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Health literacy:
Perspectives from Australia
Don Nutbeam
University of Sydney, Australia
What we need to know –
it can’t be said more eloquently
• “Reports that say that
something hasn't happened
are always interesting to
me, because as we know,
there are known knowns;
there are things we know
we know. We also know
there are known unknowns;
that is to say we know there
are some things we do not
know. But there are also
unknown unknowns - the
ones we don't know we
don't know”
Presentation objectives –
to answer some questions
• What is health literacy ?
• What is the state of the science?
• Why is it a useful concept in public
health?
• Where do we go from here?
What is literacy?
What is it?
• Functional literacy focuses on the ability to read basic
text and write a simple statement on everyday life
Why do we care?
• Those who are functionally literate are able to
participate more fully in society, and are able to exert a
higher degree of control over everyday events
How big is the problem?
• Estimates of the proportion of the population in OECD
countries lacking functional literacy skills range from 7%
to 47%* (UNDP, 2007)
*http://hdrstats.undp.org/indicators/30.html
Literacy and health*
• Relationship between low literacy and a range of health
related outcomes well established
• Some indirect effects
– Employment
– Income
• Some direct effects
–
–
–
–
Engaging in preventive health practices
Early detection of disease
Access to health care
Management of chronic disease
*Dewalt DA et al Literacy and health outcomes: a systematic review of the literature.
Journal of General Internal Medicine, 19. 128-39 2004
The emergence of the concept of
health literacy
The concept of health literacy emerged
from different roots:
• in clinical care, mainly from the US
• in public health, from Australia, and
more recently Canada and the UK
• The two different roots led to quite
different conceptualizations of health
literacy as a “risk” and as an “asset”
What is health literacy?
Health literacy in clinical care
• emanating from concerns about the
impact of low literacy on patient care
• health literacy is seen more as a risk or
deficit that needs to be mitigated,
• set of capacities that act as a mediating
factor in achieving health and clinical
outcomes.
What is health literacy?
US Institute of Medicine* defines health literacy as:
• “The degree to which individuals have the capacity to
obtain, process and understand basic health information
and services needed to make appropriate health
decisions”
But recognition of social context of health literacy
• “based on the interaction of the individual’s skills with
health contexts…and broad social and cultural factors at
home, at work and in the community”
*Institute of Medicine. Health Literacy: A Prescription to End Confusion.
Washington DC, National Academies Press 2004
What is health literacy #1?
• Health literacy is a set of individual capabilities in four
domains*
–
–
–
–
Cultural and conceptual knowledge
Speaking and listening skills
Writing and reading skills
Numeracy
• Focus on individual capacities indicates that
– health literacy may be developed (and can decline)
– Health literacy is partly knowledge based, and may be
developed through educational intervention
– Health literacy is context specific and subject to
influence by health care interactions and structures
*For a thoughtful examination and critique of the IOM definition see Barker D, The
Meaning and Measure of Health Literacy. Jnl of General Internal Medicine 21.8,
878-883. 2006
Health literacy and health*
• Development of measurement tools and
“screening aids” (eg TOFHLA, REALM)
• Led to more sophisticated understanding of
health-related literacy and its association with a
range of health practices and outcomes,
especially
– Effective management of chronic disease
– Compliance with medication and other health advice
– Participation in health and screening programs
*Institute of Medicine. Health Literacy: A Prescription to End Confusion.
Washington DC, National Academies Press 2004
Figure 1: Conceptual model of health literacy as a risk.
Tailored
health information,
communication,
education
Health literacy assessment Health-related reading fluency,
numeracy, prior knowledge
Figure 1: Conceptual model of health literacy as a risk.
Improved clinical outcomes
Enhanced capability
for self management,
improved compliance
Tailored
health information,
communication,
education
Health literacy assessment Health-related reading fluency,
numeracy, prior knowledge
Figure 1: Conceptual model of health literacy as a risk.
Improved clinical outcomes
5. Enhanced capability
for self management,
improved compliance
Tailored
health information,
communication,
education
Health literacy assessment Health-related reading fluency,
numeracy, prior knowledge
Improved access to
health care, and
productive interaction with
health care professionals
Organizational practice
sensitive to
health literacy
1. Barker D, The Meaning and Measure of Health Literacy. Jnl of General Internal Medicine 21.8, 878-883. 2006
2. Paasche-Orlow MK, Wolf MS. The causal Pathway linking health literacy to health outcomes.
American Journal of Health Behaviour; 2007; 31 (Supplement 1): S19-26
What is health literacy #2?
Draws upon
• broader concepts of literacy,
• principles of adult education,
• concepts of health promotion
Drawing on wider concepts of literacy*
Functional literacy –
• basic skills in reading and writing, capacity to apply
these skills in everyday situations
Communicative/interactive literacy
• more advanced cognitive and literacy skills, capacity to
actively participate, derive meaning, apply new
information quickly to changing circumstances
Critical literacy
• most advanced cognitive and literacy skills, critical
analysis of information, ability to use information to exert
greater control over life events and situations
*
See for example: Freebody P, Luke A. ‘Literacies’ Programs: Debates and
Demands in Cultural Context. Prospect; 1990; 5(3): 7-16.
What is health literacy?
#2 health literacy in public health
• origins in health education and health promotion
• a set of capacities that enable individuals to exert
greater control over their health and the range of
personal social and environmental determinants of
health.
• health literacy is seen as an asset to be built, as an
outcome to health education and communication that
supports greater empowerment in health decisionmaking.
Principles of adult education
• Adults have a foundation of life experiences and
knowledge that can be used as as a resource, requires
an understanding of learners’ experiences and
communities.
• Adults respond well to instructional materials that are
based on students’ lives, sometimes referred to as
contextualized learning,
• Adults are autonomous and generally respond well to
self-direction in learning, including involvement in
program planning and implementation.
For a good overview of adult learning principles:
S Imel; Using Adult Learning Principles in Adult Basic and Literacy Education;
Clearinghouse on Adult, Career, and Vocational Education 1998
http://www.cete.org/acve/docs/pab00008.pdf
Concepts of health promotion
• Process of enabling people to exert greater
control over the determinants of health
• Includes actions directed at strengthening the
skills and capabilities of individuals, and
• action directed towards changing the social
determinants of health so as to alleviate their
impact on public and individual health
What is health literacy?
• “Health literacy represents the cognitive and social
skills which determine the motivation and ability of
individuals to gain access to, understand, and use
information in ways which promote and maintain
good health”
• “Health literacy means more than being able to
read pamphlets and make appointments. By
improving peoples’ access to health information
and their capacity to use it effectively, health
literacy is critical to empowerment”
*Nutbeam D. Health Promotion Glossary. Health Promotion
International, 13(4): 349-364. 1999 (also - WHO/HPR/HEP/98.1)
Types of Health Literacy*
Health
Literacy Type
& Goal
Functional
Health
Literacy:
Communication
of information
Content
Outcome
Transmission of
Improved
factual
knowledge of
information on health risks and
health risks and health services,
health services compliance with
utilisation
prescribed actions
Examples of
educational
Activity
Transmit
information
through existing
channels,
opportunistic
inter-personal
contact, and
available media
*Nutbeam D. Health Literacy as a Public Health Goal: A challenge for contemporary health education
and communication strategies into the 21st Century. Health Promotion International . 15; 259-67.
2000
Types of Health Literacy
Health
Literacy Type
and Goal
Content
Functional Health
Literacy:
Transmission of factual
information on health risks
and health services
utilisation
Communication of
information
Outcome
Examples of
Educational
Activity
Improved knowledge of health Transmit information through
risks and health services,
existing channels, opportunistic
compliance with prescribed
inter-personal contact, and
actions
available media
Interactive
Opportunities to
Improved capacity
Health Literacy: develop skills in a to act independently
supportive
on knowledge,
Development of
environment
improved motivation
personal skills
and self-confidence
Tailored health
communication,
facilitation of selfhelp and social
support groups
Types of Health Literacy
Health Literacy type
and Goal
Functional Health
Literacy:
Communication of
information
Interactive Health
Literacy:
Content
Transmission of factual
information on health risks
and health services
utilisation
Improved knowledge of health
risks and health services,
compliance with prescribed
actions
Opportunities to develop
skills in a supportive
environment
Improved capacity to act
independently on knowledge,
improved motivation and
self-confidence
Provision of
information on social
and economic
determinants of
health, assessment
of opportunities to
achieve change
Improved individual
and community
capacity to act on
social and economic
determinants of health;
community
empowerment
Development of personal
skills
Critical Health
Literacy:
Personal and
community
empowerment
Outcome
Examples of
Educational
Activity
Transmit information through
existing channels,
opportunistic
inter-personal contact, and
available media
Tailored health
communication, facilitation of
community self-help and social
support groups
Provision of technical
advice to support
community action,
advocacy
communication to
community leaders and
politicians; facilitation
of community
development,
Improved
Health Literacy
Developed
knowledge
and capability
Tailored information,
communication, education
Prior understanding of individual
capacity - reading fluency, numeracy,
existing knowledge
Figure 3: Health literacy as an asset: a simple linear model
Improved health outcomes,
healthy choices
and opportunities
Changed health
behaviours and
practices
Improved
Health Literacy
Developed
knowledge
and capability
Tailored information,
communication, education
Prior understanding of individual
capacity - reading fluency, numeracy,
existing knowledge
Figure 3: Health literacy as an asset: a simple linear model
10. Improved health outcomes,
healthy choices
and opportunities
7. Changed health
behaviours and
practices
4. Skills in
social organization
and advocacy
6. Improved
Health Literacy
3. Developed
knowledge
and capability
5. Skills in
negotiation and
self management
2. Tailored information,
communication, education
1. Prior understanding of individual
capacity - reading fluency, numeracy,
existing knowledge
Figure 3: Developing interactive health literacy skills
Improved health outcomes,
healthy choices
and opportunities
Engagement in
social
action/advocacy
for health
Skills in
social organization
and advocacy
Changed health
behaviours and
practices
Improved
Health Literacy
Developed
knowledge
and capability
Participation in
changing social
norms and service
practices
Skills in
negotiation and
self management
Tailored information,
communication, education
Prior understanding of individual
capacity - reading fluency, numeracy,
existing knowledge
Figure 3: Developing interactive and critical health literacy skills
Measurement of health literacy
• Current measures (such as TOFLA and REALM) now
well established in the US - useful for clinical screening,
but limited for research purposes and wider population
assessment
• Limited in the extent to which they focus on reading
(and numeric) skills, and not oral communication
• Focus on ability to comply with pre-determined
behaviours
• If health literacy depends on the relationship between
individual communication capacities, the health care
system, and broader society, then measures only at the
individual level are clearly inadequate.
Barker D, The Meaning and Measure of Health Literacy. Jnl of General Internal
Medicine 21.8, 878-883. 2006
Measurement of health literacy
• More comprehensive measures being developed - In the US,
the Health Activity Literacy Scale (HALS) includes different health related
competencies in five domains such as health promotion, disease
prevention, and health care systems
• Different measurement tools will be required for different ages
and stages in life
• Different measures will be required to distinguish between
functional, interactive and critical health literacy.
• These measures will need to include assessment of a
person’s ability to
– gain access to age and context specific information from a variety
of different sources;
– discriminate between sources of information
– understand and personalise health information that has been
obtained
– appropriately apply relevant health information for personal
benefit
Summary remarks –
What is the state of the science –
the known knowns?
• Good research in clinical settings linking poor healthrelated literacy with range of clinical outcomes
• Some intervention trials in clinical settings demonstrate
potential effectiveness and cost savings
• Undeveloped but promising research outside health care
settings (schools, adult education, E-learning)
• Relatively little evidence of systematic incorporation of
health promotion concepts and adult learning principles
• Progress in development of measures of health-related
literacy in clinical settings, but limited progress in
development of comprehensive measures
Summary remarks
Where to from here in research –
the known unknowns
• Development of measures that incorporate wider set of
skills and capacities represented by health literacy - eg
inclusion of measures of knowledge of social determinants
of health, and knowledge related self-efficacy
(confidence/capacity to act)
• Continue to broaden research outside of health care
setting and disease groups into schools, adult learning,
community development – eg maternal health literacy,
school health literacy etc
Summary remarks –
where to from here in practice development
- the unknown unknowns
• Health literacy fundamentally dependent upon levels of
basic literacy in the population – make links between these
two social goals,
• Developing self confidence to act on knowledge and the
ability to support others requires more personal, and
community-based educational outreach – incorporation of
adult learning principles and health promotion concepts
• Promoting greater independence and empowerment
requires acknowledgement of “political” aspect to
education, focussed on overcoming structural barriers to
health