Midwives’ self-reported knowledge and skills to assess and promote maternal health literacy: A national cross-sectional survey
Introduction
Health literacy is the capacity to access, understand, and use health-related knowledge [1]. The World Health Organization regards health literacy as one of three key pillars for global action towards the United Nations Sustainable Development Goals [2]. However, more than half the Australian population have poor health literacy which adversely impacts on their capacity to make informed decisions and participate in their own care [3]. Previous population-based studies have tended to assess functional aspects of literacy, such as understanding text, finding information, and problem-solving [4]. In Australia, the recent National Health Survey [5] included the Health Literacy Questionnaire which moves beyond a functional approach to a conceptual understanding about how individuals not only find but use health information; how they manage their health; and interact with healthcare providers [4].
Pregnant women need health literacy to guide decisions that affect their own health and that of their infant [6]. For example, a recent review on the influence of health literacy on women’s reproductive knowledge, outcomes, and behaviours showed breastfeeding rates and use of prenatal vitamin supplements were lower in women with poor health literacy [7]. Midwives play an important role in providing pregnant and postpartum women with information about their health, childbirth choices and early parenting [8,9]. However, an extensive search of the literature identified few studies on midwives’ knowledge and skills to assess and promote maternal health literacy.
Hughson et al. [10] conducted semi-structured interviews with 18 Australian health professionals (including seven midwives) to investigate communication about health literacy issues when providing care to women from culturally and linguistically diverse backgrounds. In addition to challenges associated with language and cultural differences such as inadequate interpreter resources, barriers to optimal delivery of health care information included women’s non-attendance at appointments, time constraints, and high workload. As anticipated, awareness of potential communication problems was more acute when the risk of low health literacy was obvious, such as speaking to women from other cultures. However, less obvious indicators of low health literacy such as poor reading skills were overlooked by health professionals, particularly when time-pressed [10].
Wilmore et al. [11] explored the extent and quality of tailored health communication by midwives providing antenatal care to clients from diverse backgrounds. The authors conducted individual and group interviews with a total of 21 midwives, observed practice, and held informal discussions. Midwives identified health literacy as a key factor in women’s understanding and application of health information but did not formally assess health literacy level; again, citing time as a constraint [11]. A phenomenological study with seven nurse-midwives in the United States (US) identified that tailoring communication based on women’s needs and meaningful midwife/woman relationships were important in evaluating and building health literacy levels of women [12].
Published quantitative studies have investigated health literacy of nurses rather than midwives. One web-based survey of 76 US registered nurses identified limited understanding of health literacy and skills [13]. Nurses described the importance of health literacy in understanding health information but seldom acknowledged the importance of health literacy in making health decisions [13]. Only one third of respondents (n = 23) reported asking if a patient had any difficulty reading medical information or completing medical forms, key indicators of low health literacy [13].
Similar findings were obtained from a survey of 456 US nurse practitioners [14]. Although most nurses were aware of patient characteristics likely to indicate low health literacy skills (such as poor reading ability, poverty, and being from a cultural minority group), two thirds (n = 299) never used formal screening tools and one quarter did not understand the adverse consequences of low health literacy [14]. One third (n = 146) never evaluated the reading level of information material they gave to patients [14].
A large online survey of 736 healthcare professionals in Taiwan identified a range of strategies used to improve patient understanding of healthcare information such as using plain language, teach back, making eye contact, and paying attention to questions that were asked repeatedly [15]. However, participants were less likely to use other mediums of information delivery such as audio-visual or web-based teaching aids or designing specific resources.
In a novel US study, new parents (n = 59) of an infant being discharged from neonatal intensive care were asked to complete a brief health literacy measure [16]. Nurses independently rated parents’ level of understanding about the discharge instructions on a 5-point Likert scale from ‘1 = did not understand at all’ to ‘5 = complete understanding’. Not only was there no correlation between parents’ health literacy scores and nurses’ perception of parental understanding, but nurses perceived adequate comprehension in 83% of parents who had low health literacy [16]. Failure to adequately assess and tailor communication to parents’ level of health literacy when providing important information and instructions at discharge places vulnerable infants at risk [16].
Globally, there is growing acknowledgement that health literacy is crucial to optimal health, but a lack of research on midwives’ understanding of maternal health literacy. The current study addresses this gap through the development and testing of a new tool to measure Australian midwives’ health literacy knowledge, skills and attitudes.
Section snippets
Study design
A cross-sectional design was used to collect self-reported online survey data.
Instrument development
We followed the tool development process recommended by De Vellis [17] which involved item generation, expert panel review, pilot testing, and item and factor evaluation. A literature review of measures of health literacy with health professionals was conducted to generate a comprehensive list of potential health literacy competencies and practices appropriate for adaptation to midwifery. Thirty-six draft items were
Participant characteristics
The Australian College of Midwives email was opened by 1438 recipients and 92 members clicked through to the survey; the view rate was 0.1% which is common for a voluntary survey [25]. Snowball sampling through email sharing and social media precluded an overall response rate being determined. A total of 358 midwives opened the survey and 307 of those commenced, giving a completion rate of 85.7%. Survey forms with any section completed in full were retained, refer to Table 1 for sample numbers.
Discussion
This is the first reported study to develop and test a tool to assess midwives’ knowledge and skills in maternal health literacy. The significance of the results is discussed in terms of: (1) reliability and validity of the TMCC Health Literacy tool; and (2) implications for midwifery practice, education and research.
Conclusions
Australian midwives may lack the skills required to facilitate active maternal decision-making using a health literacy framework. Midwives need to provide information in an uncomplicated and accessible manner, and actively ensure that maternal understanding has occurred. The TMCC Health Literacy Scale can be used to quickly determine midwives’ health literacy skills and knowledge. Findings can inform professional development activities, education, and workforce research. The extent to which the
Funding
None declared.
Ethical statement
The study received approval from Griffith University Human Research Ethics Committee (Ref No: 2019/186) on 5 March 2019.
Conflict of interest
None declared.
CRediT authorship contribution statement
Debra K Creedy: Conceptualization, Investigation, Methodology, Project administration, Writing - original draft, Writing - review & editing. Jenny Gamble: Conceptualization, Writing - review & editing. Rhonda Boorman: Investigation, Validation, Writing - original draft, Writing - review & editing. Jyai Allen: Conceptualization, Writing - review & editing.
Acknowledgement
None.
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