Literacy, health education, health literacy and health outcomes

1
Literacy, health education, health literacy and
health outcomes How do they fit?

• Don Nutbeam
• University of Sydney

2
What is literacy?

• What is it?
• Functional literacy is a measure of a persons
  ability to read basic text and write a simple
  statement relevant to 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
• Literacy levels are related to public health
  outcomes

3
Distribution of Global Adult Illiterate
Population (15 and over) by Region, 2005-2007
(Total Number of Adult Illiterate Population
775 millions)
"More than two-thirds of the world's adult
illiterates live in Asia and the Pacific Region"
4
Distribution of adult illiterate population (15
and over) by sub-region and gender, 2005-2007
(Total Number of Adult Illiterate Population
775 millions)
Rates of illiteracy are higher in SW Asia,
especially in India, Bangladesh and
Pakistan Women continue to constitute the
majority of the illiterate. Source Asia-Pacific
Literacy database - http//www.accu.or.jp/litdbase
/index_h.htm
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As Female Literacy Rates Climb, Total Fertility
Rate Drops
List of country codes Afghanistan AFG Bangladesh
BGD Bhutan BTN Cambodia KHM China CHN India
IND Indonesia IDN Iran   IRN Lao LAO Malaysia MY
S Maldives MDV Mongolia MNG Myanmar MMR Nepal NPL
Pakistan PAK Papua NG PNG Philippines PHL Sri
Lanka LKA Thailand THA Viet Nam VNM
NB. Total fertility rate is the number of
children that would be born per woman if she
were to live to the end of her child-bearing
years and bear children at each age in
accordance with prevailing age specific fertility
rates.
Source Asia-Pacific Literacy database -
http//www.accu.or.jp/litdbase/index_h.htm
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As Mothers Learn to Read, More Children Survive
List of country codes Afghanistan AFG Bangladesh
BGD Bhutan BTN Cambodia KHM China CHN India
IND Indonesia IDN Iran   IRN Lao LAO Malaysia MY
S Maldives MDV Mongolia MNG Myanmar MMR Nepal NPL
Pakistan PAK Papua NG PNG Philippines PHL Sri
Lanka LKA Thailand THA Viet Nam VNM
NB. Under-5 mortality rate is probability of
dying between birth and exactly five years of
age expressed per 1,000 live births. Source
Asia-Pacific Literacy database -
http//www.accu.or.jp/litdbase/index_h.htm
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Literate People Tend to Live Longer
Life expectancy at birth is the number of years
newborn children would live if subject to the
mortality risks prevailing for the cross-section
of population at the time of their births
Source Asia-Pacific Literacy database -
http//www.accu.or.jp/litdbase/index_h.htm
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Commission on Social Determinants of Health

• Education and the life-course
• Removing the numerous barriers to achievement of
  primary education will be a crucial part of
  action on the social determinants of health
• Literacy has central role in health equity in
  countries rich and poor
• http//www.who.int/social_determinants/resources/i
  nterim_statement/en/index.html

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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
• Key messages
• Literacy is a public health goal
• Achieving the MDGs in relation to literacy will
  have major public health benefits

Dewalt DA et al Literacy and health outcomes a
systematic review of the literature. Journal of
General Internal Medicine, 19. 128-39 2004
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A brief history of health education (1)

• A central component of efforts to promote health
  an prevent disease throughout this century
• Evolved from health propaganda campaigns focused
  on eradication of infectious disease into healthy
  lifestyle programs
• Found to be most effective in reaching and
  influencing the most literate, best educated and
  economically advantaged in the community

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Contemporary health education how to maximise
impact on health outcomes

• New generation of health education focussed on
  the social context of health decision-making, the
  development of personal skills and capabilities
• Informed by evolving psycho-social theory
• Supported by more sophisticated understanding of
  media, and adaptation of social marketing
  techniques to health campaigns
• Greater understanding of the need to
  contextualise communication, making it relevant
  to defined target populations, and needs of low
  literacy populations
• Well documented successes in improving knowledge
  and health related skills, and in changing health
  behaviours relevant to the MDGs, for example in
  relation to smoking, food choices, physical
  activity and sexual practices

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The emergence of the concept of health literacy

• Literacy is context and content specific more
  accurate to talk about literacies for example
• financial literacy,
• consumer literacy,
• IT literacy and,
• health literacy
• Even where a person has advanced literacy skills
  their ability to obtain, understand and apply
  information about health may be poor hence
  findings indicating high prevalence of poor
  health literacy from US, Australian and Canadian
  studies.

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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)

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Health literacy public health origins in
Australia
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Australias health literacy goals 1993

• To achieve the goals of the Australian Language
  and Literacy Policy
• To enhance knowledge and improve health literacy
  to enable people to make informed choices about
  their health
• To enhance knowledge and improve health literacy
  to enable people to take an active role in
  bringing about changes in the environments that
  shape their health
• Nutbeam D, Wise M, Bauman A et al on Health
  Literacy in Goals and Targets for Australias
  Health, Canberra, AGPS 1993

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Improved health outcomes, healthy choices and
opportunities
Changed health behaviours and practices
Improved Health Literacy
Developed knowledge and capability
Health education directed to knowledge
improvement and compliance with pre-determined
actions
Established population literacy reading
fluency, numeracy, existing knowledge
Developing functional health literacy a simple
linear model
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Improved health outcomes, healthy choices and
opportunities
Changed health behaviours and practices
Improved Health Literacy
Skills in negotiation and self management
Skills in social organization and advocacy
Developed knowledge and capability
Health education directed to knowledge and
personal skills development to promote active
engagement in health decision-making
Established population literacy reading
fluency, numeracy, existing knowledge
Developing interactive health literacy skills
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Improved health outcomes, healthy choices and
opportunities
Participation in changing social norms and
service practices
Engagement in social action/advocacy for health
Changed health behaviours and practices
Improved Health Literacy
Skills in negotiation and self management
Skills in social organization and advocacy
Developed knowledge and capability
Health education directed to knowledge and
personal skills development to promote active
engagement in health decision-making
Established population literacy reading
fluency, numeracy, existing knowledge
Developing interactive and critical health
literacy skills
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How would this look in practice?

• Schools and health literacy strong and
  consistent evidence exists for
• providing a comprehensive and integrated health
  education program for students, based on
• Content that includes both basic personal health
  information, and exposure to the influence of
  social, economic conditions, and the role of the
  media
• Teaching and communication methods based on well
  researched psycho-social theory and effective
  classroom interaction
• Outcomes focus on enhanced health literacy
  through improved knowledge and development of
  personal and social skills

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Schools and health promotion

• Efforts to promote health literacy will be
  greatly enhanced by
• Adopting organisational practices which
  complement and support the teaching program
• Offering a supportive social environment for
  students
• Fostering links with health resources in the
  community, including optimal use of school health
  services
• creating a safe an secure physical environment

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Summary remarks What is the state of the
science

• Good research in health care settings linking
  poor health- related literacy with range of
  clinical outcomes
• Some intervention trials in health care settings
  demonstrate potential effectiveness and cost
  savings
• Good research on the efficacy of modern health
  education in schools and other settings, but less
  developed research on the intermediate concept of
  health literacy in these settings (eg adult
  education, E-learning)
• Progress in development of measures of
  health-related literacy in clinical settings, but
  limited progress in development of comprehensive
  measures

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Summary remarks where to from here in practice
development

• Health literacy fundamentally dependent upon
  levels of basic literacy in the population
  essential to make policy and practical program
  links between these MDGs,
• 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 critical health literacy and
  well informed independent decision-making
  requires recognition of social and environmental
  context to decision-making, enabling individuals
  to address structural barriers to health

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Summary remarks What needs to be done first?

• Develop programs that are context and content
  specific in priority areas in relation to MDGs
• Improving capability to obtain, understand and
  apply relevant information through
• Maternal and child health programs
• School Health programs
• Cross-sectoral collaboration on adult literacy
  programs

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Skilled for Health (UK)

• Skilled for health
• Integrates goals of health improvement with
  improving literacy, language and numeracy (LLN)
  skills of adults
• Cross government-voluntary sector initiative
  combines adult LLN learning with peoples wish
  for a better understanding of health
• http//www.dfes.gov.uk/readwriteplus/embeddedlearn
  ing/