathway or a specific phenotype such as CD. In general, GWAS tests hundreds of thousands of SNPs throughout the patient genome and matched the control ethnic group [44]. These SNPs often affecting the recognition of transcription factors, resulting in differences in the expression of regulatory genes shared with other autoimmune diseases. After GWAS studies, it was possible to verify by immunochip analysis that several non-MHC genes have been related as CD susceptibility factors. Until then, 39 loci with 57 independent association signals were described, contributing 14% of the genetic variance for CD [45].
Many of these genetic variances are shared with other autoimmune diseases such as type 1 diabetes mellitus and rheumatoid arthritis [46]. After GWAS studies, once evidenced correlations with metabolic pathways and shared inflammatory response between CD and other autoimmune diseases, new strategies that make use of different cellular models can be applied to CD [47].
Clinical CD manifestations are very heterogeneous and often subtle, which may confuse the clinician and delaying the definitive diagnosis. According to the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), CD diagnosis depends on clinical manifestations, significant level of the presence of specific antibodies (positive serology), presence of predisposing HLA-DQ2 and/or HLA-DQ8 genes, and presence of histopathological abnormalities from the intestinal mucosa evidenced by the biopsy [8].
ESPGHAN advises that CD diagnosis should be considered in children and adolescents who present gastrointestinal (diarrhea, abdominal pain, nausea, vomiting, etc.) and extraintestinal manifestations (anemia, dermatitis herpetiformis, chronic fatigue, etc.). It is also recommended that CD diagnosis be evaluated in asymptomatic children and adolescents (but belong to a risk group for CD development). Risk CD groups are composed of individuals with type 1 diabetes, Down’s syndrome, Turner’s syndrome, Williams’s syndrome, autoimmune thyroid disease, autoimmune liver disease, selective IgA deficiency, and first-degree relatives of celiac [8]. American Gastroenterology Association recommends that CD diagnosis be considered in any individual with a clinical condition indicative of CD or belonging to at-risk groups [48].
The production of anti-endomysium (EMA), anti-gliadin, antitransglutaminase (anti-tTG) and gliadin-tTG complexes is part of the CD pathogenesis process. Serological tests used in the laboratory CD diagnosis are intended to detect levels of these antibodies in the serum (CD-suspected individuals). The available CD diagnostic tests include anti-gliadin IgA and IgG antibodies, anti-EMA IgA and IgG, IgA and IgG anti-tTG [48, 49].
Anti-gliadin antibodies are not currently considered sufficiently sensitive or specific to be used in the CD diagnosis [20] and have been replaced by anti-gliadin deaminated (anti-DGP) antibodies of both IgA and IgG because they have greater sensitivity and specificity. Anti-DGP IgG test is used in IgA deficiency cases where anti-DGP IgG antibodies are detected [49]. Both IgA and IgG anti-DGP assays are commonly used as additional tests in patients who are negative for other serological tests but presenting characteristic clinical CD symptoms, especially in patients younger than 2 years old [8, 49].
Anti-tTG antibodies are commonly detected by ELISA method usually by human recombinant tTG as antigen [8]. Anti-tTG IgA serological test is considered the most sensitive method for diagnosing CD, with sensitivity close to 97% [20]. This test has high specificity, close to 99% [48]. Although anti-tTG IgA assay has high sensitivity and specificity, it is possible to find false-positive results in patients with liver disease, congestive heart failure, arthritis, and inflammatory bowel disease [48]. Anti-tTG IgA test is generally used as the first test in the initial approach for diagnosing CD because it is a quantitative test that can be automated and does not depend on the observer interpretation such as the anti-endomysium test [8, 49].
Although the main methodology used for dosing tTG and gliadin is performed by ELISA, in the last two decades, new methodology is available; it is worth mentioning the indirect chemiluminescence immunoassay (CLIA) [50, 51] and the fluorescent enzyme immunoassay (FEIA or EliA) [52].
IgA-EMA antibodies are detected by indirect immunofluorescence, which requires microscopic evaluation. This method is of subjective evaluation, being subject to variations depending on different observer interpretations. However, when well interpreted by the experienced observer, the specificity of the IgA-EMA serological test is close to 100% [48], being considered a reference test for detecting specific CD antibodies [8].
For the anti-endomysium (EMA), although new methods have not been developed, it is now possible to carry out the technical procedure in a fully automated way, and reading by integrated software. Even with this great advance and agility in sample processing time, and in the technical standardization of the employed method, the existence of characteristic fluorescence patterns still requires that the analyzes be interpreted according to the knowledge and subjective observation of the microscopist or the observed, which causing high intra- and interlaboratory variability, which in laboratory practice is considered the major problem for diagnosing autoimmune diseases in general.
Also, the use of molecular methodologies in the laboratory diagnosis currently allows the detection of HLA genotypes associated to CD, in a highly specific way, mainly using the RT-PCR methodology.
CD is an example of a multifactorial disorder in which the genetic test is of great clinical relevance, since the disease rarely develops in the absence of HLA-specific genes (HLA-DQ2 and HLA-DQ8) [15, 53]. The HLA-DQ2 and HLA-DQ8 genes are required for developing CD but are not sufficient [54]. If an individual carries these genetic markers, it does not necessarily mean that the subject will develop CD, but having a risk for developing the disease. Therefore, the absence of the HLA-DQ2 and HLA-DQ8 genes has a high negative predictive value for the diagnosis of CD, ie, the chance of an individual who does not have these genes develop CD is extremely low, whereas the presence of these genes markers has a relevant positive predictive value [55].
HLA typing can be used to rule out the diagnostic hypothesis of CD in patients with doubtful diagnosis, excluding the disease possibility in individuals who do not have these genes. Chang and Green [53] suggested that HLA typing be performed prior to serological testing to reducing the number of false-positive results and thereby decreasing the number of biopsies required. However, ESPGHAN recommends that the HLA test be performed prior to the serological tests only in the case of asymptomatic patients belonging to risk groups (first-degree relatives of celiac, type 1 diabetic patients, and Down syndrome, for example) [8].
In CD, the heterodimers are called human leukocyte antigen (HLA) and belong to HLA-DQ loci present on chromosome 6. Genotypes that are strongly associated to the onset of the immune response triggered by gluten are HLADQ2.5, HLA-DQ2.2, and HLA-DQ8 [56, 57, 58]. It is known that genotypes HLA-DQ2.5 (DQA1 * 05: 01, DQB1 * 02: 01), HLADQ2.2 (DQA1 * 02: 01, DQB1 * 02: 02), and HLA- DQB1 * 03: 02) are necessary but not sufficient for developing CD, since more than 30% of the general population in the world have these genotypes and only 3–5% will develop CD [9, 59, 60, 61].
Virtually, all CD patients carry the alleles encoding the HLA-DQ2 and/or DQ8 molecules or at least one DQ2 heterodimer chain, usually the DQB1 * 02 allele-encoded strand. The CD occurrence in the absence of these risk factors in DQ is extremely rare, but the presence of these molecules also fails to predict with precision when and if the CD will develop, since they are present in 25–50% of the general population, although the vast majority of these individuals never develop the disease throughout life [58].
Even with this knowledge, performing HLA-DQ typing for determining future CD risk has been widely discussed, although its practical use is mostly associated to risk groups where genetic testing of individuals could eliminate the need for future antibody tests in more than 60% of the population considered to be at low CD risk (DQ2 or DQ8 negative). On the other hand, the identification of high-risk individuals would allow a safer prospective screening, allowing an early therapeutic intervention [5], and a more precise monitoring, since the risk of developing the disease is more likely in these individuals. In the scientific literature, the first study that calls attention to the determination of CD risk development associated to the presence of HLA-DQ genotypes was performed by Megiorne et al. [62] in the Italian population, the best characterized thesis in the world. Results showed that considering the prevalence of 1: 100 established in this population, which corresponds to 1% that is the prevalence in populations of Caucasian origin in the world population, the risks for developing CD were higher when associated to the presence of genotypes DQ2.5/DQ2.5 and DQ2.5/DQ2.2, in addition to DQ2.5/DQ8, where the risk found was 1: 7, 1:10, and 1:24 (Figure 1).
Risk calculated by Megiorni et al. [62] in the Italian population. Adapted from Megiorni et al. [62].
After this publication, rare study has appeared, is the case of Almeida et al. [2] and Murad et al. [64], that given the existence of the estimated prevalence of these populations in other studies in the same region, were able to calculate the CD risk development in the populations of Brazil and Syria, respectively.
Results found by Almeida et al. [2] showed that the risks associated to DQ2.5/DQ2.5, DQ2.5/DQ2.2 and DQ2.5/DQ8 genotypes in the Brazilian population were 1:7, 1:10, and 1:19, respectively, such as described by Megiorni et al. [62].
Murad et al. [64] found in the Syrian population, a slightly different risk for DQ2.5/DQ2.5, DQ2.5/DQ2.2, and DQ2.5/DQ8 genotypes and the associated risks were, respectively, 1:12.5, 1:20, and 1:10, emphasizing that in this population of origin other than Caucasians, the risk associated to these genotypes are somewhat different in terms of prevalence, but they continue to confer the greatest risks for developing CD (Figures 2 and 3).
Calculated Risk (Brazilian population)—Almeida et al. [2].
Calculated Risk—Murad et al. [64].
Because it is not possible to calculate the risk for the various world populations, there are many where the absence of disease prevalence data does not allow this calculation to be carried out, an estimate for populations of Caucasian origin seems to produce very close results suggesting that calculations are accurate in these populations. Considering the relevance of risk demonstrated by the most prevalent and important genotypes for the development of CD, DQ2.5/DQ2.5, DQ2.5/DQ2.2, and DQ2.5/DQ8, it can be recommend that population studies, especially those for clinical diagnosis, which until now considering the risk for development CD associated only to the presence of the DQ2.5/DQ2.5 and DQ2.5/DQ8 genotypes, which consider the inclusion of the DQ2.5/DQ2.2 genotype in their research, because this genotype does indeed pose a high risk for CD development and should not be neglected.
Over the last decade, there have been many studies on a variety of interventions to decrease mortality by improving the health of patients through literacy. Some researchers such as [1] have addressed direct literacy related barriers primarily by testing interventions to make health education materials easier to understand. While other researchers like [2] have focused on indirect barriers by providing more general supportive interventions.
\nAccording to the [3] individuals with low to moderate health care, literacy skills face implications that may include the incompetence to carry out positive self-management, it also means higher medical costs due to more medication and treatment errors, more frequent hospitalizations, longer hospital stays, more visits to their health care provider, and a lack of necessary skills to obtain needed services.
\nNotwithstanding the colossal implications of low health literacy, there remains a significant amount of misunderstanding surrounding the concept and its implications for healthcare professionals and facilities in Jamaica [4]. Health literacy is not a new concept to the Jamaican healthcare community, however, it has not been a concept that is practiced on a daily basis in our facilities [4]. In other countries, it has caught the attention of researchers, policy makers, and healthcare professionals due to its prevalent impact on health and well-being.
\nThe purpose of this chapter is to outline health literacy as a concept and explore some appropriate interventions that can assist researchers and healthcare professionals to reduce its negative impact on health outcomes such as mortality. The chapter will also address issues concerning low health literacy in developed and developing countries. Firstly, the major definitions of health literacy are presented in the introduction. Then, the description of interventions, how they have been applied, the challenges and outcomes, the discussion of resources required for implementation, the authors’ unique perspective on the issue and proposed a framework for the implementation and evaluation of health literacy interventions, including culturally appropriate programming and the multi-disciplinary team approach.
\nThe term health literacy was introduced in 1974 in a paper calling for minimum health education standards for all grade-school levels in the United States (US) [5]. The World Health Organization (WHO) later defined health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” [6].
\nKirsch et al. [7] explained that the inability to read, write, and use numbers effectively, is common and is associated with a wide range of adverse health outcomes in the Caribbean and the Americas. There are five health outcomes of low health literacy, which are health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. However, this chapter will only focus on health knowledge and health behaviors because research indicates that knowledge affects behavioral outcomes [7]. Additionally, in order to reduce hospital mortality rates, individuals must have the knowledge base to obtain, process, and understand basic health information and services needed to make appropriate health decisions [8].
\nHealth knowledge, or health education, refers to the knowledge and understanding people have about health-related issues [9]. It is important that people understand the causes of ill-health and recognize the extent to which they are vulnerable to, or at risk from, a health threat. The World Health Organization’s (WHO) definition of health was expanded in 1996 as a state of complete physical, mental and social well-being and now includes a social dimension. Additionally, some social scientist of that era, believed that WHO expansion of the health, must include a spiritual dimension [10].
\nAccording to the aforementioned [11] definition of health, it summarized complete health as the development of the social, physical, mental and spiritual dimension of a person. These four aspects of health were highlighted in the Bible, by Jesus Christ, when he said in Luke 2 verse 52 “he (Jesus) increased in wisdom (mental health) and stature (physical health) in favor with God (spiritual health) and man (social health),” [12]. Therefore, in order for a person to experience complete health, there must be growth in these four dimensions. Individuals in this twenty-first century must know that impairment in any one of these dimensions will affect the proper function of the other dimensions. These four components of health knowledge, spiritual, mental, social and physical will be defined and discussed below.
\nThe term “spiritual intelligence” was coined by Danah Zohar in 1997. Additionally, Ken O’Donnell in 1997 who is an Australian author and consultant living in Brazil, also introduced the term “spiritual intelligence” and Michal Levin in 2000 use this “spiritual intelligence” in his book to draw attention to the concept of linking the spiritual and the material reality of life that is eventually concerned with the well-being of the universe and those who coexist in it [13, 14, 15].
\nIt appears challenging to outwardly define spiritual health or spiritual intelligence without comprehending that the perception of spirituality is divergent from religiosity [16]. Fogel [17] opines that, for a very long time “spiritual” was, considered to be separate from “religious” and our secular societies prefers to steer as far as possible away from discussions on religion, for fear of kindling dormant conflicts or intruding on a taboo subject.
\nHowever, some researchers have tried to coin some functional definitions. For instance, [18] “spiritual intelligence is concerned with the inner life of mind and spirit and its relationship to being in the world.” On the other hand, [19] defines spiritual intelligence as “the ability to act with wisdom and compassion, while maintaining inner and outer peace, regardless of the circumstances.”
\nResearch conducted by medical ethicists has reminded us that religion and spirituality form the basis of meaning and purpose for many people [20]. It is important to note that patients in health care institution, not only have the pain of physical ailment to confront with but the mental and spiritual pain that is associated with their sickness.
\nAccording to [21], mental health literacy (knowledge) is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention.” According to [22], there are key areas that help to equip persons with mental health knowledge. This will assist them with overcoming cultural and societal obstacles by challenging the fear of stigmatization. These areas include, but are not limited to; (a) the ability to recognize specific mental health problems, (b) knowledge and beliefs about risk factors, self-management approaches and the professional help available, (c) knowledge and beliefs about self-help interventions, (d) attitudes which facilitate recognition and appropriate help-seeking behaviors and (e) knowledge of how to seek and access mental health information.
\nThe economic impacts of mental illness include its effects on personal income. These effects can only be quantified based on the ability of the persons with mental disorders or their caregivers to gauge the measurable economic burden of mental illness [23]. Bloom et al. [24] on the World Economic Forum (WEF) described three different approaches used to quantify economic disease burden, which do not only acknowledge the “hidden costs” of diseases, but also their impact on economic growth at a macroeconomic level (Figure 1).
\nDifferent approaches used to estimate economic costs of mental disorders [25].
Mental health is now getting a great deal of scrutiny around the world, it is an area of health that developing countries are seeking to end stigmatization and discrimination through literacy [26]. In a study conducted by [27] opines that the most commonly expressed emotional response to the mentally ill and mental illness was fear, often specifically a fear of “dangerousness.” While the study reported some positive and empathetic responses, the most prominent emotional response was fear. Mental health literacy is the one of the most effective ways that fear towards the mentally challenged can be mitigated [28].
\nThe possible recommendation could be that, to be effective and relevant, mental health educators must seek to improve individual literacy and numeracy skills. Furthermore, mental health information needs to be written clearly and the information must be accessible to those who need it. This type of information must be useful in improving practical social skills and the communicative elements should aid these persons to access and maintain health [29].
\nThe idea of social health is less recognizable to that of physical or mental health, but nonetheless, it’s one of the four pillars (spiritual, mental and physical) that forms the WHO definitions of health. According to [30] accentuates that “a society is healthy when there is equal opportunity for all and access by all to the goods and services essential to full functioning as a citizen.” Therefore, the success of a healthy society is influenced by the rule of law, equality in wealth distribution, public involvement in the decision-making process and a level of social capital.
\nIn developing countries like Jamaica, there are many determinants of social health that affects the livelihood of many such as inequality, poverty, exploitation, violence and injustice, these are at the root of ill-health and the deaths of poor and marginalized people [31]. According to [32] mentioned that a determinant is any factor that contributes to person current state of health. Based on researchers, it is believed that social determinants of health are the situations in which people are born, grow, live, work and age. These conditions are molded base on the supply of money, power and resources at the global, national and local levels [33].
\nJulianne et al. [34] postulated that the quality of life and social relationship are closely related to mental health and the mortality rate. Furthermore, their opinion is that this modern way of life limits individual’s social interactions, which results in people living insolation from extended families in developing countries. It is clear, that people of all different ages around the world are living alone, and loneliness on this crowded planet is becoming common [35].
\nAccording to [36], physical health literacy is the ability to move with competence and confidence in a wide variety of physical activities in multiple environments that benefit the healthy development of the whole person. Moreover, it is supported by researchers that physical literacy is an essential and valuable human competency that can be described as a disposition learnt by human individuals surrounding that enthusiasm, confidence, physical competence, knowledge and understanding that establishes physical quests as an important part of their lifestyle [37].
\nIn her research, [38] gave a summary of the key features of physical literacy:
Everyone can be physically literate as it is appropriate to each individual’s endowment,
Everyone’s physical literacy journey is unique, physical literacy is relevant and valuable at all stages and ages of life,
The concept embraces much more than physical competence,
At the heart of the concept is the motivation and commitment to be active, the disposition is evidenced by a love of being active, born out of the pleasure and satisfaction individuals experience in participation,
A physically literate individual values and takes responsibility for maintaining purposeful physical pursuits throughout the life course and charting of progress of an individual’s personal journey must be judged against previous achievements and not against any form of national benchmarks.
There are several definitions for health behavior, one such researcher, [39] defined health behavior as the activity undertaken by people for the purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image. Conner and Norman [40] added that any activity that is undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing is defined as a health behavior. In the Handbook of Health Behavior Research, [41] defines health behavior as behavior patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement’ (Vol. 1, p. 3). Behaviors within this definition include medical service usage (e.g., physician visits, vaccination, screening), compliance with medical regimens (e.g., dietary, diabetic, antihypertensive regimens), and self-directed health behaviors (e.g., diet, exercise, smoking, alcohol consumption and illegal drug use).
\nIt is common to differentiate health enhancing from health impairing behaviors. Institute of Medicine (US) Committee on Health and Behavior Research, Practice, and Policy [42] explained that health impairing behaviors have harmful effects on health or otherwise predispose individuals to diseases and even mortality. Such behaviors include smoking, excessive alcohol consumption, illegal drug misuse and high dietary fat and sugar consumption [42]. In contrast, [43] stated that engagement in health enhancing behaviors conveys health benefits or otherwise protect individuals from disease. Such behaviors include exercise, fruit and vegetable consumption, consumption of water instead of juice, limited alcohol consumption, no usage of illegal drugs and condom use in response to the threat of sexually transmitted diseases [43].
\nThis chapter utilized a multiple method approach to understand health literacy as an intervention to improve health outcomes. A meta-analysis, design was employed using three key phrase search and six keywords search resulting from the analysis of 43 articles. A breakdown of the methodologies using the two of the three key phrases is tabulated below (Tables 1 and 2).
\nAuthor | \nPopulation | \nParticipants | \nMethods | \n
---|---|---|---|
[44] | \nOne-third (77 million) | \nOver 19,000 adults from 38 states and the district of Columbia participated in the national and state-level assessments to create data for the NAAL. | \nThe 2003 National Assessment of Adult Literacy (NAAL) which is a nationally representative assessment of English health literacy was distributed to American adults age 16 and older. | \n
Showing key phrase: the relationship between health literacy and health outcomes.
Author | \nPopulation | \nParticipants | \nMethods | \n
---|---|---|---|
[45] | \nNot stated | \nThe demographic sample was 25 elderly and health illiterate persons using a mixed method and a convenience sampling approach. | \nThe instrumentations used were verbal questioning (perception of drug visual aide assistance) and a written questionnaire on how prescription medication instructions should be written currently and in the future; since the sample was compiled of both literate and illiterate people, questions were asked verbally and the questionnaire was administered. The methods used were paper & pencil recording of the types of prescriptions each individual tool, what they should have taken and if they felt comfortable taking their current prescriptions. | \n
[46] | \nNot stated | \nThere were 15 studies dating from 1997 to 2006, a review confined to complex intervention study design was used and a sample range of 40-2046 participants. | \nA systematic review of randomized and quasi-randomized controlled trials with a narrative synthesis. The search strategy included searching eight databases from start date to 2007, reference checking and contacting expert informants. After the initial screen, two reviewers independently assessed eligibility, extracted data and evaluated study quality. | \n
[47] | \nNot stated | \nThere were 20 studies dating from 1992 to 2002, a controlled or uncontrolled experimental design was used and a sample range from 28 to 1744 participants. | \nThe 20 studies were of three types: randomized controlled trials (n = 9), nonrandomized controlled trials (in which subjects were assigned to intervention or control groups by the day or the week or some other nonrandom fashion; n = 8), and uncontrolled, single-group trials (n = 3). The number of participants enrolled ranged from 28 to 1744; most studies had between 100 and 500 participants. All but 2 studies were conducted in the United States. Most interventions and outcome assessments were administered in single sessions. Interventions to improve dietary behavior and one other study delivered multisession interventions and/or followed participants longitudinally to assess changes in outcomes. | \n
Showing key phrase: health literacy interventions to reduce mortality.
U.S. Department of Health and Human Services [8] explained in their research that low health literacy has been correlated with negative health outcomes, including reduced use of preventive health services, poor disease-specific outcomes for certain chronic conditions, and increased risk of hospitalization and mortality. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association [48] agreed in their publication that health literacy is assumed to be a stronger predictor of health outcomes than social and economic status, education, gender, and age. With that being said, [49] stated that individuals with low health literacy have poorer health outcomes regardless of the illness they are diagnosed with. They went on to explain that low health literacy is more prevalent among vulnerable populations, such as the elderly, minorities, persons with lower education, and persons with chronic disease.
\nSeveral researches have shown that low literacy can have a direct and negative effect on health. Berkman et al. [50] explained that they expect this effect to be predominantly important for conditions that require substantial and complex self-care on the part of the patient because of the barriers to accessing and using health information, particularly written and calculated information. DeWalt et al. [2] agreed with [51, 48] by adding that low literacy can also be a marker for other conditions, such as poverty and lack of access to health care, that lead to poor health outcomes especially outcomes such as mortality.
\nThe National Assessment of Adult Literacy report [44] explained that only 14% of adults have attained proficient health literacy, so in other words, nearly nine out of 10 adults may lack the skills needed to manage their health and prevent diseases. Additionally, it was reported that 16% of adults (50 million people) in having below basic health literacy and these adults were more likely to report their health as poorer (42%) than adults with proficient health literacy. Low literacy has been linked to poor health outcomes such as higher rates of hospitalization, less frequent use of preventive services and even hospital mortality [44].
\nIn a study conducted by [45], a health literacy intervention was carried out in the cities of Black River, Balaclava, and Parottee, Jamaica by creating prescription drug visual aids that will assist the elderly health illiterate population with their medication adherence and to promote health literacy.
\nThe results from the questionnaire used in the research showed that 80% of the overall sample were below the sixth-grade education literacy level, with 64% below the third-grade level and 16% between the fourth and sixth-grade levels. Additionally, 12% of respondents specifically from the city of Black River reported the ability to read but not to write. From the verbal questioning, 60% of the 64% of respondents who were below the third-grade education literacy level believed that visual aids would make medications easier to take. Furthermore, 8% of the 16% of respondents who were between the fourth and sixth grade education literacy levels believe that visual medication aides will benefit them. The results also displayed that a health literacy problem does exist in the areas in St. Elizabeth, Jamaica.
\nThe findings indicated that the health literacy of the elderly population in rural Jamaica is a national health concern [45]. If these persons are incapable of understanding what type of medications they are taking and why, they are less likely to take them regularly and as scheduled/prescribed. However, many of these same persons understand and acknowledge that they also need help in terms of understanding and taking their medications and illnesses. The outcome of this study stated that rural elderly Jamaicans believe visual medication aides will benefit them and the results indicated that a health literacy problem does exist in the area, and visual aides are needed due to the literacy level and health literacy level of the region.
\nThe main limitation stated for this intervention was that the sample size used was relatively small (25) and it might have played a role in respondents indicating their receptiveness to visual aids. Future implications of this research suggested that there is a need to conduct further research on the public health disparity between individuals in urban versus rural areas and that research might reveal disparities in the health outcomes.
\nAnother study conducted by [46] in the United States of America, to evaluate the published literature of the effects of complex interventions intended to improve the health-related outcomes of individuals with limited literacy or numeracy. The focus of the 15 studies aforementioned in the methodology was on: health professionals (n = 2), literacy education (n = 1), and health education/management interventions (n = 12). In most of these studies (9 out 15), outcomes were measured in the intervention session or immediately afterwards. One study did not specify its follow-up period. The other five studies reported follow-up periods ranging from 1 week to 10.5 months with a median 5.5 months.
\nThe primary results showed that there were statistically significant in 13/15 trials, though 8/13 had mixed results across primary outcomes. Two trials showed no significant positive finding in primary outcomes: one failed to show a significant improvement in health knowledge and the other failed to show significant changes in cholesterol and blood pressure changes. It was recommended that health related improvements were reported across all four intervention types, however, all interventions were complex interventions and it is not known which components of each initiative were effective. This, combined with the fact that some of the interventions were resource intensive, demands that future initiatives are carefully designed and based on sound theoretical and pragmatic reinforcements. The wider empowerment and community participation aspect of some of the interventions represent a welcome, broader approach to health literacy.
\nIt was concluded that a variety of interventions for adults with limited literacy can be beneficial in improving some health outcomes especially mortality. The classes of outcome most likely to improve based on the study such as knowledge and self-efficacy. The implications suggested that more research was needed on the mechanisms of interventions that are most effective for improved health outcomes (specifically mortality). Additionally, there was limited evidence on interventions that targeted health professionals and their aptitude to deliver care optimally to patients with limited health literacy and to improve mortality rates especially in a hospital setting.
\nPignone et al. [47] reported on a systematic review of interventions designed to improve health outcomes for persons with low health literacy in developed countries defined as United States, Canada, Western Europe, Japan, Australia and New Zealand. The focus of the studies were easy-to-read printed materials (n = 4), video/audio tapes (n = 4), computer-based programs (n = 3) and individual or group instructions (n = 9). The primary results displayed that the diversity of outcomes limits conclusions about the effectiveness, though effectiveness “appeared mixed”. There were limitations in research quality that also hindered the drawing of conclusions. The five articles which dealt with the interaction between literacy level and the effect of the intervention stated mixed results. It is therefore recommended that research is needed to establish whether the correlation between low literacy and poor health outcomes is direct or indirect so as to most efficiently direct interventions.
\nThe results of the interventions should be stratified by literacy level and future studies should focus on intermediate to longer term outcomes rather than short-term knowledge outcomes or health behaviors. There is no research which has considered how interventions may impact on health disparities or care costs based on race, ethnicity, culture or age. Multi-component interventions should be analyzed to establish efficacy and effectiveness.
\nIt was concluded that several interventions based on the study have been developed to improve health for individual with low health literacy. There were limitations in the interventions tested and outcomes assessed make drawing deductions about effectiveness very difficult. Finally, advanced research is required to have a better understanding of the types of interventions that are most effective and efficient for overcoming health literacy-related barriers to good health and to improve health outcomes such as mortality.
\nWorld Health Organization Regional Office for South-East Asia [51] stated in their Health Literacy Toolkit for Low- and Middle-Income Countries that the Optimizing Health Literacy and Access to health information and services (Ophelia) approach is an effective system that supports the documentation of community health literacy needs, and the advancement and testing of possible solutions to reduce mortality. Each Ophelia project seeks to improve health and equity by increasing the availability and accessibility of health information and services in locally appropriate ways [51].
\nProjects have been carried out in Lavender Hill, an informal settlement, Cape Town: Ophelia South Africa under the title, “Identifying health literacy needs and developing local responses to health emergencies”; in Thailand under the title, “Optimizing health literacy needs of people” in Thailand and in New Zealand under the title, “Health literacy and Whanau Ora Outcomes: Ophelia New Zealand.” The outcomes generated new data and tools that were used to inform practice and policy and aid practitioners at both the patient and organization levels to comprehend and meet the needs of the community, targeting those with low health literacy [52]. Batterham et al. [52] stated that the Ophelia approach is innovative as it recognizes that health literacy is multidimensional and different people may have different health literacy needs and that it took a systematic and grounded approach to intervention development.
\nIn both developed and developing countries, a significant portion of the population has challenges in understanding health information which affect how they traverse the health care system. Decades of investigation show that there is a strong correlation between limited literacy in dealing with challenges in the health care and lower health knowledge intertwine with misinterpretation of prescriptions and lower receipt of preventive care [53].
\nIn both developed and developing countries for the population to benefit from better health care, they must be knowledgeable about the various aspects of health care. Mayagah and Wayne [54] identified six general themes that help determine why health literacy is important for population health, firstly, large numbers of people affected because some developed countries have high adult literacy rates, while in developing countries approximately half have rates below the global developing country average of 79%. Research indicated that in developing countries literacy rates are lower among women than men, which is affecting how these persons respond to health information [55]. Additionally, difficulties with health literacy affect all people, but the elderly and chronically ill are most at-risk, and also have the greatest health care needs and expenses [56]. People with low health literacy are overwhelmed by health care because their skills and abilities are challenged by the demands and complexity required [57].
\nSecondly, poor health outcomes, findings indicated that there is a clear correlation between inadequate health literacy as measured by reading fluency and increased mortality rates. Report on the Council of Scientific Affairs [58] suggested that poor health literacy is “a stronger predictor of a person’s health than age, income, employment status, education level, and race.” Moreover, UNICEF, reported that hundreds of millions of people around the globe are living in extreme poverty. Both poverty and poor health are linked and can be the result of social, political, and economic injustices. The linkage is a vicious, self-perpetuating cycle where poverty causes poor health and poor health keeps communities in poverty. Research cited that people who are economically deprived and living in poor environments are faced with many health risk factors in their everyday life [59].
\nThirdly, increasing rates of chronic disease are estimated to account for almost half (47%) of the total burden of disease. Likewise, chronic diseases often occur with co-morbidities (concomitant but unrelated diseases) and co-morbidity further increases the demand for health care. For example, individuals with diabetes and very high co-morbidity are expected to use 10 times the healthcare resources of the population average [60]. Research done on the Canadian Health Care System that indicated help is provided to people with chronic conditions such as diabetes, asthma, congestive heart failure, renal failure and chronic obstructive pulmonary disease. A large proportion of the available healthcare resources are devoted to treating chronic conditions and, in Canada, 67% of all health care costs are incurred as a result of caring for those with chronic conditions. More than half of Canadians aged 12 or older report at least one chronic condition and at age 65, 77% of men and 85% of women have at least one chronic condition [61]. Health literacy plays a crucial role in chronic disease self-management. In order to systematically manage chronic conditions on a daily basis, individuals must be able to assess, understand, evaluate, and use health information [62]. According to the Adult Literacy and Life Skills Survey, more than half (55%) of working-age Canadians do not have adequate levels of health literacy and only one in eight adults (12%) over age 65 has adequate health-literacy skills [63]. Also, [1] specified that populations most likely to experience low-literacy levels are among those being asked to manage their condition such as older adults, ethnic minorities, people with low levels of educational attainment, people with low income levels, nonnative speakers of English, and people with compromised health [64].
\nAlso, those with low literacy skills are not likely to attend voluntary peer-led self-management programs even if they are aware, they exist. In 2003, the Institute of Medicine in its priority areas for national action, identified self-management/health literacy as an area that cut across many health problems [64]. Schloman [65] opines that “improved health literacy was put forward as a condition necessary to enable active self-management of patients for most conditions.”
\nFourthly, health care costs; the additional costs of limited health literacy range from 3 to 5% of the total health care cost per year. Research has indicated that, insufficient health literacy has been associated with an increased need for disease management, higher medical service utilization among older, racial, ethnic minorities, and with low educational attainment [1]. Research conducted by the [66] in managing care, suggested that individuals with low health literacy have higher medical costs and are less efficient when using services than those individuals with adequate health literacy. Their findings estimated the costs associated with inadequate health literacy among adults at the national level to be $73 billion annually.
\nFifthly, health information demand has created discrepancies between the reading levels of health-related materials and the reading skills of the intended audience. Often, the use of jargon and technical language made many health-related resources unnecessarily difficult to use [54]. The populations in both developing and developed countries are challenged with the increasing demands to understand and utilize health information, which are some of the complexities that are facing modern health care systems [67]. Additionally, the increasing proportion of people living with chronic conditions, competencies for proactive self-management of health and participation in collaborative care have become key public health agendas. The ability to take active part in shared decision making with healthcare providers is important for adherence to treatment, self-management of chronic diseases [68].
\nLastly, equity is a factor that suggests that low levels of health literacy often means that a person is unable to manage their own health effectively, access health services effectively, and understand the information available to them and thus make informed healthy decisions [54]. Researchers over the past two decades, have been investigating the importance of health literacy and have examined over 1600 related research articles such as the field of “health care disparities” [69]. Improving the health literacy of those with the worst health outcomes is an important tool in reducing health inequalities [54].
\nIt’s evident that the challenges with [70] equity may still exist today. Many countries have failed to document data about the population that will make inferences about the disparities that have contributed to the lower quality of care. Due to the limited data about these disparities, situations that affects individuals with low literary skills are often times overlooked and efforts to address inequities in health care are rendered as ineffective. Furthermore, health care researchers are of the view that data to properly assess these disparities can be collected. However, health care organizations are lacking in the measurement tools to assess patient literacy in populations served by operating health care systems [70]. Isham [70] further lamented that quality measures for improving health literacy are lacking. Therefore, the current problems of low health literacy should perhaps be viewed less as a patient problem and more as a challenge to health care providers and health systems to reach out and more effectively communicate with patients. The United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute of Statistics (UIS) projected that over 776 million adults, which is about 16% of the world’s adult population lacking basic literacy skills [71]. These figures appear to be alarmed by the strides that the human race has made in development of education. Additionally, a recent survey of health literacy among 2000 adults in the United Kingdom found that one in five people had difficulty with the basic skills required for understanding simple information that could lead to better health [72].
\nIt seems that quality health care is advancing in the developed countries due to the developments in technology [73], while on the other hand, the population in developing countries is affected by low literacy levels due to the limited advancement of technology [74]. However, research has indicated that 60% of adult Canadians (ages 16 and older) lack the capacity to obtain, understand and act on health information and services, and also the ability to make appropriate health decisions on their own. In addition, the proportion of adults with low levels of health literacy is significantly higher among certain groups. These findings raise questions of equity [54].
\nFindings from comparable studies done in Europe, Australia, Latin America and other countries have correlated literacy levels with access to education, ethnicity and age as determinants to better health care [75]. Other studies have indicated that having limited literacy or numeracy skills also acts as an independent risk factor for poor health, which lead to medication errors and insufficient understanding of diseases and treatments [76]. Additionally, [49] from their review determined that there is a relationship between literacy and health outcomes that was directly corresponding to several adverse health-related factors, such as, knowledge about health and health care, hospitalization, global measures of health, and some chronic diseases.
\nIn exploring the link between literacy and mortality, Baker and colleagues suggest that there is a strong correlation between inadequate health literacy—as measured by reading fluency—and increased mortality rates [77]. Neuroscience and Behavioral Health specialists opine that health literacy is essential to overall patient care. It’s very important for every citizen in both developed and developing countries to understand basic health information. This understanding will empower people to make better decision as it relates to self-care and medical decisions. Educating the population of any country about health is crucial in mitigating inequalities that exist in health care systems. It is evident that individuals with low health literacy have poorer health status and higher rates of hospital admission, are less likely to adhere to prescribed treatments and care plans, experience more drug and treatment errors, and make less use of preventive services [78].
\nPoor health literacy with limited access to education may result in a deficiency in patient self-management. According to [79] believes that lack of understanding of procedures of basic health information, will interfere with their ability to take better care of themselves and make health related informed decisions. Therefore, it’s evident that patients who are involved self-management will mostly experience positive health outcomes and place fewer demands on the healthcare system.
\nThe role of healthcare facilities and health care professionals is to assist patients in becoming better in self-management and limit the patients’ dependency on the health care system. It’s important to understand that health literacy is pivotal in the management of chronic medical conditions. Patients need to learn and understand self-management by having access to health information which will enable them to better cope with daily challenges (includes a complex medical regimen, plan and make lifestyle adjustment) that comes with chronic illness [80].
\nAnother major issue that affects both developed and developing countries is the cost that is attached to health care. Research has concluded that is difficult to correctly evaluate the real economic cost that is associated with low health literacy. Factors such as what constitutes health literacy and insufficient data collection on the frequency of low literacy help to compound the challenge of economic cost. Researchers believe that despite these challenges in evaluating the impact of limited health literacy studies that are available underscore the importance of addressing limited health literacy from a financial perspective [81].
\nVernon et al. [82] revealed that the findings of a health literacy cost study that was based on an analysis of US National data revealed that the cost of low health literacy to the U.S. economy is in the range of $106–$238 billion annually. Additionally, he stated, “when one accounts for the future costs of low health literacy that result from current actions (or lack of action), the real present-day cost of low health literacy is closer in range to $1.6–$3.6 trillion” [82].
\nIt is clear that tracking the economic cost associated with low health literacy will strongly depend on the strength of the economic status of the developed and developing countries. Rootman and Ronson [83] stated that inequality is another major factor that affects the citizens of all countries. They postulate that “a person’s literacy level is influenced by many factors and conditions; these determinants of literacy are similar to the determinants of health commonly referred to in the health promotion literature.” Studies have indicated that factors like education, personal ability, early childhood development, aging, living and working conditions, gender and culture and language help to influence literacy rates in countries around the world [83].
\nResearch in the United Kingdom indicated [84] that low health literacy is emphatically connected with more unfortunate health outcomes, and every dynamic increment towards higher health literacy is related to a more prominent probability of participating in a solid and healthier way of life, explicitly eating at least five servings of fruits and vegetables and being a non-smoker. Likewise, [83] expressed that low levels of health literacy frequently imply that an individual cannot deal with their own wellbeing adequately, access health services viably, or comprehend the data accessible to them and therefore settle on educated and sound health choices. Enhancing the health literacy of those with the poor, negative health outcomes is a critical device in diminishing health inequalities [83].
\nIt’s important for developing countries to comprehend that health literacy entails development of individual level of knowledge, personal skills and the confidence to take action to improve self-management and community health by encouraging changes in the personal lifestyle and living conditions. Therefore, health literacy is more than people reading pamphlets and making appointments but is the overall improvement in the individual’s ability to access health data and their capacity to effectively use that information [85].
\nIn both developed and developing countries but mostly in developing nations, health care systems need to address the needs of communities and breaking down the barriers that exist through health literacy, such as, lack of compliance medication regime. Lack of health educators working with vulnerable citizens in communities like women, those living rural areas and immigrants. Other barriers like language, socio-political, economic and cultural barriers and time constraints pose challenges to health care providers and health literacy advancement. Research has shown that these vulnerable people have significantly worse outcomes which is associated with high mortality and morbidity rates due to the lack health literacy levels. Therefore, developing countries like the Caribbean in tackling the economic cost of low literacy must apply a comprehensive, and integrated health approach to the services that are important in transforming in the model of care [79].
\nPan American Health Organization [79] reported that regardless of the improvements has been achieved in health literacy, poverty and inequities remain a challenge in the Region. Recent data suggest that Latin America and the Caribbean (LAC) remains the most inequitable region in the world, with 29% of the population below the poverty line and the poorest 40% of the population receiving less than 15% of total income. Such inequities are reflected in health outcomes: for example, the Region of the Americas did not achieve the Millennium Development Goal (MDG) target for the reduction of maternal mortality by 2015, and despite significant reductions in infant mortality, very sharp differences exist between countries. Without specific interventions to transform health systems, economic growth is not sufficient to reduce inequities.
\nAs a developing country, Jamaica is confronted with many health issues. Specifically, there are concerns with an ever-aging population, which continues to grow in size at an astounding rate of 11.3% each year [86]. Coverson [45] asked these impertinent questions, “who will take care of this aging population, what services will be available, and how the elderly will maintain a reasonable quality of life are all questions that are facing Jamaica in the near future. People are living longer and with this increase in life-years come other concerns such as the cost of care, who will administer the care, and access to care as travel becomes more difficult with increased age.”
\nPaul and Bourne [87] suggested that this vulnerable group in the population that are affected by reading difficulties have greater challenges in understanding the high level of grammar associated with health care instruments, diagnostic tests, directions and medications. This lack of comprehension can result in patients experiencing confusion in navigating the healthcare system, and are significantly handicapped in the task of self-management or caring for their family members.
\nBaker [88] concurring with other researchers agree that culturally, health care is multifaceted idea. National Center for Cultural Competence [89], culture has been defined as the “integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group.”
\nState of illness is viewed through a cultural lens in countries around the world. With these cultural lens people summarize health and sickness and based on their perception will respond to the health message. It’s important to note that culture will help people determine what treatment options are best (by going to the medical doctor or the herbalist), and it helps people interpret symptoms [90]. It is important to recognize that based on these cultural health beliefs that an individual has, will greatly impact how they think and feel about their health and health challenges. It also affects the kind of people that they seek care from and how they respond to recommendations to make changes to their lifestyle and how they accept health intervention messages [91].
\nDue the complex nature of health literacy and cultural practices, health literacy cannot have one “sprang” approach in reaching the populace. Health literacy is not determined solely by an individual’s capacity to read, understand, process, and act on health information. However, it’s dependent on the request that individuals make for health information and their ability to decode, interpret, and understand the information presented. Furthermore, health literacy is not constant, but is a dynamic state that may change with the situation [88]. Researchers have agreed that in order to effectively deal with low health literacy in the health care system, there needs to be an aggressive research agenda that will in cooperate evidence base tools that will provide relevant data in order to address these challenges [92].
\nCultures also vary in their styles of communication, in the meaning of words and gestures, and even in what can be discussed regarding the body, health, and illness. Health literacy requires communication and mutual understanding between patients and their families and healthcare providers and staff. Culture and health literacy, both influences the content and outcomes of health care encounters [29]. Cooper and Roter [93] review the relationship that exists between the relationship between culture, patient-provider interaction, and quality of care and have concluded that culture gives significance to health information and messages. The awareness that people have about the definitions of health and illness, preferences, language and cultural barriers, and stereotypes are strongly influenced by the individual’s culture which can greatly sway health literacy and health outcomes. Furthermore, others challenges are developed due to the different educational backgrounds among patients and providers and those responsible to create health information can lead to cultural challenges based on the wording used to share the information [93].
\nResearch done on the importance of culture and health literacy in European-American cultural groups indicated that the use of language differs in discussing symptoms such as pain [94, 95]. Base on the cultural, linguistic differences were linked with changes in diagnoses, regardless of symptomology. African-American patients frequently experience shorter physician-patient interactions and less patient-centered visits than Caucasian patients [93, 96].
\nWith the ever increasing melting pot of ethnicity in countries around the world, health care systems are forced to recognize these different ethnic groups with cultural diversity in order to be inclusive [93]. Therefore, cultural, social, and family norms have transformed the attitudes and beliefs which will significantly impact the levels of health literacy (native language, socioeconomic status, gender, race, and ethnicity are considered as influencers that limits person’s control which affects his or her ability to participate fully in a health-literate society [97]. It behooves the health care providers to properly utilize the various modes of communication such as news publishing, advertising, marketing, and the plethora of health information sources available through electronic channels are also integral to the social-cultural landscape of health literacy when communicating with cultural masses [29].
\nBy incorporating a greater focus on health literacy, health care professionals will move closer toward a patient-centered health care system (Figures 1 and 2).
\nThe intersection of health literacy with health care improvement [98].
Governments around the world must understand that need to develop a health care system that works is not the burden of health care consumer. The need to improve health literacy must be seen as a partnership between public and private organizations whose primary focus is to help citizens become health literate. This cohesive partnership will help both developed and developing nation’s realized improvements in health literacy will play a major role in improving health care systems and the holistic health for their citizens [73].
\nSince health literacy is not constant, but dynamic, governments must observe health literacy as fundamental to health, and essential for improving quality of patient care. Low levels of health literacy present a formidable challenge to the widespread and effective use of patient self-management [99]. However, these challenges can be met. Although, health literacy continues to get more attention at the national level and economic cost becomes visible, improving health literacy will be crucial in reducing adverse outcomes that are connected with low health literacy [73]. Within the twenty-first century there is no universal solution, but by gathering relevant data and implementing best practices can be strategies that can be steadily used to improve health literacy for populations around the world. By simplifying health literacy information which will increase the usability of this information must be the priority focus. When patients can relate health information in plain language in both the written and spoken formats will help in improving the decision-making capacity of the client [92]. The method of assessing and responding to health literacy at the governmental level has been a progression in the focus of health literacy as a responsibility of the patient. However, organizations and systems are accountable for designing service delivery that challenges the health literacy needs of the clients of health care providers [99].
\nGovernments, policy makers, organizations, health practitioners and community members must work in partnership to address health literacy issues contributing to poor health outcomes such as mortality and morbidity. We are therefore recommending the following:
Implementing the Ophelia (Optimizing Health Literacy and Access to health information and services) Australian approach in our health care system and in extent in all developing countries. This approach involves the collaboration of a wide range of healthcare professionals, government leaders or representatives, community health center or hospital patients and leaders to develop health literacy interventions that are based on needs identified within a hospital or community.
Develop and implement policies that promote documentation of health literacy issues and the implementation of targeted responses.
Develop and implement policies that promote equitable access to health information and services for all citizens.
This visualization for health literacy as an intervention to reduce hospital mortality and morbidity rates can be effective as the data presented shows the importance of meeting the needs of patients with low health literacy in Jamaica. Healthcare professionals have an important role to play, but the responsibility for achieving real progress for patients facing challenges related to health literacy must extend to greater government involvement by creating health literacy policies and programs in both rural and urban areas.
\nGreater emphasis needs to be placed where the hard-to-reach or disadvantaged or vulnerable groups which include the elderly, children and patients with disability (mental/physical/intellectual). In Jamaica, we are still stuck at the developmental stage of understanding the scope of health literacy and the challenges patients face and developing cultural relevant interventions to address them. The relationship between health literacy and health outcomes such as mortality and morbidity needs to be explored through further research. The interventions identified in this chapter are stepping stones which need significantly greater support, resources for research and implementation of interventions.
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\n\n\n\nIntechOpen is committed to disseminating high-quality scientific research in a manner that exemplifies the best practice in scholarly publishing. IntechOpen is an official member of the Committee on Publication Ethics (COPE), which advocates the maintenance of the highest ethical standards for all parties involved in the act of publishing, including Authors, Academic Editors of the book, Peer Reviewers, the publisher and Societies, where applicable.
\n\nIn line with publication ethics practices recommended by COPE, ICMJE, and other similar organizations, IntechOpen's contributing Authors, Academic Editors, and Peer Reviewers are required to declare fully all possible conflicts of interest.
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\n\n\n\nThe Internet has changed the dynamics of scholarly communication and publishing which is why we find it necessary to clearly indicate our stance on what we consider to be a published scientific work. A significant number of working papers, early drafts, and similar works in progress are shared openly online between members of the scientific community. It has become common practice for researchers to announce their work on a personal website or a blog in order to gather comments and suggestions from other researchers. Such works and online postings are ‘published’ in the sense that they are made publicly available, but this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\n\n\n\nTo identify instances of fraud and misconduct during the publishing process, IntechOpen implements a robust policy governing such occurrences. In line with our general commitment to openness, and in order to maintain the highest scientific standards, we are committed to transparency about our editorial policy regarding retractions and corrections.
\n\n\n\nWhen faced with potential misconduct, IntechOpen accepts its responsibility to maintain the integrity of the academic record. For particularly complex cases, IntechOpen might ask for the assistance of formal industry bodies or seek advice from an appropriate team of advisors.
\n\nIntechOpen's advisors are professionals and scholars with broad knowledge and understanding of different aspects of the scientific publishing process: editorial, authorship, and reviewing roles; publication ethics, copyright, and general legal issues; as well as bibliographic and technical standards.
\n\nIn order to provide us with unbiased insights, without compromising the privacy of third parties, IntechOpen presents problematic cases to its advisors in an anonymized format.
\n\nIntechOpen publishes books in the English language. If you are interested in the translation of Book Chapters, please check IntechOpen's Translation Policy.
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\n\nAt IntechOpen we realize that exceptional circumstances can occur, resulting in a request for a refund. We will honor all justified requests in the specific instances outlined in our Refund Policy.
\n\n\n\nAll chapters will be published via IntechOpen's 'Online First' service meaning chapters will be published individually, immediately after review and before the entire book is ready for publication, allowing content to be shared, searched and cited straightaway, thereby generating early stage interest and momentum for your research
\n\nOnline First Chapters are considered published on the day they are posted and are citable from that date.
\n\nChapters will remain listed as Online First until the final versions of the books are published online. Following publication of the full monograph, Chapters will be redirected from the Online First version and will be available only through the final link of the official published page.
\n\nYou are invited to download, use, reproduce, make derivative works of, display, distribute and cite the Online First works. You can find "How to Cite and Reference" by following the link at the end of each online book chapter. Please be aware that it is possible that further editing and changes might be made before the final release of the book.
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