Health literacy: Perspectives from Australia

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Health literacyPerspectives from Australia

• Don Nutbeam
• University of Sydney, Australia
  

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What we need to know it cant be said more
eloquently

• Reports that say that something hasn't happened
  are always interesting to me, because as we know,
  there are known knowns there are things we know
  we know. We also know there are known unknowns
  that is to say we know there are some things we
  do not know. But there are also unknown unknowns
  - the ones we don't know we don't know

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Presentation objectives to answer some
questions

• What is health literacy ?
• What is the state of the science?
• Why is it a useful concept in public health?
• Where do we go from here?

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What is literacy?

• What is it?
• Functional literacy focuses on the ability to
  read basic text and write a simple statement on
  everyday life
• Why do we care?
• Those who are functionally literate are able to
  participate more fully in society, and are able
  to exert a higher degree of control over everyday
  events
• How big is the problem?
• Estimates of the proportion of the population in
  OECD countries lacking functional literacy skills
  range from 7 to 47 (UNDP, 2007)
• http//hdrstats.undp.org/indicators/30.html

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Literacy and health

• Relationship between low literacy and a range of
  health related outcomes well established
• Some indirect effects
• Employment
• Income
• Some direct effects
• Engaging in preventive health practices
  
• Early detection of disease
• Access to health care
• Management of chronic disease
• Dewalt DA et al Literacy and health outcomes a
  systematic review of the literature. Journal of
  General Internal Medicine, 19. 128-39 2004

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The emergence of the concept of health literacy

• The concept of health literacy emerged from
  different roots
• in clinical care, mainly from the US
• in public health, from Australia, and more
  recently Canada and the UK
• The two different roots led to quite different
  conceptualizations of health literacy as a risk
  and as an asset

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What is health literacy?

• Health literacy in clinical care
• emanating from concerns about the impact of low
  literacy on patient care
• health literacy is seen more as a risk or deficit
  that needs to be mitigated,
• set of capacities that act as a mediating factor
  in achieving health and clinical outcomes.

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What is health literacy?

• US Institute of Medicine defines health literacy
  as
• The degree to which individuals have the
  capacity to obtain, process and understand basic
  health information and services needed to make
  appropriate health decisions
• But recognition of social context of health
  literacy
• based on the interaction of the individuals
  skills with health contextsand broad social and
  cultural factors at home, at work and in the
  community
• Institute of Medicine. Health Literacy A
  Prescription to End Confusion. Washington DC,
  National Academies Press 2004

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What is health literacy 1?

• Health literacy is a set of individual
  capabilities in four domains
• Cultural and conceptual knowledge
• Speaking and listening skills
• Writing and reading skills
• Numeracy
• Focus on individual capacities indicates that
• health literacy may be developed (and can
  decline)
• Health literacy is partly knowledge based, and
  may be developed through educational intervention
• Health literacy is context specific and subject
  to influence by health care interactions and
  structures
• For a thoughtful examination and critique of the
  IOM definition see Barker D, The Meaning and
  Measure of Health Literacy. Jnl of General
  Internal Medicine 21.8, 878-883. 2006

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Health literacy and health

• Development of measurement tools and screening
  aids (eg TOFHLA, REALM)
• Led to more sophisticated understanding of
  health-related literacy and its association with
  a range of health practices and outcomes,
  especially
• Effective management of chronic disease
• Compliance with medication and other health
  advice
• Participation in health and screening programs
• Institute of Medicine. Health Literacy A
  Prescription to End Confusion. Washington DC,
  National Academies Press 2004

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Figure 1 Conceptual model of health literacy as
a risk.
Tailored health information, communication,
education
Health literacy assessment - Health-related
reading fluency, numeracy, prior knowledge
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Figure 1 Conceptual model of health literacy as
a risk.
Improved clinical outcomes
Enhanced capability for self management, improved
compliance
Tailored health information, communication,
education
Health literacy assessment - Health-related
reading fluency, numeracy, prior knowledge
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Figure 1 Conceptual model of health literacy as
a risk.
Improved clinical outcomes
5. Enhanced capability for self
management, improved compliance
Tailored health information, communication,
education
Improved access to health care, and productive
interaction with health care professionals
Health literacy assessment - Health-related
reading fluency, numeracy, prior knowledge
Organizational practice sensitive to health
literacy
1. Barker D, The Meaning and Measure of Health
Literacy. Jnl of General Internal Medicine 21.8,
878-883. 2006 2. Paasche-Orlow MK, Wolf MS. The
causal Pathway linking health literacy to health
outcomes. American Journal of Health Behaviour
2007 31 (Supplement 1) S19-26
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What is health literacy 2?

• Draws upon
• broader concepts of literacy,
• principles of adult education,
• concepts of health promotion

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Drawing on wider concepts of literacy

• Functional literacy
• basic skills in reading and writing, capacity to
  apply these skills in everyday situations
• Communicative/interactive literacy
• more advanced cognitive and literacy skills,
  capacity to actively participate, derive meaning,
  apply new information quickly to changing
  circumstances
• Critical literacy
• most advanced cognitive and literacy skills,
  critical analysis of information, ability to use
  information to exert greater control over life
  events and situations
• See for example Freebody P, Luke A.
  Literacies Programs Debates and Demands in
  Cultural Context. Prospect 1990 5(3) 7-16.

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What is health literacy?

• 2 health literacy in public health
• origins in health education and health promotion
• a set of capacities that enable individuals to
  exert greater control over their health and the
  range of personal social and environmental
  determinants of health.
• health literacy is seen as an asset to be built,
  as an outcome to health education and
  communication that supports greater empowerment
  in health decision-making.

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Principles of adult education

• Adults have a foundation of life experiences and
  knowledge that can be used as as a resource,
  requires an understanding of learners
  experiences and communities.
• Adults respond well to instructional materials
  that are based on students lives, sometimes
  referred to as contextualized learning,
• Adults are autonomous and generally respond well
  to self-direction in learning, including
  involvement in program planning and
  implementation.
• For a good overview of adult learning principles
  
• S Imel Using Adult Learning Principles in Adult
  Basic and Literacy Education Clearinghouse on
  Adult, Career, and Vocational Education 1998
  http//www.cete.org/acve/docs/pab00008.pdf

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Concepts of health promotion

• Process of enabling people to exert greater
  control over the determinants of health
• Includes actions directed at strengthening the
  skills and capabilities of individuals, and
• action directed towards changing the social
  determinants of health so as to alleviate their
  impact on public and individual health

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What is health literacy?

• Health literacy represents the cognitive and
  social skills which determine the motivation and
  ability of individuals to gain access to,
  understand, and use information in ways which
  promote and maintain good health
• Health literacy means more than being able to
  read pamphlets and make appointments. By
  improving peoples access to health information
  and their capacity to use it effectively, health
  literacy is critical to empowerment
• Nutbeam D. Health Promotion Glossary. Health
  Promotion International, 13(4) 349-364. 1999
  (also - WHO/HPR/HEP/98.1)

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Types of Health Literacy

Nutbeam D. Health Literacy as a Public Health
Goal A challenge for contemporary health
education and communication strategies into the
21st Century. Health Promotion International .
15 259-67. 2000
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Types of Health Literacy
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Types of Health Literacy
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Improved Health Literacy
Developed knowledge and capability
Tailored information, communication, education
Prior understanding of individual capacity -
reading fluency, numeracy, existing knowledge
Figure 3 Health literacy as an asset a simple
linear model
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Improved health outcomes, healthy choices and
opportunities
Changed health behaviours and practices
Improved Health Literacy
Developed knowledge and capability
Tailored information, communication, education
Prior understanding of individual capacity -
reading fluency, numeracy, existing knowledge
Figure 3 Health literacy as an asset a simple
linear model
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10. Improved health outcomes, healthy choices
and opportunities
7. Changed health behaviours and practices
6. Improved Health Literacy
5. Skills in negotiation and self management
4. Skills in social organization and advocacy
3. Developed knowledge and capability
2. Tailored information, communication, education
1. Prior understanding of individual capacity -
reading fluency, numeracy, existing knowledge
Figure 3 Developing interactive health literacy
skills
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Improved health outcomes, healthy choices and
opportunities
Participation in changing social norms and
service practices
Engagement in social action/advocacy for health
Changed health behaviours and practices
Improved Health Literacy
Skills in negotiation and self management
Skills in social organization and advocacy
Developed knowledge and capability
Tailored information, communication, education
Prior understanding of individual capacity -
reading fluency, numeracy, existing knowledge
Figure 3 Developing interactive and critical
health literacy skills
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Measurement of health literacy

• Current measures (such as TOFLA and REALM) now
  well established in the US - useful for clinical
  screening, but limited for research purposes and
  wider population assessment
• Limited in the extent to which they focus on
  reading (and numeric) skills, and not oral
  communication
• Focus on ability to comply with pre-determined
  behaviours
• If health literacy depends on the relationship
  between individual communication capacities, the
  health care system, and broader society, then
  measures only at the individual level are clearly
  inadequate.
• Barker D, The Meaning and Measure of Health
  Literacy. Jnl of General Internal Medicine 21.8,
  878-883. 2006

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Measurement of health literacy

• More comprehensive measures being developed - In
  the US, the Health Activity Literacy Scale (HALS)
  includes different health related competencies in
  five domains such as health promotion, disease
  prevention, and health care systems
• Different measurement tools will be required for
  different ages and stages in life
• Different measures will be required to
  distinguish between functional, interactive and
  critical health literacy.
• These measures will need to include assessment of
  a persons ability to
• gain access to age and context specific
  information from a variety of different sources
• discriminate between sources of information
• understand and personalise health information
  that has been obtained
• appropriately apply relevant health information
  for personal benefit

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Summary remarks What is the state of the
science the known knowns?

• Good research in clinical settings linking poor
  health- related literacy with range of clinical
  outcomes
• Some intervention trials in clinical settings
  demonstrate potential effectiveness and cost
  savings
• Undeveloped but promising research outside health
  care settings (schools, adult education,
  E-learning)
• Relatively little evidence of systematic
  incorporation of health promotion concepts and
  adult learning principles
• Progress in development of measures of
  health-related literacy in clinical settings, but
  limited progress in development of comprehensive
  measures

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Summary remarks Where to from here in research
the known unknowns

• Development of measures that incorporate wider
  set of skills and capacities represented by
  health literacy - eg inclusion of measures of
  knowledge of social determinants of health, and
  knowledge related self-efficacy
  (confidence/capacity to act)
• Continue to broaden research outside of health
  care setting and disease groups into schools,
  adult learning, community development eg
  maternal health literacy, school health literacy
  etc

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Summary remarks where to from here in practice
development- the unknown unknowns

• Health literacy fundamentally dependent upon
  levels of basic literacy in the population make
  links between these two social goals,
• Developing self confidence to act on knowledge
  and the ability to support others requires more
  personal, and community-based educational
  outreach incorporation of adult learning
  principles and health promotion concepts
• Promoting greater independence and empowerment
  requires acknowledgement of political aspect to
  education, focussed on overcoming structural
  barriers to health