Health Literacy Research in Europe
and Ireland: The State of the Art
Dr Gerardine Doyle
University College Dublin
FP7 Diabetes Literacy Consortium and HLS-EU Consortium
1
Overview
 The State of the Art in Europe
 European Health Literacy Survey – generation of first data set
 Recent data collection in Portugal, Belgium and Denmark
 Commencement of data collection in Italy
 Health Literacy and Health behaviours – evidence from HLS-EU
 Health Literacy and Chronic Disease Management
 The role of technology and connected health solutions?
 Key Messages
2
The State of the Art in Europe
 First time data for 8 European countries – HLS-EU
 Now need to generate the second wave of data - National and
EU monitoring of health literacy over time
 Key findings
 Implications of key findings
3
 Health literacy is a significant problem – inform policy
 Social gradient - reduce health disparities associated with
education and social exclusion
 Design health literacy interventions for vulnerable groups
The objectives were to:
1. Develop a model instrument for measuring health literacy
in Europe
2. Generate first-time data on health literacy in European
countries, providing indicators for national an EU
monitoring
3. Make comparative assessment of health literacy in
European countries
4
Integrated HLS-EU Model of Health Literacy
Societal and environmental determinants
Life course
Sitauational
Determinants
Health
service
use
Health
costs
Health
behavior
Health
outcomes
Participation
Empowerment
Equity
Sustainability
Understand
Access
Knowledge
Health care
Motivation
Health
information
Competences
Disease
prevention
Health
promotion
Appraise
Apply
Personal
Determinants
Individual level
Population level
5
Antecedents
Cultural
General Literacy
Language,
Reading,
Numeracy,
Religious beliefs
Prior experience
with the
healthcare
system
Psychosocial
Social support
Demographic
SES, Occupation,
Income
6
Health
Literacy
Individual
Characteristics
Age, Gender
Percentages of different levels of General
Health Literacy, for countries and total sample
General Health Index
100%
90%
10.4%
11.9%
34.8%
26.7%
80%
70%
19.7%
9.5%
22.3%
39.9%
39.0%
50%
40%
30%
22.1%
17.0%
36.6%
36.7%
47.9%
35.1%
38.1%
35.1%
30.4%
49.8%
16.7%
AT
∅32.2
BG
∅30.7
34.5%
25.7%
26.3%
0%
31.8%
29.5%
20%
10%
24.8%
33.4%
34.4%
60%
15.8%
10.8%
13.9%
7.3%
9.3%
DE(NRW)
∅34.6
EL
∅33.6
ES
∅33.0
IE
∅35.4
inadequate HL
0-25 Points
problematic HL
>25-33 Points
7
sufficient HL
>33-42 Points
1.6%
NL
∅37.1
9.5%
11.8%
PL
∅35.0
Total
∅34.0
excellent HL
>42-50 Points
General Health Literacy
Mean Scores by Age and Country
40
35
30
25
AT -0,15*
BG -0,27*
DE(NRW) +0,01
EL -0,36*
ES -0,23*
IE -0,01
NL +0,06
PL -0,24*
Total -0,16*
20
25 or younger between 26 between 36 between 46 between 56 between 66
and 35
and 45
and 55
and 65
and 75
76 or older
*Pearson’s correlation coefficient,*p<0.05
 Austria
8
 Bulgaria

Germany
(NRW)
 Greece
 Spain

Ireland

Netherlands
 Poland
 TOTAL
General Health Literacy
Mean Scores by Perceived Social Status and Country
40
35
30
25
20
Very Low
Low
AT +0,15*
BG +0,37*
DE(NRW) +0,11*
EL +0,36*
ES +0,15*
IE +0,32*
NL +0,21*
PL +0,25*
Total +0,30*
Lower
middle
Middle
Upper middle
High
 Greece
 Spain
 Ireland
 Netherlands
Very high
*Pearson’s correlation coefficient,*p<0.05
 Austria
9
 Bulgaria
 Germany
(NRW)
 Poland
 TOTAL
General Health Literacy
Mean Scores by Financial Deprivation and Country
40
38
36
34
32
30
AT -0.26*
DE(NRW) -0.26*
BG -0.44*
PL -0.41*
26
EL -0.41*
ES -0.13*
24
IE -0.34*
NL -0.19*
22
Total -0.33*
28
20
-1.20
-0.80
-0.40
0.00
0.40
0.80
1.20
1.60
2.00
2.40
2.80
*Pearson’s correlation coefficient,*p<0.05
 Austria
10
 Bulgaria
 Germany
(NRW)
 Greece
 Spain
 Ireland
 Netherlands
 Poland
 TOTAL
General Health Literacy Index
Mean Scores by Self-Assessed Health and Country
40
35
30
25
AT -0,32*
BG -0.31*
DE(NRW) -0.23*
EL -0,39*
ES -0.28*
IE -0,23*
NL -0.17*
PL -0.32*
Total -0,30*
20
Very good
Good
*Pearson’s correlation coefficient,*p<0.05
 Austria
11
 Bulgaria
 Germany
(NRW)
Fair
 Greece
 Spain
Bad
 Ireland
 Netherlands
Very bad
 Poland
 TOTAL
Summary of Results
1.
Limited Health Literacy is a relevant problem for European
member states (on different national levels)
2.
Not only for health or literacy but also for health literacy there
is a considerable social gradient in European member states
3.
Vulnerable groups with specific risks of limited health literacy
have been identified
4. Member states do not only differ in levels of health literacy
but also by associations with social gradient indicators
12
Summary
General Health Literacy (Europe)
Financial Deprivation
Decreasing Health Status
Age
Social Status
Functional Health Literacy
(reading/writing)
13
Current Research
14
Recent Data Collection: Portugal
General HLS-Portugal Distribution of Health Literacy levels
15
Recent Data Collection: Portugal
16
Conclusions of HLS - Portugal
 Portuguese General Health Literacy Index: 6th place among HLS
Consortium
 The younger the respondent, the higher the level of health literacy
 The higher the level of education, the higher the level of health
literacy
 Positive correlation between health literacy and literacy practices,
(involve reading a range of different materials, or using information
and communication technologies):
 Health literacy cannot be dissociated from literacy in general
 ICT emerged as a strong alternative to disseminate health information
and promote/develop healthy behaviours
 There is a very vulnerable group of respondents that should be
considered and targeted for public health policies
17
Recent Data Collection: Belgium –
HLS-EU-Q16
 The Study:
 A study of 9616 members of the largest health insurance fund
in Belgium (French and Dutch speaking)
 Part of a larger study on socio-emotional aspects of health
 HLS-EU-Q16 online survey (not face to face)
18
Recent Data Collection: Belgium –
HLS-EU-Q16
 Key Findings:








12% insufficient health literacy
30% limited health literacy
58% sufficient health literacy
Gender finding: Females have better HL than males
HL decreased with age
HL increased with educational level
Flemish had better HL than Walloons or Brussels
HL is a significant mediator for eating, physical activity and
medicine use but not tobacco use
 Alcohol consumption did not vary by education level – not
tested for mediation
19
Recent Data Collection: Belgium
20
Recent Data Collection: Belgium
21
Recent Data Collection: Denmark
The objective of the study:
1. Describe the level of
a) the ability to understand health information
b) the ability to actively engage with healthcare
providers
2. Examine the association between socio-demographic
characteristics and these dimensions of health literacy
22
Denmark: Research Design
• Design: A cross sectional
population based survey
study
• Sample: A random sample
of 46,354 individuals (>25
years) living in the Central
Denmark Region
• A total of 29,473 (63.6%)
responded to the survey
23
24
Results – response distribution
Item
missing
Items
%
‘Understanding’
1a
6.9
2a
7.3
3a
6.7
4a
6.4
5a
7.0
‘Engagement’
1b
6.8
2b
6.5
3b
5.9
4b
7.3
5b
7.0
25
Population-weighted proportion in
each response category
Population-weighted
difficulty level of items
Very
difficult
Difficult
Easy
Very
easy
(% of respondents rating items
as difficult or very difficult)
%
%
%
%
% (95%CI)
2.6
1.4
2.0
3.2
1.0
13.4
13.1
10.8
17.0
7.8
57.2
61.3
58.3
56.0
64.7
26.7
24.2
28.9
23.8
26.6
16.0
14.5
12.8
20.2
8.8
(15.5 - 16.6)
(14.0 - 15.0)
(12.4 - 13.3)
(19.6 - 20.8)
(8.4 - 9.2)
2.5
1.7
2.2
2.0
1.6
15.8
12.8
14.4
16.3
13.7
57.8
57.4
56.2
56.9
59.2
24.0
28.2
27.3
24.8
25.5
18.3
14.5
16.6
18.3
15.3
(17.7 - 18.8)
(14.0 – 15.0)
(16.1 - 17.1)
(17.8 - 18.9)
(14.8 - 15.8)
Results – single items by SD characteristics
Education
Education
Age
Income
40
30
20
10
0
1a
2a
3a
4a
5a
1b
Item
Low
26
Medium
High
2b
3b
4b
5b
Italy
A. Measurement of Health Literacy
 HLS-EU-Q has been translated into Italian
 HLS-EU-Q 16 or 47 items
 Sample size = 1,500 citizens aged 15 years and older
 Computer assisted personal interviewing technique (CAPI)
B. Assessing Health Literacy barriers in Italian Health care settings
 Three health care settings - North, Central and South Italy
 Ospedale Maggiore Parma
 A.O.S. Andrea di Roma
 A.O.S. Garibaldi di Catania
Data Collection: July-September 2015
 Study sponsored by MSD Italy, co-ordinated by Lingomed s.r.l.Ita
27
Health Literacy and Health
behaviours: Evidence from HLS-EU
28
The Curious Case of Health Literacy
and Health Behaviour
 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
29
 Information Processing pathways; what matters for
behaviour?
 Accessing, understanding, evaluating, applying
Health Literacy and Health Behaviour among
People aged 50+ in Ireland
Difference in Mean Health Literacy Scores by Contrasting
Categories of Health Behaviours and Health Status
Community Engagement (Often/Never)
Exercise (Most days/Never)
Alcohol (Problematic/Never)
Smoking (Yes/Never)
Hospital Use (None/ 6 or more)
Doctors Visit (None/ 6 or more)
Health Status (Good/Bad)
-10
-5
Health Promotion
14.01
Doctors Visit
(None/ 6 or
more)
7.23
Prevention
11.58
4.54
Health Status
(Good/Bad)
30
0
Hospital Use
(None/ 6 or
more)
4.99
3.51
5
Smoking
(Yes/Never)
-5.13
-3.18
10
Alcohol
Exercise (Most
(Problematic/Ne
days/Never)
ver)
-1.6
8.76
-1.38
5.25
15
Community
Engagement
(Often/Never)
7.06
4.92
Health Literacy and Health Behaviour among
People aged 50+ in Ireland
Difference in Mean Health Literacy Scores by Contrasting
Categories of Health Behaviours and Health Status
Community Engagement (Often/Never)
Exercise (Most days/Never)
Alcohol (Problematic/Never)
Smoking (Yes/Never)
Hospital Use (None/ 6 or more)
Doctors Visit (None/ 6 or more)
Health Status (Good/Bad)
-14
-12
Health Status
(Good/Bad)
-10
-8
-6
Doctors Visit
Hospital Use
(None/ 6 or more) (None/ 6 or more)
-4
Smoking
(Yes/Never)
Health Care
-9.06
-3.73
-3.45
2.82
General
31
-11.29
-5.27
-3.93
3.97
-2
0
2
Alcohol
Exercise (Most
(Problematic/Nev
days/Never)
er)
2.06
-3.94
1.54
-5.89
4
6
Community
Engagement
(Often/Never)
-0.64
-4.14
Information Processing Pathways and Health
Behaviour (Smoking and Alcohol)
39.00
38.00
37.00
Finding
36.00
35.00
Understanding
34.00
33.00
Evaluating
32.00
31.00
Applying
30.00
29.00
28.00
Never Smoker
Smoker
Smoking
32
Light
Excessive
Alcohol Consumption
Health Literacy and Chronic Disease
Management
 Diabetes Literacy Consortium
‘Enhancing the cost effectiveness of diabetes self management
education: A comparative assessment of different educational
approaches and conditions for successful implementation’
 Applied Research in Connected Health
Costing of dementia care pathway and pre/post study of the deployment
of a new connected health solution
 IROHLA Consortium
‘Towards Sustainable Health Systems: The IROHLA evidence based
guidelines on improving health literacy in the ageing population’
33
The role of technology and
connected health solutions?
 Connected Health describes a technology - enabled model of health care
delivery where key stakeholders are connected to ensure improved
continuity of care and an efficient flow of information
 Connected Health model was implemented into the dementia care
pathway for 28 patients and their caregivers over a period of 6.5 weeks
 Results:
 Compliance with the use of the portal was 77% with no drop outs during the
study
 Benefits were seen in Caregiver Strain Index and Caregiver Sleep Quality
 Health literacy of the caregivers was measured (HLS-EU-Q16) both pre and
post deployment of the CH intervention
 A positive correlation between increased log-ins to the Information section
of the portal with an improved dementia specific literacy score
 If the CH intervention can delay the typical progression of dementia into the
mild-moderate and moderate-severe states of disease, the intervention can
bring about an improvement in the patients quality of life
34
Key Research Areas
Responding to the Health Literacy Epidemic
“Nearly half the American population may
have difficulties in acting on health
information” (Institute of Medicine, 2004)
Emerging areas:
Improved
communication with
low literacy patients
Health Literacy
Screening
Research
Areas
Cost and outcomes of
poor health literacy
35
Causal pathway of
how poor health
literacy influences
health
• Role of health educators in
promoting health literacy
• Health communication
• Prevalence of limited health
literacy
• Relationship between HL and
health behaviours
• Cost-effectiveness studies of
health literacy interventions
• Connected Health Solutions
Current Areas of Health Literacy Research in Ireland
Health System
Chronic Disease
Individual-level
36
•Interventions for healthy ageing (FP7)
•Health promoting hospitals
•Informal care
•Connected health solutions
•Type 2 Diabetes (FP7)
•Dementia (ARCH)
•Pain management
•Medication adherence
•Diet, exercise, risk behaviours
Key Messages: Research Agenda
 National and EU monitoring of health literacy over time
 Health literacy as an instrument to:
 Improve self management of chronic disease
 Thereby generating cost savings
 Offers a simple solution to a complex and costly epidemic
 Future research to provide evidence to inform policy
 Longitudinal studies of cost-effectiveness of health literacy
interventions, especially in the context of chronic disease and
healthy ageing
37
Key Messages: Actionable Policy
 Policies
 Strengthen health literacy to empower individuals and communities in:
 reducing health disparities associated with education and social
exclusion (Healthy Ireland: 2013-25)
 achieving better self management of chronic disease and
 changing health behaviours
 To lead to:
 Improved health literacy of the population
 Improved Self Management of chronic disease
 More efficient health service utilisation
 Cost savings – better use of scarce resources
 Sustainable health care
38
Policies that can strengthen health literacy
offer a simple solution to complex and
costly health care
39
Thank you
 Acknowledgements:
 The HLS-EU Consortium
 The Diabetes Literacy Consortium
 Prof. Rita Espanha, ISCTE Instituto Universitário de Lisboa,
Portugal
 Prof. Stephan van den Broucke, Universite Catholique de
Louvain, Belgium
 Prof. Helle Terkildsden, Aarhus University, Denmark
 Dr Marco Musello, Universitá degli Studi di Salerno, Italy
 Royal Irish Academy & Dr Sarah Gibney
 Contact: gerardine.doyle@ucd.ie
40