Literacy, health education,

health literacy and health

outcomes –
How do they fit?

Don Nutbeam
University of Sydney
 What is literacy?
What is it?
• Functional literacy is a measure of a person’s 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
 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"
 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 S&W 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

 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 MYS
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

 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 MYS
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

 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

 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/resou
rces/interim_statement/en/index.html
 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
 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
 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
 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.
 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)
Health literacy – public health origins
in Australia
 Australia’s 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 Australia’s Health, Canberra, AGPS 1993
 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

 Improved health outcomes,
healthy choices
and opportunities

Changed health
behaviours and
practices

Improved
Skills in Health Literacy Skills in
social organization negotiation and
and advocacy self management
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

 Improved health outcomes,
healthy choices
and opportunities
Engagement in Participation in
social Changed health changing social
action/advocacy behaviours and norms and service
for health practices practices

Improved
Skills in Health Literacy Skills in
social organization negotiation and
and advocacy self management
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

 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
 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
 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
 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
 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
 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 people’s
wish for a better
understanding of health
http://www.dfes.gov.uk/readwriteplus/embedd
edlearning/