Health Literacy: The Solid Facts Stephan Van den Broucke UC Louvain Gérer sa santé : rêve ou réalité ? Gezondheidsinfo : een doolhof? Mutualités Libres/Onafhankelijke Ziekenfondsen Brussel, 31 Mei 2016

Healthy literacy Not a new concept … • The concept of « literacy » -

To be literate = being “knowledgeable or educated in a particular field or fields”

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Increased attention since the mid 20th century -

The ability to identify, understand, interpret, create, communicate, compute and use printed and written materials associated with varying contexts (UNESCO)

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Applied to a range of competences deemed important to function in the 21st century

• Application to the health sector in the 1970s -

Emphasis on individual competences in the context of health care (« medical health literacy»)

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More recently enlarged and applied to disease prevention and health promotion (« public health literacy»)

… an extended concept … Improved capacity to act on social and economic determinants of health, improved community empowerment

Community

Improved capacity to influence social norms, and interact with social groups

Increased participation in population health programs

Imrproved knowledge of health services, better compliance with prescribed actions

Improved individual resilience to social and economic adversity

Improved capacity to act independently on knowledge, improved motivation and selfconfidence

Basic skills in reading and writing necessarry for effective functioning in a health context

Ability to critically analyze and use information to participate in actions that overcome structural barriers to health

More advanced cognitive literacy and social skills that enable active participation in health care

Individual

… a multidemensional concept « A person’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course» WHO. Health literacy. The solid facts. Health, 2016.

Conceptual model of Health Literacy

Sørensen et al., Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80

Importance of Health Literacy • An outcome of health education (as a strategy of health promotion)

• A determinant of the quality of health care • A determinant of health outcomes and health care costs • A mediator of the relationship between SES / education and health outcomes • A leverage to create and strengthen health literacy friendly settings

Health Literacy as an outcome of Health Education

Nutbeam, Evaluating Health Promotion – Progress, problems and solutions. Health Promotion International, 1998, 13(1), 27-44

Health Literacy as a determinant of the quality of health care People with low health literacy have difficulty to • understand information provided by health carers • understand written health information • find their way in the health care services • find their way in health insurance • take control over their own health

Health literacy as a determinant of health outcomes • Outcomes of health care People with low health literacy have - lower adherence to recommendations for treatment - less self care - more chronic disease - 1,5 times higher mortality (Baker et al., Arch Int Med, 2007).

• Outcomes of prevention People with low health literacy - have less healthy lifestyles - participate less in screening

• Health care expenditure More (unnecessary) use of health care services leads to higher costs – Between 143 $ and 7 798 $ extra per patient/year (Eichler et al, Int J Public Health 2009)

– in The Netherlands estimated at 61 millions €

Health Literacy and perceived health

World Health Organization (2013). Health literacy. The solid facts. WHO Regional Office for Europe: Copenhagen.

Health Literacy and physical activity

Health literacy as a determinant of health outcomes

Duong et al. Asian Pacific Journal of Public Health 2015;1-10

Health Literacy and health care use (in Belgium)

GH = General hospital; PH = psychiatric hospital; ODC = One Day Clinic; ODSC = One Day Surgical Clinic; GP = General Practitioner; SP = Specialist Practitioner. IRR = incidence rate ratio defined as eβ, where β is the regression coefficient.

Vandenbosch et al (2016) JECH

Health Literacy and health care costs (in Belgium)

GH = General hospital; PH = psychiatric hospital; ODC = One Day Clinic; ODSC = One Day Surgical Clinic; GP = General Practitioner; SP = Specialist Practitioner. IRR = incidence rate ratio defined as eβ, where β is the regression coefficient.

Vandenbosch et al (2016) JECH

Health literacy as a mediator between low SES and health

Van der Heide et al, Journal of Health Communication 18 (2013): 172-184

How can health literacy contribute to health inequalities? Low literacy may cause health disparities by • reducing the accessibility to and the effectiveness of medical care received • reducing the likelihood that individuals are adequately informed and activated with regard to healthy behaviors • increasing a person’s stress in addressing the challenges of navigating through daily life • diminishing an individual’s self-efficacy (i.e., the ability to exert control over one’s life and surroundings) Saha, Journal of General Internal Medicine, 2006, 21.8: 893-895.

Health literacy as a mediator between education and health behaviour •

Use of HLS-EU-Q16 on a representative sample of 9616 Belgians

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Test of the mediating role of HL on the relationship between education and behaviour

(Renwart & Van den Broucke, 2014)

Health literacy as a mediator between education and health behaviour

Measuring Health Literacy • A large range of measures available, with important differences in terms of objectives and target groups • 122 instruments listed in the Health Literacy Tool Shed • HL Screeing in a clinical context: Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy (TOFHLA), Newest Vital Sign (NVS) • Population survey: National Assessment of Adult Literacy survey (NAAL), Health Literacy Questionnaire

• European Health Literacy Survey (HLS-EU) • Concept validated tool of 47 self-report items • 12 sub-scales addressing difficulties in accessing, understanding, appraising and applying information to make decisions in health care, disease prevention, and health promotion • Used to collect data on 8000 respondents in 8 EU countries • Used on a total of 10,024 respondents in 6 Asian countries (Indonesia, Kazakhstan, Malaysia, Myanmar, Taiwan, Vietnam)

• Short forms of 16 and 6 items increasingly used

Current levels of health literacy • USA Nearly half of the adult Americans have difficutlty to understand health information correctly (IOM, 2004)

• Europe - 48% have a low level of health literacy - 15% have difficulties in understanding their doctor’s explanation - 23% are unable to correctly read the dose of medication - 22% have difficulties finding information about illnesses - 26% have difficulties finding information about the treatment of illnesses (HLS-EU, 2012)

• Asia mean general health literacy index of 34.4 ± 6.6 on a scale of 50 in Taiwan (HLS Taiwan, 2014)

Current levels of health literacy

Health Literacy in Belgium

Wallonie

Bruxelles

LS insuffisante LS limitée LS suffisante Flandre

Belgique

LS insuffisante LS limitée LS suffisante

What can be done about low health literacy? Measure personal HL competences

Measure the fit of HL competences to demands

Improve individual and population HL through Education and training

Compensate for low HL of disadvantaged groups by specific compensatory measures

Measure situational HL demands and support

Improve organizational HL by reducing situational demands and offering specific institutional support

What can be done about low health literacy? A shared responsibility for • • •

The health sector Citizens Policy makers

Address health literacy Health sector • Screening of low health literacy • Adapt oral and written information in care and prevention by - balancing the depth of the information provided - checking comprehension - visual support of the communication - ensuring enough time for consultation

• Specific courses e.g, self-management for chronic patients

• Communication training • Use of social media

Address health literacy Education and training • Integration of health in educational programmes, professional training, and adult education

Policy measures • Stimulate community development • Specific actions for elderly and disadvantaged groups or communities

Create and strengthen health literacy-friendly settings 1. Has leadership that makes health literacy integral to its mission, structure, and operations. 2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. 3. Prepares the workforce to be health literate and monitors progress. 4. Includes populations served in the design, implementation, and evaluation of health information and services. 5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization. 6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. 7. Provides easy access to health information and services and navigation assistance. 8. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. 9. Addresses health literacy in high-risk situations, including care transitions and communications about medicines. 10. Communicates clearly what health plans cover and what individuals will have to pay for services.

Create partnerships for Health Literacy • Combine efforts to empower individuals and communities to address health literacy

• Examples of partnerships – – – –

IUHPE Global Working Group on Health Literacy Health Literacy Europe Asian Health Literacy Association National Alliance for Health Literacy (Netherlands) more than 60 organizations: patients, providers, health institutions, health insurance providers, academia, industry, business, …

– Multistakeholder Collaboration (Ireland) – Well Done – MSD Health Literacy Awards

Well Done – MSD Health Literacy Awards ceremony 2014

Conclusion

https://www.youtube.com/watch?v=fzMA9TlPJUk