1

Title: Provider Health Literacy, cultural and communication competence: towards an integrated approach in the Northern Territory.

Authors: Lowell, A1., Schmitt, D.2, Ah Chin, W.2 & Connors, C.3 2014.

Preamble The purpose of the paper is to articulate commonalities across the three themes of health

literacy, health communication and cultural security.

The paper consolidates contemporary literature and research findings and presents these

perspectives within the Northern Territory (NT) health services context to generate further

discussion for implementation and application within the NT health services.

This paper will assist the Department of Health to take a greater lead in establishing a

culturally appropriate organisation through developing effective health literate systems,

buildings, staff and clients.

Executive summary

Health literacy is increasingly recognised internationally, nationally and locally as an

important influence on the safety and quality of health care and as a factor influencing health

outcomes. However, there is considerable variation in the ways in which the term ‘health

literacy’ is conceptualised and applied. Cultural and linguistic diversity introduces further

complexity which must be considered, particular in a context of high diversity such as the

Northern Territory. This paper considers a range of definitions, dimensions, and approaches

to measurement of health literacy, and their relevance to health care in the NT. In summary,

key issues include: consideration of the health literacy environment (including the health

literacy of organisations, systems, services, and staff) - rather than focusing solely on

consumer health literacy

implications of cultural and linguistic diversity for addressing health literacy

the relationship between health literacy, health communication and cultural security/

cultural competence

adoption of a ‘universal precautions’ approach to meet diverse needs rather than a focus

on limitations of individuals

measurement of health literacy that encompasses provider health literacy and the health

literacy environment;

1 Charles Darwin University, Northern Territory

2 Department of Health, Northern Territory

3 Top End Health Services, Northern Territory

2

integration of cultural competence, communication and health literacy to reflect the

extent to which they are interrelated and to enable efficient and appropriate action across

all levels of health care.

The need to consider health literacy within the context of language and culture is crucial in

the NT given the diversity of the population. The influences beyond the consumer, as well as

accommodation of the needs of consumers, are also emerging as important concepts in the

health literacy debate. Health literacy, cultural competence and communication competence

need to be addressed at organizational, system and individual levels to ensure health care is

responsive to diverse needs. There is increasing recognition of the extent to which these

concepts are interrelated but there have been few attempts at integration, for example, in staff

training or in the development of organizational standards or performance measures. The

evidence presented in this paper suggests that integration of health literacy, cultural and

communication competence can support provision of culturally responsive, equitable and

high quality services for Indigenous Territorians to optimize improvements in health

outcomes.

1. Definitions of health literacy

Health literacy is increasingly recognised as an important influence on the safety and quality

of health care and as a determinant of health. The Calgary Charter on Health Literacy

(Coleman et al., 2011) states that: Improving health literacy can contribute to more informed

choices, reduced health risks, increased prevention and wellness, better navigation of the

health system, improved patient safety, better patient care, fewer inequities in health, and

improved quality of life (Coleman et al., 2011, p. 2).

Despite the growing awareness of the importance of health literacy there is no clear

consensus regarding the definition of health literacy, which in turn complicates the

measurement of health literacy (Frisch, 2011). Key areas of difference relate to whether

health literacy is considered to be an individual-level construct or incorporates factors beyond

the individual, and whether health literacy level is considered static or dynamic (Berkman,

Davis, & McCormack, 2010). Definitions also range from those that consider health literacy

as a set of skills to broader definitions that move towards defining health literacy as a theory

of behavior change (Pleasant & McKinney, 2011) or as social practice (Rubin, Parmer,

Freimuth, Kaley, & Okundaye, 2011). Health literacy has been described as ‘complex and

multifaceted’ (Zarcadoolas, 2011, p. 1) and the multiple skill categories and applications that

are required to be ‘health literate’ contributes to the challenges in reaching a consensus on a

definition of health literacy (Berkman et al., 2010). This is further complicated by different

conceptualizations of the range of skill categories.

Early definitions (and assessment tools) were confined to the ability of consumers/ patients to

access print-based information. However, most definitions now recognise health literacy as

more than general literacy skills. For example, The Calgary Charter on Health Literacy

(2011) includes: reading, writing, listening, speaking, numeracy, and critical analysis, as

well as communication and interaction skills (Coleman et al., 2011, p. 1). A working

knowledge of disease processes, ability to use technology, social networking and interaction,

self-efficacy and motivation for political action regarding health issues are also included in

some definitions (Berkman et al., 2011).

3

The ability to navigate health services is also included in some health literacy frameworks.

For example, a report on a project conducted in the NT (Christie, 2010) suggested that:

“health literacy” needs to be defined in terms of both what Aboriginal clients know about the

biomedical understandings of their health and sickness, and also in terms of the services,

systems and resources which are available for them to access help in discussions over health

an sickness, and their ability to access and use those systems” (Christie, 2010, p. 6).

Similarly, Coleman et al. (Coleman et al., 2011) suggest that: Health literacy includes an

awareness of and ability to navigate differences between the cultures of the health system and

the public. It also includes an awareness of and ability to minimize the power imbalances

between the health system and the public (Coleman et al., 2011, p. 4).

Cultural and conceptual knowledge are increasingly included within the domain of health

literacy (e.g. Baker, 2006). An example of a definition that incorporates conceptual

knowledge is that proposed by Zarcadoolas et al. (2005): “the wide range of skills and

competencies that people develop to seek out, comprehend, evaluate and use health

information and concepts to make informed choices, reduce health risks and increase quality

of life” (Zarcadoolas, Pleasant, & Greer, 2005, pp. 196-197). Their model of health literacy

encompasses four domains: fundamental literacy (reading, writing, speaking and numeracy),

science literacy (levels of competence with science and technology, including and

understanding of scientific uncertainty and the possibility of rapid change), civic literacy (the

ability to become aware of public issues and to become involved in the decision-making

process) and cultural literacy (the ability to recognize and use collective beliefs, customs,

world-view and social identity in order to interpret and act on health information)

(Zarcadoolas et al., 2005, p. 197). The need to consider differences in worldview in

approaches to improving health literacy has been also been strongly argued in the context of

Indigenous health education in the N.T. (Vass, Mitchell, & Dhurrkay, 2011)

Health literacy as a strategy for empowerment is a key concept within some frameworks.

A frequently cited analysis of health literacy by Nutbeam (2000) describes three levels of

health literacy that progressively lead to greater autonomy and personal empowerment:

basic/functional (reading and writing skills needed to function in everyday life;

communicative/interactive (cognitive and literacy skills combined with communication and

social skills need to participate in a range of situations and to apply information to changing

circumstances); and critical health literacy (more advanced cognitive skills required for

critical analysis of information to exert greater control over life events and situations)

(Nutbeam, 2000).

Such expanded concepts of health literacy are reflected in a discussion paper about improving

health literacy for Canadians (Mitic & Rootman, 2012)which described a health-literate

individual as one who is “able to seek and assess the health information required to 1)

understand and carry out instructions for self-care, including the administering of complex

daily medical regimens, 2) plan and achieve the lifestyle adjustments required for improved

health, 3) make informed positive health-related decisions, 4) know how and when to access

health care when necessary, 5) share health promoting activities with others, and 6) address

health issues in the community and society (Mitic & Rootman, 2012, p. 3).

Nutbeam (2008) suggests that an important distinction can also be made between definitions

that view health literacy as a clinical ‘risk’ and those that view health literacy as a personal

‘asset’. He suggests as an example of health literacy as ‘risk’ a widely used definition from

an influential report by the US Institute of Medicine (Nielsen-Bohlman & Panzer, 2004)

4

which was originally developed by Razdan and Parker (2000) i.e.: The degree to which

individuals have the capacity to obtain, process and understand basic health information and

services needed to make appropriate health decisions. Nutbeam argues that this definition

places health literacy as a risk factor that needs to be identified and appropriately managed in

clinical care. In contrast, the World Health Organisation definition: ‘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’ reflects health literacy

as a personal ‘asset’. In this definition health literacy is a means to enabling individuals to

exert greater control over their health and the range of personal, social and environmental

determinants of health, rather than simply a set of functional capabilities. Such fundamental

differences have important implications for both measurement and application of health

literacy in clinical as well as community settings (Nutbeam, 2008).

2. Health literacy and providers of health services

Concepts of health literacy also differ in the extent to which health literacy is considered an

individual-level construct or is conceptualized more broadly. Many definitions, as the

examples above illustrate, have focused exclusively on the patient/consumer. In the context

of NT health services the definition of health literacy is also consumer-focused i.e. ‘Having

access to the information necessary, as well as the skills and resources required, to make

decisions for one’s own health’ (Department of Health and Families, 2009, p. 25). However,

there appears do be little discussion in the literature regarding who determines what

information is ‘necessary’ and there is evidence that there is a mismatch between the

perceptions of health service providers and the perceptions of Indigenous consumers about

the level of health literacy they want and need to make informed decisions (Lowell et al.,

2012).

The influence of health staff and health systems on consumer health literacy is increasingly

acknowledged and there is a growing focus on the health literacy of organisations, systems

and staff. A major report on health literacy in the United States (Nielsen-Bohlman & Panzer,

2004) emphasized the factors beyond the individual that must be considered in a

comprehensive approach to the assessment of health literacy:

“Health literacy is a shared function of social and individual factors…. Equally important

are the communication and assessment skills of the people individuals interact with

regarding health, and the ability of the media, the marketplace, and government agencies to

provide health information in a manner appropriate to the audience” (Nielsen-Bohlman &

Panzer, 2004, p. 5).

Similarly, a recent discussion paper produced to stimulate discussion about health literacy in

Australia includes a focus on the ‘health literacy environment’:

“the infrastructure, policies, processes, materials and relationships that exist within the

health system that make it easier or more difficult for consumers to navigate, understand and

use health information and services to make effective decisions and take appropriate action

about health and health care” (Australian Commission on Safety and Quality in Health Care,

2013, p. 5).

The communication processes and relationships that exist between consumers and healthcare

providers are considered an important component of the health literacy environment,

5

including shared decision making processes, tailoring of information to individual needs and

checking that information is understood (Australian Commission on Safety and Quality in

Health Care, 2013, p. 12).

The Calgary Charter proposes that health literacy applies to all individuals (including

consumers and health staff) and to health systems and provides the following examples:

An individual can be health literate by using the skills needed to find, understand, evaluate,

communicate, and use information.

Health care professionals can be health literate by presenting information in ways that

improve understanding and ability of people to act on the information.

Systems can be health literate by providing equal, easy, and shame-free access to and

delivery of health care and health information (Coleman et al., 2011, p. 2)

The U.S. Institute of Medicine has also produced a discussion paper which identifies ten

attributes of a health literate organization and one of these attributes is to prepare the

workforce to be health literate (Brach et al., 2012). The health literacy of providers was also

identified as important by Christie et al. (2010) who proposed the term ‘both ways health

literacy’ “to emphasise the importance of valuing both biomedical and Aboriginal

knowledges’, structures and processes in relation to developing shared understanding about

human being, the body, pathology, sickness and health (wellness) (Christie, 2010, p. 6). The

Australian Safety and Quality Council Goals for Health Care now include ‘becoming a health

literate organisation’ as a core outcome within the priority area of ‘partnering with consumers’

(Australian Safety and Quality Goals for Health Care, 2012).

Concern with reduction of health disparities is a recurring theme in the health literacy

literature, particularly where it relates to culturally and linguistically diverse populations. Lie,

Carter-Pokras, Braun, and Coleman (2012)suggest that health provider competencies can

address unequal access to shared understanding of information between the patient and health

professional. Specifically, health professionals can contribute to reduction in health

disparities by:

“recognizing the existence of a culture of the health professions as well as their own

assumptions and biases, deploying appropriate communication skills and utilizing team

resources to recognize, diagnose, and address low health literacy and cultural differences”

(Lie et al., 2012, p. 15).

The increasing emphasis on providers’ accommodation of the needs of consumers and

lowering barriers to access, rather than focusing on the health literacy limitations of

consumers, is particularly relevant to contexts with culturally and linguistically diverse

populations such as the N.T.

3. Health literacy and health communication

A lack of consensus in the literature regarding the relationship between health literacy and

health communication is also evident and communication is positioned in different ways in

various frameworks of health literacy. Health communication has been defined as

interpersonal or mass communication activities focused on improving the health of

individuals and populations (Ishikawa & Takahiro, 2010). In general, health communication

and health literacy are seen as related but distinct concepts: health communication is the

6

process of exchanging information whereas health literacy is the use of a set of skills and

abilities (see Figure 1.). Berkman et al. (2010) describe health literacy as “an integral

component of health communication (Berkman et al., 2010, p. 18). Communication has also

been viewed as a mediator within the patient-provider interaction between health literacy and

health outcomes (e.g.Paasche-Orlow & Wolf, 2007). Squiers, Peinado, Berkman, Boudewyns,

and McCormack (2012) propose that, as health information is often conveyed orally,

communication skills including the ability to listen, speak and negotiate are dimensions of

health literacy that contribute independently to the overarching construct of health literacy

skills (Squiers et al., 2012, p. 12). They also highlight the importance of the communication

skills of “ the messenger” as being “critical to an individual’s skill in interpreting the

message being delivered” (Squiers et al., 2012, p. 49). Although there is a connection

between health literacy and communication skills, it is possible to have excellent

communication skills but not be very health literate although health literacy is necessary to

communicate effectively about health. Both health literacy and communication should be

addressed, measured, and evaluated (Coleman et al., 2011).

Berkman et al. (2010) consider a conceptual model of health literacy that embraces the role

of language, culture and social capital to be appropriate and useful but caution that “the

conceptualization of health literacy does not become immeasurable and blur with other

concepts, such as patient-centered communication” (Berkman et al., 2010, p. 17). There is an

increasing move to integrate health literacy and cultural competence due to the extent to

which they are interrelated (see Section 4). Inclusion of health communication in this process

of integration and alignment would also appear to be logical due to the extent of intersection

and interdependence between both the concepts of health literacy and cultural competence

with health communication.

7

Figure 1. Relationship between health literacy and communication and factors influencing both.

4. Culture, language and health literacy

A limitation of many definitions of health literacy is the decontextualisation and assumption

of Western socio-cultural contexts (Smylie, Williams, & Cooper, 2006, p. 13). The

importance of considering health literacy in the context of language and culture is

increasingly being recognized – and it has been suggested that health literacy should be

viewed through “multicultural and multilingual lenses” (McKee & Paasche-Orlow, 2012, pp.

10-11). This is particularly relevant in the context of the Northern Territory where 26.8% of

the population is Aboriginal according to the 2011 Census data (Australian Bureau of

Statistics, 2012) and approximately 70% speak a language other than English at home. In

remote areas, the percentage is much higher. For example, in the East Arnhem region of the

N.T. 97.5% of the population is Aboriginal and 2.1% of the population speaks English only at

home (Australian Bureau of Statistics, 2012).

A report by Institute of Medicine in the U.S. states that: Health literacy is a shared function

of social and individual factors. Individuals’ health literacy skills and capacities are

mediated by their education, culture, and language (Nielsen-Bohlman & Panzer, 2004, p. 5).

This report recognizes the importance of understanding and addressing the interrelationship

of literacy, language and culture for health services with diverse populations and suggests

that: Differing cultural and educational backgrounds between patients and providers, as well

as between those who create health information and those who use it may contribute to

problems in health literacy (Nielsen-Bohlman & Panzer, 2004, p. 12). Depending on

8

contextual factors, language barriers may be more significant than limited health literacy in

obstructing interactive patient–physician communication (Sudore et al., 2009).

Consideration of culture and language therefore requires

an interpretation of health literacy as dynamic rather than

static, as the health literacy of an individual will vary

depending on the cultural, conceptual and linguistic

demands of the context. In terms of interactions with the

healthcare system, culturally influenced perceptions,

definitions and barriers can help to determine the

adequacy of health literacy skills in different settings

(Nielsen-Bohlman & Panzer, 2004, p. 12). Health literacy

as a dynamic concept, varying according to context and

participants, is illustrated in two scenarios described in

Box 1.

The influences beyond the consumer, as well as

accommodation of the needs of consumers, are emerging

as important concepts in the health literacy debate.

Cultural competence - and related concepts such as

cultural safety, cultural security and cultural respect - are

widely recognized as important in health care provision

for culturally and linguistically diverse populations.

However, there has been little consideration in the

literature of the relationship between such concepts and

health literacy. Concern has been expressed, for example,

about the teaching of “health literacy” or “cultural

competence” separately to health professionals and Lie et

al. (2012)suggest a “collaborative of health literacy and

cultural competence educators working together to share

tools, training strategies, and resources for the common

goal of health disparities reduction…” (Lie et al., 2012,

p. 20).

For a health professional to be ‘health literate’ i.e. to

present information in ways that improve understanding

and ability of people to act on the information(Coleman

et al., 2011) cultural and linguistic competence is also

necessary in interactions with consumers from diverse

backgrounds. An organization must also be culturally

competent to be health literate, that is, providing services

that are responsive to the cultural and linguistic needs of

consumers. Health literacy, cultural competence and

linguistic competence all need to be addressed to ensure

effective communication - without such integration health care will not be responsive the

needs of vulnerable groups (Pleasant & McKinney, 2011).

5. Measurement of health literacy

Despite the wide range of definitions and broadening scope of health literacy described in

Box 1. Illustration of health literacy as dynamic Scenario 1: An Aboriginal client and a health professional from the same cultural and language group discussing diabetes management (health-promoting information e.g. traditional foods, medicines, exercise through hunting and gathering, ceremony e.t.c and health-damaging factors e.g. sources of stress and disempowerment). Both the client and health professional will have a relatively high level of health literacy in this context due to their shared language, cultural background and health-related knowledge relevant to their specific cultural, social, economic and environmental context. Scenario 2: An Aboriginal client (who speaks a language other than English at home) and a non-Aboriginal health professional discussing diabetes management (medication, diet, exercise, cause and consequences). An interpreter has not been used in this interaction. Both the client and health professional will have a relatively low level of health literacy in this context due to the absence of shared language and cultural knowledge. The client may not be familiar with the Western medical concepts and language related to the body and illness and the health professional may not be familiar with the client’s understanding of the body, causation, socio-cultural and economic influences on health and health management. System health literacy is also low as standards for service provision with clients from cultually and linguistically diverse backgrounds have not been met.

9

earlier sections of this paper this is not reflected in the dominant approaches to measurement.

Pleasant and McKinney (2011) suggest that ‘there is a distinct mismatch between the

attributes included in the most recent definitions and theories of health literacy and the

attributes actually included in existing screening or measurement devices for health literacy’

(Pleasant & McKinney, 2011, p. 97). Confusion and debate about the definition of health

literacy is reflected in lack of agreement about how it should be measured (Baker, 2006).

Just as definitions of health literacy initially focused on print literacy, measures of health

literacy have been almost exclusively text-based and focus on what patients can read in a

clinical context (Nielsen-Bohlman & Panzer, 2004; Pleasant, McKinney, & Rikard, 2011).

Lack of consistency even across these narrowly focused measures has also been documented.

A study that examined variation across three commonly used brief health literacy assessment

instruments (Test of Functional Health Literacy in Adults; the Rapid Estimate of Adult

Literacy in Medicine; and a 4-Item Brief Health Literacy Screening Tool) found that these

instruments measure health literacy differently and appear to be conceptually different

(Haun, Luther, Dodd, & Donaldson, 2012). An Australian study that compared the results

of three tests (Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional

Health Literacy in Adults (TOFHLA) and Newest Vital Sign (NVS)) also found that the

measures appeared to measure different (although related) constructs and used different cut

offs to indicate poor health literacy (Barber et al., 2009).

Although oral communication skills (speaking and listening) are considered a critical

component in recent definitions of health literacy (e.g. Berkman et al., 2010) few assessment

tools measure communicative /interactive health literacy (Ishikawa & Takahiro, 2010).

Recently developed tools such as the TALKDOC (Helitzer, Hollis, Sanders, & Roybal,

2012)and the Health Literacy Skills Instrument (Bann, McCormack, Berkman, & Squiers,

2012) consider oral communication but measure only listening skills. TALKDOC does,

however, measure constructs of knowledge and attitudes that are not addressed in other

assessment tools. Self-reports of health literacy skills are a more recent development in

measurement although their utility as measures of health literacy remains largely

unconfirmed (Begoray & Kwan, 2012, p. 23).

System navigation has also been included in more recent health literacy assessment tools

(e.g.Bann et al., 2012) but other critical skills such as cultural and conceptual knowledge,

how individuals use information and communication between health professionals and

systems are not included (Nielsen-Bohlman & Panzer, 2004; Pleasant et al., 2011). Baker

(2006) also argues that measures are inadequate in commonly used screening tools to assess

the relationship between individual communication capacities, the health care system, and

broader society. Nutbeam (2008) suggests that different tools are needed assess interactive

and critical literacy which require ‘additional assessment of oral literacy and social skills

such as those involved in negotiation and advocacy’ (Nutbeam, 2008, p. 2076). He also

suggests that different tools are required at different ages and stages of life and in different

social contexts (Nutbeam, 2008).

There are increasing doubts being raised about the utility and relevance of measuring health

literacy at the individual consumer level and two opposing views are reflected in the

literature. Some authors argue that assessment of individual health literacy in clinical

contexts is critical to ensure effective communication (e.g. Barber et al., 2009; Heinrich,

2012). Others argue that due to importance of health literacy as a determinant of public and

individual health and the risk of labeling individuals as ‘low health literate’ in a clinical

10

setting, resources would be better used to lower barriers to access for everyone (e.g.Baker,

2006; Pleasant et al., 2011). Baker (2006) suggests that, rather than individual screening, it

may be better to adopt the principle of “universal precautions” to avoid miscommunication

and suggests the use of plain language, communication tools (e.g., multimedia), and ‘‘teach

back’’ (having an individual repeat back instructions to assess comprehension) with all

patients (Baker, 2006, p. 881).

A number of health literacy frameworks now include competencies of both the providers of

health care and information (health care professionals, systems or disseminators of public

health messages) and consumers. Approaches to assessment of health literacy must therefore

address the health literacy capacity of both providers and consumers as well as the broader

array of skills included in such expanded conceptual frameworks (Pleasant et al., 2011). An

example of a measure of health literacy that aims for a more comprehensive approach

capable of assessing health literacy needs across individuals and organisations – the Health

Literacy Questionnaire - has recently been developed in Australia. It is based on consumer

responses to 44 items across nine scales that include: feeling understood and supported by

healthcare providers; having sufficient information to manage my health; actively managing

my health; social support for health; appraisal of health information; ability to actively

engage with healthcare providers; navigating the healthcare system; ability to find good

health information; and understand health information well enough to know what to do

(Osborne, Batterham, Elsworth, Hawkins, & Buchbinder, 2013). Approaches to

measurement of provider health literacy, although emerging, do not yet reflect the importance

now attributed to the competencies of providers and the health literacy environment.

Measurement of health literacy in culturally and linguistically diverse populations is

particularly problematic. A report examining health literacy in Australia (Australian Bureau

of Statistics, 2006) found a low level of health literacy in people born overseas in a non-

English speaking country. Very remote parts of Australia were excluded from the survey,

thus excluding information on the health literacy of Australian-born (i.e. Indigenous) people

who speak a language other than English. Another Australian study (Barber et al., 2009) also

found that being born in a non-English speaking country was associated with lower scores on

all three health literacy measures used in their research. Few of the tools currently in use are

appropriate for assessing health literacy (of either consumers or providers) with individuals

who do not speak English as their first language (Parker et al., 2012). Results from the use of

such tools with consumers from non-English speaking backgrounds will be confounded by

cultural and language differences and will provide no indication of the individual’s health

literacy, for example, in contexts where their primary language is used (Todd & Hoffman-

Goetz, 2011). The limitations of current tools for assessing either provider or consumer

health literacy in the context of culturally and linguistically diverse populations is particularly

relevant in the Northern Territory.

6. Strategies to address health literacy

To address health literacy in a coordinated way, it is necessary to embed health literacy into

high-level systems and organisational policies and practices. Clear, focused and useable

health information, effective interpersonal communication and integration of health literacy

into education for consumers and healthcare providers are also required (Australian

Commission on Safety and Quality in Health Care, 2013). In an evironment of high diversity

the interconnections between health literacy, culture and language must also be considered in

policies, practice and training.

11

As well, engagement of those that directly experience the barriers and benefits of health

literacy in the process of developing a comprehensive approach is crucial. Active dialogue is

needed with all those who have

an interest in the role of health

literacy as a determinant of

health including individuals,

community-based groups and

government agencies (Pleasant

et al., 2011, p. 18).

Extensive work has been carried

out on the development of

organizational and professional

standards for cultural and

linguistic competence in health

care and to a lesser extent for

health literacy (e.g.Brach et al.,

2012; Mitic & Rootman, 2012)

but there appear to have been

few attempts at developing an

integrated approach. A notable

exception is the work of

Andrulis & Brach (2007) who

developed an initial model,

integrating standards and

strategies related to health literacy with cultural and linguistic competence, for health care

providers and organisations to improve health care quality(Andrulis & Brach, 2007). There is

a need to develop assessment methods that are comprehensive and locally relevant across all

dimensions of health literacy, including competencies of providers (staff, systems and

organisations in health and related domains). The first step in this process requires a

consensus on the dimensions of health literacy and development of relevant standards against

which to measure performance.

Many areas of intersection are evident between the professional and organizational standards

developed for cultural competence and those developed for health literacy. Integration of

cultural competence, communication and health literacy within a unified set of standards

would reflect the extent to which they are interrelated. Such integration would also facilitate

more efficient and appropriate monitoring and assessment across all domains to promote

provision of services that are responsive to the diverse needs of consumers in the NT.

The level of provider cultural and communication competence and health literacy will

collectively determine the extent to which health care is responsive to the diverse cultural and

communication needs of consumers. Systems and services that effectively accommodate

these needs promote consumer health literacy and facilitate improvements in health outcomes.

This interconnection between the competencies of health care providers (systems, services

and staff) and consumer health outcomes is illustrated in Figure 2.

12

7. Conclusion

The evidence presented in this paper supports a coordinated approach, integrating health

literacy, cultural and linguistic competence at organisational, system, service and individual

levels. Such an approach promotes improvement across all domains to achieve culturally

responsive, equitable and high quality services for all Territorians, ensuring effective

communication and enhancing health literacy, to optimize health outcomes.

13

References

Andrulis, D. P., & Brach, C. (2007). Integrating Literacy, Culture, and Language to Improve

Health Care Quality for Diverse Populations. American Journal of Health Behaviour,

31(Suppl 1), 122-133.

Australian Bureau of Statistics. (2006, 24 July 2008). Health Literacy, Australia Retrieved

20 July, 2012, from

http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/73ED158C6B14BB5ECA25

74720011AB83/$File/42330_2006.pdf

Australian Bureau of Statistics. (2012). 2011 Census quickstats. Retrieved 21 June 2012,

from

http://www.censusdata.abs.gov.au/censusservices/getproduct/census/2011/quickstat/7

Australian Commission on Safety and Quality in Health Care. (2013). Consumers, the health

system and health literacy: Taking action to improve safety and quality. Consultation

Paper. Sydney: ACSQHC.

Australian Safety and Quality Goals for Health Care. (2012). Goal 3. Partnering with

Consumers Action Guide. Retrieved from http://www.safetyandquality.gov.au/wp-

content/uploads/2012/08/3-Partnering-with-consumers.pdf

Baker, D. W. (2006). The meaning and the measure of health literacy. J Gen Intern Med,

21(8), 878-883. doi: 10.1111/j.1525-1497.2006.00540.x

Bann, C. M., McCormack, L. A., Berkman, N. D., & Squiers, L. B. (2012). The Health

Literacy Skills Instrument: A 10-Item Short Form. J Health Commun, 17(sup3), 191-

202. doi: 10.1080/10810730.2012.718042

Barber, M. N., Staples, M., Osborne, R. H., Clerehan, R., Elder, C., & Buchbinder, R. (2009).

Up to a quarter of the Australian population may have suboptimal health literacy

depending upon the measurement tool: results from a population-based survey.

[Research Support, Non-U.S. Gov't]. Health Promot Int, 24(3), 252-261. doi:

10.1093/heapro/dap022

Begoray, D. L., & Kwan, B. (2012). A Canadian exploratory study to define a measure of

health literacy. [Research Support, Non-U.S. Gov't]. Health Promot Int, 27(1), 23-32.

doi: 10.1093/heapro/dar015

Berkman, N. D., Davis, T. C., & McCormack, L. (2010). Health Literacy: What Is It?

Journal of Health Communication: International Perspectives 15(S2), 9-19.

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A., Crotty, K., . . .

Harden, E. (2011). Health literacy interventions and outcomes: An updated systematic

review.

Brach, C., Dreyer, B., Schyve, P., Hernandez, L. M., Baur, C., Lemerise, A. J., & Parker, R.

(2012). Attributes of a Health Literate Organization. Retrieved from

http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-

Papers/BPH_HLit_Attributes.pdf

Christie, M. (2010). East Arnhemland Client Education and Interpreting Scoping Report and

Project Proposal – June 2010 Retrieved 10/6/12, from

http://www.cdu.edu.au/centres/hl/

Coleman, C., Kurtz-Rossi, S., McKinney, J., Pleasant, A., Rootman, I., & Shohet, L. (2011).

The Calgary Charter on Health Literacy: Rationale and core principles for the

development of health literacy curricula. . Retrieved from

http://www.centreforliteracy.qc.ca/sites/default/files/CFL_Calgary_Charter_2011.pdf

Department of Health and Families. (2009). Northern Territory Chronic Conditions

Prevention and Management Strategy 2010-2020. Darwin: Department of Health and

Families.

14

Frisch, A. C., L. Diviani, N. & Schulz, P.J. (2011). Defining and measuring health literacy:

how can we profit from other literacy domains? Health Promotion International,

27(1). doi: doi:10.1093/heapro/dar043

Haun, J., Luther, S., Dodd, V., & Donaldson, P. (2012). Measurement Variation Across

Health Literacy Assessments: Implications for Assessment Selection in Research and

Practice. J Health Commun, 17(sup3), 141-159. doi: 10.1080/10810730.2012.712615

Heinrich, C. (2012). Health literacy: the sixth vital sign. J Am Acad Nurse Pract, 24(4), 218-

223. doi: 10.1111/j.1745-7599.2012.00698.x

Helitzer, D., Hollis, C., Sanders, M., & Roybal, S. (2012). Addressing the "Other" Health

Literacy Competencies-Knowledge, Dispositions, and Oral/Aural Communication:

Development of TALKDOC, an Intervention Assessment Tool. J Health Commun, 17

Suppl 3, 160-175. doi: 10.1080/10810730.2012.712613

Ishikawa, H., & Takahiro, K. (2010). Health literacy and health communication.

BioPshychoSocial Medicine, 4(18). Retrieved from http://www.bpsmedicine.com

website:

Lie, D., Carter-Pokras, O., Braun, B., & Coleman, C. (2012). What Do Health Literacy and

Cultural Competence Have in Common? Calling for a Collaborative Health

Professional Pedagogy. J Health Commun, 17(sup3), 13-22. doi:

10.1080/10810730.2012.712625

Lowell, A., Mayilama, E., Yikaniwuy, S., Rrapa, E., Williams, R., & Dunn, S. (2012).

"Hiding the story": Indigenous consumer concerns about communication related to

chronic disease in one remote region of Australia. International Journal of Speech-

Language Pathology, 14(3), 200-208.

McKee, M. M., & Paasche-Orlow, M. K. (2012). Health Literacy and the Disenfranchised:

The Importance of Collaboration Between Limited English Proficiency and Health

Literacy Researchers. J Health Commun, 17(sup3), 7-12. doi:

10.1080/10810730.2012.712627

Mitic, W., & Rootman, I. (2012). An intersectoral approach for improving health literacy for

Canadians. A discussion paper.: Public Health Association of British Columbia.

Nielsen-Bohlman, L., & Panzer, A. M. (2004). Health literacy: a prescription to end

confusion: National Academy Press.

Nutbeam, D. (2000). Health literacy as a public health goal: a challenge for contemporary

health education and communication strategies into the 21st century. Health

Promotion International, 15(3), 259-267. doi: 10.1093/heapro/15.3.259

Nutbeam, D. (2008). The evolving concept of health literacy. Soc Sci Med, 67(12), 2072-

2078. doi: 10.1016/j.socscimed.2008.09.050

Osborne, R. H., Batterham, R. W., Elsworth, G. R., Hawkins, M., & Buchbinder, R. (2013).

The grounded psychometric development and initial validation of the Health Literacy

Questionnaire (HLQ). BMC Public Health 13(658). Retrieved from

doi:10.1186/1471-2458-13-658

Paasche-Orlow, M. K., & Wolf, M. S. S., S19–S26. (2007). The causal pathways linking

health literacy to health outcomes. American Journal of Health Behavior, 31(Suppl.1),

S19-S26.

Parker, E. J., Misan, G., Chong, A., Mills, H., Roberts-Thomson, K., Horowitz, A. M., &

Jamieson, L. M. (2012). An oral health literacy intervention for Indigenous adults in a

rural setting in Australia. BMC Public Health, 12(1), 461. doi: 10.1186/1471-2458-

12-461

Pleasant, A., & McKinney, J. (2011). Coming to consensus on health literacy measurement:

an online discussion and consensus-gauging process. [Consensus Development

15

Conference]. Nursing Outlook, 59(2), 95-106 e101. doi:

10.1016/j.outlook.2010.12.006

Pleasant, A., McKinney, J., & Rikard, R. V. (2011). Health Literacy Measurement: A

Proposed Research Agenda. Journal of Health Communication: International

Perspectives, 16(sup3), 11-21.

Rubin, D. L., Parmer, J., Freimuth, V., Kaley, T., & Okundaye, M. (2011). Associations

Between Older Adults' Spoken Interactive Health Literacy and Selected Health Care

and Health Communication Outcomes. Journal of Health Communication, 16(sup3),

191-204.

Smylie, J., Williams, L., & Cooper, N. (2006). Culture-based literacy and Aboriginal health.

Canadian Journal Of Public Health. Revue Canadienne De Santé Publique, 97 Suppl

2, S21-S25.

Squiers, L., Peinado, S., Berkman, N., Boudewyns, V., & McCormack, L. (2012). The Health

Literacy Skills Framework. J Health Commun, 17(sup3), 30-54. doi:

10.1080/10810730.2012.713442

Sudore, R. L., Landefeld, C. S., Pérez-Stable, E. J., Bibbins-Domingo, K., Williams, B. A., &

Schillinger, D. (2009). Unraveling the relationship between literacy, language

proficiency, and patient–physician communication. Patient Educ Couns, 75(3), 398-

402. doi: http://dx.doi.org/10.1016/j.pec.2009.02.019

Todd, L., & Hoffman-Goetz, L. (2011). Predicting health literacy among english-as-a-

second-language older chinese immigrant women to canada: comprehension of colon

cancer prevention information. Journal of Cancer Education, 26(2), 326-332. doi:

10.1007/s13187-010-0162-2

Vass, A., Mitchell, A., & Dhurrkay, Y. (2011). Health literacy and Australian Indigenous

peoples: an analysis of the role of language and worldview. Health Promotion

Journal of Australia, 22(1), 33-37.

Zarcadoolas, C. (2011). The simplicity complex: exploring simplified health messages in a

complex world. Health Promot International, 26(3), 338-350.

Zarcadoolas, C., Pleasant, A., & Greer, D. S. (2005). Understanding health literacy: an

expanded model. Health Promot Int, 20(2), 195-203. doi: 10.1093/heapro/dah609