Health Literacy for NCD

1. HEALTH LITERACY FOR NON
COMMUNICABLE DISEASES
PREVENTION AND MANAGEMENT
Dipsikha Aryal
MPH 2021
SPH and CM
BPKIHS, Dharan

2. OUTLINE OF PRESENTATION
1) Literacy
2) Health Literacy concept and introduction
3) Conceptual framework
4) Health Literacy Assessment tools
5) Methods to increase Health Literacy
6) Health Literacy for NCD prevention and management
7) Conferences focusing on Health Literacy
8) Conclusion
9) References
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3. LITERACY
 Literacy is the ability to identify, understand, interpret, create, communicate
and compute, using printed and written materials associated with varying
contexts. Literacy involves a continuum of learning in enabling individuals to
achieve their goals, to develop their knowledge and potential, and to participate
fully in their community and wider society.
- (UNESCO, 2004; 2017)
Ref: http://gaml.uis.unesco.org/wp-content/uploads/sites/2/2018/12/4.6.1_07_4.6-defining-literacy.pdf

4. LITERACY…CONTD
 Literacy refers to the ability to read and write at a level whereby individuals
can effectively understand and use written communication in all media (print
or electronic), including digital literacy.
Types of literacy:
Functional Literacy, Transliteracy and Alliteracy.
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5. CONCEPT BEHIND HEALTH
LITERACY
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6. HEALTH LITERACY
 Over the last decade, health literacy has become a vibrant area of research. Investigators
have elucidated the prevalence of limited health literacy and the relationship of limited
health literacy with patients’ knowledge, health behaviors, health outcomes, and medical
costs, as summarized in reports by several prominent organizations.
 As the field of health literacy has expanded in scope and depth, the term ‘‘health literacy’’
itself has come to mean different things to various audiences and has become a source of
confusion and debate.
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7. The concept of health literacy has developed in two distinctive settings –
 In clinical care where low health literacy is viewed as a risk factor for poor
health and poor compliance with health care advice; and
 In public/community health where health literacy can be viewed as a
personal and population asset offering greater autonomy and control over
health decision-making.
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8. INTRODUCTION TO HEALTH LITERACY
 Health literacy refers to the cognitive and social skills that determine the motivation and
ability of individuals that enable them to access, understand and use information in the
maintenance and promotion of good health.
-WHO
The constellation of skills, including the ability to perform basic reading and numerical
tasks required to function in the health care environment, including ‘‘the ability to read and
comprehend prescription bottles, appointment slips, and other essential health-related
materials.
- American Medical Association,1999
Ref: https://apps.who.int/iris/bitstream/handle/10665/205244/B5148.pdf?sequence=1&isAllowed=y

9. INTRODUCTION…CONTD
 The degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate
health decisions.’’ -Health People 2010 and Institute of Medicine (US)
The degree to which individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate health decisions.
- Ratzan and Parker, 2000
Ref: history of HL.pdf

10.  The concept goes beyond just reading health information and utilizing healthcare
services; it refers to the state of empowerment of an individual to be able to access and use
health information to improve one’s own health and the health of others.
 Health literacy is the ability to function in the health care environment, it must depend upon
characteristics of both the individual and the health care system.
 An individual’s health literacy may vary depending upon the medical problem being
treated, the health care provider, and the system providing the care.
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11. INTRODUCTION..CONTD
 Health literacy refers to the personal characteristics and social resources needed for
individuals and communities to access, understand, appraise and use information and
services to make decisions about health.
 Health literacy includes the capacity to communicate, assert and enact these
decisions.
 Health literacy is a challenge to healthcare provision all over the world. Health
literacy is referred to as a priority public health goal for the twenty-first century.
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12. INTRODUCTION..CONTD
 Health-related decisions may be about a person’s own health, the health of
another person, or the health of the community.
 These decisions may be made either by a group of people (e.g., a family or
community) or an individual.
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13. DIGITAL HEALTH LITERACY
Digital health literacy (or eHealth literacy), is the ability to seek, find,
understand, and appraise health information from electronic sources and apply
the knowledge gained to addressing or solving a health problem.
 Eight of the 10 health-related consultations on health information were
performed on search engines like Google, Yahoo or Bing and one out of 20
searches on Google is related to health.
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14. DIGITAL HL…CONTD
The increasing number of users on social media, the frequency of use, and the
interaction they generate have favored health interactions, including health
promotion.
Health institutions play a key role in facilitating reliable and trustworthy health
information within a context in which anyone can post health-related
information.
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15. FACTORS AFFECTING HL
Health care language- use of language that patients don’t understand
Low educational skills- reading skills
Cultural barriers to health care
Limited English proficiency
Learning disabilities
Cognitive decline and language barriers between clinician and patient
Readability of text and use of illustrations
Patient’s current state of health
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16. THE IOM EXPERT PANEL DIVIDED THE DOMAIN OF
‘‘HEALTH LITERACY’’ INTO:
(1) cultural and conceptual knowledge,
(2) oral literacy, including speaking and listening skills,
(3) print literacy, including writing and reading skills, and
(4) numeracy
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19. CONCEPTUAL MODEL OF HEALTH LITERACY
Ref: HL, A Prescription to end confusion

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Literacy • Ability to read and write
Health
Literacy
• Cognitive and social skills that enable
them to access, understand and use
information for maintenance of good
health

22. DIFFERENCES:
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24. LOW HEALTH LITERACY LEADS TO:
 Poor health-related outcomes, such as increased hospital admissions and
readmissions
less participation in preventive activities
Poorer self-management of chronic conditions
Poorer disease outcomes
Lower functional status
 Increased mortality
Ref: HLRP: Health Literacy Research and Practice • Vol. 4, No. 4, 2020

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26.  A two-year-old is diagnosed with an inner ear infection and prescribed an
antibiotic. Her mother understands that her daughter should take the
prescribed medication twice a day. After carefully studying the label on the
bottle and deciding that it doesn't tell how to take the medicine, she fills a
teaspoon and pours the antibiotic into her daughter's painful ear.
(Parker et al., 2003).
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27.  A 29-year-old African-American woman with three days of abdominal pain
and fever was brought to a Baltimore emergency department by her family.
After a brief evaluation she was told that she would need an exploratory
laparotomy. She subsequently became agitated and demanded to have her
family take her home. When approached by staff, she yelled “I came here in
pain and all you want is to do is an exploratory on me! You will not make me a
guinea pig!” She refused to consent to any procedures and later died of
appendicitis.
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28. POTENTIAL INTERVENTION POINTS IN CONTEXT
OF NEPAL
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29. 1) CULTURE AND SOCIETY
Culture is crucial for understanding, thinking, and responding to human
experiences and world events.
 Availability of culturally appropriate and native language health information.
 Making health service access and effective use for behavioral change.
Deep understanding of local population need and service extension.
Reducing poverty, inequity and opportunity loss.
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30. 2) THE EDUCATION SYSTEM
 Including NCD as a part of the school curriculum by coordination between MoHP
and MoE
 By designing and available of simple reading materials of NCD in both English and
Nepali language
Capacity building workshops and training for teachers on NCD and it’s risk factors
Having mass communication campaigns delivering key message in a simple manners
Increasing access to relevant information on NCD through social media
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31. 3) HEALTH SYSTEM
Offering screening services for NCD free of cost/ at subsidized cost in each local level
 Regular training of healthcare providers and community health workers
Increasing government funding for prevention and care of NCD
 Online and offline resources available via official site of MOHP, Health directorate,
Health offices and Hospitals
 Supportive care, counseling and understandable prescription of Medicine for patients
with NCD
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32. THE OPHELIA APPROACH TO OPTIMIZING
HEALTH LITERACY
 The Ophelia approach is a system that supports the identification of
community health literacy needs, and the development and testing of potential
solutions. It allows easy application of evidence-based health promotion
approaches to the field of health literacy.
OPHELIA Means
Optimizing
Health
Literacy
Access to health information and services
Ref: WHO Health Literacy Toolkit

33. TOOLS FOR MEASURING HEALTH LITERACY
1) Health Activities Literacy Scale of NALS
2) Health Literacy Skills Instrument (HLSI)
3) Health Literacy Assessment Using Talking Touchscreen Technology (Health
LiTT)
4) Health Literacy Management Scale (HeLMS)
Ref: WHO Health Literacy Toolkit

34. TOOLS…CONTD
5) Health Literacy Questionnaire (HLQ)
6) The European Health Literacy Survey (HLS-EU-Q)
7) Information and Support for Health Actions Questionnaire (ISHA-Q) has
been developed to measure health literacy in cultures where decisions about
health are often made by family or peer groups, for LMIC
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35. HEALTH LITERACY QUESTIONNAIRE
 The Health Literacy Questionnaire (HLQ) is used to identify the specific health
literacy strengths and limitations of people and communities. It examines nine
areas of health literacy.
 The HLQ offers the potential for practitioners, organizations and governments to
identify and understand the health literacy profiles of individuals and/ or
populations as a basis for intervention development.
 It is suitable for use in a range of different cultures and is available in several
languages.
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37. THE INFORMATION AND SUPPORT FOR ACTIONS
QUESTIONNAIRE (ISHA-Q)
 The Information and Support for Actions Questionnaire (ISHA-Q) was
developed to measure health literacy in low- and middle-income country
settings, and cultures where decision-making about health often occurs as a
collective activity of family or peer groups.
 The ISHA-Q has fourteen core scales and ten supplementary scales for people
with chronic illnesses, people with a physical disability, people who are blind
and people who are deaf.
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39. VALIDATION OF QUESTIONNAIRE
 The HLQ has been translated into more than 15 languages.
 The HLQ was developed over 9 y in consultation with individuals from the
community, health practitioners and policymakers. The tool has undergone
psychometric evaluation in a range of contexts, including in university student
settings.
 The HLQ consists of 44 items across nine scales.
 The HLQ reveals the health literacy strengths and weaknesses of individuals and
groups, providing a framework for intervention development
Ref: HL in health care professionals.pdf

40. Health Literacy for NCD
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41. NCD AND HEALTH LITERACY
 Noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes
and chronic lung disease, are collectively responsible for almost 71% of all deaths
worldwide.
Almost three quarters of all NCD deaths, and 82% of the 16 million people who died
prematurely, or before reaching 70 years of age, occur in low- and middle-income
countries.
Ref: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

42.  The deaths due to NCDs (Cardio-Vascular Disease, diabetes, cancer and
respiratory disease) have increased from 60% of all deaths in 2014 to 66% in
2018 (WHO Nepal Country profile 2018).
 Need to make daily health-related decisions for both prevention and
management of NCDs. Thus, Health Literacy holds the key to living a healthy
life.
 Health related decisions are search, access, understand health related
information and can correctly apply it in daily life.
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43. IMPORTANCE OF HL FOR PATIENT WITH NCD
 HL helps improve knowledge and understanding of health determinants and
can motivate people to adopt healthy behaviors.
HL plays a pivotal role in prevention, adherence to treatment, self care and the
use of health care system
Limited HL hinders patients ability to access health care, adhere to physician
instructions and stay compliant with medication.
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44. IMPORTANCE …CONTD
Limited HL negatively affects a patients ability to understand the relationship
between health outcomes and lifestyle factors
Also, addressing HL is thought to be a key factors for attaining SDGs.
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47. Methods to Improve HL for
Prevention and Management of NCD
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48. 1) HEALTH EDUCATION
 Health literacy can best be improved through a structured educational programs
or through well designed on-line/mobile learning programs.
 Community health education for NCD prevention has been considerably
strengthened by the development of a new generation of more sophisticated, theory-
informed interventions.
Ref: Discussion paper on promoting, measuring and implementing HL

49. HEALTH EDUCATION…CONTD
 Access to a wider range of communication tools and methodologies that
have evolved with the development of the internet and mobile
communications.
 Helped to identify and explain the complex relationships between knowledge,
beliefs, and perceived social norms, and provide practical guidance on the
content of health education programs to improve interactive and critical health
literacy.
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50. HEALTH EDUCATION…CONTD
 In clinical practice, there is good evidence that comprehension of health
information among individuals with low health literacy can be improved
through modifications to communication, and that intensive mixed-strategy
interventions produces improved health outcomes including reduced reported
disease severity, unplanned emergency department visits and hospitalizations.
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51. 2) POLICY AND PRACTICE
At government level:
Health literacy has been adopted by several countries as a population measure
of human capacity and development.
 Health literacy is an observable, measurable outcome from health
education. It provides a well-defined bridge between a range of health/patient
education inputs and NCD risks and outcomes.
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52. POLICY AND PRACTICE…CONTD
Our country should also develop national targets to improve health literacy
and/or related policies across the spectrum of health care and public health
education.
Health literacy is monitored in countries and specific populations in a variety
of ways that are practical and relevant to local circumstances.
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53. POLICY AND PRACTICE…CONTD
Strategies to promote health literacy will remain closely tied to more general
strategies to promote literacy, numeracy and language skills in populations,
requiring alliances between health and education sectors in pursuing the goal
of improved literacy levels in the population.
Continued investment in developing the underpinning science is essential.
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54. In the health care system:
Attention to improving health literacy in the health care system is helping to
reform clinical practice, patient education and service organization.
Greater awareness of the causes and risks of low health literacy has led to
improvement to the quality of interpersonal communications in clinical care,
and more effective patient engagement in self-care and self-management,
and has led to improved clinical outcomes, including better management of
NCDs and associate risks.
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55. Use simple language. Avoid complicated medical terminology or jargon. Use
common, simple words to be as clear as possible and minimize the risk of
misunderstanding. For example:
• Say “swallow” instead of “take”
• Say “harmful” instead of “adverse”
• Say “fats” instead of “lipids”
Speak more slowly when providing instructions. Be respectful and clear without
being patronizing.
Use graphics and pictures instead of long written instructions.
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56. 3) IN PUBLIC HEALTH
 Health literacy is directly and indirectly associated with health status in
populations.
 Higher levels of health literacy in a population support a wide range health
actions to prevent and better manage NCDs, including greater capacity to
change personal behaviours.
 Health literacy can best be improved through structured, theory-informed
educational programs.
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57.  Interventions that are context and content relevant - linked to critical life stages
(eg adolescence, parenthood, aging and retirement) and events (eg diagnosis of
chronic disease) - are likely to be more successful in producing sustainable
change.
 Civic society can explore and develop the potential of health education not
only to enable individual change but also to strengthen collective action for
NCD prevention.
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59. How to use health literacy to improve
understanding and responses to NCDs?
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66. APPLYING HL FOR PREVENTION OF NCD
 Primordial prevention- HL create awareness about the importance of physical
exercise, low salt, carbohydrate and fat intake also prevents from the harmful
use of tobacco and alcohol.
 Primary prevention- Education and knowledge about health and disease,
modifying dietary pattern, driving safely
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67.  Secondary prevention- Regular screening of disease, regular medical check
up, prompt diagnosis and treatment
 Tertiary Prevention- significant behavioral and lifestyle modification,
adherence to prescribed medication, following rehabilitation requirements after
surgery.
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68. APPLYING HEALTH LITERACY RESPONSES FOR
MANAGEMENT OF NCD
 In the action plan for prevention of noncommunicable diseases, the WHO has
advocated for plans to promote health literacy as part of the effort to
prevent chronic diseases.
Make information and services for chronic disease management more available
and accessible.
 Enhance the ability and willingness of people with chronic disease to:
a. engage with chronic disease related information and services that are
already available.
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69. ROLE OF HL FOR MANAGEMENT OF
NCD…CONTD
b. communicate and assert their health decisions;
c. Helps to take appropriate actions to implement the decisions they make
about their health.
Health literacy is required to enable participation in health negotiations and
decision-making
Timely diagnosis, compliance, treatment and follow up
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70. ROLE OF HL FOR NCD MANAGEMENT…
Health literacy is required to optimize caring for one’s own health and the
health of others
Health literacy is required to enable people to have high quality interactions
with health service providers
Health literacy is required to enable people to access and utilize healthcare
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71. HEALTH LITERACY REQUIREMENT:
For government levels to strengthen the structure
• E.g. Making the Services/Choices available (Healthy food etc) • E.g. Policy
makers identifying priority interventions for policy
For healthy people Preventing Risk factors
• E.g. Making healthy choices for food and lifestyles • E.g. People Speaking out
for themselves
Ref: file:///C:/Users/Owner/Desktop/Health%20literacy%20for%20NCD/9-s3-budhathoki.pdf

72. HL IS REQUIRED AT…CONTD
For at risk people preventing disease onset
• E.g. Minimize the activities that put health at risk • E.g. Smoking cessation
For diseased people preventing complications
• E.g. Taking up Early diagnosis & treatment • E.g. Ability to choose treatment
options
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73. OUTCOME OF HEALTH LITERACY INTERVENTION
At National/Global level
• Decreased incidence of NCDs and their risk factors
At population level
• Scores at different domains that make up the HL of people & communities
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74. Measures around the following 4 areas may be useful
1. People accessing and utilizing healthcare
2. People having high quality interactions with health service providers
3. People caring for one’s own health and the health of others
4. People participating in health negotiations and decision-making
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75. Furthermore…
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76. CONFERENCE ON HEALTH PROMOTION
The Nairobi Call to Action for Closing the Implementation Gap in Health Promotion
identifies five key strategies and actions for reducing health inequities and poverty, and
improving health and quality of life:
Building capacity for health promotion
Strengthening health systems
Partnering and intersectoral action
 Community empowerment
Health literacy and health behaviours 11/26/2021 1:15 PM 76

77. TO ADVANCE THE HEALTH LITERACY AND HEALTH
BEHAVIOURS
Strategy, policy is needed to generate actions that:
 support empowerment, e.g., by ensuring communities can access and act on
knowledge and overcome any barriers;
 embrace information and communication technologies
 build and apply the evidence base, e.g., by developing systems to monitor,
evaluate, document and disseminate health literacy.
 Governments, organizations, practitioners and community members must work in
partnership to address health literacy.
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78. 9TH GLOBAL CONFERENCE ON HEALTH
PROMOTION
Health Literacy empowers and drive equity
Health literacy empowers individual citizens and enables their engagement in
collective health promotion action.
A high health literacy of decision-makers and investors supports their
commitment to health impact, co-benefits and effective action on the
determinants of health.
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79. NEPAL HEALTH CONCLAVE 2021
 The objective of the session is to identify various factors that contribute to
health illiteracy and analyze the efficacy and shortcomings of the programs.
Especially in light of Covid-19 literacy efforts.
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83. CONCLUSION (1)
 Health literacy is an observable, measurable outcome from health education.
 Higher levels of health literacy can support a wide range health actions to prevent
and better manage NCDs, including changed personal behaviours, social actions for
health, and the capability of influencing others towards healthy decisions.
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84. CONCLUSION (2)
 Health education is most likely to improve health literacy when the messaging
and delivery are tailored to the specific needs of individuals and
populations across their life course
 Health education and improved health literacy need to be viewed in the wider
context of a comprehensive and integrated set of actions to prevent and manage
NCDs in populations.
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85. REFERENCES
1) https://www.who.int/global-coordination-mechanism/working-groups/hl_youth.pdf
2) WHO Health Literacy Toolkit
https://apps.who.int/iris/bitstream/handle/10665/205244/B5148.pdf?sequence=1&isAllowed
=y
3) Sørensen et al. BMC Public Health 2013, 13:948 http://www.biomedcentral.com/1471-
2458/13/948
4) HLRP: Health Literacy Research and Practice • Vol. 4, No. 4, 2020
5) HL in health care professionals.pdf
6) History of HL,history of HL.pdf
7) https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
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86. REFERENCES (2)
8) Yadav et al. BMC Public Health (2020) 20:300 https://doi.org/10.1186/s12889-020-8404-7
9) . Shrestha ASS, Khanal VK, Bhattarai S, Maskey R, Pokharel PK. Health Literacy and
Knowledge of Chronic Diseases in Nepal. Health Lit Res Pract. 2(4):e221
10) Discussion paper on promoting, measuring and implementing health literacy: Implications
for policy and practice in non-communicable disease prevention and control
11) Health Literacy: A Prescription to End Confusion
Available from: https://www.nap.edu/read/10883/chapter/1
12) Intarakamhang U, Macaskill A. Effectiveness of a health literacy intervention based on
transformative learning and incorporating positive psychology on health behavior and well-being
of Thai families with NCDs risk
13) http://gaml.uis.unesco.org/wp-content/uploads/sites/2/2018/12/4.6.1_07_4.6-defining-
literacy.pdf
14) 9-s3-budhathoki.pdf
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87. Knowing is not enough, we must apply. Willing is not enough, we
must do…..
- Goethe
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