Health Literacy:
Principles-Measures-Research-Policy
Dr Sarah Gibney
FP7 Diabetes Literacy Consortium
University College Dublin
Overview
 Principles
 Background
 Definitions and components
 Measures (examples)
 Research


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Antecedents and consequences of poor health literacy
Key research areas
European Health Literacy Survey (inc. Ireland)
Action areas
 Policy
 Key Messages
2
Background
Background
 Increasing complexity of health systems and proliferation of health information
 From ‘industrial age medicine’ to ‘information age health care’ (Smith, 2006)
Since the 1990s
 Rapid growth of interest internationally and in different health fields (Rudd
et al. 2007)
 Growing evidence-base linking literacy to health status, behaviour, beliefs,
outcomes
 Potentially a cost effective way of addressing health (Eicler et al. 2009)
 Reflects a rights-based approach to equality in healthcare (access and
outcome)
3
Health Literacy
World Health Organisation (WHO) Perspective
 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 behaviourorientated 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
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Measuring Health Literacy
5
What Should be Included When Assessing
Health Literacy?

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)
Critical Components
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Key Differences
•
Communication
Comprehension
Quantitative/Numeracy
Navigation
Health information seeking
Function
Decision making / Critical thinking
Self-efficacy
Motivation
Cognitive skills
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6
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
Health Literacy Measures (Examples)
Functional Health Literacy (basic skills in reading and writing):
Rapid Estimate of Adult Literacy in Medicine (REALM-SF, REALM-Teen)
Test of Functional Health Literacy in Adults (TOFHLA, STOFHLA (Spanish, TOFHLiD)
Newest Vital Sign (NVS)
Single Items: BRIEF, SILS
Health Promotion:
Functional Health Literacy Test
Health Activity Literacy Scale (HALS) Excludes oral skills, lacks measures of problem
solving tests, neglects to measure attitudes, values and beliefs.
Healthcare, Health Promotion and Disease Prevention and Information Processing
and Problem Solving:
European Health Literacy Survey (HLS-EU-Q)
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Condition and Population-Specific Health
Literacy Measures
 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
8
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Antecedents
Cultural
General Literacy
Language,
Reading,
Numeracy,
Religious beliefs
Prior experience
with the
healthcare
system
Psychosocial
Social support
Demographic
SES, Occupation,
Income
Health
Literacy
10
Individual
Characteristics
Age, Gender
Consequences
Health Literacy as a Public Health Issue
•Improper use of
medication
•Inappropriate use or no
use of health services
•Inadequate response to
emergency situations
•Lack of selfefficacy and selfesteem
•Poor self-management
of chronic conditions
•Poor health outcomes
Healthcare
Health
Personal
Societal
•Financial burden on
individuals and society
•Social inequity
11
(Zarcadoolas et al. 2006)
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
Causal pathway of
how poor health
literacy influences
health
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• 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
The European Health Literacy Survey
 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
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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
14
Health Promotion Questions
(Examples)
 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?
15
Disease Prevention Questions
(Examples)
 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?
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Healthcare Questions (Examples)
 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?
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HLS-EU Questionnaire
 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)
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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HLS-EU Questionnaire
Additional Items
 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
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HLS-EU-Q Measurement Tools




47 Items (General; Domains; Information Processing)
16 Items (General)
6 Items (General)
3 Items - in development – (General)
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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
 Bulgaria

Germany
(NRW)
 Greece
 Spain
21
 Ireland

Netherlands
 Poland
 TOTAL
General Health Literacy
Mean Scores by Functional Health Literacy (NVS
SCORES) and Country
40
35
30
AT +0,22*
EL +0,35*
NL +0,10*
25
BG +0,37*
ES +0,21*
PL +0,32*
DE(NRW) 0,18*
IE +0,22*
Total +0,27*
20
0
1
*Pearson’s correlation coefficient,*p<0.05
 Austria
 Bulgaria
 Germany
(NRW)
2
 Greece
3
 Spain
22
4
 Ireland
5
 Netherlands
6
 Poland
 TOTAL
General Health Literacy
Mean Scores by Perceived Social Status and Country
40
35
30
25
AT +0,15*
EL +0,36*
NL +0,21*
20
Very Low
Low
Lower
middle
BG +0,37*
ES +0,15*
PL +0,25*
Middle
DE(NRW) +0,11*
IE +0,32*
Total +0,30*
Upper middle
High
Very high
*Pearson’s correlation coefficient,*p<0.05
 Austria
 Bulgaria
 Germany
(NRW)
 Greece
23
 Spain
 Ireland
 Netherlands
 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
 Bulgaria
 Germany
(NRW)
 Greece
 Spain
24
 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
 Bulgaria
 Germany
(NRW)
 Greece
Fair
25
 Spain
Bad
 Ireland
 Netherlands
Very bad
 Poland
 TOTAL
Summary
General Health Literacy (Europe)
Financial Deprivation
Decreasing Health Status
Age
Social Status
Functional Health Literacy
(reading/writing)
26
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

Information Processing pathways; what matters for behaviour?
 Accessing, understanding, evaluating, applying
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Other
Considerations …
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)
Functional / General
Health Literacy
Disease Prevention
Health Promotion
Health care
Evaluating
Accessing
Understanding
Health Literacy Gradient: Is the relationship between
HL and HB the same at all level of health literacy?
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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)
-14
-12
-10
Health Care
-9.06
Doctors Visit
(None/ 6 or
more)
-3.73
General
-11.29
-5.27
Health Status
(Good/Bad)
-8
-6
Hospital Use
(None/ 6 or
more)
-3.45
-3.93
-4
Smoking
(Yes/Never)
2.82
29
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
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)
0
Hospital Use
(None/ 6 or
more)
4.99
30
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
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
Light
Smoking
Excessive
Alcohol Consumption
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Health Promotion and Health Behaviours
What Research can Add
 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
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Current Areas of Health Literacy Research in Ireland
Health System
Chronic Disease
Individual-level
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•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
Health Literacy on the Policy Agenda
 Area of priority action in the European Commission’s Health Strategy 20082013
 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)
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Key Messages
 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)
35
Thank you
 Acknowledgements:
 The HLS-EU Consortium
 Royal Irish Academy
 NALA and the Health Literacy Advisory Panel
 Contact: sarah.gibney@ucd.ie
 Questions …
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