Working togetherUpdate on the Royal College of General

Practitioners and NHS England report and action plan

Health literacy – Making it everybody’s business Thursday 25th June 2015

Gill Rowlands, Professor, University of Newcastle and Aarhus University

June 20151

2http://www.rcgp.org.uk/news/2014/june/~/media/Files/Policy/RCGP-Health-Literacy-2014.ashx

Gill Rowlands Joanne Protheroe Hannah PriceBob Gann Imran Rafi

This presentation• What did we discuss at the workshop in July 2013?– What is health literacy? – Is health literacy important?– What challenges does health literacy bring to patients,

health care staff, managers and commissioners?– What can be done to make things better?– A Call for Action

• Progress so far• Next steps• Do we need to know anything else about health literacy?

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What is health literacy

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“the personal characteristics and social resources needed for

individuals and communities to access, understand, appraise and

use information and services to make decisions about health.”

World Health Organization. Health literacy toolkit for low- and middle-income countries. A series of information sheets to empower communities and strengthen health systems. 2015.www.searo.who.int/entity/healthpromotion/documents/hl_tookit/en/

Yes! People with low health literacy are sicker than people with higher health literacy. They:•Die earlier1,2

•Find it more difficult to take their medication as instructed1

•Are more likely to have one or more long-term conditions (LTCs)3

•LTCs more likely to be limiting3

•Are less likely to engage with disease prevention e.g. cancer screening, immunisation1

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1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health literacyinterventions and outcomes: An updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality., 2011 Contract No.: 11-E006. 2. HLS-EU Consortium: Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012 3. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. British Medical Journal. 2012;344:e1602.

Is health literacy important?

Yes! People with low health literacy are less healthy than people with higher health literacy. They have:•More unhealthy behaviours; alcohol, poor diet/obesity, smoking2,3

•Fewer healthy behaviours; good diet/normal weight2,3

•Lower levels of self-rated health1,2

•Lower response to public healthy living campaigns3

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1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health literacyinterventions and outcomes: An updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality., 2011 Contract No.: 11-E006. 2. HLS-EU Consortium: Comparative report of health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012 3. Buck D, Frosini F. Clustering of unhealthy behaviours over time. Implications for policy and practice. . London: King's Fund, Aug 2012.

Is health literacy important?

Is health literacy a common problem? Yes!

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% of the adult working age population unable to fully read,

understand, and act on health information in common

circulation.

National average 61%

Rowlands, G., Protheroe, J., Richardson, M., Seed, P., Winkley, J., and Rudd, R. (2015). The health information gap: the mismatch between population health literacy and the complexity of health information; an observational study. British Journal of General Practice 65 e379 -e386.

Is low health literacy associated with other social determinants of health? Yes!

Male (literacy)Female

(numeracy)

Male (literacy)Female

(numeracy)Aged 45+Aged 45+ BMEBME

Born outside of the UK

Born outside of the UK

English not first language

English not first language

Below expected by

age 16

Below expected by

age 16

UnemployedUnemployed Lowest job grade

Lowest job grade

Income less than £10,000Income less

than £10,000

Not a home owner

Not a home owner

Top 5 most deprived

areas

Top 5 most deprived

areas

Not statistically significant when considered together

Rowlands G, Protheroe J, Richardson M, et al. The health information gap: the mismatch between population health literacy and the complexity of health information; an observational study. BJGP Accepted for publication. 2015.

What challenges does health literacy bring?

• Patients: – coping with a complex system that is not tailored to their health

literacy needs• Health care professionals:

– Lack of knowledge about the importance and impact of low health literacy

– Lack of skills in tailoring communication and services to patients’ health literacy needs

• Managers:– Developing ‘health literate’ systems and services tailored to patient

need– Up-skilling health care staff

• Commissioners– Ensuring people with low health literacy have a voice and can

influence the design of services to meet their needs– Using the power of commissioning to develop health literate health

services 9

Can anything be done to help? Yes

Improving the system•Improving how information is written improves understanding of information1

•Use of pictograms improves understanding of risk2

•Current international service development project involving several UK sites: the Ophelia project3 is exploring how health care organisations’ understanding of patients’ health literacy needs can be used to improve the service

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1. Scott, T.L., et al., Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care, 2002. 40(5): p. 395-404. 2. Garcia-Retamero R, Galesic M. Communicating treatment risk reduction to people with low numeracy skills: a cross-cultural comparison. Am J Public Health. 2009;99(12):2196-202 3. http://www.deakin.edu.au/health/research/phi/OPHELIA.php

Can anything be done to help? YesBuilding citizens health literacy skills•Improves knowledge and skills1

•Improves lifestyle (diet and exercise)1

•Improves mental health1,2

•Improves Diabetes self-management3

Building health professionals’ health literacy awareness and skillsCurrent project: Awareness raising and training of health care staff: Community Health and Learning Foundation

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1. Evaluation of the second phase of the Skilled for Health Programme. London: The Tavistock Institute and Shared Intelligence, 2009. 2. Weiss BD, Francis L, Senf JH, Heist K. Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial. J Gen Intern Med 2006;21:823–8 3. Rothman RL, DeWalt DA, Malone R, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. Journal of the American Medical Association. 2004;292(14):1711-6.

What are some solutions: the joint RCGP and NHS England call for action

1. To work with the Health Literacy Group UK to take the ‘Call for Action’ forward.

2. To improve GP training.3. To develop recommendations for Clinical Commissioning Groups

(CCGs) to consider health literacy approaches by NHS service providers when commissioning services.

4. To develop pilot sites where CCGs can commission health literacy training for patients from adult learning providers, with assessment of the impact of these pilots on patient skills, patient satisfaction with NHS services and their use of NHS services.

5. To ensure that those aspects of the Digital Inclusion Strategy relevant to general practice are highlighted to GPs.

6. To work with the Information Standard to develop a health literacy guide to be circulated to all NHS Trusts.

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Progress so far• NHS England is committed to working with partners to

support progress around health literacy – it is an agenda that cannot be addressed unilaterally

• This needs to be undertaken in parallel with other activities to improve and streamline health information and communication systems

• The Information Standard has been brought ‘in house’ to improve it’s engagement and effectiveness (especially for NHS Trusts) and streamline costs

• NHS England has pulled together a roundtable involving Health Literacy Group UK, Royal College of GPs, ALBs, and a range of other organisations to identify next steps and ensure a co-ordinated approach

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Next steps

• Develop a wider programme of work which addresses both the quality and accessibility of health information alongside ensuring people have the skills to be able to understand and apply it

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• Work with partners to develop a plan to support progress with health literacy which might include:– Using the Information Standard to improve the ‘health

literacy’ of health information– Provide implementation support for the Accessible

Information Standard as a way of supporting people with access and communication needs

– Work with the NHS England digital inclusion strategy to widen digital skills and participation for health

– Establish the best way to use the commissioning system to support action on health literacy, both in public engagement and in the services which are commissioned

– Work with the partners to improve the health literacy skills of health professionals

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Conclusions

• Health literacy affects a significant proportion of people (6 out of 10 in England)

• It results in less health and more illness, but much can be done to improve both health literacy skills and the approaches of the health and education sectors

• Progress is being made against the objectives in the ‘Call for Action’ but more needs to be done

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Points for discussion• The call for action: what needs prioritising and why?• Do we need to know anything more? What about:– The cost of health literacy to patients, the public and the

NHS?– What are the cost / benefits of lifelong learning

interventions – both in health but also in communities and wider society

– Health literacy and wider skills, employability and productiveness?

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Working togetherUpdate on the Royal College of General

Practitioners and NHS England report and action plan

Health literacy – Making it everybody’s business Thursday 25th June 2015

Gill Rowlands, Professor, University of Newcastle and Aarhus University

June 201518

Additional slides if needed

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National Qualifications level: Literacy level 1 / Numeracy level 1Key Stage Skill Equivalent Ages:

Literacy 11-14 years, Numeracy 11-14 years Number (%) English adults 16-65 yrs. UNABLE to understand and use this:

21 million people (61%)

Example: Bowel Cancer Screening Kit

NQF level

Key stage equivalent

At this LITERACY level an adult understands

Entry level 1

5-7 years Short texts with repeated language patterns on familiar topics

Entry level 2

7-9 years Short straightforward texts on familiar topics and from familiar sources

Entry level 3

9-11 years Short straightforward texts on familiar topics accurately and independentlyInformation from everyday sources

Level 1 11-14 years

Short straightforward texts of varying length on a variety of topics accurately and Independently

Level 2 14-16 years

A range of texts of varying complexityaccurately and independentlyInformation of varying length and detail

Material levelMaterial level

Population level

Skills QualificationFramework

Literacy

NQF level

Key stage equivalent

At this NUMERACY level an adult understands

Entry level 1

5-7 years Numbers and symbols in a simple format

Entry level 2

7-9 years Numbers, symbols, simple diagrams and charts in a simple format

Entry level 3

9-11 years Numbers, symbols, diagrams and charts used for different purposes and in different ways

Level 1 11-14 years

Straightforward mathematical information, can independently select relevant information

Level 2 14-16 years

Mathematical information used for different purposes, can independently select and compare relevant information from a variety of sources

Material levelMaterial level

Population level

Skills QualificationFramework Numeracy

Is low health literacy a common problem? YesThe situation in Europe.

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From the HLS-EU final report. SLIDE COURTESY OF Prof. Jürgen M. Pelikan Ludwig Boltzmann Institute Health Promotion Research, WHO-CC for Health Promotion in Hospitals and Health Care, Vienna/ Austria.