Literacy is often referred to as a tool, but I prefer to think of it as a key. Many of us have multiple keys at our disposal for unlocking different kinds of knowledge – a key for understanding information about health, a key for understanding information about science, a key for negotiating our communities and cultures, a key for understanding written and spoken languages – and the more keys we have, the more knowledge we can unlock for ourselves. But if we don’t have the keys, either because we haven’t been given access or they are being kept from us, then the gatekeepers of that knowledge are ensuring we cannot have access to it. Too often in health, we as health professionals are the gatekeepers of access when those gates should be open wide.
The featured review from this issue, “Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency,” highlights this problem by exploring how full, equal communication improves care, which in turn improves health outcomes.1 Another review from this issue, “Effects of health literacy interventions on health-related outcomes in socioeconomically disadvantaged adults living in the community,” identifies some effective ways that health literacy, or the ability of individuals to understand and apply health information, can be improved.2 The third review in this month's issue is a scoping review titled “Adults with intellectual and developmental disabilities and interprofessional, team-based primary health care,” in which the literature is mapped and described in terms of the health benefits of this system of care.3
Aside from addressing issues pertinent to communication and equity in health care and bringing together the evidence, these three reviews share something else in common. All these well-conducted reviews of rigorous studies reveal added measures health systems can take to make health care more accessible. Because right now, no matter where you are, there are people experiencing difficulty accessing health care, whether due to racism, ableism, homophobia, transphobia, a lack of cultural safety, or other discriminatory structures built into health care systems.4
What if there was no need to add extra measures? What if our social systems were actually designed to help all the people who use them? Perhaps if we adapted the systems so they worked for everyone, we could prop the gates open and people wouldn’t need to earn new keys to be able to get through them. Health care as it stands all over the world works well for some of the people some of the time. The rest of the time, it enforces inequalities, excludes and actively damages people who have every right to expect the same level of care as the majority of the population.
Racism is strongly associated with negative health services experiences, according to a meta-analysis of 70 studies with 250,850 participants.5 That's not an accident or a few “bad apples” – rather, it is indicative of broken systems that are failing their users. For example, a national survey in Peru of people with disabilities reported a lower rate of seeking health care among those who experienced discrimination in health care settings, and significant effects of discrimination for people with communication disabilities and physical disabilities.6 If health care were culturally safe, fewer Indigenous people would die because going to hospital or seeing a doctor would not be the demeaning, disempowering experience it currently can be.7
If people feel unsafe accessing health care, if they feel there is no point because they can’t make themselves understood or get the help they need, it's clear that they will avoid seeking care until it becomes unavoidable or they die. People who wait until they are very unwell to seek treatment have poorer outcomes, spend longer in hospital, and are more expensive to treat. This isn’t news; we’ve known it for a long time. It's time to stop introducing programs to “fix” the people who use our systems and instead introduce permanent changes to fix our systems. It's time to stop treating one group of people as the default human and everyone else as a somewhat faulty version. The best time to have removed the gates that keep people from participating was yesterday; the second-best time is now.
1. Boylen S, Cherian S, Gill FJ, Leslie GD, Wilson S. Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review. JBI Evid Synth
2020; 18 (7):1360–1388.
2. Stormacq C, Wosinski J, Boillat E, Van den Broucke S. Effects of health literacy interventions on health-related outcomes in socioeconomically disadvantaged adults living in the community: a systematic review. JBI Evid Synth
2020; 18 (7):1389–1469.
3. Bobbette N, Ouellette-Kuntz H, Tranmer J, Lysaght R, Ufholz L, Donnelly C. Adults with intellectual and developmental disabilities and interprofessional, team-based primary health care: a scoping review. JBI Evid Synth
2020; 18 (7):1470–1514.
4. Krieger N. Discrimination and health inequities. Int J Health Serv
2014; 44 (4):643–710.
5. Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: a systematic review and meta-analysis. PLoS One
2017; 12 (12):e0189900.
6. Moscoso-Porras MG, Alvarado GF. Association between perceived discrimination and healthcare–seeking behavior in people with a disability. Disabil Health J
2018; 11 (1):93–98.
7. Laverty M, McDermott DR, Calma T. Embedding cultural safety in Australia's main healthcare standards. Med J Aust
2017; 207 (1):15–16.