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Review Paper

Health literacy: applying current concepts toimprove health services and reduce healthinequalities

R.W. Batterham a,b, M. Hawkins a, P.A. Collins c, R. Buchbinder d,e,R.H. Osborne a,*

a Deakin University, Health Systems Improvement Unit, Centre for Population Health Research, School of Health and

Social Development, Geelong, Victoria, Australiab Health Systems Research Institute, Nonthaburi, Thailandc Person Centred Care, NHS Englandd Monash Department of Clinical Epidemiology, Cabrini Institute, Australiae Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash

University, Australia

a r t i c l e i n f o

Article history:

Received 5 January 2016

Accepted 7 January 2016

Available online 9 February 2016

* Corresponding author.E-mail address: richard.osborne@deakin.

http://dx.doi.org/10.1016/j.puhe.2016.01.0010033-3506/© 2016 Published by Elsevier Ltd

a b s t r a c t

The concept of ‘health literacy’ refers to the personal and relational factors that affect a

person's ability to acquire, understand and use information about health and health ser-

vices. For many years, efforts in the development of the concept of health literacy exceeded

the development of measurement tools and interventions. Furthermore, the discourse

about and development of health literacy in public health and in clinical settings were

often substantially different. This paper provides an update about recently developed ap-

proaches to measurement that assess health literacy strengths and limitations of in-

dividuals and of groups across multiple aspects of health literacy. This advancement in

measurement now allows diagnostic and problem-solving approaches to developing re-

sponses to identified strengths and limitations. In this paper, we consider how such an

approach can be applied across the diverse range of settings in which health literacy has

been applied. In particular, we consider some approaches to applying health literacy in the

daily practice of health-service providers in many settings, and how new insights and tools

e including approaches based on an understanding of diversity of health literacy needs in a

target community e can contribute to improvements in practice. Finally, we present a

model that attempts to integrate the concept of health literacy with concepts that are often

considered to overlap with it. With careful consideration of the distinctions between pre-

vailing concepts, health literacy can be used to complement many fields from individual

patient care to community-level development, and from improving compliance to

empowering individuals and communities.

© 2016 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.

edu.au (R.H. Osborne).

on behalf of The Royal So

ciety for Public Health.

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 24

What is health literacy and why is it important?

Since its emergence in the 1970s,1 the concept of health lit-

eracy has become increasingly broad. It began as a notion

that concentrated only on people's ability to read and un-

derstand written information. The concept now includes

numerous factors that affect a person's ability to access,

understand and use health information from many sources.

Although health literacy is in many health policies around

the world, it remains challenging to embed health literacy

principles into routine practice. It is of paramount impor-

tance that we attend to this problem because people with low

health literacy have lower rates of health service use and

worse health outcomes than people with higher health

literacy.2,3

In this paper, we take the view that health has biological,

psychological and social determinants. Indeed, health literacy

is increasingly recognised as not just an individual trait, but a

characteristic related to families, communities and organisa-

tions providing health and social services. The paper exam-

ines potential approaches to health literacymeasurement and

intervention in healthcare and community settings. It con-

siders a new approach based on understanding the varying

health literacy strengths and limitations of individuals and

communities. Assessment of these strengths and limitations

can assist healthcare providers to better support patients and

communities, particularly those who experience poor access

and outcomes.

Table 1 e Purposes for health literacy measurement and analy

Levels at which health literacy can be measured Po

Health service settings

1. Individual patients � To problem solv

� To train staff in

2. Patient groups � To identify com

� To plan for serv

� To inform advo

3. Individual health services � To diagnose hea

how these streng

participation in h

� To develop spec

Community and population settings

4. Local areas (both health and

community services/authorities)

� To plan market

� To assess the ab

health planning a

to enable their pa

5. National surveys (to compare

regions and groups)

� To identify relat

in order to develo

� Plan health edu

services, screenin

� Assess regional

that it takes more

low health literac

6. Countries (international comparisons) � Advocacy for go

� Identify countri

of populations

Health literacy: multiple components andmultiple settings

Health literacy is a multidimensional concept and this has led

to the emergence of several definitions. The World Health

Organization defines health literacy as ‘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’ and states that ‘health literacy

implies the achievement of a level of knowledge, personal skills and

confidence to take action to improve personal and community health

by changing personal lifestyles and living conditions’.4 The

mention of ‘community health’ and ‘living conditions’ is in

recognition of the fact that health literacy is not only impor-

tant for personal health care but also for participation in

community debates and planning about issues that affect

health (referred to as critical health literacy).5

Health literacy assessment can be used to improve clinical

service delivery, community participation in health, health

service planning, public health education, and policy devel-

opment.6 Six levels of health literacy assessment are pre-

sented in Table 1. These are grouped into health service

settings, and community and population settings. Both set-

tings provide opportunities for improving health equity and

outcomes by responding appropriately to health literacy

needs.

Health literacy affects health equity and outcomes through

four main causal pathways (Fig. 1).4,7,8 Two of these pathways

sis at different levels.

tential purposes for measuring health literacy

e for complex patients

responding to differing health literacy needs

mon factors that contribute to poor access and health outcomes

ices to respond to health literacy needs

cacy activities

lth literacy strengths and limitations of the target population and

ths and limitations contribute to known inequalities of access,

ealth and health outcomes

ific strategies for responding to common health literacy limitations

ing and education strategies across services

ility of community members to participate in community-based

ctivities (critical health literacy) and develop suitable approaches

rticipation

ionships between health literacy and access, equity and outcomes,

p appropriate health service and public health policies and strategies

cation campaigns, or campaigns to support the introduction of new

g initiatives (e.g., bowel or skin cancer) or vaccination programs.

‘patient difficulty’ for planning and funding purposes (assuming

intensive resources to improve health outcomes for people with

y than it does for people with higher health literacy)

vernments in countries where there is systemic low health literacy

es that are role models for how to improve health literacy levels

Fig. 1 e Causal pathways through which health literacy

influences health outcomes. Sources: Informed by

Paasche-Orlow and Wolf, 20077 and Nutbeam 1998.4

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 2 5

are most relevant to the healthcare sector (those on the upper

half of the figure) while the other two are more relevant to the

community sector (those on the lower half).

Measurement of health literacy

Measuring the many components of health literacy, as they

exist in various settings and contexts, is an important step in

addressing issues of health inequity. Aweakness in the health

literacy field is that themost commonly used toolsmainly test

reading, comprehension and numeracy skills, and some

cognitive tasks, rather than the broad range of issues included

in modern definitions of health literacy.2,3,9e14

The development of new measurement tools, which

identify specific health-literacy-related strengths and limi-

tations in individuals and communities,15,16 opens the way

for new and more comprehensive approaches to health lit-

eracy research and intervention development. The Health

Literacy Questionnaire (HLQ)15 identifies nine separate

health literacy scales that reflect an individual's compe-

tencies and experiences when attempting to engage with

health practitioners and services. Box 1 presents the nine

scales with two patient vignettes (developed from HLQ scale

scores and patient interviews) that show differing health

literacy profiles. If health literacy were represented as a

single score (that is, the HLQ scored as an average score

across nine scales) then these two hypothetical patients

would score similarly. However, these profiles, commonly

seen in clinical practice, reveal different health literacy

needs for each person. Appropriate responses to these needs

are also likely to differ.

Health literacy strategies in health servicesettings

One of the assumptions underlying the measurement of

health literacy is that different strategies of engagement, ed-

ucation and service delivery are appropriate for people with

different health literacy needs. This is not to say that every

patient of a health service must have their health literacy

measured, but that health service personnel must to be aware

of, and sensitive to, the range of health literacy needs that

patients present with. In this section we propose three main

strategies for health service settings:

a) At the organisational level: Complete an organisational

review using the Health Literacy Universal Precautions

Toolkit or similar resources as shown in Box 2.

b) At the healthcare personnel level: Ensure that all health-

care personnel have a sound understanding of common

health literacy needs and appropriate strategies to deal

with these needs as part of routine clinical practice.

c) At the patient level: Assess and discuss health literacy

needs using the HLQ or similar tools for patients with

complex needs, chronically poor outcomes and/or

serious limitations to the way they access or use health

services.

a) Organisational-level strategies

The universal precautions approach does not require

practitioners to assess or even know the health literacy of

individual patients. It does, however, require that practi-

tioners understand health literacy and good practice related to

it, and that they have a range of relevant skills.17e19

The most well-known example of this approach is the

Health Literacy Universal Precautions Toolkit developed for

primary care practices by the Agency for Healthcare

Research and Quality in the USA.20 Advocates of this

approach refer to the need to ‘structure the delivery of care as

if every patient may have limited health literacy’.21,22 The

Toolkit contains resources to support practitioners and

organisations to promote health literacy in their practices

(see Box 2).

One of the difficulties with a universal precautions

approach is that it is extensive and it is not possible for or-

ganisations to do everything all at once. In practice, the

Universal Precautions Toolkit is most usefully applied after

gaining an understanding of the types of health literacy

needs that are prevalent among the organisation's patients

or target community. Collecting, analysing and discussing

health literacy data from either a representative sample or a

selected group of patients who have difficulties can help

organisations focus their selection of strategies, and assist

providers to better understand the range of health literacy

issues that their patients and potential patients present with

(see Box 3).

b) Strategies with healthcare personnel

While we argue that it is not necessary to assess the

health literacy of every patient, it is important that all staff

in healthcare organisations be alert and sensitive to a range

of health literacy needs. This would include a) under-

standing how health literacy issues, other than simply a

lack of information, affect how people act on their health; b)

understanding common health literacy presentations and

strategies to address these; and c) having skills in teach-

back methods and other techniques to assess the accuracy

Box 1Vignettes representing potential health literacy profiles derived from the nine dimensions of the Health LiteracyQuestionnaire.

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 26

and practicality of a patient's understanding, as well as

problem solving skills for when patients have difficulty

understanding. The limited research about doctors' and

medical students' knowledge and use of health literacy, and

related strategies, indicates that most lack confidence in

their ability to communicate effectively with people with

low health literacy, and have difficulty finding suitable

educational resources,23 but that this can be improved with

training and practice.24e26

There are numerous resources and training opportunities

to assist staff in healthcare organisations to develop these

understandings and skills (see Box 2). One particularly useful

Box 2Resources for health literacy.

Tools for small and large health services

� Universal precautions toolkit20 e nchealthliteracy.org/

toolkit/

� Ophelia (OPtimising Health Literacy and Access) process,

including health literacy needs assessment and intervention

development e www.ophelia.net.au

� Building health literate organizations: A guide book for

achieving organizational change49 (includes excellent case-

studies and teach-back resources) e unitypoint.org/health-

literacy-guidebook.aspx

� ‘Always use teach-back’ training toolkit e

teachbacktraining.org/

Tools for medium to large health services

� Enliven organisational health literacy self assessment

resource50 (strongly based on the ‘Ten attributes of health

literate health care organizations’51) e www.enliven.org.

au/library.html

Multidimensional health literacy measurement tools

� Health Literacy Questionnaire (HLQ) and Information and

Support for Health Actions Questionnaire (ISHA-Q) www.

ophelia.net.au

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 2 7

approach is for staff to reflect on data about the health literacy

strengths and limitations of users and potential users of the

services in their organisation or region. This can be particu-

larly powerful when patients are involved in the process of

reflecting on the data and identifying strategies to respond to

people with different health literacy needs.

The ability to respond to patients with varying health lit-

eracy needs requires health personnel to have a repertoire of

strategies and skills. Experienced healthcare practitioners

often develop strategies to enhance their effectiveness, even

with people with very poor health literacy. Capturing and

sharing the best of this expertise, and incorporating it into

normal practice,27 makes health literacy an integral part of

excellent clinical practice, not an add-on. This is the basis for

the Ophelia process (OPtimising HEalth LIteracy and Ac-

cess),27,28 which utilises the local wisdom of health workers

and builds a community of practice that identifies and shares

best practice so as to make it routine clinical practice (see link

to resources in Box 2).

c) Patient-level strategies

Contrary to the Universal Precautions approach, some

authors have suggested that health literacy screening tools be

used within routine clinical practice.17,19,29e32 However, the

proposed tools fail to capture many aspects of health literacy

and were validated on the basis of their ability to predict

scores on older health literacy tools, which are now ques-

tionable gold standards.33

Themain danger of health literacy screening for individual

patients is that of false negatives. Patients may pass the

screening questions and so the assumption is that they do not

have health literacy needs when, in fact, they may have sub-

stantial needs. Jean in patient vignette 2 in Box 1 is an example

of this. Health literacy screening is not a way to discover all

the people who have health literacy needs.

A further limitation of screening is the potential for stig-

matisation. People who have low levels of health literacy may

have feelings of shame and may, as a result, disengage from

health services that are not responsive to their specific

needs.34,35

Rather than advocate application of specific health literacy

screening tools, we would encourage practitioners to develop

the habit of applying teach-back methods. This ensures that

practitioners are constantly doing in-context checking of the

limitations of patients' abilities to understand and apply

health information in a non-blaming way (see Box 4).

There are situations, however, whenmeasuring the health

literacy of individual patients is indicated. This would include

patients who have been chronically difficult to engage in the

care of their own health; those who have low engagement

with health services; or patients for whom adherence to

medical advice is a critical life-and-death issue. In such cases,

the most useful tool is one that identifies particular health

literacy strengths and limitations, and assists healthcare

personnel to have discussions with patients about what is

most helpful to them, rather than a tool that gives a single

health literacy score.

Health literacy and access to health services: weneed to consider those who don't make it to theclinic door

One of the problems with many approaches to health literacy

interventions in healthcare settings is that they focus only on

those patients who are already accessing health services.

However, the overall effectiveness of a health service organi-

sation is largely dependent on whether or not the people who

need it most actually access the service. Low health literacy e

as represented by such issues as low educational attainment

and low socio-economic positione is a major barrier to access

for many people.2,36,37 While this is important in developed

countries, it is crucial in countries undergoing economic

transition and that are seeking to set up systems for universal

access to health care.38

Fig. 2 presents ways in which health literacy limitations

can be barriers to different stages of accessing and engaging

with health services. Often, the people most at risk are those

who drop out in the earlier stages (that is, the upper levels of

Fig. 2 of simply approaching, being accepted into and

receiving services). It is for this reason that awareness of

health literacy is essential for first-contact staff and in-

context checking of health literacy should be incorporated

into intake and assessment procedures.

Box 3Suggested actions where health literacy can be used to improve health outcomes and equity.

Small clinics and individual practitioners

� Health professionals apply a multidimensional health literacy tool (e.g., the HLQ or ISHA-Q) with a few (3e4) complex

patients and discuss the results with those patients to determine what the results mean to the person and what they

believe would help them. Discuss all findings in a team meeting and identify strategies to support these patients and

others like them.

� Examine the resources for small and large health services in Box 2 e develop and implement a plan to ensure that all staff

are skilled in teach-back methods (see Box 4).

� Ensure that all staff are skilled in non-stigmatising communication practices.

� Include health-literacy as a standard component of clinical case study presentations.

Health services

� Examine available data to determine what levels of the Ophelia Access and Equity Framework (Fig. 2) are limiting the

organisations effectiveness.

� Conduct a survey, with a multidimensional health literacy tool, of patients in a specific sub-group (e.g., people with

chronic disease; people who drop out or fail to attend).

� Examine the resources in Box 2 and consider which elements are a priority given the identified health literacy needs.

� Use a multidimensional health literacy tool as an indicator of patient experience. If patients are leaving a health services

with the same or lower health literacy as they came inwith, then explore the useability and relevance of patient education

and support processes.

Community settings (villages, urban communities, work places)

� Conduct a survey using amultidimensional health literacy tool with a sampling strategy that allows health literacy issues

that are common within the group to be identified.

� Talk to people about who they discuss health issues with. Try to get an understanding of the social networks that in-

fluence health beliefs, knowledge and decisions. This should include key peers, key leaders and key health personnel.

� Involve the key people in the social network in discussing health literacy strengths and weaknesses and health beliefs.

� Develop and implement culturally appropriate strategies for engaging peers, leaders and health personnel in creating

constructive conversations and supportive environments for health.

Regional and national policy settings

� Ensure that all health and social care agencies and staff have access to language and culturally appropriate information,

resources and training related to universal precautions for health literacy.

� Establish and support networks of health and social services.

� Identify and survey populations that have poor access to health and social services to identify health literacy barriers to

access.

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 28

Health literacy strategies in community andpopulation settings

Many people live in situations where health-related decisions

are notmade just by individuals but are strongly influenced by

family members, peers or community leaders. Communal

decision-making processes are common in much of Asia and

Africa, and are apparent in immigrant and refugee

groups.39e42

The concept of distributed health literacy was proposed

by Edwards et al.43 and refers to the way in which health

literacy is distributed throughout a group of individuals or a

community. An example is seen in a study that revealed

that the average literacy level for women in the villages

studied was a stronger correlate for childhood immunisa-

tion rates than was the literacy level of individual

mothers.44 This suggests that the sharing of information

and experiences among mothers increased the likelihood

that they would immunise their children. The importance of

distributed health literacy is likely to vary from culture to

culture depending on the extent to which it really is the

village that raises the child.

Development of health literacy interventions in com-

munity settings requires an understanding of the ways in

which discussions that occur within families, among friends

and peers, and within other social networks influence how

people think about and act in relation to their health. In

high-income countries, some programs and interventions

use a peer-support model.45 In some low- and middle-

Box 4Developing a habit of ‘teach-back’.

Developing a habit of applying ‘teach-back’ is a good alternative to screening for health literacy; it can provide healthcare

providers with directly relevant, cumulative and up-to-date information about a person's health literacy and build a more

sophisticated understanding of the health literacy needs of patients.

However, not everyone's experienceswith applying teach-back have lived up to this potential. Sometimes, when it is used in

an overly simplistic way that judges the patient rather than the way the message has been delivered, it just confirms the

prior opinion that certain patient don't have the capacity to understand. For teach-back to be effective, health care personnel

need the ability to not only identify that a patient has a problem but to know strategies to overcome those problems. The key

issue is what you do when they don't understand. Some key principles of applying teach-back are:

� Select the most important information that the patient needs to be aware of immediately and don't try and cover

everything.

� Ask open ended questions to get the patient to explain what they understand, rather than asking yes or no questions

about whether or not they understood.

� Ensure that the patient understands that they are not being tested, but rather you are checking the information you

provided because you are concerned that you wish to meet their needs.

� Ask the patient to explain things in an action-oriented way; ‘Tell me exactly what you need to do to take the medicine at

home’ is better than ‘can you please explain to me what I have just taught you using your own words’.

� Do repeated small checks throughout the appointment rather than waiting till the end. This helps identify issues and

informs you promptly about your educational approach as well as avoiding memory overload for the patient.

� Where possible providewritten instructions that reflect the patient's ownwords. Over time the practicewill develop hand-

outs that reflect patients' own language.

� Build teach-back skills in the whole team, it is just as important for reception staff to check that patients understand

information about their appointments, referrals, collection of results etc. as it is for the doctors and nurses to check the

information they provide

� Take time as a team to discuss what has been learned from implementing teach-back and what it means for your

organisational communication approaches.

Further resources for teach-back training are available at ‘Always Use Teach Back!’ teachbacktraining.org/

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 2 9

income countries, peer-support programs, such as village

health volunteers or women's health networks, are wide-

spread in every village.46 In both of these types of settings, it

is critical to understand how discussions about health in

communities influence how people find, interpret and apply

health information. In conjunction with the Thai Ministry

for Public Health and Thai researchers, we developed a tool

for this purpose: the Information and Support for Health

Actions Questionnaire (ISHAQ).9

Toward an inclusive model of health literacy

Over the past few decades, health literacy work has

occurred in diverse settings: from settings where people are

overwhelmed by an abundance of choice of health infor-

mation, health services, and treatments, to settings where

people have limited education and few healthcare options.

The scope of health literacy assessment varies from indi-

vidual care planning in clinical settings to making interna-

tional comparisons. Research about health literacy also

depends on issues such as ideology and culture. Much of the

literature focuses on health literacy as a means to promote

adherence to medical advice.3,47 There is, however, a large

body of literature about health literacy as a means of patient

empowerment and a facilitator of choice.48 A further

complexity is the indistinct boundaries between health lit-

eracy and a wide range of associated concepts such as

health equity, self-management, patient empowerment,

and patient activation.

Fig. 3 maps some of these concepts onto a broad model of

health literacy that ranges from individual to community

and population foci on the one hand (Y axis), and from a

focus on compliance to a focus on empowerment on the

other (X axis).

Conclusion

Needs-based health literacy assessment can identify and

help healthcare providers develop strategies that build the

capacities of individuals and communities to make de-

cisions that promote health. This is not solely a concern and

responsibility for front-line health practitioners. It must be a

concern and responsibility at all levels of health systems.

Practitioners, health service managers, policy makers,

academics and consumer groups need to understand and

measure health literacy so as to comprehend the ways in

which health literacy strengths and limitations can and do

vary within the groups of people for whom they are

responsible. While it is not necessary to measure the health

literacy of all patients, a tool that captures the many aspects

Fig. 2 e Ophelia Access and Equity Framework e Health literacy related barriers to access at different levels of engagement.

Source: Batterham et al., 2014.27

Fig. 3 e An integrative framework for health literacy.

p u b l i c h e a l t h 1 3 2 ( 2 0 1 6 ) 3e1 2 11

of health literacy will lead to a better understanding of

the needs of individuals or at-risk populations, and can

identify particular areas of focus for care-planning,

problem-solving, training or intervention development.

Improving clinical, community and population health

responses to low health literacy has enormous potential to

increase access to health care, improve health outcomes

and advance health equity.

Author statements

Acknowledgements

This is an invited review which has been subject to peer

review.

Ethical approval

None sought.

Funding

Richard Osborne is funded in part through a National Health

and Medical Research Council (NHMRC) Senior Research

Fellowship #APP1059122. Rachelle Buchbinder is funded by an

NHMRC Senior Principal Research Fellowship #APP1082138.

Competing interest

The authors have no competing interests.

Author contributions

Richard Osborne and Roy Batterham conceived the paper, and

with Rachelle Buchbinder, developed the first draft. Melanie

Hawkins and Alf Collins then contributed to extensive re-

visions. All authors approved the final revision of the

manuscript.

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