Health Literacy and Infectious Diseases: Interview with PLOS ONE Academic Editor Enrique Castro-Sanchez

To continue our series on health literacy, this week we interview PLOS ONE Academic Editor Dr. Enrique Castro-Sanchez, who tells us about the importance of health literacy in infectious diseases research, and the benefits of Open Science.

Dr. Enrique Castro-Sanchez is the Senior Lecturer in Planetary Health at the BASc Global Challenges programme at Brunel University London (UK), a position he combines with an honorary lectureship at Imperial College London (UK), and visiting posts at University of Balearic Islands (Spain), and Shifa university (Pakistan).

His clinical experience focuses on infections, infection control, and antimicrobial stewardship. From 2012-20 he was Lead Nurse for Research at the NIHR Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance at Imperial College London. In 2016, Enrique was selected as Emerging Leader in International Infectious Diseases, and in 2017 he worked as Consultant for the World Health Organization developing leadership education for national leaders. That year, he was also appointed as one of the 70 NIHR 70@70 Senior Nurse Research Leaders to increase research capacity for nurses in the national health service in England.

He received an MSc Public Health from the London School of Hygiene and Tropical Medicine, and completed his PhD in 2015. Enrique has gained funding from NIHR, AHRC, ESRC, BRC, with research in UK, Pakistan, India, Rwanda, South Africa, Mexico, Chile, Argentina, and Spain. He is Editor-in-Chief of Infection Ecology and Epidemiology journal, and holds editorial positions in PLOS ONE, JAC-AMR, BMC Public Health, and BMC Health Services Research.

Please tell us a little bit about your research, and how it relates to health literacy.
My research focuses on how people (healthcare workers, patients, citizens, policymakers) make decisions about antibiotics, infections, and infection control. I have always been interested in communication and how to best inform different audiences about these topics. Despite its importance, health literacy has not traditionally been the focus of attention for those working in infectious diseases, with many gaps identified by some of my work.

The WHO has identified antimicrobial resistance as one of the top 10 global public health threats facing humanity. How can health literacy research address this threat?
Health literacy research can significantly contribute towards interventions to improve how antimicrobials are used by healthcare professionals, patients, and citizens, and help policymakers to support such interventions. For example, at a fundamental level, it is vital to identify the knowledge and skills that people need and have so they can make informed decisions about antibiotics and their use. The evidence from this research would help us clinicians and public health workers to then develop appropriate educational interventions that can increase the understanding of the population about infections, antibiotics, antibiotic resistance, and so on. We could improve the communication skills of healthcare workers, to make information about antibiotics and infections more accessible and easier to understand for patients, and even some national agencies could improve how they communicate with the population (see some work we did on Ebola here).

Also, health literacy can contribute towards the understanding of the underlying factors that influence behaviors related to antibiotic use. Recognizing these behaviors, together with the barriers and facilitators to using antibiotics appropriately, would allow us once again to develop effective interventions. For example, people are more likely to use antibiotics inappropriately if they have low health literacy, if they are under pressure from family or friends to take antibiotics, or if they believe that antibiotics are always the best way to treat infections (which would not be the case in viral infections like a cold, for example), so we can address these social and cultural factors that influence antibiotic use.

One of your interests is the relationship between health literacy and health inequalities. What are the most important research questions in this area?
Yes, I am particularly interested in this relationship, which is a complex one. Emerging work using holistic conceptualization of health literacy includes a powerful component of equity. We need to have a solid understanding of the mediating role of health literacy between social determinants of health and health outcomes. These social determinants (for example, poverty, education, ethnic group, etc.) are known to play a major role in health inequalities. Health literacy may help to explain how social determinants of health influence health outcomes.

Also, we lack evidence about most effective interventions for improving health literacy among those populations typically left behind, ostracized, and marginalized by health and social care services as well as public health systems. Data about any of these interventions should strive to include evidence on sustainability, and implementation.

The COVID-19 pandemic has had a hugely disruptive impact on society. How has it changed the landscape of health literacy research?
Absolutely, the pandemic has been hugely and suddenly disruptive, and it would have been surprising if health literacy research and work had been free from such disruption. The pandemic has highlighted the importance of health literacy in several ways. For example, we have seen how people with low health literacy were more likely to experience poorer clinical and health outcomes. This situation should not have been really a surprise, considering the relation between socioeconomic position and COVID-19 infection and disease, and the interplay between this position and health literacy. An example connecting health literacy and COVID-19 may have been that people with low health literacy would likely have more difficulty understanding and following public health and self-care guidelines, leading to admission to hospital and death from COVID-19. The pandemic has disproportionately affected groups of people left behind and marginalized, which are more likely to have low health literacy. I feel that globally, more work could have been carried out by national and international agencies to ensure that these groups were adequately supported.

The pandemic has also shown how essential health literacy is for effective public health communication. Public health and government officers faced the challenge of communicating complex and rapidly changing information to a wide range of audiences. Health literacy research can help inform the development of communication strategies that are accessible and understandable to everyone. Disinformation and misinformation have appeared as crucial challenges to explore and address.

What kind of health literacy research would you be most excited to read about as an Editor for PLOS ONE?
I would love PLOS ONE to publish multidisciplinary papers offering insights on the development and evaluations of interventions for populations left behind, and studies exploring the intersection of health literacy and social determinants of health. I would also be delighted to read experiences using large language models and chatbots as part of health literacy interventions. Finally, it would be great to see reports of co-design and co-development between researchers and populations focused on health literacy.

How can health literacy principles be applied when authors share the results of their research, and what is the role of Open Science?
Authors can profit from health literacy principles to engage with the public and citizens, as well as researchers from other disciplines, and policymakers. They can adopt approaches such as using clear and concise sentences, avoiding unnecessary and obscure terms, and striving to use plain language. There is a good debate going on about ‘antimicrobial resistance’, for example, and whether ‘drug-resistant infections’ may be a better term. Authors could also increase their efforts to explain the implications of their research, and what it may mean for citizens and society’s wellbeing, or the implications for public policy or clinical practice.

In terms of Open Science, it is imperative to make research accessible and transparent to everyone. I often think that the research community, with research and salaries routinely funded by the taxpayer, could do more to ensure citizens can see and learn about our work, methods, and findings. It may help dispel myths about the evidence we use to decide what to do in case of a pandemic, for example. Open Science initiatives contribute to that benefit.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS

Keep reading next week for research highlights on health literacy and cancer.

References:
Castro-Sanchez E, Chang PWS, Vila-Candel, R, Escobedo AA (2016) Health literacy and infectious diseases: why does it matter? Int J Infect Dis. 43:103-110.
Castro-Sanchez E, Spanoudakis E, Holmes AH (2015) Readability of Ebola Information on Websites of Public Health Agencies, United States, United Kingdom, Canada, Australia, and Europe. Emerg Infect Dis. 21(7):1217-9
Cabellos-Garcia AC, Castro-Sanchez E, Martinez-Sabater A, Diaz-Herrera MA, Ocana-Ortiz A, Juarez-Vela R, Gea-Callero V (2020) Relationship between Determinants of Health, Equity, and Dimensions of Health Literacy in Patients with Cardiovascular Disease. Int. J. Environ. Res. Public Health 17(6), 2082
Hange N, Agoli AM, Pormento MKL, Sharma A, Somagutta MR, Paikkattil N, et al. (2022) Impact of COVID-19 response on public health literacy and communication. Health Promot Perspect. 12(1): 1-9