Obesity in Australia increased from 19% to 27% in the period from 1995 to 2011-12. Strongly correlated with lower socio-economic status, especially in women, its high rates contribute to the increased prevalence of chronic diseases, such as cardiovascular disease (CVD), diabetes and cancers. Overweight and obesity are second only to smoking as a contributor to the burden of disease in Australia. People who are obese are often discriminated against in the workplace. Stigma in health care contributes to reluctance to seek treatment for weight management. This stigma is also associated with unhealthy eating behaviours and reduced physical activity (PA).
Obesity is common in general practice with the proportion of obese adults seeing general practitioners (GPs) increasing from 22% in 2005-06 to 28% in 2014-15. Primary health care (PHC), therefore, plays an important role in addressing obesity. Patients’ health literacy has a significant impact on the management of obesity in PHC and is an important factor that has been shown to influence the frequency of preventive assessment, advice and referral.
The World Health Organization defines health literacy as “the cognitive and social skills which determine the motivation and the ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health”. Low health literacy affects 59% of the Australian population and contributes directly and indirectly to health disparities. It has been found to explain a substantial proportion of the difference in the uptake of preventive programs and self-management of chronic diseases.
In clinical care, low health literacy is often viewed as a deficiency that needs to be identified and managed. However, it can also be thought of as an asset for patients that, if developed, can empower individuals to exert greater control over their own health. Health literacy has been theorised to influence the use of services, the quality of communication between patient and provider and self-management behaviours. We have demonstrated the link between health literacy and risk behaviours in our previous research. People with low health literacy miss opportunities for prevention and suffer adverse health outcomes as a result. Furthermore, low health literacy has significant impacts on health care utilisation and health outcomes.
The National Health and Medical Research Council (NHMRC) clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia identify a role for PHC across the 5As in Asking about and Assessing patient risk and motivation; providing Advice on the benefits of a healthy lifestyle and discussing Agreed goals and priorities; Assisting patients to develop a weight management plan which often involves referral to other services; and Arranging follow-up in order to prevent weight gain. Multiple interventions targeting nutrition, PA and psychological approaches to behavioural change are more likely to be effective in addressing overweight and obesity than single component interventions.
However, there is evidence that these recommendations are not being adequately implemented in general practice. Less than a quarter of patients attending general practice had their body mass index (BMI) measured in the previous 12 months and less than 5% had their waist circumference measured. Few at-risk patients receive advice on diet or PA and even fewer have been referred to other services.
Patients’ low health literacy may be one of the barriers to preventing and managing obesity in PHC. When patients do not ask questions or engage in a discussion about weight loss, providers often interpret this as lack of patient motivation. However, patients with low health literacy may not feel confident to ask questions or engage in a discussion about weight loss with their primary health care provider. Providers may incorrectly assume that obese patients are not interested in taking an active role in their health care.25 Despite the potential impact of low health literacy on weight loss management for obese patients in PHC, it has received little attention in research. It is not known how PHC providers should best manage obesity in the context of low health literacy.
Our aim was to develop and evaluate the feasibility and impact of a PHC approach to weight management tailored to the level of health literacy of obese patients. There were three key activities undertaken in this regard: 1) a literature review; 2) a pilot study; and 3) a weight management trial called “Better Management of Weight in General Practice” (BMWGP).
In this report we describe the three activities and use the BMWGP baseline data to explore three issues. First, we look at the effectiveness of a screening tool to identify patients with low health literacy in general practice. Second, we describe the association between health literacy and a range of factors, behavioural intentions, lifestyle behaviours and quality of life to better understand the link between health literacy and health in a population of patients with obesity attending general practices. Third, we identify the groups most likely to experience weight stigma and how stigma relates to health literacy.