Literacy — the ability to understand and use written information well enough to work, learn and take part in everyday life — underpins every aspect of modern life, yet a significant proportion of Australian adults struggle with foundational literacy skills. 

Research from the Programme for the International Assessment of Adult Competencies indicates that around 44% of Australians aged 15 to 74 have literacy skills at Level 2 or below — meaning they can comprehend only basic texts on familiar topics. At Level 1, adults can read brief texts on familiar topics and locate a single piece of specific information identical in form to information in the question.

This baseline challenge has profound implications when we consider how people engage with health information:

• Like many other developed countries, almost 60% of adult Australians have low individual health literacy, which means they may not be able to effectively exercise their choice or voice when making healthcare decisions. 
• The Australian Institute of Health and Welfare found that in 2006, only 41% of Australians aged 15–74 were assessed as having adequate or more than adequate health literacy skills. 

These figures paint a concerning picture for workers' compensation stakeholders.

Literacy as a barrier in workers’ compensation

For injured workers navigating the compensation system, low health literacy creates significant barriers. Understanding medical terminology, treatment options, medication instructions and rehabilitation protocols requires skills that many workers simply don't have. 

Low individual health literacy is associated with higher use of health services, low levels of knowledge among consumers and poorer health outcomes. In the workers' compensation context, this can manifest as delayed recovery, poor treatment adherence and difficulty engaging with RTW processes.

People with low health literacy are between one-and-a-half and 3 times more likely to experience an adverse health outcome than those with higher health literacy. 

Research has also linked poor health literacy to low medication adherence and a lower likelihood of following advice from doctors. 

The role of others

The role of treating practitioners, case managers and rehabilitation providers becomes paramount in this environment. When workers cannot independently assess or interpret health information, they place substantial trust in those guiding their recovery. 

Every explanation from a physiotherapist, every instruction from a treating doctor and every message from a claims manager carries considerable weight. These communications shape how injured workers understand their condition, their recovery trajectory and their capacity to return to work.

When trust meets misinformation — the danger of non-evidence-based messaging

This trust, while essential to the therapeutic relationship, becomes problematic when the messages providers give diverge from evidence-based practice. 

An injured worker with limited health literacy has little capacity to critically evaluate the information they receive. They cannot cross-reference advice against clinical guidelines or distinguish between outdated beliefs and current best practice. They simply trust what they are told.

The research on this phenomenon is compelling. Patients who are faced with stressful experiences or life-threatening events, such as accidents, injuries or acute illnesses, are often in a natural trance state and so highly suggestible to whatever their doctors communicate to them. They are also vulnerable to misunderstandings resulting from literal interpretations, ambiguities and unclear communications. 

Consider the consequences when a treating practitioner communicates — explicitly or implicitly — that an injury is severe, that certain movements are dangerous or that returning to work will cause further harm. For a worker who lacks the health literacy to question such statements, these messages become deeply embedded beliefs. 

Medical situations are hot spots in the life of a patient with potentially long-lasting effects arising from the use of either negative expressions or encouraging statements. 

This is the nocebo effect in action: when negative expectations lead to negative outcomes. Research demonstrates that any symptom can be induced or worsened by inappropriate communication about it. When providers use catastrophic language, over-medicalise routine conditions or recommend excessive rest contrary to evidence that supports early activation, they inadvertently program the injured worker for prolonged disability.

The fear-avoidance cycle

The fear-avoidance model of musculoskeletal pain provides a robust framework for understanding how negative messaging translates into poor outcomes. It suggests that after musculoskeletal injury there are 2 potential recovery pathways — depending on the presence of negative affect, threatening-illness information, pain catastrophising, fear of pain and pain anxiety. When psychological factors are elevated by provider messaging, the potential for avoidance behaviours increases dramatically.

Research consistently shows that fear of movement-related pain and avoidance behaviours can be rapidly acquired during an acute pain episode and are associated with the development and maintenance of chronic disabling pain. And evidence also suggests that fear-avoidance beliefs in people with chronic musculoskeletal pain are associated with poor treatment outcomes. 

The consequences extend beyond physical recovery. Negative catastrophic thoughts lead to avoidance of activities and hypervigilance in monitoring bodily and pain sensations. This is followed by withdrawal from recreation and family activities, which then can lead to depression, physical disuse, deconditioning and disability. This creates a self-perpetuating cycle that becomes increasingly difficult to break.

Pain catastrophising is preventable 

When injured workers receive negative messaging, they are at increased risk of developing pain catastrophising — a maladaptive cognitive response with serious implications. 

Pain catastrophising has been associated with a range of adverse clinical outcomes, such as suicidal ideation, opioid overuse and prolonged disability. High scores on measures of pain catastrophising predict poor response to analgesic medication, physical therapy, multidisciplinary rehabilitation and surgical interventions. 

Research on trauma survivors specifically shows that fear of movement and catastrophising explained a significant proportion of variance in pain intensity (29%), pain interference (34%) and physical health (19%). The study concluded that fear of movement and catastrophising are risk factors for poor long-term outcomes after traumatic injury. 

These findings have direct relevance to workers' compensation. When pain from an original injury is interpreted as threatening (pain catastrophising) it results in fear of re-injury, which leads to movement avoidance, hypervigilance and muscle reactivity. That in turn leads to disuse, depression and disability — all of which maintain pain. 

A system-wide responsibility

Effective, evidence-aligned communication in the workers’ compensation sector is not merely good practice but fundamental to achieving recovery outcomes. By acknowledging the health literacy challenges facing Australian workers, we can design systems and interactions that support, rather than hinder, their return to health and work.

Training providers in health literacy-sensitive communication is essential. So too is establishing mechanisms to identify and address messaging that contradicts evidence-based recovery principles. Instead of focusing on limitations, best-practice guidelines recommend that patient education and counselling strategies should promote an understanding of the:

• anatomical and structural strength inherent in the human spine
• neuroscience that explains pain perception
• overall favourable prognosis
• use of active pain coping strategies that decrease fear and catastrophising
• early resumption of normal or vocational activities even when still experiencing pain, and 
• the importance of improvement in activity levels, not just pain relief. 

When we understand that injured workers often can’t advocate for themselves or challenge the information they receive, we accept that the responsibility lies with us — the professionals, the systems and the sector — to get it right. 

When health care personnel are aware of and evaluate what patients are exposed to, hear and see, when they know more about the effects of nocebo’s and negative suggestions and pay more attention to these matters, they will better recognise the detrimental influences in their own clinical environment.