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: sarah.gibney@ucd.ie

Questions …

Thank you

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