Health Literacy: Principles-Measures-
Research-PolicyDr Sarah Gibney
FP7 Diabetes Literacy Consortium University College Dublin
Principles Background Definitions and components
Measures (examples) Research
Antecedents and consequences of poor health literacy Key research areas European Health Literacy Survey (inc. Ireland) Action areas
Policy Key Messages
Overview
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Background Increasing complexity of health systems and proliferation of health informationFrom ‘industrial age medicine’ to ‘information age health care’ (Smith, 2006)
Since the 1990sRapid growth of interest internationally and in different health fields (Rudd et al. 2007)Growing evidence-base linking literacy to health status, behaviour, beliefs, outcomesPotentially a cost effective way of addressing health (Eicler et al. 2009)Reflects a rights-based approach to equality in healthcare (access and outcome)
Background
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Defined as cognitive and social skills which determine the motivation and ability of individuals to access, understand and use information in ways which promote and maintain good health
More than being able to read pamphlets and successfully make appointments
Goes beyond the concept of health education and individual behaviour-orientated communication
Addresses the environmental, political and social factors that determine health
By improving peoples’ access to health information and their capacity to use it effectively, health literacy is critical to empowerment
Links with international health and development goals
Health Literacy World Health Organisation (WHO)
Perspective
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Measuring Health Literacy
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Various definitions, however most concern Cognitive Capabilities, Skills and Behaviour
Most reflect an individuals’ capacity to function in the role of a patient within the healthcare system (Sørensen et al. 2012)
What Should be Included When Assessing Health Literacy?
Critical Components Key Differences• Communication • Comprehension • Quantitative/Numeracy• Navigation • Health information seeking • Function• Decision making / Critical
thinking• Self-efficacy • Motivation • Cognitive skills
• Instruments vary from screening items to performance-based measures
• Tools vary in their approach to operationalising the concept into a measurable construct
• Administration styles vary• Time and resources needed
vary • Scoring, ranges and levels vary
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Health Literacy Measures (Examples)
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Diabetes Numeracy Test (DNT-15); Literacy Assessment for Diabetes
Asthma Numeracy Questionnaire Food Label Literacy for Applied Nutrition
Questionnaire (FLLANK) Literacy Measure for Patients with HIV Spanish/Hebrew/Korean Health Literacy
Test and Test for Singapore
Condition and Population-Specific Health Literacy Measures
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Antecedents
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(Zarcadoolas et al. 2006)
Consequences Health Literacy as a Public Health
Issue
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Key Research AreasResponding to the “Health Literacy
Epidemic”
“Nearly half the American population may have difficulties in acting on health information” (Institute of Medicine, 2004) Emerging areas:
•Role of health educators in promoting health literacy•Public health literacy for lawyers•Health communication •Prevalence of limited health literacy •Health literacy as an empowerment tool for low income mothers •Comparative research 12
Response to calls for internationally collaborative research (Protheroe et al. 2009)
European Commission action areas include the promotion of health literacy programmes for different age groups
Mismatch between concept of health literacy and measures of health literacy
Link between poorer health outcomes and poorer use of health services now well established (Berkman et al. 2011)
8 Countries (Ireland, Greece, the Netherlands, Spain, Germany, Poland, Bulgaria, Austria)
2011; Ireland n= 1,005
The European Health Literacy Survey
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Integrated HLS-EU Model of Health Literacy
Individual level Population level
Personal Determinant
s
Sitauational Determinant
s
Life course
Health behavior
Health outcome
s
Health service use
Health costs
Knowledge
Motivation
Competences
Access
Understand
Appraise
Apply
Health careHealth
promotionDisease
prevention
Health information
Partici-pation
Empower-ment
Equity Sustain-ability
So
ciet
al a
nd
en
viro
nm
enta
l det
erm
inan
ts
On a scale from very easy to very difficult, how easy would you say it is to … Find information on how your neighbourhood could
be more health-friendly? (Instructions: Reducing noise and pollution, creating green spaces, leisure facilities)
Understand information on food packaging? Judge how your housing conditions help you to stay
healthy? make decisions to improve your health? Take part in activities that improve health and well-
being in your community?
Health Promotion Questions (Examples)
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On a scale from very easy to very difficult, how easy would you say it is to … Find information about how to manage unhealthy
behaviour such as smoking, low physical activity and drinking too much?
Understand why you need vaccinations? Judge how reliable health warnings are, such as
smoking, low physical activity and drinking too much?
Decide how you can protect yourself from illness based on advice from family and friends?
Disease Prevention Questions (Examples)
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On a scale from very easy to very difficult, how easy would you say it is to … Find information about symptoms of illnesses
that concern you? Understand what to do in a medical emergency? Judge the advantages and disadvantages of
different treatment options? Use information the doctor gives you to make
decisions about your illness?
Healthcare Questions (Examples)
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47 questions: Index score created: 0-50 with thresholds
Sub-indices by Domain: Health Care, Disease Prevention and Health Promotion (0-50 scale with thresholds)
Sub-indices by information processing pathway: Access, Understand, Evaluate, Apply (0-10 scale, no thresholds)
HLS-EU Questionnaire
Scores and Thresholds
Scores of 25 or less points = inadequate (rated at least 50% of items as difficult or very difficult)
Scores >25-33 points = problematic
Scores >33-42 points = sufficient
Scores >42-50 points = excellent
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Socio-demographic and socio-economic indicators (age, gender, education, marital status, children, employment, perceived income deprivation)
Lifestyle and behaviour (exercise, smoking, alcohol consumption, height and weight (BMI), community engagement)
Functional health literacy test (NVS-UK)
Perceived social status
Healthcare utilisation and self-reported health and disability status
HLS-EU Questionnaire Additional Items
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47 Items (General; Domains; Information Processing)
16 Items (General) 6 Items (General) 3 Items - in development – (General)
HLS-EU-Q Measurement Tools
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General Health Literacy Mean Scores by Age and Country
Austria Bulgaria
Germany
(NRW)
Greece
Spain Ireland
Netherlan
ds
Poland TOTAL
*Pearson’s correlation coefficient,*p<0.05
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General Health Literacy Mean Scores by Functional Health
Literacy (NVS SCORES) and Country
Austria Bulgaria Germany
(NRW)
Greece Spain Ireland Netherlands
Poland TOTAL
*Pearson’s correlation coefficient,*p<0.05
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General Health Literacy Mean Scores by Perceived Social Status
and Country
Austria Bulgaria Germany
(NRW)
Greece Spain Ireland Netherlands
Poland TOTAL
*Pearson’s correlation coefficient,*p<0.05
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General Health LiteracyMean Scores by Financial Deprivation and
Country
Austria Bulgaria Germany
(NRW)
Greece Spain Ireland Netherlands
Poland TOTAL*Pearson’s correlation coefficient,*p<0.05
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General Health Literacy IndexMean Scores by Self-Assessed Health and
Country
Austria Bulgaria Germany
(NRW)
Greece Spain Ireland Netherlands
Poland TOTAL
*Pearson’s correlation coefficient,*p<0.05
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SummaryGeneral Health Literacy (Europe)
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Functional health Literacy and Reading Ability-based Measures No association / inconsistent patterns (BMI, alcohol
consumption) Frequent negative association (smoking) These measures focus on understanding health
information only
Some aspects of health literacy are more related to health behaviours than others
✓ Disease prevention
✓ Health promotion
✗ Healthcare
Information Processing pathways; what matters for behaviour? Accessing, understanding, evaluating, applying
The Curious Case of Health Literacy
and Health Behaviour
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Other Considerations
…
Functional / General Health
LiteracyDisease
PreventionHealth Promotion
Health care
Accessing
Understanding
Evaluating
Applying
Gender: Is the relationship between HL and behaviours the same for men and women? Eg. Alcohol
Age: Patterns drinking behaviour and smoking initiation/continuation differ across the life course
Social Context: Cultural norms around activity, smoking, alcohol consumption
Social Gradient: HL correlated with education and SES (financial deprivation, perceived social status)
Health Literacy Gradient: Is the relationship between HL and HB the same at all level of health literacy?
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Health Literacy and Health Behaviour among People aged 50+ in Ireland
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Health Literacy and Health Behaviour among People aged 50+ in Ireland
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Information Processing Pathways and Health Behaviour (Smoking and
Alcohol)
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Medical education historically relied on rational choice model; people choose to pursue behaviours needed for health
Misses key sources of influence Behaviour should be understood in the broader
context: social class/SES, financial constraint, health beliefs, self-efficacy, stress, social support
Research identifying areas within health literacy which are more associated with behaviour offers greater opportunity to support behavioural change: Health Promotion, Disease Prevention Skills in the area of evaluating, applying and finding health
information
Health Promotion and Health Behaviours
What Research can Add
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Current Areas of Health Literacy Research in Ireland
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Area of priority action in the European Commission’s Health Strategy 2008-2013
Ireland National Adult Literacy Agency research and policy
recommendations (McCarthy & Lynch, 2002; National Adult Literacy Agency 2009; Health Service Executive & National Adult Literacy Agency 2009; Lynch, 2010)
National Health Literacy Advisory Panel Healthy Ireland (2013-25) National Framework for Health
and Wellbeing Policy adopted a social determinants of health framework Reducing health inequalities associated with education
and social inclusion Strengthen health literacy to empower individuals and
communities in reducing these health disparities (2013-25)
Health Literacy on the Policy Agenda
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Concept and definition Cognitive and social skills which determine the motivation and ability of
individuals to access, understand and use information in ways which promote and maintain good health
Measures Increasing number of disease and population specific measures to
address research priority and question Research
Macro (health system) – meso (health conditions) – micro (individual behaviour)
Spans multiple disciplines (public health, health economics, psychology, social policy, sociology, equality, gender studies)
Policy Strengthen health literacy to empower individuals and
communities in reducing these health disparities associated with education and social exclusion (Healthy Ireland: 2013-25)
Key Messages
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Acknowledgements: The HLS-EU Consortium Royal Irish Academy NALA and the Health Literacy Advisory Panel
Contact: [email protected]
Questions …
Thank you
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