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Don Nutbeam | The evolving concept of health literacy
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Don Nutbeam | The evolving concept of health literacy

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Professor Don Nutbeam, Vice Chancellor of the University of Southampton in the UK, spoke to the HARC network in April 2010 to help us consider how to improve healthcare delivery for people with low ...

Professor Don Nutbeam, Vice Chancellor of the University of Southampton in the UK, spoke to the HARC network in April 2010 to help us consider how to improve healthcare delivery for people with low health literacy.

HARC stands for the Hospital Alliance for Research Collaboration. HARC is a collaborative network of researchers, health managers, clinicians and policy makers based in NSW, Australia managed by the Sax Institute.

HARC Forums bring members of the HARC network together to discuss the latest research and analysis about important issues facing our hospitals.

For more information visit saxinstitute.org.au.

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Don Nutbeam | The evolving concept of health literacy Don Nutbeam | The evolving concept of health literacy Presentation Transcript

  • The evolving conceptof health literacyProfessor Don NutbeamApril 2010
  • What we need to know• It can not be said more eloquently..• “….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 dont know we dont know” 2
  • Presentation Objectives• To answer some questions• What is the relationship between literacy and health• What is health literacy and why is it important?• How can health care providers improve service delivery for people with low health literacy?• What are the implications for health care policy and practice 3 View slide
  • What is literacy?• Functional literacy is defined in terms of the basic skills in reading and writing and the capacity to apply these skills in everyday situationsHow do we measure literacy?• Literacy can be measured in absolute terms (distinguishing between those who can read and write basic text and those who cannot) and• In relative terms by assessing the skill differences between adults who are able to perform relatively challenging literacy tasks and those who are not.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 eventsHow 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 4 View slide
  • Relative differences in skills based literacy*Functional literacy• basic skills in reading and writing, capacity to apply these skills in everyday situationsCommunicative/interactive literacy• more advanced cognitive and literacy skills, greater ability obtain relevant information, derive meaning, and apply new information to changing circumstancesCritical literacy• most advanced cognitive and literacy skills, critical analysis of information, ability to use information to respond, adapt and control 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. 5
  • Literacy and Health• Relationship between low literacy and a range of health related outcomes well established• Some indirect effects related to employment and lifetime income• Some direct effects* – Engaging in preventive health practices – Early detection of disease – Access to and use of health care services – Medication adherence and chronic disease management *Dewalt DA et al Literacy and health outcomes: a systematic review of the literature. Journal of General Internal Medicine, 19. 128-39 2004 6
  • Literacy and Health• “People who read at lower levels are generally 1.5 to 3 times more likely to have an adverse (health) outcome as people who read at higher levels”*• *Dewalt DA et al Literacy and health outcomes: a systematic review of the literature. Journal of General Internal Medicine, 19. 128-39 2004 7
  • Literacy and health equity• Failure to address the impact of literacy on health may inadvertently exacerbate existing inequalities• 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• Promoting literacy is a public health goalhttp://www.who.int/social_determinants/resources/interim_statement/ en/index.html 8
  • Literacy is context and content specific• More accurate to talk about literacies for example: – financial literacy, – Media literacy, – IT literacy (new literacy) and, – health literacy 9
  • What is health literacy?content specific literacy in a health context.Short version:“the ability to access, understand, and use information for health”• Even where a person has advanced literacy skills their ability to obtain, understand and apply health information in a specific health context may be poorsee: Nutbeam D. Health Promotion Glossary (1999) Health Promotion International, 13(4): 349-364. 1999 (also - WHO/HPR/HEP/98.1) 10
  • Health literacy is also context and content specific– related to age and stage of life a person with diabetes who a pregnant woman attendingis receiving patient education, ante-natal classes a young person receiving health education on illicit drugs at school. 11
  • Health literacy is not new in Australia –health literacy goals for Australia in 1993 12
  • Why do we care about health literacy?• Review of effectiveness of strategies for informing educating and involving patients* indicates mostly positive results from different strategies• Improving clinical decision-making, through shared and informed decision making using decision-aids and other educational interventions• Self care and self management based on tailored patient education• Improving patient safety primarily through improvement in the use of medicines• Improving health literacy is described by authors as the “key” to improved patient engagement *Coulter A, Ellins J. 2007. Effectiveness of strategies for informing, educating and involving patients. BMJ 335:24-7 13
  • Summarised findings of systemic reviews on effectiveness ofstrategies to inform, educate and involve patients in their treatment* Total Effects on Effects on Effects on Effects on Topic number patients’ patients’ use of health health of reviews knowledge experience services behaviour and found health status Reported in Reported in Reported in Reported in Improving 13 Reviews: 16 reviews: 14 reviews: 13 reviews: health 25 10 positive 10 positive 9 positive 4 positive literacy 2 mixed 5 mixed 3 mixed 6 mixed 1 negative 1 negative 2 negative 3 negative Improving Reported in Reported in Reported in Reported in clinical 22 10 reviews: 19 reviews: 10 reviews 8 reviews: decision 8 positive 12 positive 6 positive 2 positive making 2 mixed 6 mixed 4 mixed 1 mixed 1 negative 5 negative Improving self Reported in Reported in Reported in Reported in care and self 67 19 reviews: 40 reviews: 25 reviews: 60 reviews: management all positive 24 positive 14 positive 39 positive of chronic 11 mixed 9 mixed 15 mixed disease 5 negative 2 negative 6 negative Reported in Reported in Reported in Reported in Improving 18 4 reviews: 1 review: 3 reviews: 17 reviews: patient safety all positive positive 2 positive 8 positive 1 negative 9 mixed 14*Coulter A, Ellins J. 2007. Effectiveness of strategies for informing, educating and involving patients. BMJ 335:24-7
  • Two distinctive conceptualizations of healthliteracy*The concept of health literacy emerged from different roots:• in clinical care, mainly from the US• in public health, from Australia, Canada, Switzerland and the UK• The two different roots led to quite different conceptualizations of health literacy as a “risk” and as an “asset” *Nutbeam D. 2008. The evolving concept of health literacy. Social Science and Medicine. 67. 2072-78 15
  • Health literacy as a clinical “risk factor”• Emanating from concerns about the impact of low literacy on patient care• health literacy conceptualised as a “risk factor” that needs to be mitigated,• Defined as set of capacities that act as a mediating factor in achieving pre-determined health and clinical outcomes*• Response takes the form of “risk assessment” and tailored clinician communication *For a thoughtful examination and critique of established definitions see: Barker D, The Meaning and Measure of Health Literacy. Journal of General Internal Medicine 21.8, 878-883. 2006 16
  • Conceptual model of health literacy as a risk Improved clinical outcomes Enhanced capability for self management, improved compliance Tailored health/patient communication and education Health literacy assessment - Health-related reading fluency, numeracy, prior knowledge 17
  • Health literacy as a clinical “risk factor”• Progressive improvement in understanding of health service organisation and environmental factors that exacerbate or minimise impact of low literacy, for example: – ease of making appointments – functional organisation of clinics – use of appropriate communication materials/signage 18
  • Conceptual model of health literacy as a risk Improved clinical outcomes Enhanced capability for self management, improved compliance Tailored Improved access to health/ patient health care, and communication and productive interaction with education health care professionals Health literacy assessment - Organizational practice Health-related reading fluency, sensitive to numeracy, prior knowledge 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. 19 American Journal of Health Behaviour; 2007; 31 (Supplement 1): S19-26
  • Health literacy and clinical care• Research over past 15 years (mostly in the US) has led to more sophisticated understanding of poor literacy and its association with a range of health practices and outcomes – established case for action• Demonstrated that rapid assessment of health literacy is feasible in normal clinical practice• Tested a range of intervention studies specifically designed to address consequences of low literacy provide mostly positive results*, in many cases limited by poor study design. *Pignone, M., DeWalt, D., Sheridan, S., Berkman, N. & Lohr, K.N. (2005). Interventions to improve health outcomes for patients with low literacy. Journal of General Internal Medicine, 20, 185-192. Coulter A, Ellins J. 2007. Effectiveness of strategies for informing, educating and involving patients. BMJ 335:24-7 20
  • Health literacy in public health• Origins in contemporary 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 decision- making. 21
  • Developing functional health literacy – a simple linear model Improved health outcomes, healthy choices and opportunities Changed health behaviours and practices Improved Health Literacy Developed knowledge and capability Tailored health/patient education to promote active engagement in health decision-making Established population literacy – reading fluency, numeracy, existing knowledge 22
  • More advanced concepts of health literacy*Functional health literacy• ability to apply basic literacy skills in reading and writing in everyday health decision-making,• ability to respond successfully to the communication of factual information on health risks, and on how to use the health system;Supported by health/patient education• directed towards improved knowledge of health risks and health services, and compliance with prescribed actions (eg clinician advice, traditional health education)*Nutbeam D. (2001) Health Literacy as a Public Health Goal: A challenge for contemporary health educationand communication strategies into the 21st Century. Health Promotion International, 15; 259-67 23
  • More advanced concepts of health literacyInteractive health literacy• Ability to apply more advanced cognitive and literacy skills to independently obtain relevant health information, derive meaning, and apply information to personal and family health circumstances.Supported by health/patient education• Directed towards improving personal capacity to act independently on knowledge, to improving motivation and self confidence to act on advice received (eg school health education). 24
  • More advanced concepts of health literacyCritical health literacy• Ability to apply more advanced cognitive and literacy skills to the critical analysis of health related information,• Ability to use information to exert greater control over a broad range of health determinants – personal and social.Supported by health/patient education• Directed towards provision of information on full range of determinants of health, and assessment of opportunities to achieve change in these determinants (personal and community capacity building) 25
  • Developing interactive and critical health literacy skills Improved health outcomes, health services and clinical practice Active participation in Engagement in health decision making, social Changed health changing service action/advocacy behaviours and expectations and for health practices practices Improved Health Literacy 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 26
  • Health literacy in Australia in 2009 27
  • Health literacy – four quick wins• In health and clinical care – maternal health literacy, – patient/consumer education• In schools – health literacy measurement• In the community – adult basic skills 28
  • Case study 1 – maternal health literacy*Maternal health literacy:• The ability of women “to access understand and use information in ways that promote and maintain their health and that of their children”• Study of content of and context for ante-natal education in a major Sydney maternity hospital• Interviewed pregnant women, women in the first year after childbirth, ante-natal educators, and early childhood nurses• Explored the content and delivery learning using health literacy framework *Renkert S, Nutbeam D (2001) Opportunities to improve maternal health literacy through antenatal education. Health Promotion International 16.4. 381-8 29
  • Case study 1 – maternal health literacyKey findings:• Little account taken of variation in underlying literacy and language skills at commencement• Content largely confined to pregnancy and childbirth• Teaching methods mostly didactic, transfer of information, and promotion of compliance with preferred practice• Relatively little emphasis on the development and mastery of specific skills, or autonomy in decision-making• Lack of time cited most frequently as reason for limits on content and methods 30
  • Case study 1 – maternal health literacyKey conclusions• Importance of health literacy screening tool to assist in pre-assessment of existing “maternal health literacy”• In method, education better tailored to existing literacy level of group - enable greater participation in the learning process• In outcome focus on the ability of women to obtain and evaluate information from a variety of sources, and on development of skills and confidence to act on information• In content, recognise that early parenting is also important 31
  • Case study 2Skilled 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 people‟s wish for a better understanding of healthhttp://www.dfes.gov.uk/readwriteplus/embeddedlearning/ 32
  • Skilled for Health EvaluationKey findings:• SfH targets and recruits individuals who do not traditionally participate in public health or adult learning programmes.• That health is a significant “hook” into learning for participants,• That participants‟ health knowledge increased significantly after undertaking a SfH intervention• That the programme opens up two kinds of learning progression routes – improvement in skills levels and high motivation to continue learning, with 25% registered on further courses.• That the programme had an 80% retention rate among participants. http://www.continyou.org.uk/files/file/reports/skilledforhealthev al.pdf 33
  • Summary remarksWhat is the state of science – the known-knowns• Good research in clinical settings linking poor health- related literacy with range of clinical outcomes• Rapid assessment of health literacy is feasible in normal clinical setting• 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) 34
  • Summary remarksWhere 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 context specific self- efficacy (confidence/capacity to act)• Continue to broaden intervention development and evaluation outside of health care setting and disease groups into schools, adult learning, community development – eg maternal health literacy, school health literacy etc 35
  • Summary remarksWhere to from here in policy and practice?• Health literacy fundamentally dependent upon levels of basic literacy in the population – make links between these two social goals,• School health education provides important foundations for health literacy, make it count through measurement• Adult education and skills development programs can provide ideal partnership 36
  • Summary remarksWhere to from here in policy and practice?In clinical practice:• target obvious priorities for patient engagement in decision-making and self care (eg diabetes, maternal and child health)• Developing self confidence to act on knowledge requires broader range of educational and communication methods than commonly used (eg repeat-back)• Effective communication can be supported by service management and organization that is “literacy sensitive” (eg minimise/simplify form- filling) 37
  • The end Thank you
  • 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 task based reading (and numeric) skills, and not on skills based literacy• Focus on ability to comply with pre-determined behavioursSee: Barker D, The Meaning and Measure of Health Literacy. Jnl of General Internal Medicine 21.8, 878- 883. 2006 39
  • 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 required for different ages and stages in life, and different health contexts 40
  • Measurement of health literacy• Different measures required to distinguish between functional, interactive and critical health literacy.• These measures 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 41