Health literacy is defined by the Center for Disease Control in the USA as, "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others” (Santana et al). It is no secret that in Kuwait we have poor health literacy in our population. A study on diabetic patients in Kuwait found that 44 percent of diabetic patients in Kuwait have poor health literacy (Hussein et al).
Anecdotally, I can attest to the countless patients I have seen with misunderstandings about their health and conspiracies regarding healthcare as a whole. I often wonder if there is a single person out there on a WhatsApp group chat who is intentionally spreading misinformation. But alas that is too simple of an explanation for our current state. The issue with poor health literacy is that it does not just manifest as arguments with doctors or relatives over health decisions; rather it takes the form of poor health outcomes.
Poor health literacy
The research has shown patients with poor health literacy are more likely to attend emergency rooms, are hospitalized more, and are less likely to take their medicines properly (Berkman et al). The issue of health literacy gets even more complicated when it relates to mental rather than physical health. I do not believe many would disagree when I say that stigma against mental health in Kuwait is a pressing issue. And for those who would disagree, research done by Scull et al. supports the existence of mental health stigma in Kuwait (Scull et al).
Combine stigma with poor health literacy and what we get are people that are less likely to seek treatment and stick to their treatment plan. This is not to say that great strides have not been made in recent years. For example, many polyclinics now can manage common mental health issues like mild depression. However, much of the public discourse surrounding mental health focuses on diagnosis. But from my experience working in mental health both at Amiri hospital and the Kuwait Center for Mental Health is that the public still has a poor understanding of treating mental health issues.
When someone gets a chest infection due to bacteria, the solution to their health issue is intuitive: if we get rid of the bacteria, we get rid of the health problem. The patient is then happy to take their antibiotics for a week and then feels back to normal. In the world of psychiatry, the issue is a bit more complex. Nothing illustrates this more than a question I am asked, on average, three times a week: is my condition genetic? My answer: partially.
The usual follow up is: is this because of the stressors in my life. My answer, once again: partially. The truth about mental health is that it is a complicated interplay between environmental, genetic, psychological, and personal factors. In this way, mental health can be compared to a cake- you need all the ingredients to make a cake, not just the eggs. With something so complicated, it is no wonder that we have yet to find a single pill to be a cure-all for psychiatry.
Bio-psycho-social model
So where does this leave health service users? More often than not, it leaves them confused when they don’t see a complete improvement the day after taking their medicines. It leaves them dubious of the doctor who is prescribing their treatments. Better health literacy about how doctors decide on treatment may be the solution. Specifically, the model that doctors use in every consultation they perform: the bio-psycho-social model.
The bio-psycho-social model is an approach in medicine which views patient health holistically. It holds that health is the result of biological, psychological, and social factors and that treatment of any condition requires addressing all these elements. This model is of particular significance in the realm of mental health. Let’s take depression for example. Biologically, we know that there are certain brain chemicals, specifically serotonin, which are not balanced in episodes of depression.
Psychologically, we know that maladaptive thought patterns and beliefs serve as triggers and fuel to said episodes. Socially, we know that poor social support and circumstances like poverty are linked with depression. Using this model, we can appreciate how managing depression would therefore include a combination of medications (bio), talk therapies (psycho), and seeking social support where needed (social).
The research supports this approach; for example, antidepressants and talk therapies like cognitive behavioral therapy have shown similar efficacy in managing depression, but the treatment choice which has shown longer lasting remission is a combination of both. The problem that myself and other doctors working in mental health face is we often can only address the "bio” part of the model through the use of medication.
Patient’s psychological
Realistically, even with consultations lasting up to an hour, a single meeting with a psychiatrist cannot address all of a patient’s psychological and social needs. This is in addition to the fact that it is not within our expertise to do so despite our best efforts/intentions. For example, although I may provide some psychological and emotional support during my consultations with patients, I cannot provide a structured therapy program like a clinical psychologist can.
This is where referrals to programs like group or individual therapy are critical, and it is the responsibility of doctors to provide them. Beyond this, sadly, the responsibility rests on the patient So how can we address the psychological and social aspects of mental health treatment? I believe that a big part of the answer lies in empowering people to address the parts of their treatment that doctors cannot.
The key to this empowerment lies in improved health literacy relating to our community’s understanding of the bio-psycho-social model. If we shift our mindset, as a community, that treating mental health is as simple as taking a pill, we may see people start to address the parts of the model that doctors cannot.
For example, we may see a greater willingness to engage with talk therapies without fear of stigma or shame. The best part of this shift is that these health and social support systems are already in place in Kuwait. Seeing a psychologist is as simple as asking for a referral. The bottom line is that people want to feel better and live normally with their mental health struggles, but only seeing their health through a single lens is unlikely to yield the results they hope for.