1.
Working together
Update on the Royal College of General
Practitioners and NHS England report and action
plan
Health literacy – Making it everybody’s business
Thursday 25th
June 2015
Gill Rowlands, Professor, University of Newcastle and
Aarhus University
June 2015
1

2.
2
http://www.rcgp.org.uk/news/2014/june/~/media/Files/Policy/RCGP-Health-Literacy-2014.ashx
Gill Rowlands
Joanne Protheroe
Hannah Price
Bob Gann
Imran Rafi

3.
This presentation
• What did we discuss at the workshop in July 2013?
– What is health literacy?
– Is health literacy important?
– What challenges does health literacy bring to patients,
health care staff, managers and commissioners?
– What can be done to make things better?
– A Call for Action
• Progress so far
• Next steps
• Do we need to know anything else about health literacy?
3

4.
What is health literacy
4
“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.”
World Health Organization. Health literacy toolkit for low- and middle-income countries. A series of
information sheets to empower communities and strengthen health systems. 2015.
www.searo.who.int/entity/healthpromotion/documents/hl_tookit/en/

5.
Yes! People with low health literacy are sicker than people with
higher health literacy. They:
•Die earlier1,2
•Find it more difficult to take their medication as instructed1
•Are more likely to have one or more long-term conditions
(LTCs)3
•LTCs more likely to be limiting3
•Are less likely to engage with disease prevention e.g. cancer
screening, immunisation1
5
1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health literacy
interventions and outcomes: An updated systematic review. Rockville, MD: Agency for Healthcare
Research and Quality., 2011 Contract No.: 11-E006. 2. HLS-EU Consortium: Comparative report of
health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012
3. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older
adults: longitudinal cohort study. British Medical Journal. 2012;344:e1602.
Is health literacy important?

6.
Yes! People with low health literacy are less healthy than people
with higher health literacy. They have:
•More unhealthy behaviours; alcohol, poor diet/obesity,
smoking2,3
•Fewer healthy behaviours; good diet/normal weight2,3
•Lower levels of self-rated health1,2
•Lower response to public healthy living campaigns3
6
1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, et al. Health literacy
interventions and outcomes: An updated systematic review. Rockville, MD: Agency for Healthcare
Research and Quality., 2011 Contract No.: 11-E006. 2. HLS-EU Consortium: Comparative report of
health literacy in eight EU member states. The European Health Literacy Survey (HLS-EU). 2012
3. Buck D, Frosini F. Clustering of unhealthy behaviours over time. Implications for policy
and practice. . London: King's Fund, Aug 2012.
Is health literacy important?

7.
Is health literacy a common problem?
Yes!
7
% of the adult working age
population unable to fully read,
understand, and act
on health information in common
circulation.
National average 61%
Rowlands, G., Protheroe, J., Richardson, M., Seed, P., Winkley, J., and Rudd, R. (2015).
The health information gap: the mismatch between population health literacy and the complexity of
health information; an observational study. British Journal of General Practice 65 e379 -e386.

8.
Is low health literacy associated with
other social determinants of health?
Yes!
Male (literacy)
Female
(numeracy)
Male (literacy)
Female
(numeracy)
Aged 45+Aged 45+ BMEBME
Born outside
of the UK
Born outside
of the UK
English not
first language
English not
first language
Below
expected by
age 16
Below
expected by
age 16
UnemployedUnemployed Lowest job
grade
Lowest job
grade
Income less
than £10,000
Income less
than £10,000
Not a home
owner
Not a home
owner
Top 5 most
deprived
areas
Top 5 most
deprived
areas
Not statistically
significant when
considered
together
Rowlands G, Protheroe J, Richardson M, et al. The health information gap: the mismatch
between population health literacy and the complexity of health information; an
observational study. BJGP Accepted for publication. 2015.

9.
What challenges does health literacy
bring?
• Patients:
– coping with a complex system that is not tailored to their health
literacy needs
• Health care professionals:
– Lack of knowledge about the importance and impact of low health
literacy
– Lack of skills in tailoring communication and services to patients’
health literacy needs
• Managers:
– Developing ‘health literate’ systems and services tailored to patient
need
– Up-skilling health care staff
• Commissioners
– Ensuring people with low health literacy have a voice and can
influence the design of services to meet their needs
– Using the power of commissioning to develop health literate health
services
9

10.
Can anything be done to help? Yes
Improving the system
•Improving how information is written improves understanding
of information1
•Use of pictograms improves understanding of risk2
•Current international service development project involving
several UK sites: the Ophelia project3
is exploring how health care
organisations’ understanding of patients’ health literacy needs
can be used to improve the service
10
1. Scott, T.L., et al., Health literacy and preventive health care use among Medicare enrollees in a
managed care organization. Med Care, 2002. 40(5): p. 395-404. 2. Garcia-Retamero R, Galesic M.
Communicating treatment risk reduction to people with low numeracy skills: a cross-cultural
comparison. Am J Public Health. 2009;99(12):2196-202
3. http://www.deakin.edu.au/health/research/phi/OPHELIA.php

11.
Can anything be done to help? Yes
Building citizens health literacy skills
•Improves knowledge and skills1
•Improves lifestyle (diet and exercise)1
•Improves mental health1,2
•Improves Diabetes self-management3
Building health professionals’ health literacy awareness and skills
Current project: Awareness raising and training of health care
staff: Community Health and Learning Foundation
11
1. Evaluation of the second phase of the Skilled for Health Programme. London: The Tavistock Institute
and Shared Intelligence, 2009. 2. Weiss BD, Francis L, Senf JH, Heist K. Literacy education as treatment
for depression in patients with limited literacy and depression: a randomized controlled trial.
J Gen Intern Med 2006;21:823–8 3. Rothman RL, DeWalt DA, Malone R, et al. Influence of patient
literacy on the effectiveness of a primary care-based diabetes disease management program.
Journal of the American Medical Association. 2004;292(14):1711-6.

12.
What are some solutions: the joint
RCGP and NHS England call for action
1. To work with the Health Literacy Group UK to take the ‘Call for
Action’ forward.
2. To improve GP training.
3. To develop recommendations for Clinical Commissioning Groups
(CCGs) to consider health literacy approaches by NHS service
providers when commissioning services.
4. To develop pilot sites where CCGs can commission health literacy
training for patients from adult learning providers, with
assessment of the impact of these pilots on patient skills, patient
satisfaction with NHS services and their use of NHS services.
5. To ensure that those aspects of the Digital Inclusion Strategy
relevant to general practice are highlighted to GPs.
6. To work with the Information Standard to develop a health literacy
guide to be circulated to all NHS Trusts.
12

13.
Progress so far
• NHS England is committed to working with partners to
support progress around health literacy – it is an agenda that
cannot be addressed unilaterally
• This needs to be undertaken in parallel with other activities to
improve and streamline health information and
communication systems
• The Information Standard has been brought ‘in house’ to
improve it’s engagement and effectiveness (especially for
NHS Trusts) and streamline costs
• NHS England has pulled together a roundtable involving
Health Literacy Group UK, Royal College of GPs, ALBs, and a
range of other organisations to identify next steps and ensure
a co-ordinated approach
13

14.
Next steps
• Develop a wider programme of work which addresses both
the quality and accessibility of health information alongside
ensuring people have the skills to be able to understand and
apply it
14

15.
• Work with partners to develop a plan to support progress
with health literacy which might include:
– Using the Information Standard to improve the ‘health
literacy’ of health information
– Provide implementation support for the Accessible
Information Standard as a way of supporting people with
access and communication needs
– Work with the NHS England digital inclusion strategy to
widen digital skills and participation for health
– Establish the best way to use the commissioning system to
support action on health literacy, both in public
engagement and in the services which are commissioned
– Work with the partners to improve the health literacy
skills of health professionals
15

16.
Conclusions
• Health literacy affects a significant proportion of people (6
out of 10 in England)
• It results in less health and more illness, but much can be
done to improve both health literacy skills and the
approaches of the health and education sectors
• Progress is being made against the objectives in the ‘Call for
Action’ but more needs to be done
16

17.
Points for discussion
• The call for action: what needs prioritising and why?
• Do we need to know anything more? What about:
– The cost of health literacy to patients, the public and the
NHS?
– What are the cost / benefits of lifelong learning
interventions – both in health but also in communities and
wider society
– Health literacy and wider skills, employability and
productiveness?
17

18.
Working together
Update on the Royal College of General
Practitioners and NHS England report and action
plan
Health literacy – Making it everybody’s business
Thursday 25th
June 2015
Gill Rowlands, Professor, University of Newcastle and
Aarhus University
June 2015
18

19.
Additional slides if needed
19

20.
National Qualifications level: Literacy level 1 / Numeracy level 1
Key Stage Skill Equivalent Ages:
Literacy 11-14 years, Numeracy 11-14 years
Number (%) English adults 16-65 yrs. UNABLE to understand and use this:
21 million people (61%)
Example: Bowel Cancer
Screening Kit

21.
NQF
level
Key stage
equivalent
At this LITERACY level an adult
understands
Entry
level 1
5-7 years Short texts with repeated language
patterns on familiar topics
Entry
level 2
7-9 years Short straightforward texts on
familiar topics and from familiar
sources
Entry
level 3
9-11 years Short straightforward texts on
familiar topics accurately and
independently
Information from everyday sources
Level 1 11-14
years
Short straightforward texts of varying
length on a variety of topics
accurately and Independently
Level 2 14-16
years
A range of texts of varying complexity
accurately and independently
Information of varying length and
detail
Material levelMaterial level
Population level
Skills
Qualification
Framework
Literacy

22.
NQF
level
Key stage
equivalent
At this NUMERACY level an adult
understands
Entry
level 1
5-7 years Numbers and symbols in a simple
format
Entry
level 2
7-9 years Numbers, symbols, simple diagrams
and charts in a simple format
Entry
level 3
9-11 years Numbers, symbols, diagrams and
charts used for different purposes
and in different ways
Level 1 11-14
years
Straightforward mathematical
information, can independently
select relevant information
Level 2 14-16
years
Mathematical information used for
different purposes, can
independently select and compare
relevant information from a variety
of sources
Material levelMaterial level
Population level
Skills
Qualification
Framework
Numeracy

23.
Is low health literacy a common problem? Yes
The situation in Europe.
23
From the HLS-EU final report. SLIDE COURTESY OF Prof. Jürgen M. Pelikan Ludwig Boltzmann Institute
Health Promotion Research, WHO-CC for Health Promotion in Hospitals and Health Care, Vienna/
Austria.