Health Literacy Final - WHO
ACKNOWLEDGMENTSWritten and prepared by:Mayagah Kanj and Wayne MiticConsultants to the Eastern Mediterranean Region, World Health Organization.This paper was prepared as a working document for discussion at the 7th Global Conference on HealthPromotion, "Promoting Health and Development: Closing the Implementation Gap", Nairobi, Kenya,26-30 October 2009.It may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated oradapted, in part or in whole, in any form or by any means. The views presented in this discussionpaper do not necessarily represent the decisions, policies or views of WHO or the organizations forwhich the contributors and reviewers work.
CONTENTSList of Abbreviations. 2Executive Summary.4Forward. 8What is literacy?. 9What is health literacy?. 10Why is health literacy important? . 161.The large numbers of people affected. 162.Related to poor health outcomes. 193.Increasing rates of chronic disease . 214.Health care costs . 235.Health information demands . 246.Equity. 25How are health literacy and health promotion related?. 26What models and frameworks exist to describe health literacy? . 28How is health literacy measured?. 33What methods exist to improve health literacy?. 35What examples exist in the EMRO that describe best practices and lessons learned? . 37Method . 38Overview of Findings . 38Specific Findings . 39Gaps and Recommendations. 41Next Steps . 42Annex 1. Major Systematic Reviews of Health Literacy, Behaviours and Outcomes . 44Annex 2. - Studies Reviewed in Environmental Scan . 46LIST OF ABBREVIATIONSPage 2
CQIContinuous Quality ImprovementHIVHuman Immunodeficiency VirusNCDNon-communicable disease/sPDSAPlan/Do/Study/ActRELEASEReflective learning and action systemsSEAR/SEAROSouth East Asian Region/ South East Asian Regional OfficeWPR/ WPROWestern Pacific Region/ Western Pacific Regional OfficePage 3
EXECUTIVE SUMMARYTo function well in the 21st century a person must possess a wide range of abilities and competencies,in essence many ‘literacies’. These ‘literacies’—from being able to read a newspaper to understandinginformation provided by a health care provider—are multiple, dynamic, and malleable.‘Health literacy’ is an emerging concept that involves the bringing together of people from both thehealth and literacy fields. Health literacy builds on the idea that both health and literacy are criticalresources for everyday living. Our level of literacy directly affects our ability to not only act on healthinformation but also to take more control of our health as individuals, families and communities.While many definitions for health literacy exist, the definition that has been adopted in this paper is, The degree to which people are able to access, understand, appraise and communicate information toengage with the demands of different health contexts in order to promote and maintain good healthacross the life-course.The scope of health literacy has three distinct ‘levels’: Functional literacy: Skills that allow an individual to read consent forms, medicinelabels, and health care information and to understand written and oral information givenby physicians, nurses, pharmacists, or other health care professionals and to act ondirections by taking medication correctly, adhering to self-care at home, and keepingappointment schedules. Conceptual literacy: The wide range of skills, and competencies that people developover their lifetimes to seek out, comprehend, evaluate, and use health information andconcepts to make informed choices, reduce health risks, and increase quality of life.Strengthening active citizenship for health by Health literacy as empowerment:bringing together a commitment to citizenship with health promotion and preventionefforts and involving individuals in: understanding their rights as patients and their abilityto navigate through the health care system; acting as an informed consumers about thehealth risks of products and services and about options in health care providers, and actingindividually or collectively to improve health through the political system through voting,advocacy or membership of social movements.Why is health literacy an important area to consider when planning health promotion initiatives? Thepublished literature identifies six general themes that help determine why health literacy is importantfor population health:1.The large numbers of people affected: some countries within the EMR have highadult literacy rates, however, approximately half have rates below the globaldeveloping country average of 79 percent. In most EMRO countries literacy rates arelower among women than men - the exceptions being Qatar and the UAE.2.Poor health outcomes: there is a clear correlation between inadequate healthliteracy—as measured by reading fluency—and increased mortality rates.3.Increasing rates of chronic disease: In the EMR, chronic diseases are estimated toaccount for almost half (47%) of the total burden of disease. Health literacy plays acrucial role in chronic disease self-management.4.Health care costs: the additional costs of limited health literacy range from 3 to 5% ofthe total health care cost per yearPage 4
5.Health information demands: a mismatch exists between the reading levels ofhealth-related materials and the reading skills of the intended audience. Often, the useof jargon and technical language made many health-related resources unnecessarilydifficult to use.6.Equity: low levels of health literacy often mean that a person is unable to manage theirown health effectively, access health services effectively, and understand theinformation available to them and thus make informed healthy decisions. Improvingthe health literacy of those with the worst health outcomes is an important tool inreducing health inequalitiesThe Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy inAdults (TOFHLA), are the most frequently used tools to measure health literacy and the Newest VitalSign has recently been added to the list of instruments. Unfortunately, none of these tools completelycapture health literacy as reflected in the health promotion-related definitions of health literacy thatwe have considered in this paper. They are mainly measures of reading proficiency. The HealthActivity Literacy Scale (HALS) shows great promise in addressing some of these limitations. But eventhis instrument has inherent limitations: It excludes oral skills, lacks a measure of problem-solvingtests and neglects to measure attitudes, values and beliefs. Nonetheless, some researchers considerthe HALS to be the best existing measure of health literacy.What conclusions can be drawn from systematic reviews and the vast amount of research on healthliteracy that has been completed over the past 25 years? Few rigorous evaluations of health literacy-related interventions have been carried out, andmost available research has been conducted in the United States. The evaluations that havebeen done are not definitive. Simplifying reading material by using clear language, pictures and symbols is the mostwidespread initiative reported in the literature to influence literacy levels, yet there is littleevidence that this improves health outcomes. Multimedia presentations may improve knowledge of people with both low and high literacyskills, but these do not appear to change health-related behaviours; Community-based and participatory approaches seem to show some promise. For exampleparticipatory education principles and theories of empowerment appear to help parentsaccess, understand and use health information for the benefit of their own and their children’shealth.We conducted an extensive literature search to determine the extent of health literacy interventionscurrently ongoing within countries of the EMR. Six electronic data bases were searched as well as thesites of some United Nations agencies, universities, and selected international and local non-governmentalorganizations (NGOs). To ensure that as many interventions as possible were identified the scope of oursearch included health literacy as it pertained to the “empowerment” aspects within health promotion,as well as the dimensions of community development . The criterion for selection included anyinterventions that addressed health literacy at the; functional (basic skills in reading and writing),interactive (social skills that allow active participation in health care) and critical (the ability tocritically analyze and use information to participate in actions conducive to health) level.Page 5
Sixteen initiatives spanning from 1994 to 2009 were identified. Most (14) of these initiatives werebeing implemented or coordinated by academic institutions in collaboration with national partners.Information on these activities was found in research journals (2) and the others in universitypublications. The interventions came under different titles such as “ communication for healthyliving”, “religious leaders lead the way”, “youth first project”, “post partum interventions”, “Arabwomen speak” out. Only one study used the term “health literacy” - Mental health literacy in Pakistan.Except for the latter, they all had empowerment objectives and entailed multiple activities such asdissemination of print material, use of media (television, DVD), skill building (training workshops),community mobilization and outreach and provision of services. The primary audiences orbeneficiaries of these projects were diverse, ranging from the general public to policy makers, healthproviders, youth, men, women (first time mothers, those of child bearing age), religious leaders (menand women) and special groups (diabetic patients). The health topics addressed were mainly relatedto reproductive and sexual health (family planning, maternal and child health, gender, womenempowerment, family life education) and mental health, avian flu and diabetes management.The six interventions that included an evaluation component reported positive outcomes in areas suchas increased self efficacy, engaging in positive and protective behaviours, and participation inactivities.We classified the results into one or more of the components identified in the definition of healthliteracy. Our findings were as follows: Access: All of the interventions tried to disseminate knowledge/ information on a certaintopic by using multiple channels and techniques. UnderstandOnly one study was identified that attempted to measure mental health literacy using theMental Health literacy Questionnaire (MHLQ). Besides the questionnaire, two vignettes wereused in supporting the data collection process; the vignettes enhanced participants ability torelate to the mental health issues being measured. AppraiseWomen who participated in the Arab Women Speak Out (AWSO) Initiative training, ascompared to a control group, were more likely to know where and how to access information,expressed higher levels of self efficacy to participate in economic opportunities, engage inentrepreneurship and activities that enhanced community welfare. CommunicateA study in Jordan called “Religious Leaders Lead the Way” succeeded in increasing the numberand frequency of religious leaders who speak publicly about family planning reproductivehealth and gender equity. Both female and male religious leaders underwent extensiveempowerment training that included attending workshops and discussion groups to improvetheir knowledge, and public communication skills. Results indicated that advocacy for familyplanning by religious leaders increased from 36% in 1997 to over 60 % in 2001.Page 6
As a result of our review, the following gaps and recommendations emerged as a result of our review Documentation: We believe that there are many more health-literacy related projects beingimplemented than was revealed though our Internet search. The small number ofinterventions identified indicates that very few projects in the region document their findings.Documentation should ideally be a part of the monitoring and evaluation process of ongoingproject /programs. Often however the meaningful recording of progress, process andexperiences of many projects is neglected due to lack of time, personnel and skills. Conceptual framework: None of the studies we reviewed appeared to use a conceptualframework / model or theory. Clearly, by using a framework, project planners can ensure thattheir intervention activities are connected and coherent. This would also assist them indeveloping an appropriate evaluation plan. Evaluation: Most of the studies we reviewed were not scientifically evaluated (i.e. no impactor outcome evaluation was completed). The lack of an evaluation component makes it verydifficult if not impossible to determine the effectiveness of an initiative, to draw anyconclusions or make recommendations for adoption in other locations. Several barriers toconducting an evaluation were identified including: time, funds and skills on how to do it. Definition of health literacy: The term health literacy is not one that is either familiar orbeing used by many project staff involved in this kind of work. We believe that it is importantto emphasize the concept of health literacy and reach out to organizations, health faculties andhealth departments in countries such as the East Mediterranean to make this concept a central,integrated and expected part of their health promotion activities. Scope of Health literacy interventions: Internationally, many studies have been done inthe areas of HIV/AIDS, asthma care, health services use, psychological and physical wellbeing,adherence to medication, chronic disease, diabetes, hospital admission, hypertension,cardiovascular disease, reproductive health, sexually transmitted infections etc. in relation tohealth literacy of a variety of priority populations. Most of the interventions we identified inthe EMR were on issues related to reproductive sexual health.The 7th Global Conference on Health Promotion in Nairobi, Kenya on October 26-30 has identified theimportance of health literacy in encouraging individual and collective actions to influence thedeterminants of health. Conference delegates will focus on four major topics as it relates to healthliteracy: Increasing access to health information through information and communication technologies(ICT) Increasing the use of health information through empowerment Increasing the flow of information through multi-sectoral collaboration Developing appropriate ways of measuring and reporting progress inliteracy levelsPage 7improving health
FORWARDThe purpose of this paper is to provide a background document on health literacy and healthpromotion in preparation for a presentation the authors will give at the 7th Global Conference onHealth Promotion on October 26-30, 2009 in Nairobi, Kenya. Specifically this paper will: provide an overview and summary of the current research on health literacy; develop a conceptual framework that defines relevant terms, describes the relationshipbetween health literacy and health promotion, and explores the implications of healthliteracy on health outcomes; and, provide examples of health literacy initiatives currently occurring in the EMRO/WHOthat can illustrate best practices and lessons learned.Although the literature on health literacy is still in its early stages of development, it is nonetheless avast and rapidly growing body of knowledge. There is general agreement that a relationship existsbetween health literacy and health outcomes; however, debateMuch controversy still exists as tocontinues on what actually constitutes ‘health literacy’, how itwhat constitutes ‘health literacy’,is measured, and how health literacy levels can be improved.how to measure it, and whatTo date much of the published research on health literacy hasmethods are most effective andcome out of developed countries but extensive health literacycost-effective in modifying healthactivity is now beginning to occur in the developing world.literacy levels.This paper, therefore, is a work in progress. Much informationis sure to be added to the body of knowledge in the next year,given the steadily rising level of health literacy activity in EMRO. As discussion continues and morerefined definitions of health literacy emerge, as research further pinpoints the key determinants ofhealth literacy and leads to better ways to measure health literacy levels across populations andamong at-risk groups, and as methods to influence those factors and conditions that contribute tohealth literacy become more apparent, our understanding of health literacy will increaseexponentially.The paper is organized into eight se
health and literacy fields. Health literacy builds on the idea that both health and literacy are critical resources for everyday living. Our level of literacy directly affects our ability to not only act on health information but also to take more contro
Traditionally, Literacy means the ability to read and write. But there seems to be various types of literacy. Such as audiovisual literacy, print literacy, computer literacy, media literacy, web literacy, technical literacy, functional literacy, library literacy and information literacy etc. Nominal and active literacy too focuses on
Keywords: Health literacy, Digital literacy, eHealth literacy, Self-rated health, Nursing students, HLQ, eHLQ, eHLA . self-reported capability to navigate and act in the health-care sector. In 2013, the World Health Organization (WHO) re-ported a positive correlation between self-rated health (SRH) and HL [25]. SRH is a reliable indicator of .
health literacy is complex and fluid. Research in this area has focused largely on 'functional health literacy', which reflects basic reading and writing skills [25, 26]. Two other dimensions of health literacy have received in-creasing attention in recent decades: interactive and crit-ical health literacy. Interactive health literacy refers to
The health literacy scale and health literacy tasks were guided by the definition of health literacy used by the Institute of Medicine and Healthy People 2010 (a set of national disease prevention and health promotion objectives led by the U.S.Department of Health and Human Services).This definition states that health literacy is:
Part VII. LIteracy 509 Chapter 16. A Primer on Literacy Assessment 511 Language Disorders and Literacy Problems 512 Emergent Literacy 514 Emergent Literacy Skill Acquisition 516 Assessment of Emergent Literacy Skills 520 Assessment of Reading and Writing 528 Integrated Language and Literacy Skill Assessment 536 Chapter Summary 537
limited health literacy impacts access to appropriate health-related services around the world. The Euro-pean Health Literacy Survey, for example, found that 12 percent of all respondents have inadequate general health literacy and 35 percent have problematic health literacy [2]. These numbers are likely higher in the clini-
Health insurance literacy focuses more specifically on insurance coverage, and the ACA brought the subject to the forefront. A health insurance literacy expert roundtable in 2011 defined health insurance literacy as "the capacity to find and evaluate information about health plans, select the best plan given
ASTM Methods. ASTM Listing and Cross References 266-267 Physical Properties 268-269 Sulfur Standards 270-271 PIANO. NEW 272-273 Detailed Hydrocarbon Analysis and SIM DIS 274-275 ASTM Reference Standards 276-303 Diisocyanates298 UOP Standards 304 Miscellaneous: Biocides in Fracking Fluids . NEW. 305 Skinner List, Fire Debris Biofuels 306-309 TPH, Fuels and Hydrocarbons 310-313 Brownfield .
