Health literacy: Perspectives from Australia

Health literacy:Health literacy:Perspectives from AustraliaPerspectives from Australia

Don Nutbeam

University of Sydney, Australia

What we need to know – What we need to know – it can’t be said more eloquentlyit can’t 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”

Presentation objectives – Presentation objectives – to answer some questionsto 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?

What is literacy?What is literacy?What is it?• Functional literacy focuses on the ability to read basic

text and write a simple statement on everyday lifeWhy 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

Literacy and health*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

The emergence of the concept of The emergence of the concept of health literacyhealth 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”

What is health literacy?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.


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 individual’s skills with

health contexts…and 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

What is health literacy #1?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

Health literacy and health*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

Health literacy assessment -Health-related reading fluency,

numeracy, prior knowledge

Tailoredhealth information,

communication, education

Figure 1: Conceptual model of health literacy as a risk.

Enhanced capabilityfor self management,improved compliance



Improved clinical outcomes




5. Enhanced capabilityfor self management,improved compliance



Improved clinical outcomes



Organizational practice sensitive to

health literacy

Improved access to health care, and

productive interaction withhealth care professionals


1. Barker D, The Meaning and Measure of Health Literacy. Jnl of General Internal Medicine 21.8, 878-883. 20062. 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

What is health literacy #2?What is health literacy #2?

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

Drawing on wider concepts of literacy*Drawing on wider concepts of literacy*Functional literacy – • basic skills in reading and writing, capacity to apply these skills in

everyday situationsCommunicative/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.


#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.

Principles of adult educationPrinciples 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

Concepts of health promotionConcepts 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

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)

Types of Health Literacy*

Health Literacy Type

& Goal

Content Outcome Examples of educational

Activity

Functional Health

Literacy:

Communication of information

Transmission of

factual information on health risks and health services

utilisation

Improved

knowledge of health risks and health services, compliance with

prescribed actions

Transmit information

through existing channels,

opportunistic inter-personal contact, and

available media

*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

Types of Health LiteracyHealth

Literacy Type and Goal

Content Outcome Examples of Educational

Activity Functional Health

Literacy:

Communication of information

Transmission of factual information on health risks

and health services utilisation

Improved knowledge of health risks and health services,

compliance with prescribed actions

Transmit information through existing channels, opportunistic

inter-personal contact, and available media

Interactive Health Literacy:

Development of personal skills

Opportunities to develop skills in a

supportive environment

Improved capacity to act independently

on knowledge, improved motivation and self-confidence

Tailored health communication,

facilitation of self-help and social support groups

Types of Health LiteracyHealth Literacy type and Goal

Content Outcome Examples of Educational Activity

Functional Health Literacy: Communication of information

Transmission of factual information on health risks and health services utilisation

Improved knowledge of health risks and health services, compliance with prescribed actions

Transmit information through existing channels, opportunistic inter-personal contact, and available media

Interactive Health Literacy: Development of personal skills

Opportunities to develop skills in a supportive environment

Improved capacity to act independently on knowledge, improved motivation and self-confidence

Tailored health communication, facilitation of community self-help and social support groups

Critical Health Literacy: Personal and community empowerment

Provision of information on social and economic determinants of health, assessment of opportunities to achieve change

Improved individual and community capacity to act on social and economic determinants of health; community empowerment

Provision of technical advice to support community action, advocacy communication to community leaders and politicians; facilitation of community development,

Improved Health Literacy

Tailored information, communication, education

Prior understanding of individual capacity - reading fluency, numeracy,

existing knowledge

Developedknowledge

and capability

Figure 3: Health literacy as an asset: a simple linear model



Improved health outcomes,healthy choices

and opportunities


existing knowledge

Developedknowledge

and capability

Figure 3: Health literacy as an asset: a simple linear model

Changed health behaviours and

practices

6. Improved Health Literacy

2. Tailored information, communication, education

10. Improved health outcomes,healthy choices

and opportunities

5. Skills in negotiation and self management

1. Prior understanding of individual capacity - reading fluency, numeracy,

existing knowledge

3. Developedknowledge

and capability

4. Skills in social organization

and advocacy

Figure 3: Developing interactive health literacy skills

7. Changed health behaviours and

practices



Improved health outcomes,healthy choices

and opportunities

Skills in negotiation and self management


existing knowledge

Developedknowledge

and capability

Skills in social organization

and advocacy

Participation in changing social

norms and servicepractices

Engagement insocial

action/advocacy for health

Figure 3: Developing interactive and critical health literacy skills

Changed health behaviours and

practices

Measurement of health literacyMeasurement 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

Measurement of health literacyMeasurement 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 person’s 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

Summary remarks – Summary remarks – What is the state of the science – What is the state of the science –

the known knowns?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

Summary remarks Summary remarks Where to from here in research – Where to from here in research –

the known unknownsthe 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

Summary remarks – Summary remarks – where to from here in practice developmentwhere to from here in practice development

- the unknown unknowns- 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

Documents

Health literacy: Perspectives from Australia