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Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary (2013)

Chapter: Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States

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Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Appendix A

Health Literacy Around the World:
Part 1
Health Literacy Efforts
Outside of the United States1

by

Andrew Pleasant, Ph.D.
Director of Health Literacy and Research
Canyon Ranch Institute
Tucson, Arizona


Commissioned by
Institute of Medicine
Roundtable on Health Literacy

___________

1 The author is responsible for the content of this article, which does not necessarily represent the views of the Institute of Medicine.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

ACKNOWLEDGMENTS

First and foremost, I want to offer my sincere gratitude to every participant who took the time to respond to the request for information. When investigating what is essentially an unknown phenomenon such as the subject of this discussion paper, it becomes increasingly difficult to design an efficient data collection tool. The data collection tool employed in this exercise inherently had no choice but to place the bulk of the burden on respondents to respond in English. I dearly wish that reliance on the English language and the burden created by an open-ended inquiry could have been reduced. However, the resources available, the context of health literacy as a field of research and practice, and my own personal skills required an open-ended inquiry in English. Truly, and necessarily, this was not a health literate process of collecting information. I had to rely on the motivation and health literacy skills, in English, of the respondents. Thus, I cannot thank the participants enough. This effort would also not have been possible without the inspiration and support from the staff and members of the Institute of Medicine Roundtable on Health Literacy. In particular, I would like to recognize the tireless role that Lyla Hernandez plays in keeping the Roundtable on Health Literacy moving forward.

While many of the many hours I had the pleasure to invest in this project occurred in the evening and weekends, many hours also necessarily overlapped with my primary employment at Canyon Ranch Institute (CRI), which is a 501(c)3 nonprofit public charity located in Tucson, Arizona, in the United States. Without the active support of my colleagues at CRI, this discussion paper would have never materialized. Thus, I want and need to extend my heartfelt thanks to my colleagues Dr. Richard Carmona, Athena DeLay, Jan McIntire, Russell Newberg, Chuck Palm, Maura Pereira-Leon, and must offer a special thank-you and acknowledgment to CRI Executive Director and Board Member Jennifer Cabe. Nothing that anyone at CRI accomplishes—including this project—would occur without her inspiring leadership.

Additionally, I want to acknowledge a few specific individuals who supported this process in a variety of ways, including reviewing reports on specific countries, encouraging colleagues to participate, helping to gather specific data, or just being necessary in other ways. These individuals are Andre de Quadros, Nicola Dunbar, and the entire staff at the Australian Commission on Safety and Quality in Health Care, Mahiri Mwita, R.V. Rikard, Irv Rootman, Gillian Rowlands, Mallika Sarabhia, and Kristine Sørensen. If you do not know of those individuals already, please take my advice and get to know their work.

First efforts such as this will necessarily be burdened with errors.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Any faults are my own. Hopefully, I will be able to correct any errors and improve the process and reporting in the future.

Respectfully,

Andrew Pleasant, Ph.D.

Health Literacy and Research Director, Canyon Ranch Institute

Member, Institute of Medicine Roundtable on Health Literacy

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

INTRODUCTION

In the history of health and medicine, health literacy is a dramatically new idea and area of activity.

That newness of the concept of health literacy creates the motivation and the possibility for an effort to better understand the health literacy efforts ongoing around the world. That newness is also what makes such an effort challenging, if not impossible, to truly and systematically complete. The source of that challenge lies in multiple realities. For example, there is no international organization of health literacy practitioners, researchers, or academics. There is no existing database of individuals and organizations that actively work with health literacy. Further, there is not universal agreement of the definition of health literacy and, partly as a result, translation of the concept across languages is fraught with difficulty.

The results of an effort to learn about health literacy activities ongoing around the world are reported in this discussion paper, and a companion paper to follow that will focus on health literacy efforts in the United States. The idea for this discussion paper emerged during the planning for an Institute of Medicine Roundtable on Health Literacy workshop on health literacy in international contexts titled “Improving Health, Health Systems, and Health Policy Around the World.” More details about the workshop are available at http://www.iom.edu/Activities/PublicHealth/HealthLiteracy/2012-SEP-24.aspx.

This paper is prepared to stimulate workshop discussion and help to

  • Initiate a dialogue among existing organizations from all sectors.
  • Document the use of health literacy in international contexts (policy, practice, and research).
  • Examine health literacy interventions, measurement, practice, and research.

HEALTH LITERACY: A BRIEF SYNOPSIS OF THE FIELD

The first use of the phrase “health literacy” in the peer-reviewed academic literature occurred in 1974 (Simonds, 1974). That use had, by the author’s own report, nothing at all to do with the current understanding of the concept and was more an accident of English than an intentional representation of a singular concept. Health literacy began appearing in the academic peer-reviewed literature in earnest in the early 1990s and has experienced nearly exponential growth since that beginning (Pleasant, 2011).

From a total of 569 peer-reviewed publications identified in 2011

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2 With the assistance of R. V. Rikard, Doctoral Candidate at North Carolina State University, the review searched for articles with “health literacy” in either the title, abstract, or keywords published from 1950 to 2011. The databases searched include Pubmed, ISI Web of Science, Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ingenta, and Science Direct. Duplicate citations were removed and/or collapsed into a single citation. In addition, Google Scholar was used to obtain any missing citation information such as the country of the lead author and/or publication year.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

through a search of multiple scholarly databases,2 the first author of more than 200 of the articles is from a nation other than the United States (Table A-1). Several nations were represented by a single peer-reviewed publication during 2011. These are the Czech Republic, Denmark, Italy, Jamaica, Portugal, Qatar, the Republic of Korea, Romania, Saudi Arabia, Serbia, Slovakia, South Korea, Sri Lanka, Turkey, and the West Indies. This indicates a growing internationalization of the field of health literacy—a field that has been dominated in at least quantitative aspects by the United States but truly does have very international roots, for example, in the work of Brazilian scholar Paulo Freire.

Mapping the number of peer-reviewed articles in 2011 by country (Figure A-1) clearly indicates that health literacy has spread around the world and is definitively not a U.S.-only phenomenon.

The field of health literacy has grown in many ways beyond the academic peer-reviewed literature. For example, there are an increasing number of conferences with an explicit focus on health literacy. Equally, conferences with a more general focus on public health, for example, seem to also be featuring a growing number of presentations that address health literacy. Anecdotally, at least, these also seem to be attracting larger and larger audiences as more individuals are becoming aware of the importance of health literacy.

What we have learned about health literacy has steadily increased over the years as well. For example, numerous research efforts over the years have demonstrated that patients with low health literacy experience less understanding, poorer use of health services, and are less healthy. Specific outcomes associated with low health literacy include, but are not limited to, poor adherence to medical regimes, poor understanding of the complex nature of their own health, a lack of knowledge about medical care and conditions, poorer comprehension of medical information, low understanding and use of preventive services, poorer overall health status, and earlier death (IOM, 2009, 2011a,b).

The growth in the field of health literacy has, in fact, been so rapid that the field of health literacy is becoming at risk for losing track of its own successes and failures. This and the forthcoming report are an attempt to inform the field about its growth and diffusion around the

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

TABLE A-1 Peer-Reviewed Publications on Health Literacy by Nation of First Author (2011)

Country Frequency
United States 360
Australia 48
United Kingdom 37
Canada 25
Netherlands 14
Germany 12
Japan 7
Spain 6
South Africa 4
Sweden 4
Brazil 3
China 3
Iran 3
Israel 3
Netherlands 3
New Zealand 3
Nigeria 3
Taiwan 3
Argentina 2
Belgium 2
India 2
Malaysia 2
Norway 2
Singapore 2
Switzerland 2
Thailand 2

world as well as about how health literacy is appearing in policy, research, education, and on-the-ground projects.

METHODOLOGY

Gathering information about any social phenomenon on a global basis is a significant undertaking that is often rife for failure and nearly always guaranteed to draw criticism. Critiques of this effort and discussion paper are certainly possible and warranted, and the main areas the approach used in this initial effort to collect information about health literacy activities on such a large scale is certainly open to future improvements.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

image

FIGURE A-l Frequency of health literacy publications by country (2011).

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

The central challenge to this project was to try to gather information, catalogue, and analyze all of the health literacy activities currently ongoing around the world. That is an ambitious goal and one that has still not been accomplished. Thus, this effort is essentially a baseline against which future efforts can be compared to learn of changes and improvements in methodology and of the status of health literacy work around the world. This first attempt to reach the goals of identifying, cataloguing, and analyzing efforts in health literacy around the world relied upon three distinct methodologies. Overall, data collection for this effort occurred between June 7, 2012, and September 6, 2012.

First, this effort employed a non-probability purposive sampling strategy of snowballing. Snowball sampling is often the best method to reach a population that is unknown or inaccessible to the researchers. Both conditions were true in this case. In snowball sampling, the sampling process begins with individuals who are known to be members of the population of interest (Faugier and Sargenat, 1997). Those individuals are then contacted, asked to provide information, and asked to identify other members of the population of interest they may know. The hope is that the sample literally grows like a snowball rolling down a hill and accumulating more snow with each revolution. In this project, the snowball sampling process was initiated by sending e-mail invitations directly to individuals who worked in health literacy or worked in a position such that they should be aware of health literacy work in their country or organization. These individuals were requested to participate in the online survey and to forward the e-mail invitation to others they knew of who work in health literacy. This process started with an initial e-mail, with at least one reminder at a later date, sent to 574 individuals around the world believed to be associated with health literacy, health promotion, or health communication efforts. This initial effort garnered 169 responses from 32 countries.

Second, the same snowball method was used but with a distinctly different delivery mechanism. Versus sending the invitation to participate and to forward the invitation to participate to known individuals, electronic listservs and discussion groups were the means of delivery in the second method employed in this project. In this instance, the invitation to participate and to forward the invitation to others was delivered to 13 topically related e-mail discussion lists or organizational membership lists. This effort garnered 195 responses from 27 countries.

Additionally, a small group of fewer than 10 individuals responded directly via e-mail versus using the online survey platform and are not reflected in the above tallies. Furthermore, not all e-mail addresses included in the initial invitation rounds were valid. Response rates cannot

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

be determined in this methodology, as there is no way to truly know how many people received the initial invitation.

The third method employed was a direct online search for health literacy projects and policies. The main search phrase used in this method was “health literacy” and a country name in combination. For countries that do not primarily use English, the term health literacy was translated via freely available online translators. This method was focused primarily on nations where the expected response rate was very low. In addition to identifying online resources that became a part of the evidence reported on here, this method also identified new individuals who were included in the sampling strategy for the first methodology described above.

Finally, a small number of nations were selected for a final “fact-checking” stage with an in-country expert. Nations selected for this stage were those that received the most responses. Fact checkers in the selected nation were recognized experts in health literacy working within that nation. This was essentially a validity and reliability check on the basic methodology. Very few errors in fact were discovered in this process and the volunteer fact checkers reported that they actually learned something new about health literacy within their own nation that they were unaware of prior to reviewing the information collected through this process.

While a goal of this project was to catalogue all the health literacy activities ongoing around the world, that goal is clearly unreachable. The many realities that transform that ideal into an impossibility include

  • There is not a universal consensus of what is and is not a health literacy project or policy. This is due to underlying variations in theoretical approaches; definitions; desired outcomes; and to political, social, and cultural contexts in which participants in this project work.
  • There is not a global organization for health literacy researchers, practitioners, and policymakers. Therefore, there is no known structure through which to contact practitioners, researchers, academics, and policymakers working with health literacy.
  • As the actual population of interest is undefined, probability sampling techniques are not possible to employ.
  • This project did not have the resources to conduct the inquiry in multiple languages. However, using English only is clearly a very limiting factor. Hopefully, future efforts will have the resources to expand to multiple languages.
  • Further, there is no universally equitable means to translate the concept of “health literacy” into multiple languages. The conceptual understandings of health literacy reported from around the world have far exceeded the literal understanding of both “health”
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • and “literacy.” As a result, accurate translation between languages is increasingly problematic.
  • Given timelines and costs, this project was solely conducted online using e-mail as the means of recruiting participants and the Internet as the sole means of gathering responses and information. Clearly, that makes it impossible for many around the world to participate. Further, many potential recipients have indicated that the timeline this project was conducted within made it difficult for them to participate.
  • Verifying the accuracy of all responses is impossible. Therefore, analysis must proceed in good faith. However, the responses do make it very clear that there are multiple conflicts in how people understand, define, and operationalize health literacy. This project recruited fact-checkers in some, but not all nations. The hope is that recruiting fact-checkers in nations from which multiple people participated in this country provided the best means to validate the methodology. To date, this seems to have been a fruitful approach.
  • Many participants seemed to be unclear as to whether the efforts they described were policies, practices, or projects. At times, participants used these three words (policy, practice, project) interchangeably. Therefore, the editing process is another source of potential error as participants may have intended to indicate something that did not survive the editing and analysis process.
  • Many participants either explicitly stated or clearly assumed that the organizer of this project possessed prior knowledge about their work or about other health literacy work ongoing in their country. While that may or may not be true, what is clear is that several responses were deliberately less than complete because of that assumption. For example, one participate wrote, “I know of all the standard policies in the U.S. that I’m sure you are already familiar with. I’m not sure if you are trying to determine what is going on, or if you’re more interested in how many people know about what is going on. So I’m assuming you are just trying to learn what is happening. Therefore, if I believe you already know the answers for the U.S., I’m not going to spend much time on the question.” Several similar responses were received from participants in several nations. That perception (of prior knowledge on the part of the researcher) may have unfortunately negatively influenced this discussion paper as well.

Readers of this and the forthcoming discussion paper focusing on the health literacy activities in the United States may too quickly assume that health literacy research, practice, and policy are more advanced in

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

the United States than elsewhere around the world. A necessary and warranted caution to be offered to those coming to that conclusion is that the findings of this project, given the above caveats, should in no way be taken to prove that health literacy is more advanced in one country versus another.

The information in this discussion paper and the companion paper on U.S. efforts is not based on a perfect sample of respondents, nor is it fully representative of the health literacy work ongoing around the world. Nonetheless, the effort reported on in these two companion papers does seem to represent the largest documentation of health literacy efforts around the world to date and will hopefully serve as a functional baseline for future efforts to help better understand how health literacy is advancing around the world.

BOX A-1
How Did You First Learn About Health Literacy?

As a part of this effort, some participants were asked how they first learned about health literacy. These stories will be interspersed throughout the two reports. They will be anonymous to the extent possible according to the nature of the story and are shared with permission.

RESULTS

Information from each country follows and is organized by sections on governmental policy, health literacy initiatives (governmental and nongovernmental), education efforts focusing on health professionals, and how health literacy is defined in each nation or effort.

Australia

GOVERNMENTAL POLICY

Australia is one of the few nations around the world to have completed a national assessment of health literacy to provide evidence upon which to base future policy and practice. A complete summary of the methodology and findings can be found at http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4233.0Main%20Features22006?

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

opendocument&tabname=Summary&prodno=4233.0&issue=2006&num=&view=.

The assessment of health literacy in Australia is a component of the Adult Literacy and Life Skill Survey (ALLS)3 that was last completed in 2006 and reported by the Australian Bureau of Statistics. The methodology consisted of 191 items in four conceptual domains of prose, document, numeracy, and problem solving. These items were also classified according to relevance to health promotion, health protection, disease prevention, health care maintenance, and systems navigation. The assessment indicated that health literacy for Australians generally increases between the ages of 15 to 19 until 40 years of age and then begins to decline for older adults. There were not regional variations of note except for the Australian Capital Territory, where health literacy was generally higher than the rest of the nation (Australian Bureau of Statistics, 2006).

Respondents varied in their qualitative assessments of health literacy policies in Australia. Some reported a forward-moving robust process of policy development while others characterized that same effort as lacking except for the acknowledgment that there is a problem. For instance, participants reported that currently there is not a national health literacy policy in Australia and that there has not been a systematic comprehensive review of government policies that include health literacy in Australia.

One participant offered an observation that Australia’s health policies are moving in the direction of a more “joined up” health system with less silos between health providers. The hope is that this will change the experience of consumers with the health system. Also, this participant adds, the government is sending a very strong message that people need to be self-responsible for their health through funding health promotion and health literacy programs and through a tax for those who don’t invest in private health insurance.

Notably, participants reported that there is a national safety and quality policy that explicitly includes health literacy in its framework (http://www.safetyandquality.gov.au/our-work/national-perspectives/australian-safety-and-quality-framework-for-health-care). This policy sets

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3 According to the Australian Bureau of Statistics, “the ALLS is an international survey that has been completed by participating countries in successive waves. In 2003, the first wave of countries that participated in the Adult Literacy and Life Skills Survey were Bermuda, Canada, Italy, Mexico, Norway, Switzerland and the United States. Second wave countries to take part were Australia, New Zealand, the Netherlands, Hungary and South Korea. The health literacy domain was only derived for some countries, as it was provided as an additional service (requiring additional funding). It also was not derived on the same basis for all countries. To date, Canada is the only country with a health literacy domain comparable to Australia’s; however, due to the unavailability of Canada’s health literacy microdata, no detailed health literacy comparisons have been made between the two countries.”

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

out to describe safe and high-quality care and the actions needed to achieve those goals for Australia. The goals specified by the policy are that safe, high-quality health care is always consumer-centered, driven by information, and organized for safety (http://www.safetyandqualitygov.au/wp-content/uploads/2012/01/32296-Australian-SandQ-Framework1.pdf). The consumer-centered goal discussion within this policy specifies health literacy as an action area. A participant in this project reported that the goal is to ensure that there are effective partnerships between consumers, health care providers, and organizations at all levels of health care provision, planning, and evaluation. One of the outcomes identified within this goal is for health care organizations to become health literate organizations. The Australian Health Ministers, participants noted, recently endorsed these goals.

Participants in this project reported that starting in January 2013, that all hospitals in Australia will be assessed against a set of 10 standards, the National Safety and Quality Health Service Standards (http://www.safetyandquality.gov.au/our-work/accreditation/nsqhss). Participants also reported that while health literacy is not explicitly included, health literacy concepts are embedded throughout the standards. For example, the standards include action items regarding

  • Having mechanisms in place to align information provided with the patient’s capacity to understand;
  • The need to get feedback from consumers on patient information publications developed by the hospital, and take action to incorporate this feedback into final documents;
  • Developing a medication management plan in partnership with patients and carers4;
  • Providing information to patients about medication treatment options, benefits, and associated risks; and
  • Developing fall prevention plans in partnership with patients and caregivers.

Health literacy and related concepts are also reported to be included in a range of other Australian national health policies that focus on the educational and societal aspects of health literacy, including issues such as raising awareness, prevention, self-management, and shared decision

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4 The term “carers” in Australia and the United Kingdom is roughly equivalent to “caregivers” in the United States, usually referring to someone who is responsible for the care of someone who has poor mental health, is physically disabled or whose health is impaired by sickness or old age. The terms are most often used to refer to unpaid relatives or friends versus health care professionals.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

making. Two examples of such policies that were highlighted by survey participants are:

At the state level in Australia, two Australian states are reported to have developed policies that include health literacy as a key priority area. The Department of Health and Human Services in Tasmania developed a Communication and Health Literacy Action Plan (http://www.dhhs.tas.gov.au/pophealth/health_literacy). This plan outlines the actions that will be taken between 2011 and 2013 to improve communication across health and human services, and to help improve health literacy in Tasmania. The four areas to be focused on are (1) raising awareness of the importance of effective communication and health literacy; (2) helping people access, understand, and use services and information; (3) helping staff, volunteers, and those who use health services to be more health literate; and (4) improving health literacy across Tasmania. The report is available at http://www.dhhs.tas.gov.au/data/assets/pdf_file/0009/75870/poh_Action_Plan_communication_and_health_literacy_20120313.pdf.

Victoria is the second Australian state reported to have developed health literacy policies. For example, participants reported that the Victorian Health Priorities Framework 2012-2022 developed by the Victorian Department of Health establishes a framework for the planning and development of priorities for health services across the Victorian health care system by the year 2022, and then articulates the particular planning and development priorities. The framework identifies that improving health literacy is a fundamental precursor to improving health outcomes of the population and that better health literacy improves access to a range of programs to help maintain good health. See http://www.health.vic.gov.au/healthplan2022.

In that report, health literacy underpins the seven priority areas for reform. Those reform priorities are to develop a system that is responsive to people’s needs; improving every Victorian’s health status and health experiences; expanding service, workforce, and system capacity; increasing the system’s financial sustainability and productivity; implementing continuous improvements and innovation; increasing accountability and transparency; and using e-health and communication technology.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

BOX A-2
How Did You First Learn About Health Literacy?

“I became interested in health literacy in 2007 when I read a UNAIDS report and was alarmed with HIV/AIDS statistics in Africa. In December 2007, I made a presentation at a youth conference highlighting the impact of HIV/AIDS on the youth.”

Participant from Malawi

One participant reported that regulations set by the Australian government also are reported to require private health insurers to present information regarding coverage in a standardized format so that consumers choosing between them can compare “apples and apples.”5 Participants also reported that Australia has just moved to a national registration for health providers, a unique health identifier for consumers, and have launched a person-controlled electronic health record that hopes to facilitate consistent communication between different providers dealing with the one patient.

A participant reported that most population specific (e.g., children, adults, older people) and disease specific (e.g., mental health, diabetes) policies in Australia do have a community education and health literacy-related component. Others reported that policies at national and state/territory levels do address needs of people from culturally and linguistically diverse backgrounds such as Aboriginal and Torres Strait Islander Australians.

Other relevant policies indicated by participants in, or aware of, health literacy efforts in Australia include

  • National Primary Health Care Reform: This effort explicitly addresses health literacy, cultural appropriate and timely care, increased focus on prevention, including support of health life-
___________

5 According to a 2009 report from the Commonwealth Fund, “Australia has a mixed public and private health care system. The core feature is public, taxation-funded health insurance under Medicare, which provides universal access to subsidized medical services and pharmaceuticals, and free hospital treatment as a public patient. Medicare is complemented by a private health system in which private health insurance assists with access to hospital treatment as a private patient and with access to dental services and allied health services. There is a strong reliance on out-of-pocket payments.” See http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1417_Squires_Intl_Profiles_622.pdf.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

In the state of Victoria, several other policies are relevant to health literacy. These include

In other states and territories, policies relevant to health literacy reported by participants include

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Key sources of data related to information related to health literacy in Australia are the Australian Bureau of Statistics and the Australian Institute of Health and Welfare.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

As a part of its work to encourage patient-centered, high-quality care, the Australian Commission on Safety and Quality in Health Care (http://www.safetyandquality.gov.au) is conducting a comprehensive “stocktake” of health literacy initiatives that is ongoing as of the preparation of this report. The effort, much like what produced this report, sought information on health literacy projects, programs, research, and initiatives at local, state, and national levels within Australia. The goals were to gain a greater understanding of the types of health literacy initiatives being implemented and the potential effectiveness and impact of these initiatives, identify areas of best practices for national promotion, as well as areas requiring further development within the health literacy field, and investigate opportunities for future national activities the Commission could undertake to support improvements to health literacy (http://www.safetyandquality.gov.au/our-work/patient-and-consumer-centered-care/health-literacy).

Working in collaboration with the state government of Victoria, academics Richard Osborne (http://www.deakin.edu.au/health/hsd/staff/index.php?username=rosb) and Rachelle Buchbinder (http://monash.edu/research/profiles/profile.html?sid=440&pid=2691) are reported to have led teams to develop a person-centered measure of health literacy called the Health Literacy Questionnaire. They have assessed 380 patients at four health care provider organizations. The research helped inform the partnership between the government and universities to develop the Victorian Health Literacy Response Framework. The goal of the project is for the partnership to co-create a statewide system to improve equitable service provision through assessment of consumers/patients health literacy who enter community and hospital health care institutions. The project is reported to be funded by the Australian Research Council, Victorian Department of Health, and Deakin University.

The Australian government has also been reported by participants to have formed a partnership with the Pharmacy Guild of Australia to

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

provide access to community pharmaceutical services. This initiative is the Community Pharmacy Health Literacy Research Project. Pharmacy research and development is one of the areas included in this agreement. One of the research projects currently under way focuses on health literacy in the pharmaceutical sector. The aim of this project is to develop, pilot, and refine an educational package for pharmacists and pharmacy assistants around health literacy in order for them to better tailor information to consumers and facilitate improved health outcomes. The methodology involves a comprehensive literature review and identification of existing resources, tools, and relevant best practices of health literacy. That will be followed by the development, evaluation, and refinement of the educational package. To facilitate wide dissemination, a train-the-trainer approach will be used to prepare pharmacists to deliver the training to other pharmacists and pharmacy assistants in the workplace (Duncan et al., 2012). The package will be refined based on outcomes and then made widely available to improve consumer medicines through better quality interactions in the pharmacy setting. See, as an example of this effort, http://www.uq.edu.au/health/healthycomm/docs/IHAMay2012.pdf.

HealthInsite is an online health information service provided by the National Health Call Centre Network, a service funded by the national and state governments in Australia to provide telephone triage, advice, and health information. HealthInsite reports its aim is to improve the health of Australians by providing easy access to quality information about human health. The information provided covers a wide range of topic areas and is reviewed by an assessment panel for quality, authority, currency, accessibility, navigation, format, design, and innovation. See http://www.healthinsite.gov.au.

One participant reported that there is a national health promotion effort targeted at Aboriginal and Torres Strait Islander health needs through Closing the Gap. This effort includes funding and health initiatives aimed at reducing the gap in life expectancy between Indigenous Australians and the general Australian population. See http://www.health.gov.au/internet/main/publishing.nsf/Content/currentissue-P10000005.

Another participant in this process reported on the ongoing efforts of the Health Issues Centre, an independent, not-for-profit organization that began in 1985 to promote equity and consumer perspectives in the Australian health system (http://www.healthissuescentre.org.au). One effort of this organization, Project Participate!, hopes to increase participating organizations’ knowledge, skill, and relationship capital by building capacity for sustainable community participation in health. The effort is reported to involve local primary care organizations, community health services, and hospitals, and consumer mentoring, participating staff and consumer leaders will lead and learn from the project by

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • Identifying current participation data, activities, policy, standards and stakeholders
  • Consulting with stakeholders to analyze current gaps and opportunities
  • Developing an action-learning based community participation plan
  • Facilitating implementation and monitoring of the plan
  • Participating in the delivery of consumer leadership accredited training
  • Identifying and disseminating participation resources
  • Utilizing participation networks in the health sector
  • Collecting and analyzing participation data for internal and external reporting
  • Leading the review and improvement of the participation plan (Health Issues Center, 2012)

Several participants reported that the Department of Health, Western Australia, is supporting a Patient First Program that is designed to educate health consumers about the health care process and potential problems that can occur with their health care. The goals are to help people become more active, involved, and informed participants in their health care and reduce medical errors during a patient’s care. The Patient First Program aims to increase patients’ understanding of their condition(s) to enable better decision making through informed consent, increase patients’ awareness of the risks inherent in their health care to minimize the potential for adverse events, and increase patients’ health literacy and give them the ability to self-manage their health issues (Department of Health Government of Western Australia, 2012). Participants reported that efforts to reach those goals include the development of booklets and brochures for patients and care givers as part of the program. These materials address issues such as informed consent, managing medications, understanding risks, and making decisions about health care. See http://www.safetyandquality.health.wa.gov.au/involving_patient/patient_1st.cfm.

Multiple organizations, governmental and nongovernmental, have reportedly created a Health Literacy Network (HLN). This effort, participants report, is convened by the New South Wales (NSW) Clinical Excellence Commission (CEC) (http://www.cec.health.nsw.gov.au/home) and is a collaboration between the CEC, the Australian Commission on Safety and Quality in Health Care, the NSW Health Care Complaints Commission, and the University of Sydney School of Public Health. The HLN is reported to be committed to the improvement of health literacy by encouraging collaboration through this alliance of key stakeholders. To date, participants report that key activities of the HLN include the

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • Liaison with health education providers within NSW to encourage inclusion of health literacy-related education in clinical undergraduate or postgraduate curricula;
  • Development of a guideline to assist clinicians, public health organizations, and consumer groups to communicate, verbally and in printed form, in a manner that patients can easily understand;
  • Development of a repository of health literacy information and resources; and
  • Investigation of ways to promote awareness amongst clinicians of the signs and effects of limited health literacy and evidence-based strategies that have been shown to assist lower literacy patients.

The Cue Cards in Community Languages initiative is an effort conducted by Eastern health, a health care provider organization in the state of Victoria, that is reported to work to assist health professionals and clients/carers who do not speak the English language well or at all or have problems communicating with each other. Participants reported that in order to develop the cue cards, local government, acute and mental health organizations, residential care facilities, and dental and disability service organizations were asked to provide a list of the most commonly used words they needed to communicate on a daily basis. The organizers then developed a list of words that were used across the spectrum of health care services. Participating organizations also indicated their choices of the languages to be used for translation. Community members with little or no English language chose the images that best represented the 200-plus words listed on the cue cards. The organizers note that the cue cards are not meant to be used in lieu of accredited interpreters, but can be used by clients/carers to communicate simple needs such as hunger, thirst, or need to use a telephone and can be used by professionals to indicate simple instructions/concepts. See http://www.easternhealth.org.au/services/cuecards/default.aspx#cuecards.

Goulburn Valley Health, a hospital in Shepparton, Victoria, offers a Hospital Orientation and Health Information Tour for Migrants and Refugees in a pilot program that began in 2010. The effort provides tours of the hospital to small groups of English language students from the local technical college. The objectives of the program are to

  • familiarize community members with the hospital layout, car parking, and how to find their way around the hospital should they need to in the future, and to
  • introduce “key take home messages” provided by health service staff at “stop-off” points in the tour, including pharmacy, pathology, imaging, and emergency departments.
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Participants in this effort reported that evaluations of the pilot program were positive, so the program has been expanded to include

  • outpatient clinics, and the Sanctuary (a sacred space within the hospital which is available to people of all faiths) as part of the tour itinerary, and
  • tours for multicultural support workers and settlement support service staff so that they can better assist refugee and migrant families to access hospital services.

Participants also reported that the Penola War Memorial Hospital (http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+services/hospitals+and+health+services/country/limestone+coast/penola+war+memorial+hospital) of the government of South Australia Health System is conducting a First Impressions Activities project in an effort that has been adapted from Rima Rudd’s effort, “The Health Literacy Environment Activity Packet: First Impressions and Walking Interview” (http://www.hsph.harvard.edu/healthliteracy/files/activitypacket.pdf) in order to suit a rural hospital. The First Impressions project is reported to consist of three activities that focus on first impressions: a telephone call to the hospital, a visit to the hospital’s website, and a walking interview.

A health literacy project also reported on by participants is the Melton Shire Council, Live Eat Go! Healthy Communities Program (http://www.melton.vic.gov.au/Services/Health_safety_and_wellbeing/Health_promotion/Live_Eat_GO). This initiative aims to reduce the prevalence of overweight and obesity in participating communities by increasing the number of at-risk individuals that engaged in accredited physical activity and healthy eating programs. The program includes a range of initiatives including increasing health literacy and knowledge in groups at risk of pre-diabetes or the onset of type 2 diabetes.

A health literacy project titled “Fear and Shame: Using Theatre to Destigmatise Mental Illness in an Australian Macedonian Community” is reported as ongoing and led by individuals from the South Eastern Sydney Illawarra Area Health Service. This effort used the arts, theater in particular, to address stigma and beliefs surrounding mental health to positive effect. See Blignault, I., S. Smith, L. Woodland, V. Ponzio, D. Ristevski, and S. Kirov. 2010. Fear and shame: Using theatre to destigmatize mental illness in an Australian Macedonian community. Health Promotion Journal of Australia 21:120-126.

The Western Australian (WA) Country Health Service Chronic Conditions Self-management program is reported to include building health literacy and training as one of four overarching program goals for 2012-

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

2015 (http://www.wacountry.health.wa.gov.au/index.php?id=667). This goal includes

  • Developing a chronic condition and self-management education and training strategy for WA Country Health staff in collaboration with Learning and Development Units, Metropolitan Health Services, and relevant academic partners.
  • Liaise with Allied Health workforce development manager to review the training framework for inclusion of self-management competencies, including those that specifically address health literacy.
  • Distribute the DVD titled Self-Managing Your Long-Term Health Condition through consumer and health professional networks.
  • Distribute the On the Right Road diabetes education DVD through the Pilbara Region of WA.
  • Develop brochures and other education/promotion resources targeted to consumers and health professionals on topics, including

o   How to better self-manage a long-term condition

o   How to provide better self-management support for consumers living with long-term conditions

o   Long-term conditions such as chronic obstructive pulmonary disease, heart failure, asthma, diabetes, etc.

A participant to the query for information about health literacy activities in Australia reported that “I am challenged by the concept of health literacy as being often written for the ‘typical reader.’ I work with and for people with limited literacy—the 46% in Australia with non-functional literacy. Health literacy in its traditional description is not useful for this category of people. I write ‘Easy English’ to assist people with low or limited or non-functional literacy to access health information.” This participant reported creating materials related to asthma, domestic abuse, immunization, and other health topics. See the Business section of this report for more information. Examples include

A respondent in Australia reported that a group has been working on health literacy interventions regarding oral (dental) health for indigenous adults in rural settings. No other information was supplied.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

In general, Australian respondents note that health literacy efforts may be funded by the government, although they are often tendered out to external providers like not-for-profit/nongovernmental organizations such as health promotion charities, community service providers, and universities. The aggregate of responses from other participants clearly indicate that there are many more ongoing and diverse health literacy projects in Australia. Other health literacy-related efforts in Australia according to participants include

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

Training of health professionals in health literacy is reported to be occurring at several institutions in Australia. A respondent notes that education and training about health literacy is not coordinated in Australia. Examples of efforts conducted in the nation include

  • Training/educational classes at the University of Adelaide, University of Melbourne Dental College, Victoria Department of Health.
  • The University of South Australia has many different training programs in nursing, allied health, and specialist exercise/nutrition.
  • Two-day “Easy English” trainings reportedly draw individuals from all sectors of the health industry, including health practitioners, policy writers, nurses, and support staff.
  • A large teaching hospital in Metropolitan Melbourne is currently offering a 2-day course for Community health practitioners.
  • The chronic disease coordinator for the Wheatbelt region of the Southern Country Health Service is promoting ways to increase self-management and self-management support using health literacy. Presentations were reported to challenge the audiences of health professionals to adapt their practices when working with and communicating with clients. This work started 2.5 years ago and includes presentations to primary health care teams (physiotherapists, occupational therapists, child health and community nurses, speech pathologists, social workers, health promotion officers, and team managers). The work has also completed a second round of presentations to the primary health care teams. The second presentation focused on how health literacy may be considered even more important than the social determinants of health. The information has also been presented to three District Health Advisory Councils that are comprised of local engaged citizens and a senior hospital representative, Local Health Advisory Groups, and to asthma educators in the Asthma Foundation of Western Australia. Outcomes are reported to include an increasing familiarity with the concept of health literacy and small changes in document adaptations (http://www.acal.edu.au/conference/08/HealthLitKeleher.pdf).
  • Monash University offers a short course in health literacy: http://www.med.monash.edu.au/healthsci/shortcrse/health-literacy/health-literacy-index.html.
  • The NSW Clinical Excellence Commission and the Australian Commission on Safety and Quality in Health Care offers a Breaking down the Barriers seminar: http://www.safetyandquality.
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • gov.au/our-work/patient-and-consumer-centred-care/breaking-down-the-barriers-seminar.
  • The Royal Women’s Hospital in Victoria, Australia, offered a seminar on health literacy: http://www.thewomens.org.au/IntheirShoes.
  • La Trobe University is reported to have developed a 5-day course on health literacy.

HOW IS HEALTH LITERACY DEFINED IN AUSTRALIA?

As with many other nations, multiple participants from Australia reported multiple definitions of health literacy. One participant wrote that “there is no national health literacy policy at this stage in Australia, and no agreed definition of health literacy.” Another individual observed that, “at the moment it is more of a way of ensuring patients control their own health, particularly those with chronic illness, to reduce costs of a very expensive universal health service.”

The Tasmanian government’s report on communication and health literacy states that “there is no single agreed way of defining the term ‘health literacy.’ In this Action Plan, the term means: The knowledge and skills needed to access, understand, and use information related to physical, mental, and social wellbeing” (Department of Health and Human Services Tasmania, 2011). The Australian Bureau of Statistics report on the adult literacy survey conducted in 2006 defines health literacy as “the knowledge and skills required to understand and use information relating to health issues such as drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid, emergencies, and staying healthy” (Australian Bureau of Statistics, 2006). A participant reported that the Health Literacy Questionnaire developed by Professor Richard Osborne and team defines health literacy as consisting of the following 10 dimensions that were derived from patients, practitioners, managers and policy makers:

  1. Quality of health care provider support.
  2. Perceived adequacy of health information.
  3. Taking responsibility for health.
  4. Being health focused.
  5. Social support.
  6. Critical appraisal.
  7. Agency in relationships with providers.
  8. Navigating the health care system.
  9. Ability to access health information.
  10. Reading and writing health information.
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Another participant reported that health literacy is defined in Australian practice as the “interaction between the skills of the public and the demands of health systems.” Another reported that Australians tend to use the U.S. definition that is based on the World Health Organization (WHO) developed originally through the work of Donald Nutbeam. That is that health literacy is “the degree to which individuals can obtain, process, and understand basic health information and services they need to make appropriate health decisions” (IOM, 2004). This definition was reported as used by the Australian Commission on Safety and Quality of Health Care in its recent “stocktake” of health literacy activities in Australia referenced above.

Another reported definition is that “the ability to understand and apply health-related information is known as health literacy. Health literacy is more than just the ability to read, it includes the ability to understand and interpret health-related information and apply it to a particular situation. Health literacy skills are used every day and are necessary to be able to make decisions about, for example, when to seek treatment, which over the counter medicine might be appropriate, or what to do in a first aid emergency” (Victorian Government, 2011).

On a functional level, the Australian report to support the first national primary health care strategy states: “Health literacy refers to the ‘ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literacy is a product of the population’s knowledge and skills gained from education and experiences” (Australian Government Department of Health and Ageing, 2009).

Within the context of mental health, a participant reported that mental health literacy is defined as “the knowledge and beliefs about mental disorders which aid their recognition, management, or prevention” (Jorm et al., 1997).

Another participant reported that nongovernmental organizations (NGOs) usually define health literacy in relation to their health focus area, essentially taking a contextual approach to defining health literacy so that the context can become more important than the elements of health literacy (e.g., mental health literacy for an organization that focuses on mental health and social and emotional well-being services/issues).

A participant offering a definition from an Australian NGO perspective wrote that “As per WHO, health literacy has been defined as 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 successfully make appointments. By improving people’s access to health information and their capacity to use it effectively, health literacy is critical to empowerment.”

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Austria

GOVERNMENTAL POLICY

In Austria, participants indicated that health literacy is a relatively new entrant into the national policy stage. Participants from Austria reported that health literacy is now one of the 10 health goals of both the national and some official regional policies. These health goals were recently developed via a participatory process and health literacy (Gesundheitskompetenz) is the third of 10 targets identified through that process. For more information on that development, see http://www.gesundheitsziele-oesterreich.at/praesentation/10-rahmen-gesundheitsziele-fuer-oesterreich.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Participants reported that Austria is one of the nations that has participated in the recent European Health Literacy Survey (HLS-EU). The Fonds Gesundes Österreich/Fund for Healthy Austria sponsored this effort. In Austria, the sample for that study was enlarged to 1,800 people in order to allow regional comparisons. Additionally, participants reported that the governmental social security association sponsored a survey using the same instrument for a sample of 500 15-year-olds in Austria.

Participants also reported that Austria is now working to develop measures to begin a process to develop national health targets to guide future activities. Health literacy is one of the proposed targets. The effort is reportedly just beginning and will be conducted in the near future.

Another participant reported that the Women’s Health Center (Frauengesundheitszentrum) is offering a self-management program (http://www.fgz.co.at) that addresses health literacy.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN AUSTRIA?

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Bangladesh

See the International NGO section of this paper.

Botswana

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

In a report from 2009 on a regional health literacy initiative (http://www.tarsc.org/publications/documents/HLregional%20meeting09.pdf), the Botswana Network of Ethics, Law and HIV and AIDS (BONELA) is reported as introducing a health literacy program beginning in 2007 along with Botswana Federation of Trade Unions (BFTU) with support from Kellogg Foundation. The program is described as being a holistic approach that significantly supports the agenda of health systems strengthening, supporting communities in the abilities to understand, communicate and use information to support action and to create a platform to fully advocate for pertinent grassroots issues at the district and national levels. The program used participatory approaches to hopefully enable full engagement of communities with leadership (the Kogtla), elect leadership, health workers, and other important stakeholders at the local level. The program promoted the “bottom up” approach where communities identify their priority health needs and act upon them. The program was also described as complementing government efforts to revitalize primary health care in Botswana. A total of 30 facilitators in four districts of Botswana were trained in health literacy.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN BOTSWANA?

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Brazil

See the International NGO section of this paper.

Cameroon

GOVERNMENTAL POLICY

The government of Cameroon, according to participants, is attempting to increase the number of citizens who enroll in schools of health through the Ministry of Public Health. This effort seems to be limited to schools approved by the government, and thus that falls short of representing all schools focusing on public health. What a respondent refers to as a “cumbersome application process” appears present for hospitals and clinics hoping to participate in governmental efforts, which some feel is reducing access to health coverage for residents. However, NGOs are reported to attempt to fill the gap.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

None reported.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

Several programs offer education in multiple areas of professional medical practice, but no efforts aimed at the broader population were reported.

HOW IS HEALTH LITERACY DEFINED IN CAMEROON?

None reported.

Canada

GOVERNMENTAL POLICY

Several participants reported that to their knowledge, there are no governmental policies specifically directed at health literacy at any level of government in Canada. However, participants also noted that the federal government has policies related to communicating with the pub-

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

lic using plain/clear language and that it is possible that some provinces and territorial governments do as well.

Participants added that the Public Health Agency of Canada (PHAC) designated health literacy as a priority area of work and has had a position for a Senior Advisor in Health Education and Health Literacy for over the past 2 years. This position, however, is reported to have recently been eliminated due to Canadian federal government deficit reduction action plan (i.e., budget cuts). PHAC was also reported to have commissioned a national think tank to advise on the development of an approach to health literacy within the agency as well as supported the Public Health Association of British Columbia (PHABC) who organized subsequent national think tanks resulting in the development of a national draft approach to health literacy. The report on this effort is available at http://www.phabc.org/userfiles/file/IntersectoralApproachforHealthLiteracy-FINAL.pdf.

Health Canada is the “federal department responsible for helping Canadians maintain and improve their health, while respecting individual choices and circumstances” (Health Canada, 2011). The Department has produced reports that address health literacy at various levels. For example, in 2001 it produced a report compiling multiple documents titled Certain Circumstances: Issues in Equity and Responsiveness in Access to Health Care in Canada containing multiple references to the role of health literacy (http://www.hc-sc.gc.ca/hcs-sss/pubs/acces/2001-certain-equit-acces/index-eng.php). More recently, in 2011, the agency produced a report on a workshop, Health Canada Workshop on Health Product Plain Language Labelling (http://www.hc-sc.gc.ca/dhp-mps/prodpharma/activit/proj/monograph-rev/workshop_pll_atelier_elc-eng.php).

One participant reported that the current Government of Canada has abolished the formerly mandatory Long-Form Census that provided information about the health and wellbeing of large random samples of Canadians. This participant suggested that the absence of Long-Form Census data has seriously compromised the health literacy situation in Canada due to the lack of valid information upon which to base policy.

Another respondent reported that while there are no health literacy–specific policies, at the provincial level, the Ontario Public Health Standards do require all information and resources to be focused on priority populations and to use equity and the social determinants of health as a way of focusing various social media strategies to reach their target populations and to evaluate what works. One respondent from Ontario also reported that the Accessibility for Ontarians with Disabilities Act includes guidelines and legislation for accessibility (http://www.mcss.gov.on.ca/en/mcss/programs/accessibility/index.aspx). This Act includes elements addressing accessibility of information and communications as well as customer service.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Multiple participants reported on the state of mental health literacy policy in Canada as well. One noted that the significant role of mental health literacy was initially recognized in British Columbia in 2003 when the British Columbia Ministry of Health Services released a mental health and addictions information plan to improve mental health and substance use literacy among all British Columbians. To facilitate implementation of the plan, a coalition of seven nonprofit mental health and addictions agencies was created and called the “British Columbia Partners for Mental Health & Addictions Information.”

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

In general, respondents noted that while many health literacy projects exist in Canada, they are often transient and not embedded in a larger systematic or coordinated approach. One respondent noted that most of the leadership in respect to health literacy has come from nongovernmental program (NGP) and academic sectors rather than government with the exception of the Public Health Agency of Canada and the British Columbia Provincial Health Services Authority and BC Ministry of Health Services. Thus, in turn, efforts are reported from nongovernmental organizations, then national government efforts, and then provincial level governmental efforts in Canada.

Nongovernmental Organizations

In regard to health literacy efforts from the NGO sector, a participant reported that the Canadian Public Health Association (CPHA) has been a leader in relation to literacy and health efforts in Canada, beginning in 1994 with the establishment of the National Literacy and Health Program, that ultimately involved 26 National Professional Organizations and NGOs in health and education. Among other things, this program is reported to have sponsored two National Conferences on Literacy and Health (in 2000 and 2004) and developed various resources on Literacy and Health available online. More recently, CPHA organized and managed the Canadian Expert Panel on Health Literacy (2006–2008), sponsored a national consultation on health literacy, and contributed to the development of a Health Literacy Council. See http://www.cpha.ca/en/search.aspx?cx=004708887294457467309%3A1gs3w1uselq&cof=FORID%3A11&ie=UTF-8&q=Health+Literacy&sa.x=0&sa.y=0.

The Canadian Expert Panel on Health Literacy report recommended that “a comprehensive, coordinated, cooperative and integrated Pan-Canadian Strategy on Health Literacy be developed, funded and imple

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

mented to improve the level of health literacy in Canada and the extent to which people receive the support they need to cope with the health literacy demands they encounter” (Rootman and Gordon-El-Bihbety 2008). Since literacy and health literacy are inextricably linked, the Panel suggested that such a strategy needs to address both by pursuing three fundamental goals:

  • To improve literacy and health literacy skills in Canada
  • To reduce inequities in opportunities for developing literacy and health literacy skills in Canada
  • To enhance the capacities of systems that provide health information and services to do so effectively for people with all levels of literacy and health literacy

Another national organization that is reported by participants to have shown leadership in this area is the now defunct Canadian Council on Learning (CCL). According to participants, the Council provided financial support for the Canadian Expert Panel on Health Literacy and supported a number of research and intervention projects on health literacy, as well as conducted a number of innovative analyses of the Canadian data from the 2003 International Adult Literacy and Skills Survey and published several ground-breaking reports on health literacy. Before the CCL was dissolved in 2011 it also supported efforts to implement the recommendations of the Expert Panel, including the establishment of a National Health Literacy Council. See http://www.ccl-cca.ca/CCL/Reports/HealthLiteracy.html.

At the provincial level in Canada, participants reported that the Ontario Public Health Association (OPHA) and the Public Health Association of British Columbia (PHABC) have both been active in health literacy efforts. The former is reported to have stimulated interest in “literacy and health” in Canada when it started a project on Literacy and Health in partnership with Frontier College in 1989. That initiative, which lasted until 1993, stimulated the interest of the Canadian Public Health Association and the establishment of the National Literacy and Health Program mentioned above. More recently, the PHABC has shown leadership in this field by coordinating the BC Health Literacy Network that is reported to consist of the mental health network as well as several other networks working on aspects of health literacy such as a Library Network and a Seniors Network. This Association was also reported to be assuming a national role by hosting two national think tanks and a workshop on Health Literacy and making the products of these events, including the discussion paper on the national health literacy approach titled An Intersectoral Approach to Improving Health Literacy for Canadians

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

available on their website. See http://www.phabc.org/userfiles/file/IntersectoralApproachforHealthLiteracy-FINAL.pdf.

Another organization that multiple participants reported has been very active in regard to health literacy both in Quebec and outside of it is the Quebec Centre for Literacy, which has sponsored two Institutes on Health Literacy, one of which produced the Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. The document was the result of a 3-day institute held in Calgary, Alberta, in October 2008, which brought together participants from Canada, the United States, and the United Kingdom. The Calgary Charter on Health Literacy presents a definition of health literacy and core principles to support developing and adapting health literacy curricula and urges anyone involved in developing or evaluating health literacy curricula to incorporate them. Interested individuals may read the charter and become a signatory at http://www.centreforliteracy.qc.ca/Healthlitinst/Calgary_Charter.htm.

Beyond the effort to produce the Calgary Charter on Health Literacy, the Centre for Literacy is a centre of expertise that supports best practices and informed policy development in literacy and essential skills by creating bridges between research, policy and practice. The organization reaches those goals through learning events (including institutes and workshops), action research projects and publications, and also through its library services and website. The Centre has recently completed a scan of French-language resources and tools related to health literacy that is available at http://www.centreforliteracy.qc.ca/sites/default/files/litensant-mai2012.pdf.

Other provincial literacy organizations reported to have also been active include Decoda in British Columbia and Alberta Literacy, which among other things, has produced a tool and workshop for auditing health literacy. See http://literacyalberta.ca/workshops.

The two university hospitals in Montréal—McGill University Health Center (MUHC) and Centre hospitalier de l’Université de Montréal (CHUM)—are both reported to have developed health literacy efforts. The MUHC has educational tools in French and English on cancer and specializes in medical illustrations through the Molson Medical Informatics (http://www.muhcpatienteducation.ca). The CHUM is reported by participants to have a patient education project that focuses on the coordination of all printed patient information or education material. The organization has implemented a systematic process so that all teams and professionals consistently develop material for their patients using templates and consultants with an external firm (90 Degrés Communications). Respondents noted that this project is funded through a grant from Pfizer Canada.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

A participant reported that Accreditation Canada (http://www.accreditation.ca), which accredits hospitals and other organizations, is reported to have general guidelines related to communication and education of patients and families. The organization is a not-for-profit, independent organization accredited by the International Society for Quality in Health Care.

National Governmental Efforts

In regard to efforts of national governmental organizations, the Public Health Agency of Canada’s Centre for Chronic Disease Prevention and Control (CCDPC) is reported to have recently supported a number of projects related to health literacy. They include

  • Background papers on Research, Analysis, and Knowledge Development, Applying a Health Literacy Framework to Diabetes, and e-health literacy;
  • Two National Think Tanks and a Workshop on Health Literacy;
  • Development of a Health Literacy Prototype Online Module for Public Health Professionals;
  • Development and Evaluation of a Health Literacy Prototype Module for Health Educators K-12;
  • Health Literacy Examples from the Field Project;
  • Health Literacy Capacity Tool Project;
  • Health Literacy Scan Project;
  • Regional Health Literacy Synthesis Project;
  • Health Literacy Knowledge Translation Project;
  • Health Literacy Science Seminars;
  • Health literacy content development and publishing for new PHAC Health Literacy website (http://www.phac-aspc.gc.ca/cd-mc/hl-ls/index-eng.php);
  • HL2Go Project; and the
  • Health Literacy Module and Workshop for Health Practitioners.

In particular, respondents noted that there has been demand among health literacy academics and practitioners for PHAC’s Centre for Chronic Disease Prevention and Control to complete and disseminate the Canadian Health Literacy Examples in the Field Project as one means to help advance the health literacy agenda in Canada. This project was reported to be first suggested by health literacy academics and practitioners during the National Health Literacy Think Tank in February 2011, as a way to address a gap in the understanding of the range of possible health-related interventions targeted to priority populations and to contribute to

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

the knowledge base regarding health literacy in Canada. The Canadian Health Literacy Examples in the Field Project gathered and translated 33 examples of health literacy in practices from across the country using a consistent Canadian definition of health literacy. Examples were translated into short, user-friendly “case vignettes” to enhance health literacy awareness (e.g., what is health literacy, what does it look like, and what can it look like in practice in different contexts and in different settings). The project focused on interventions with priority populations (e.g., Aboriginals, families, children/youth, seniors, multicultural groups) and on various settings (e.g., schools, communities, workplaces, hospitals) as well as on a variety of health topic areas (e.g., chronic disease, mental health, obesity) relevant to communities in Canada. The consolidated resource reportedly will be shared online and in print with public health professionals.

Respondents from Canada also reported that an internal PHAC Branch Level Health Literacy Working Group exists, which is an action-orientated group with an interest in creating, implementing, and sustaining an integrated and cohesive health literacy approach among Centres/Directorates within PHAC. Additionally, they noted that the Strategic Initiatives and Innovation Directorate (SIID) within PHAC has provided support for a participatory research project in three provinces on embedding health literacy in existing initiatives as well as a health literacy online curriculum/module in partnership with the Canadian Medical Association, Canadian Nursing Association and others as continuing medical education (available free of charge in both official languages through http://www.mdCME.ca). The Centre for Health Promotion within PHAC was also reported to have started to incorporate health literacy concepts into their information and programming with respect to older adults via the Division of Aging and Seniors. Recent activities in this organization include a poster presentation at the 2011 Canadian Association for Gerontology Conference (The Importance of Health Literacy in an Aging Population) and a report (Literature Review: Improving Health Literacy among Older Adults in Canada).

Provincial and Local Government Efforts

In regard to health literacy efforts of provincial governments in Canada, the Ministry of Health Services in British Columbia was reported to have sponsored a Health Literacy Prototype project that involved collaboration between primary care physicians and literacy learners and coordinators in four communities. This effort also produced a Charter for Health Literacy in Communities (http://www.impactbc.ca/sites/default/

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

files/resource/n221_ibc_pasp_health_literacy_prototype_charter_2009.pdf).

Respondents reported that the Direction de la Santé Publique in Montreal (http://www.dsp.santemontreal.qc.ca) is developing guidelines to embed health literacy principles in its structure and activities. This effort is based on the Institute of Medicine’s recent report identifying 10 attributes of a health literate organization (http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_HLit_Attributes.pdf) and on a literature review of guidelines in educational tools that apply to health promotion and disease prevention. The effort is reported to include an algorithm for professionals to use, a set of guidelines for each medium (Web, written, oral, video or multimedia, through primary care clinicians, etc.). The project’s aim is to apply universal precautions so that every Montrealer can access, comprehend, and act according to the best available information on health and disease prevention.

At the school system level, a respondent reported that the British Colombia Ministry of Education’s Healthy Living Performance Standards allow students, teachers, and parents to assess a student’s progress towards accomplished learning by supporting a health literacy approach in a variety of curricular areas. See http://www.bced.gov.bc.ca/perf_stands/healthy_living/background/health_literacy.htm.

In the province of Ontario, the Ministry of Education is reported to have efforts, including training and components of curricula across the grades that address health literacy, mental health literacy, literacy, and numeracy (http://www.edu.gov.on.ca/eng).

Multiple respondents reported that in regard to mental health literacy, efforts in British Columbia are guided by the Integrated Provincial Strategy to Promote Health Literacy in Mental Health and Addiction that was created in 2007. The goal is to improve public understanding of mental health and substance use issues (including mental health promotion, prevention, early recognition, help seeking, self-management, and recovery), and to reduce the stigma related to mental health and substance use. As a capacity-building initiative, the strategy is reported to focus on coordinating and developing integrated and sustained approaches to information development, dissemination, uptake, and action targeted to the health literacy levels and needs of different population groups within British Columbia. As a result, respondents reported that a variety of mental health literacy initiatives are currently being implemented in the province of British Columbia by BC Mental Health & Addiction Services. Another participant added that the Provincial Health Services Authority in British Columbia has established a position of Director of Health Literacy for the BC Mental Health & Addictions Services (an agency of the Provincial Health Services Authority) and for the past few years the

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

agency has allocated a budget for the support of a mental health literacy network and activities in the province, as noted above. Examples of health literacy initiatives reported include

  • The Kelty Mental Health Resource Centre (http://keltymentalhealth.ca) provides free, all-inclusive virtual and in-person support to help all BC children, youth, and their families navigate mental health and substance use resources and services.
  • The Provincial Child and Youth Healthy Living Initiative established in 2009 has supported this work through the development of interactive Web resources for the Kelty Mental Health Resource Centre; Healthy Living Toolkits (http://keltymentalhealth.ca/ toolkits) designed for families and professionals dealing with mental health and substance use issues; and the development of the Provincial Mental Health Metabolic Program (http://keltymentalhealth.ca/partner/provincialmental-health-metabolic-program) based at BC Children’s Hospital.
  • Initiatives aimed at increasing mental health literacy within specific populations and settings include

o   The Disordered Eating and Eating Disorders Mental Health Literacy Initiative, which includes 13 projects that aim to enhance health literacy in the area of eating disorders and disordered eating across the continuum of mental health from promotion to treatment.

o   Cross-Cultural Mental Health Literacy Initiatives, which aim to enhance mental health literacy among culturally diverse families.

o   Mental Health Literacy School-Based Initiatives, which aim to further develop the mental health literacy of educators across British Columbia to support the mental health of children and youth in school environments.

o   A partnership with the Fraser Health Authority resulted in the 2012 provincial expansion and redesign of mindcheck.ca, a youth and young adult-focused interactive website where visitors can check out how they are feeling and get connected to support early and quickly. Support includes education, self-help tools, website links, and assistance in connecting to local professional resources (http://mindcheck.ca).

o   The health literacy portfolio was reported to also include the management of a number of provincial networks, including the BC Mental Health and Substance Use Provincial Health Literacy Network, which aim to support knowledge exchange across the province.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

o   Mental health literacy projects are also reported to be highlighted in the BC government’s Healthy Minds, Healthy People, 10-year Plan to Address Mental Health and Substance Use in British Columbia.

The BC Partners for Mental Health & Addictions Information is composed of multiple organizations. These are Anxiety BC, British Columbia Schizophrenia Society, Centre for Addictions Research of BC, Canadian Mental Health Association (BC Division), The F.O.R.C.E. Society for Kids’ Mental Health, Family Services of the North Shore (Jessie’s Legacy Program), and Mood Disorders Association of British Columbia. The BC Partners health literacy work is reported at http://heretohelp.ca. The BC Partners are reported to have made a number of key contributions which support mental and substance use health literacy in the province. These include

  • establishment of the “heretohelp” website and development of indicators to monitor website usage and reach;
  • development and dissemination of materials and resources, including fact sheets and interactive toolkits for the “heretohelp” website;
  • a range of information dissemination vehicles, projects, and events, including the Visions Journal, Healthy Minds, Healthy Campuses and Beyond the Blues; and
  • the provision of evidence-informed resources for a Provincial Health Services Authority Translation Project.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

A Canadian respondent reported that other than offering training or educational classes for their own staff, the Federal Government in Canada does not “currently” directly offer training or educational classes on health literacy to practitioners or the public.

The PHAC is reported to be currently transitioning an existing Health Literacy Workshop Module for Public Health Professionals into an interactive online module for their National Online Learning Program (Skills Online), which provides continuing education for public health practitioners in Canada. In the meantime, PHAC has reportedly supported training initiatives related to health literacy such as a 2-day, multisite summer school on Health Literacy in 2011 organized by the Public Health Association of British Columbia (http://www.phabc.org/modules/Contentccomp/files/2011%20Public%20Health%20Summer%20School%20Backgrounder.pdf). PHAC also was reported by respondents to have supported the development of an online curriculum now

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

offered through the Canadian Medical Association, Canadian Nursing Association, and others; as well as various workshops, seminars, presentations and conferences related to health literacy.

A training program from Health Canada is available in French online at http://www.alphabetismeensante.ca/lecons.aspx.

In general, respondents note that health literacy workshops and training are frequently organized and provided by local organizations such as hospitals, local health organizations, community-based organizations or nongovernmental organizations often for in-house staff.

HOW IS HEALTH LITERACY DEFINED IN CANADA?

One participant reported that the current Government of Canada defines health literacy as an individual matter even though a few years ago, the Federal Government of Canada, Health Canada, and the PHAC used the social determinants of health as the framework for discussing the health of Canadians. This participant noted that this approach is not as prominent in the current government, which does not seem to have a definition of health literacy in place.

Another participant simply replied that there are many different definitions in place in Canada as there is not an agreed-upon definition. Others offer definitions, such as “the ability to find, comprehend, evaluate and act upon health information in various contexts,” and “the ability to access, understand and act on information for health.”

The previously mentioned Calgary Charter on Health Literacy defines health literacy as allowing “the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improve the ability of people to act on information in order to live healthier lives. These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills” (Coleman et al., 2008). In addition, the Charter fairly uniquely suggests that health literacy applies to both individuals and to health systems, explaining that a system is health literate when it provides equal, easy to use, and shame-free access to and delivery of health care and health information. See http://www.centreforliteracy.qc.ca/Healthlitinst/Calgary_Charter.htm.

The 2008 Canadian Expert Panel on Health Literacy defined health literacy as, “the ability to access, comprehend, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course” (Rootman and Gordon-El-Bihbety, 2008). Closely, echoing this definition, a report produced by the Public Health Association of British Columbia edited by Wayne Mitic and Irving

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Rootman (2012), defines health literacy as, “the degree to which people are able to access, understand, evaluate and communicate information to engage with the demands of different health contexts in order to promote and maintain good health across the life-course.” See http://www.phabc.org/userfiles/file/IntersectoralApproachforHealthLiteracy-FINAL.pdf.

Chile

GOVERNMENTAL POLICY

According to the single respondent reporting on Chile, there are no specific health literacy policies in Chile at this time. However, there is a policy that regulates service provision at primary health care centers that does address health promotion and prevention efforts in addition to the provision of medical care. This is based on a family health model.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

In addition to the health promotion and prevention efforts outlined above at primary health care centers, the participants from Chile notes that there is a program called Vida Chile (Chilean Life) that promotes healthy lifestyles in communities and schools. Another program called Chile Crece Contigo (Chile Grows With You) focuses on parenting skills from pregnancy to the first year of children’s lives.

Reportedly, some schools do create alliances with health centers and work together to improve health literacy of the public. This is reported as mainly focusing on sexual education or healthy lifestyles (nutrition, physical activity, and obesity prevention). These alliances can be part of Vida Chile or occur through other funding mechanisms or sometimes as an in-kind effort between participating organizations.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN CHILE?

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

image

China

GOVERNMENTAL POLICY

The Chinese government, according to participants, has policies that address health literacy within regulations related to the registration and approval of medical institutions (http://www.gov.cn/banshi/2005-08/01/content_19113.htm) and medical practitioners (http://www.gov.cn/banshi/2005-08/01/content_18970.htm). For example, these regulations require that medical practitioners participate in continuing education and that they spread the knowledge of health care and health to their patients. A respondent also reported that another health literacy relevant policy includes a Nurse Management Act that was issued by the Ministry of Health in 2005 (http://www.gov.cn/ban-shi/2005-08/02/content_19268.htm). This regulation requires that nurses be committed to preventive health care and to publicize the knowledge to prevent and cure diseases and rehabilitation guidance, provide health education, and are obliged to provide health advice. Also, participants reported that there are regulations related to health literacy regarding the administration of health insurance (http://www.gov.cn/flfg/2006-08/14/content_361968.htm), the administration of drug advertisements (http://www.sda.gov.cn/WS01/CL0053/24527.html), measures for the administration of information reporting on monitoring public health emergencies and epidemics of infectious diseases (http://www.china.com.cn/chinese/PI-c/460481.htm), and measures on the medical and health information services provided through the Internet (http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohzcfgs/pgz/200906/41403.htm).

A respondent also reported that health literacy is addressed within

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

the law of the People’s Republic of China on Science and Technology Progress, the law of the People’s Republic of China on Popularization of Science and Technology (http://english.gov.cn/laws/2005-10/08/content_75055.htm), and finally within the Outline of the National Scheme for Scientific Literacy for all Chinese citizens released in 2006 (http://www.kxsz.org.cn/portal/findportal.do;jsessionid=D4C22322C5CFFB18371A6C199EB52B90?failure=true). For instance, the law on popularization of science and technology includes provisions that communication of science and technology efforts that “make it easy for the general public to understand, accept, and participate shall be adopted” (Chinese Government, 2012).

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Most directly related to health literacy, participants reported there is a National Plan of Health Literacy Promotion Initiatives for Chinese Citizens (2008–2010). This policy was reported to establish a health sector leading, multisector cooperating and social participatory network of “Health Literacy Promotion Initiatives.” Goals of the effort are to train at least 80 percent of the professionals in the working network, to establish a Chinese citizens’ health literacy surveillance and evaluation system, and to ensure that at least 60 percent of counties all over the country will carry out communication activities related to Health Literacy 66.

Health Literacy 66 is a book that compiles 66 health literacy goals for the population of China. The booklet was also used as the basis for an evaluation of the level of health literacy in China that was conducted in 2008. That effort included more than 79,000 individuals and reportedly found that only a little more than 6 percent of the Chinese population could be considered health literate. This effort also included organizing health literacy contests for both rural and urban residents. One report stated that there were 9,196 contests at the county/township level, 207 contests at the prefecture/city level, 46 contests at the provincial level, and 5 national contests.

The Chinese Ministry of Health conducts efforts to highlight and commend efforts related to health literacy according to participants. Examples include conferring the Norman Bethune Medal, honoring advanced collectives and individuals in the health system for their efforts, presenting awards at the 60th anniversary of the Patriotic Public Health Movement, and organizing public participation to select “My Favorite Health Guardian.” Through these activities, participants reported that the Ministry of Health gives considerable publicity to advanced collectives and individuals who are working to improve health literacy in China

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

(http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohbgt/s3582/201203/54395.htm). For example, the Norman Bethune Medal is said to be the highest medical honor in China and the honor recognizes outstanding contributions and humanitarian efforts. Accounts online of recipients include reference to Wu Dengyun, who is said to have provided care in a remote area and focused on being culturally and linguistically appropriate in his interactions with patients.

Other examples of health literacy efforts that participants reported from China include

  • A Chinese national symposium on health education and health promotion that was held in Shanghai on May 18–19, 2012. The theme of the symposium was “Achieving education and health promotion is of great significance for the deepening of the health care system reform, the protection of public health, the construction of health culture, and the promotion of harmonious socioeconomic development” (http://www.moh.gov.cn/publicfiles/business/htmlfiles/liuq/pldhd/201205/54793.htm).
  • The 24th Chinese Patriotic Health Month was held in April 2012 with a theme of “Everyone takes part in the patriotic health campaign and everyone enjoys a healthy life.”
  • China’s 5th National Healthy Lifestyle Day was held on September 1, 2011. The slogan for the day was “I act, I am healthy, I am happy!” and the theme was “Lowering salt intake to prevent hypertension.”
  • China’s 14th National Hypertension Day was observed on October 8, 2011. The theme for the Day was “Be aware of your blood pressure and control your target.”
  • The efforts of the China Association for Science and Technology (http://english.cast.org.cn) that include “to advocate scientific spirit, popularize scientific knowledge, and disseminate scientific ideas and methods. Defend the dignity of science, popularize the advanced technology, and develop the scientific and educational activities for the young people, so as to improve the scientific literacy of the whole nation” (CAST, 2011). Activities of this association related to health literacy in China include

o   During the 3rd China Food Safety Forum, about 10 governmental departments related to food safety are reported by participants to have vowed to implement stricter enforcement to assure the quality of food. A publicity week on China Food Safety is also beginning around the country. The aim is to make people know more about the State’s standard of food safety and

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

       the knowledge of additives in food (http://scitech.people.com.cn/n/2012/0626/c131715-18386349.html).

o   The special committee on drug dependence toxicology under the Chinese Society of Toxicology recently organized a science promotion activity according to respondents, that focused on “For a healthy life, keeping away from drug dependence.” The activity, with the support of the National Committee on Narcotics Control, the General Drug Prohibition Brigade under the Beijing Municipal Bureau of Public Security, Beijing Hui Long Guan Hospital, Red Cross Society of Peking University Health Science Center, and Tayuan neighborhood committee of Beijing’s Haidian District, were attended by more than 1,000 people (http://english.cast.org.cn/n1181872/n1182018/n1182077/13957747.html).

o   “Science and Technology Week” has been held annually since 2001 and more than 600 million people have participated in its activities. Various activities were organized in parks, schools or museums across the nation to improve the awareness of science and technology (http://www.cast.org.cn).

o   A 2007 International Symposium on HIV/AIDS Prevention and Control.

o   An International Symposium on Innovation and Development in Experiment Research of Integrated Traditional Chinese and Western Experimental Medicine demonstrated the achievement of new theories, new technologies in the academic field of the combination of traditional Chinese and Western medicine; explored prospects for organ fibrosis research and the hotspot of Chinese medicine drug development, thus promoting the development of Traditional Chinese Medicine, and making efforts to combining medicine into the mainstream of the world medical system.

  • Participants reported that an effort called “Beijing Home of Red Ribbon” aims to use social forces to provide HIV/AIDS patients with comprehensive care, serve their relatives and friends with HIV/AIDS care and prevention knowledge, develop various social activities on HIV/AIDS prevention and control, and promote the public’s understanding and concern for HIV/AIDS (http://www.aidschannel.cn/shownews.asp?newsid=1453). The Beijing Home of Red Ribbon program is reported to consist of six separate branches, including medical support, self-help of HIV/AIDS patients, volunteer service, social aid, Internet publicity, and legal aid. Specific efforts of this initiative participants reported on include

o   On February 11, 2012, the Beijing Home of Red Ribbon offered

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

       training courses for patients and their families in drug compliance, drug side effects, and nutritional support.

o   Conducted simulated classes for the Project of Health Red Ribbon 2+1 Entering Institutions of Higher Learning (“2” standing for volunteer medical professionals and peer educators from the Beijing Home of Red Ribbon, and “1” for college volunteers).

o   Volunteers held an AIDS awareness campaign in Beijing Ditan Hospital on November 30, 2011.

o   A Lunar New Year party for HIV-infected patients on January 25, 2011 (http://www.aidschannel.cn/index.asp).

  • The Chinese Association for Health Education (CAHE) is reported to aim to unite health education work nationwide, promote the undertaking of health education and the construction of socialist material and cultural civilization in China, and increase the knowledge of health and science among Chinese people in order that they develop healthy behaviors and lifestyles (http://www.health-china.com.cn/english/newDetail.asp?id=46). The organization created a delegation of 54 individuals to participate in 17th International Union for Health Promotion and Education World Conference (http://www.health-china.com.cn/english/newDetail.asp?id=83). (See the International NGO section of this paper for more on the IUHPE health literacy efforts.) CAHE also organized the Chinese major hospitals delegation to have a short-term hospital management training in Germany in 1999 (http://www.health-china.com.cn/english/newDetail.asp?id=86). Finally, participants reported that the organization is building cooperation projects with the American Association for Health Education.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

Courses that include health literacy training for different types of doctors and nurses are reported to be offered in many medical schools, such as Peking University Health Science Center, Chinese Academy of Medical Science, Tsinghua University School of Medicine, and Medical Center of Fudan University, and others. Among these courses are pharmacology, epidemiology, medical immunology, the history of medicine, medical psychology, anthropotomy, health evaluation, basic nursing, community nursing, nursing management, medical nursing, and surgery nursing.

As reported above, aspects of the National Plan of Health Literacy Promotion Initiatives for Chinese Citizens (2008–2010) are focused on the health sector, including creation of a participatory network of “Health Literacy Promotion Initiatives” and efforts to train at least 80 percent of the professionals in the network.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

In Hong Kong, based on WHO Trainers’ and Trainees’ Guides on infection control measures for the health care of acute respiratory diseases (ARDs) in a community setting, a culturally specific train-the-trainer program was reportedly developed for professional health workers and community workers in Hong Kong, with an aim to enhance the health literacy of the Chinese-speaking community in the prevention and control of the spread of ARDs.

HOW IS HEALTH LITERACY DEFINED IN CHINA?

None reported.

Côte d’Ivoire

GOVERNMENTAL POLICY

A participant indicates that in Côte d’Ivoire there is not yet governmental policy related to health literacy. There are reports that policy formulation related to health literacy is under way in the Western African Health Organisation. That organization, consisting of 15 member states, including Benin, Burkina Faso, Cabo Verde, Côte d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, and Togo puts forth the promotion of dissemination of best practices as a central concern. That program identifies that “lack of knowledge of behavioural best practices, of the effective approaches to disease prevention and management strategies limits health coverage and compromises the quality of care” (WAHO, 2009).

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

No specific projects were reported.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

A participant from Côte d’Ivoire reported that the Biblotheque UFR Sciences Medicales Université de Cocody provides training in health information literacy in the medical school. A participant reported that policies of Association of African Universities License-Master-Doctorate system are involving information literacy policies for the next school year and that training of librarians at the university will begin as well. Additionally, the Western African Health Documentation and Information

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Network was reported to offer trainings to enhance the competencies of librarians.

HOW IS HEALTH LITERACY DEFINED IN COTE D’IVOIRE?

None reported.

Denmark

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The Danish Ministry of Children and Education is reported to conduct a national assessment to map human resources in 10 key competency areas. These are health, literacy, learning, self-management, creativity and innovation, culture, environment, social relationships, communication, and democracy—factors that affect growth and welfare (Rushforth et al., 2006).

A participant reported that health literacy activities in Denmark are conducted by the Danish Committee for Health Education. This organization reports it was founded in 1964 and is a nonprofit nongovernmental organization with close working relations with public authorities like the Ministry of Health, the National Board of Health, and private organizations in the health field. The membership organizations are primarily professional associations in the health field and the associations of county councils and local authorities. Sponsored by mainly public health authorities, the Committee develops and produces health promotion material on many themes and to many target groups. Themes include pregnancy prevention, child and maternity health, sexually transmitted diseases, breastfeeding, child raising, and alcohol problems (http://www.sundhedsoplysning.dk).

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

HOW IS HEALTH LITERACY DEFINED IN DEMARK?

One government report seems to define health literacy (sundheds-kompetence) as including the ability to maintain both good physical health and good mental health. Health literacy is thus defined as the ability to meet the complex demands and challenges encountered in work and in civilian life, including the ability to exhibit behaviors that help to maintain or improve a healthy state of health. This construct is reported to have been measured in Denmark as consisting of three domains: Action level (skills of a person to promote and maintain and good health); Reflexive level (ideas and knowledge about interactions with the surrounding environment relevant to health); and Opinions level (physical and psychosocial experiences that a person ascribes as relevant to health).

Finland

GOVERNMENTAL POLICY

A participant reported that new recommendations and guidelines for Finnish health care professionals make promoting health literacy a central goal in health counseling.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

A participant from Finland also reported that discussions about health literacy have been increasing in Finland. During the last decade, health promotion practitioners have reportedly underlined the importance of supporting health literacy in order to improve population health and cost-effectiveness of health promotion programs.

Despite that policy development for health care professionals reported above, however, a participant reported that few empirical health literacy studies have been conducted. Commonly used health literacy measurement tools have not yet been translated in Finnish. However, some ongoing studies apply the concept of health literacy in order to explore health literacy in different age groups and circumstances.

A participant reported that the most common context where health literacy is encountered in Finland is in health education in schools. Further, another participant indicated that health education has been an obligatory subject in Finnish schools since 2002, and is based on a national curriculum.

A participant also reported that health literacy among adults and seniors has received less attention. The project “Health Information Prac-

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

tice and Its Impact” is examining the impact of information by looking at three thematic areas of knowledge production, information content and transfer, and the use of information. That project is funded by Academy of Finland and it is conducted by University of Oulu and Åbo Akademi. One subproject aims to find out how senior citizens understand information provided by health professionals during counselling, and what kind of information strategies do they use if they lack understanding (http://www.oulu.fi/hutk/info/tutkimus/HeIP/english.html).

Participants also note a growing body of academic research on the concept of health literacy is occurring in Finland. While most is reported as focusing on youth or in schools, other work is addressing health literacy in adult populations and attempting to develop a suitable measure of health literacy for the Finnish context, language, and culture. A participant noted that “there is a need for further research on health literacy in Finland. Even though, reading literacy in Finland is at high level, there are clear health inequalities between socio-economical groups. Health literacy research may help us to find methods for targeting health counselling to people with different needs.”

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN FINLAND?

A recent scholarly publication reportedly defined health literacy as a learning outcome in schools, and described the learning conditions that are relevant for targeting health literacy (Paakkari and Paakkari, 2012).

Greece

GOVERNMENTAL POLICY

While participants indicated there has been no explicit health literacy policy in Greece to date, they did report that the National Organization for Medicines of Greece (EOF) (http://www.eof.gr) is the reviewing agency for pharmaceutical research, food and drug industry information, and generally has had a social marketing campaign about reducing the use of antibiotics. While this effort does not explicitly refer to health literacy, participants felt the effort sufficiently related to health literacy for inclusion.

The Hellenic Accreditation System (ESYD) (http://www.esyd.gr) was

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

established in 2002 and succeeded the Hellenic Accreditation Council, which operated within the Ministry of Development after 1994. Participants describe ESYD as a private liability company operating in favor of the public interest with the responsibility of managing the accreditation system in Greece. The system focuses on food safety, organic certifying, laboratories, and environmental issues.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Greece was one of the participating countries in the recent HLS-EU health literacy survey (see the section of this paper focusing on the European Union for more details). In Greece, this effort was facilitated through the National School of Public Health with consultation from Hellenic American University.

The National School of Public Health and the University of Athens are reported to organize conferences where regulations, legislation, and plans of action are communicated to the public.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

Medical professional training is accomplished through the National School of Public Health (http://www.esdy.gr/nsph) in Greece, but health literacy is only considered at the master’s level according to respondents. This effort trains health professionals how to help their patients become more health literate.

Other universities, such as the University of Athens, are reported to provide training for health professionals at all levels and to incorporate topics of health literacy. However, according to one participant, there is no specific class on the health literacy at public educational institutions in Greece at this time. Health literacy is said to be addressed within the context of other courses such as at the Hellenic American University where Health Psychology and Health Communication courses address health literacy.

HOW IS HEALTH LITERACY DEFINED IN GREECE?

None reported at this time. Efforts in general are reported to coalesce around health education rather than health literacy per se.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

India

GOVERNMENTAL POLICY

The National Literacy Mission, launched in 1988, was aimed to attain a literacy rate of 75 percent by 2007 (National Literacy Mission, 2003). The effort, through the Total Literacy Campaign, attempts to bring literacy to non-literates. The Indian literacy rate reportedly increased to 74.04 percent in 2011 from 12 percent at the end of British rule in 1947. Although this was a greater than sixfold improvement, the level is well below the world average literacy rate of 84 percent (Literacy in India, 2012).

No governmental policies explicitly focusing on health literacy were reported. However, multiple government reports on health issues such as tobacco use, health equity, noncommunicable diseases, the state of urban health in Delhi, and the use of information technology for health refer to the importance of health literacy.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Kalyani is an initiative of the Ministry of Health and Family Welfare of the Government of India and has been called the longest running public health campaign in the nation (http://www.ddindia.gov.in/devcom/Program+Column+1/Kalyani.htm). The program is broadcast over Doordarshan, National Public Television, in nine states of India, targeting approximately 50 percent of India’s population. These nine states experience the poorest health indicators in the nation. Themes of the television program, reinforced by in community efforts, are Reproductive & Child Health, Malaria, tuberculosis, HIV/AIDS, Anti-Tobacco, Cancer, Water Borne Diseases, insulin-dependent diabetes (IDD), Blindness, and Leprosy and Food Safety. Knowledge of these areas among viewers of

image

Indian health literacy campaign.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

the program compared to non-viewers is consistently higher. As of 2010, this effort is reported to have produced more than 7,000 programs in 3 languages and 14 dialects, visits to more than 4,500 villages by Kalyani teams, visits by physicians and Kalyani teams to more than 1,200 villages, more than 3,000 Kalyani health clubs, and more than 79,000 Kalyani health club volunteers.

Darpana Academy, based in Ahmdabad, India, uses Indian dance, puppetry, music, theatre, and television to educate, empower, and raise awareness about critical issues facing India today—health is one of the primary focus areas for their work (Darpna, 2012). Health issues that Darpana projects are reported to have addressed include family planning; diabetes; cervical cancer; maternal and infant mortality; HIV/AIDS; children’s health; hygiene; sanitation; the medical and social impact of HIV/AIDS for at risk populations, including truck drivers, sex workers, and their clients and port labor; leprosy; and addictions.

The Public Health Foundation of India (PHFI) is a public-private initiative that is reported to have conducted community-based health literacy campaigns to effectively build engagement and facilitate action for improved health outcomes at the grassroots. The organization has conducted health literacy assessments, participatory action research projects on increasing health literacy at the grassroots relating to risk factors and symptoms of selected chronic disease prevention opportunities in three states in India. Campaigns conducted so far have reportedly used mass media through community and commercial radio, newspaper advertisements; participatory mid-level media using songs, health melas,6 street plays, puppetry, public meetings, dance, and adapted board games as well as interpersonal communication through peer education via a cascade approach. The organization also runs the website http://www.healthy-india.org. That website, funded by the government of India, began in 2007 and has the goal of increasing health literacy through the provision of credible information.

Other particular projects related to health literacy conducted by the Public Health Foundation of India are reported to include

  • “Maanavta Se Anmol Mann Tak” (2010–2012): Under the aegis of the National Mental Health Programme (NMHP), Ministry of Health and Family Welfare, Government of India, the PHFI completed the implementation of a pilot awareness generation campaign on Mental Health. This initiative was started with the objective of encouraging timely help-seeking behaviors by individuals and families through sharing information on available services
___________

6 Mela is a Sanskrit word meaning “gathering” or “to meet.”

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • and initiating efforts in stigma reduction in 10 districts of Andhra Pradesh, Assam, Gujarat, Uttar Pradesh, and Delhi. A series of activities were conducted in partnership with civil society organizations and in close collaboration with the District Mental Health Programme teams; namely, development of information, education, and communication materials for dissemination, 20 mental health awareness and check-up camps, 20 Speakers’ Bureau interactions with the public, university student sensitization workshops, and creation of student-led peer education and awareness activities, “Uniting Hearts and Minds”—a Festival of Creative Expressions on Mental Health and monitoring and evaluation. The findings of a survey and the experience of the pilot campaign are being used to create an up-scaled strategy and Behaviour Change Communication campaign on mental health, including key information and motivation to break the silence surrounding mental health illness.
  • Health Literacy Project (2009–2010): A health literacy grassroots awareness project to enhance knowledge and awareness of risk factors and symptoms related to diabetes and cervix cancer among communities in Delhi, Gujarat, and Orissa. Participatory action research with communities has supported the creation of innovative, appropriate, and culturally acceptable media, such as nukkad natak, songs, health melas, adapted board games, community radio, and other cultural art forms. Thus, the project has developed a stronger understanding of community-led communication needs and requirements in partnership with Darpana for Development, South Orissa Voluntary Action and Deepalaya.

The Self-Employed Women’s Association (SEWA) is a trade union of nearly a million self-employed women in Gujarat, India. The organization works to link health security to work security, which means that all economic activities at SEWA have a health component and all health action, in turn, is linked to producer’s groups, workers’ trade committees, and self-help groups and their economic activities (SEWA, 2009). SEWA has collectively organized health insurance to pay for health costs, organizes child care, centers for infants and young children, and campaigns with state and national level authorities for child care as an entitlement for all women workers (WHO, 2012). SEWA trains traditional midwives, so that they become the “barefoot doctors” of their communities/villages, promotes health and well-being by providing access to health information and health education, provides basic amenities like sanitation literacy and other developmental skills, and emphasizes self-reliance for women in economic terms and in terms of women themselves owning, controlling, and managing their own health activities (SEWA, 2009).

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

From Delhi, India, there are reports that Gender Resource Centers (GRCs) are “being implemented for overall empowerment of women in the areas of health literacy, legal awareness and skill development” (Ministry of Health and Family Welfare, 2007). There are efforts to achieve greater convergence of women welfare programs and activities of government and other agencies through single window information and facilitation centers for the community women to provide wider exposure to available services and better placement opportunities. At least four GRCs have been reported to exist now in Dakshinpuri, Kalyanpuri, Najafgarh, and Shahbad Daulatpur. More than 1,900 women are reported to have benefited from the health clinics, 1,130 women were provided free legal aid, and 1,207 women were assisted through skill development courses (Ministry of Health and Family Welfare, 2007).

See other activities ongoing in India in the Nongovernmental Organization section of this paper.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

The Public Health Foundation of India reports it conducted a program, Raising the discourse on the Arts and Public Health (2009). In an effort to strengthen innovative approaches to health promotion, a brain-storming was organized with experts and practitioners from the field to mine ideas for the creation of a common platform for national and international exchange of good practices in Public Health and the Arts. Enhancing the use of diverse art forms, sensitizing health professionals to use innovative approaches more often, and creation of new partnerships were part of the discussion.

HOW IS HEALTH LITERACY DEFINED IN INDIA?

One person reported that health literacy had been defined by some in India as implying the achievement of a level of knowledge, personal skills, and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy is meant to mean more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment in this definition. Health literacy is itself dependent upon more general levels of literacy.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Ireland

GOVERNMENTAL POLICY

According to participants, while the Department of Health does not have a health literacy policy in place, in recent years health literacy has been cited as a factor in a number of national health policy documents. Relevant governmental publications are reported to include

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Ireland was one of the countries participating in the recent health literacy measurement effort coordinated by the European Union. (See the European Union section for more.) In Ireland, this effort was conducted by the Department of Health and the National Adult Literacy Agency (NALA) and involved 1,005 respondents. Of the respondents in Ireland, 10.3 percent were reported to have inadequate health literacy, 29.7 percent had problematic health literacy (these figures may be combined to give a limited health literacy rate of 40 percent), 38.7 percent had sufficient health literacy, and 21.3 percent had excellent health literacy (http://healthliteracy.ie/wp-content/uploads/2012/06/Executive-Summary.pdf).

NALA offers resources and conducts multiple activities related to health literacy. For example, there are health literacy exercises for students, activities to influence governmental policy related to health literacy, working with health organizations to make their efforts more health literate. These efforts include preparation and release of

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

a 2002 report titled Health Literacy, Policy and Strategy (http://www.nala.ie/resources/health-literacy-policy-and-strategy-2002-research-report) and a 2009 Health Service Executive (HSE)/NALA publication, “Literacy Audit for Healthcare Settings” (http://healthliteracyie/wp-content/uploads/2010/11/NALA-Audit-Project-Nov-2010-report.pdf). HSE manages public health services in Ireland (http://www.hse.ie).

Ireland is also home to the Merck Sharp & Dohme (MSD)/NALA Health Literacy Initiative (http://healthliteracy.ie) which is reported as a partnership between healthcare company MSD and NALA. The aim of the initiative is to increase awareness about the issue of health literacy in Ireland. A major activity of this initiative is the Crystal Clear Awards (http://healthliteracy.ie/crystal-awards) that recognizes individuals and organizations for their efforts to advance health literacy in Ireland.

Winners of this recognition in 2012 included the following. (The following information extracted from http://healthliteracy.ie/crystal-awards—previous year award winners and information describing all finalists can also be found at this website.)

Best Project in General Practice

  • WINNER: DIT Student Health Centre, Dublin Institute of Technology (DIT). The No Umbrella Campaign. The No Umbrella Campaign was developed by Louise O’Donnell and Deirdre Adamson to make students aware of a new Sexually Transmitted Infection (STI) screening test for males that is simpler and easier than before. They also wanted to educate young males that, contrary to popular belief, STI screening no longer involves a painful and invasive test referred to as the “Umbrella Test.” Research showed that there was an especially low uptake of STI testing amongst Northside Dublin males, who in turn became DIT’s communication target. Louise and Deirdre developed a simple poster to dispel the myth and remove any fear associated with the test and increase uptake. They evaluated the success of the campaign by comparing attendance at 16 STI clinics before and after the launch of the campaign. Post launch, they found an increase of 73 percent in the number of students attending their STI clinic from their target group and an increase of 18 percent in the total number of students attending the STI clinic.

Best Project in a Hospital

  • WINNER: National Cancer Control Programme Rapid Access Lung
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • Clinic Booklet Team. “NCCP Rapid Access Lung Clinic Patient Booklets.” The National Cancer Control Programme (NCCP) developed the Rapid Access Lung Clinic patient booklet to provide information for patients about what to expect when they attend their Clinic. General practitioners (GPs) can refer patients with suspected lung cancer to a Rapid Access Lung Clinic. Early diagnosis of lung cancer increases the chance for a cure. The typical lung cancer patient is often from the lower socioeconomic groups, and therefore may have low literacy levels. The deliverable of this project was to produce and distribute the patient booklets to the eight designated cancer centres around the country. The core information in all eight booklets is standardized, and there is hospital specific information in the individual booklets. This was to ensure that clear information is available to all patients irrespective of which hospital they attend. As well as informing the patients about their visit to the clinic, they include health promotion information, in particular a focus on encouraging patients to quit smoking. The booklets have been awarded the Plain English mark by NALA. Pictures and diagrams were included to make the booklet easier to read.

Best Project in the Community or in a Social Setting

  • WINNER: Arthritis Ireland. “My Health Organiser.” Arthritis Ireland recognized that patients with arthritis could see up to 15 different health care professionals in a given year, and with no electronic record system in the country, and a lack of sharing patient files, patients were forced to give a full medical history every time they visited a health care professional. Arthritis Ireland developed My Health Organiser to encourage people with arthritis to take control and play an active part in their treatment. It also helps patients to actively engage in their health care management by providing them with somewhere to store all of their health records including diagnoses, medications and treatments in one place, literally putting the knowledge and information in their hands. The use of plain English throughout makes it easy to understand and fill out. The number of My Health Organiser booklets distributed to date is more than 6,500. The number of people calling the national helpline has doubled during the period of the campaign, resulting in an overall increased awareness of Arthritis Ireland among the public.
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Best Health Promotion Project

  • WINNER: Maeve Cusack and Laura Molloy, National Cancer Screening Service. “Bespoke cancer screening training for community health workers in the Traveller Community.” The National Cancer Screening Service (NCSS) communications and screening promotion team aims to reduce barriers and enable eligible women from the Travelling community to participate in BreastCheck and CervicalCheck. The NCSS developed a bespoke, interactive training programme for community health workers (CHWs) that supports women with low literacy levels to understand complex messages about cancer and screening. The programme incorporates pictorialled materials that support women with low literacy levels to understand often complex messages about cancer and screen ing. The overarching objective is to encourage women from the Travelling community to make informed choices about their cancer screening needs. The overwhelming response from 50 participants was that the training was enjoyable and participative. CHWs reported that the training challenged their fatalistic view of cancer. Many had never before seen the benefits of screening and getting early symptoms checked out. They are now actively sharing this positive message with their communities.

Best Health Communication Through Journalism

  • WINNER: Nicoline Greer, Conor McGinnity, and Liam O’Brien, RTE Radio 1, “My Dad’s Depression.” RTE Radio 1, led by series producer Liam O’Brien and production supervisor Nicola Greer, put together a documentary on Conor McGinnity’s personal story on how his father’s depression has affected the whole family. The aim of the documentary is to give an insight into families who live with depression, but are not sufferers themselves. To that end they did not include any “expert” opinion—rather, they heard directly from the family at the centre of this issue. This documentary received an enormous response. On the weekend it was broad cast, it reached approximately 240,000 listeners. RTE Radio 1 was inundated with e-mails for a number of weeks after the documentary aired. It got sizeable online traffic (c. 30,000 podcasts/webpage visits). It was also picked up by Liveline the following Monday and became the kernel of that day’s programming. Conor’s family,
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×
  • including his father, was taken aback by the response they personally received—and still do to this day7 (NALA, 2012).

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

NALA reports offering a health literacy initiative for members of all sectors of the health profession as well as to members of the media who specialize in health promotion.

HOW IS HEALTH LITERACY DEFINED IN IRELAND?

The NALA report “Health Literacy Policy and Strategy” offered this definition: “Functional health literacy involves more than simply understanding written and oral communication about health. Functional health literacy is the ability to use written and oral material to function in health care settings and maintain one’s health. It also includes the necessary skills to ask for clarification” (McCarthy and Lynch, 2002).

Israel

GOVERNMENTAL POLICY

A participant from Israel reported that there is a new governmental policy for Cultural and Linguistically Appropriate Health Services (available here in Hebrew: http://jer-icc.org/blog/wp-content/uploads/2011/02/hozermankalculturalcompetence-a3876_mk07_11.pdf). This effort is reported to create principles and standards for cultural accessibility in health care organizations and institutions on a national level in Israel. This includes translation services, education and training of medical staffs, and environmental adaptations of the institutions (Jerusalem Inter-Cultural Center, 2001). Additionally, quality assessment monitoring and auditing of primary care services is conducted by the Israel Ministry of Health that includes addressing health education materials in Hebrew, Arabic, and Russian as well as training of staff on cultural appropriateness. The Ministry of Health is also reportedly working to establish a national telephone translation service.

___________

7 Extracted from http://healthliteracy.ie/crystal-awards. Previous year award winners and information describing all finalists can also be found at this website.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The Israel Ministry of Health is reported to be partnering with Clalit Health Services to provide cultural liaisons in primary care clinics that serve the Ethiopian immigrant population in Israel. Participants reported that Clalit Health Services has made the topic a priority by leading the National Health Literacy Survey in Israel, implementing policies and projects for culturally appropriate health information and education, and adding health literacy to treatment guidelines and conducting training for staff at different levels on health literacy. The Clalit hospitals are voluntarily undergoing The Joint Commission accreditation process, including patient education and culturally appropriate services and information. A particular effort described by the participant from Israel is the “Refuah Shlema” program that has sustained for more than 13 years cultural liaisons/mediators in Clalit primary care clinics that serve Ethiopian immigrant populations, in partnership with the Israel Ministry of Health. Also, the participant reported that Clalit maintains award-winning health websites in Hebrew, Arabic, Russian, French, and other languages with the opportunity to receive information, ask questions and get answers from experts in the person’s preferred language and participate in discussion forums. Clalit also has adapted the “Ask Me 3” program from the United States into Hebrew, Arabic, and Russian. This participant reported that Clalit also conducts hundreds of activities each year to reach populations with special health literacy needs—all age groups, all levels of health behavior (prevention, early detection, self-care), and outreach programs in clinics, schools, hospitals, elderly clubs, and other settings. The health system also operates a call center that assists in navigation of the health care system and there is a telephone translation service for the entire system to serve the Amharic speaking population.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

A participant indicated that there is a new course from the Israel Ministry of Health for hospital representatives that coordinates culturally appropriate services and includes a unit on health literacy.

Health literacy is reported to be included in training of primary care staff at Clalit, particularly with regard to diabetes and treatment of chronic disease.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

HOW IS HEALTH LITERACY DEFINED IN ISRAEL?

The participant reported the definition of health literacy used in Israel is that health literacy is the ability to gain access to, understand, and apply health information in a way that enables making positive decisions about health.

Japan

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

An effort sponsored in part by the Saint Luke’s College of Nursing and Information Science in Tokyo, Japan, and reportedly supported by a research grant from the Japanese Ministry of Education, Science and Technology had produced a website, http://www.healthlitercy.jp, which is an attempt to provide health literate information to the Japanese population.

Further, the Saint Luke’s College of Nursing World Health Organization Collaborating Centre for Nursing Development in Primary Health Care is reported to have embarked upon a “People-Centered Health Care” initiative based on the premise that peoples’ participation is an essential part of reaching the Millennium Developmental Goals. The effort strives to help people to be empowered and strengthen their health literacy in order to control their own health. Toward that end, the effort has started health programs targeting elderly-, family-, and women-centered care, and with other people based on the people-centered care model.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN JAPAN?

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

BOX A-3
How Did You First Learn About Health Literacy?

“My personal story on how I first became aware of health literacy is quite difficult to describe as it was a dawning realisation of how disempowered and ‘out of the information loop’ most patients were, which was a stark contrast to the situation in much of the developed world in which patients were able to access unlimited health-related information via the internet…. My work in this area started with coming across the U.S. Pharmacopeial Convention pictograms years ago, thinking about their potential role in communicating health-related information to a population such as ours and then realising that many of the concepts and images used would probably be incomprehensible to our patients due to limited visual literacy, as well as cultural and lifestyle differences. During the huge number of interviews we have conducted over the years, the lack of knowledge, lack of awareness and disempowerment were glaringly apparent. What was interesting was investigating the visual literacy skills required in interpreting images and identifying the influence of culture and education in the ability to interpret them…. The two most important messages that continuously came through in every project, in every interview we conducted, were firstly to make no assumptions (e.g., that leaflet is SO simple, anyone will understand that, OR, but anyone can see that the picture is a person sitting on a toilet/rubbing cream on the skin etc.). The second message was to SIMPLIFY and take note of what patients actually want and need—which was NOT necessarily what the ‘expert’ nurse or doctor thought the patient needed to know. A huge challenge is to walk the thin line between ‘enough’ and ‘too much’ information and written text in a leaflet.”

—South African participant

Kenya

GOVERNMENTAL POLICY

A participant reporting on health literacy in Kenya reported that the nation is guided by the WHO’s 7th Global Conference on Health Promotion (which was held in Nairobi, Kenya) resolution on health literacy and health promotion. (One of the four tracks of this conference focused on health literacy and health behavior.) Further, a participant reported that the Kenyan constitution upholds the right to information access by citizens. In the Kenyan Ministry of Health, strategic documents such as the communication strategy and concepts like health literacy are reported to fall under the public education policy efforts. The overall aim reported is to transfer health care information to those otherwise marginalized and difficult to reach, including people living with disabilities.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The Kenyan government is reported to have been rolling out an initiative, “Public Access to Health Information in Kenya.” Communities in Kenya are reported to have embraced this effort that is working to translate health information materials into local languages to allow for easier access. Family Health Options Kenya (http://www.fhok.org) in partnership with the Ministry of Health is reported to have been in the forefront of this process. Through the Community Health Strategy, households are reached with health information in a language they can understand. The effort is also identifying health centers that have computers and appropriate technology so the community can visit and access health information in a language they can easily understand.

Another health literacy effort reported from Kenya is the creation of health information dialogues and reading tents where experts mingle with the community and discuss the prevailing health challenges within respective communities. These dialogues are reported to have developed suggestions better suited to alleviate health challenges and increase community ownerships of the activities.

At a 2009 conference on Health Literacy Capacities in East and Southern Africa, a participant reported on Rachuonyo Health Equity that is a Kenyan community-based organization reported to be working with people living with HIV/AIDS. The hope expressed for this effort is that

health literacy will not only empower marginalized girls in Kenya with information and knowledge but to also act responsibly to improve their own health … the Health Literacy program will benefit the institution and communities in Kenya in many ways … increasing health literacy among these marginalized groups will make them more likely to create a sustainable healthy living, they will make more informed decisions about their health and more actively support their children to attend school and hopefully overcome similar barriers in future. (TARSC, 2009)

Several organizations in Kenya are reported to be conducting Magnet Theater efforts, particularly addressing HIV/AIDS. The methodology is called “Magnet Theater” due to its natural pulling power to draw audiences. Magnet theater performances are designed to get people talking about traditional attitudes and their role in health and public health. For example, PATH (an international nonprofit organization) has used Magnet Theater to encourage community dialogue around HIV and AIDS issues, consequences of early marriage, and tuberculosis (TB) prevention and treatment. REPACTED (Rapid Effective Participatory Action in Community Theater Education and Development) in Nakuru, Kenya, uses Magnet Theater to advance health literacy about HIV/AIDS, reproductive

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

health issues, and applied the methodology to conflict resolution during the recent post election crisis.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

Kenya has health education programs within the Ministry of Health and also of Education. Various strategies are applied to educate and teach citizens on better health for quality health lives. Through health education programs, citizens at whatever level within the society are reported to be able to access health information.

HOW IS HEALTH LITERACY DEFINED IN KENYA?

None reported.

Liberia

See the International NGO section of this paper.

Malawi

GOVERNMENTAL POLICY

The government of Malawi is reported by a participant to have formulated policies that seek to address HIV/AIDS pandemic and maternal health problems, at least in part by addressing health literacy. According to this participant, the government established the National Aids Commission (NAC) to coordinate the HIV/AIDS programs in Malawi. The commission is responsible for formulating the National HIV/AIDS policy and its implementation, which includes educating the masses about the effects of HIV/AIDS on individuals and the society at large.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

A participant reported that the government of Malawi through the Presidential Initiative on Safe Motherhood has embarked on a campaign to sensitize the public on dangers that pregnant women and girls face with a focus on fistula. The government is encouraging pregnant women to seek help from antenatal clinics during and after pregnancy in order to reduce cases of fistula.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

The participant from Malawi also reported initiatives by the United Nations to address problems of malaria and infant mortality in Africa are being supported by the European Union in Malawi. Also, the participant reported that some NGOs place programs on the radio to attempt to sensitize the public on malaria prevention and treatment.

According to a 2009 report on Health Literacy Capacities in East and Southern Africa (http://www.tarsc.org/publications/documents/HLregional%20meeting09.pdf), the Malawi Health Equity Network (MHEN) with support from the Training and Research Support Centre in Zimbabwe (TRSC) carried out a needs and capacity assessment for their health literacy program in 2007. The assessment was a build up to the country review meeting held in May 2007. Both exercises informed the content of a Malawi Health Literacy manual. The Malawi Health Literacy Materials were pre-tested in two districts and peer reviewed by a technical team in Malawi (TARSC, 2009). The effort also conducted a facilitators’ training in four districts in Malawi, with 30 facilitators trained in 2008. Community Health Literacy work reportedly began in 2008. The report asserts that the Health Literacy program should also be viewed as a fundamental equity watchdog as it exposes unfair and unnecessary disparities at community level (TARSC, 2009).

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN MALAWI?

The effort supported by MHEN and TRSC defines health literacy as people’s ability to obtain, interpret, and understand basic health information and health services, and to use such information and services in ways that promote their health (TARSC, 2009).

Mexico

GOVERNMENTAL POLICY

The main policy source related to health literacy in Mexico, according to participants, is the Secretaría de Salud (http://portal.salud.gob.mx). This governmental organization encourages citizens to obtain vaccinations, donate organs, and creates awareness through health risk campaigns and similar efforts according to participants. One participant suggests that health literacy is one of the few issues related to the uptake of

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

science by the public where Mexico’s governmental policies have been successful due to good quality health professionals and a strong medical tradition. A participant also indicates that there is a challenge in making clean distinctions between health, education, and health literacy policies and initiatives in Mexico.

A participant notes that top-down efforts in the form of governmental regulations such as a new law prohibiting selling “junk food” in schools and smoking in public places indicate a position in the government that may assume health literacy is not sufficient in and of itself, but that regulations are necessary to protect and improve health.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Successful examples of governmental efforts related to health literacy that participants reported in Mexico include the governmental led vaccination campaigns. Participants note that while many parents may vaccinate their children without fully understanding the immune system, saving children’s lives has to be tackled efficiently and thus full health literacy regarding vaccinations is not always obtained or, it seems according to reports, necessary in order to meet the goal of vaccinating children. Another successful campaign that participants reported about focuses on birth control with a slogan “the small family lives better.” An emerging national priority, according to participants, is to focus programs on obesity related to diabetes.

A participant also reported that the Instituto Mexicano de Seguro Social (http://www.imss.gob.mx) works as a public insurance institution, that they work on cancer, diabetes, obesity and nutrition, women’s health, and “PrevinIMMS,” which is an integrated health program focusing on prevention through education. Another governmental led effort participants reported on is at the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (http://www.issste.gob.mx/index2.html) that has a program, “PrevenISSTE” (http://www.prevenissste.gob.mx). This program is training health professionals across Mexico—especially nutritionists and fitness instructors—to be placed in medical clinics and hospitals in order to transform the health system from a focus on treatment into a comprehensive prevention effort. The effort has also created an online portal for health information to improve health literacy that includes modules on addictions, hypertension, cancer, heart health, diabetes, and influenza. A participant notes that challenges facing these sort of efforts in Mexico may be the number of people with access to the Internet and that the information seems designed for adults but not younger people or children.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Other challenges facing health literacy programs in Mexico that participants reported include addressing pre-existing cultural prejudices, especially in regard to preventing AIDS and teenage pregnancy given the Catholic church’s strong stance against using condoms. One effort noted by participants is a radio campaign with the theme that if listeners would prefer to stay late and enjoy a party instead of taking care of a baby at home they should use a condom.

Health literacy–related efforts were also reported to be conducted by the Centro Nacional para la Salud de la Infancia y la Adolescencia (http://www.censia.salud.gob.mx) and many science centers around the country that can be identified through the Association of Mexican Science Centers (http://www.ammccyt.org.mx).

A participant, while noting a general shortage of projects or programs that explicitly focus on health literacy, did report that across the country social workers are addressing health literacy in their work in rural communities—for example, on vaccination or using medical services for prevention. Another participant reported that health professionals in Mexico continue to use very technical language to communicate with the public so often people do not understand or see the relevance of their efforts to communicate indicating a continuing need to further advance health literacy in the nation.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

Participants noted that many universities such as the Universidad Nacional Autónoma de México (http://www.unam.mx) have programs on health literacy.

HOW IS HEALTH LITERACY DEFINED IN MEXICO?

While no formal definitions were offered, one participant noted that the mission of the Secretaría de Salud has key elements that can be read to address and include health literacy. For example, the mission statement refers to promoting health as a social goal, providing universal access, meeting the needs and expectations of the population, and using honest, transparent, and efficient use of resources through broad citizen participation. In practice, one participant noted the efforts to meet that mission seem to be limited to radio and television campaigns. Other participants reported that while the exact official definition of health literacy was not known, the definition has to do with prevention that can only be achieved through addressing cultural attitudes.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Mozambique

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Massukos is a musical group that is said to be considered a national treasure in Mozambique, renowned both for their music and the humanitarian work that they perform (http://www.massukos.org). Feliciano dos Santos, the leader of Massukos, is also the director and founder of a non-governmental organization named Estamos. Originating from Niassa in northern Mozambique, one of the poorest parts of Africa, Massukos uses their high profile to speak out against the hardships that have affected their lives and the nation. The band delivers simple life-saving messages—i.e., improves health literacy—about hygiene, sanitation, water, and HIV/AIDS through their music (PooP Creative, 2009). Estamos delivers public health programs that work to install latrines and clean water points as well as improve hygiene behaviors and provide HIV/AIDS education.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN MOZAMBIQUE?

None reported.

Netherlands

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

There has been research on health literacy conducted in the Netherlands. For example, scholar Alja Bosch performed a literature study to better understand and operationalize health literacy at the Netherlands

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Institute for Health Promotion. That work (not in English), in 2005, concluded that health literacy is an almost unknown concept in Dutch health promotion efforts, but there was interest in the concept (http://essay.utwente.nl/57803/1/scriptie_Bosch.pdf).

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

A workshop addressing health professionals was held in Finland in 2010 featuring multiple examples and speakers about health literacy (http://www.compriz.nl/nieuws/23).

HOW IS HEALTH LITERACY DEFINED IN THE NETHERLANDS?

The 2005 research mentioned above noted that there was no single operationalized definition of health literacy in the Netherlands, and that was an area that needed to be addressed in the future.

New Zealand

GOVERNMENTAL POLICY

New Zealand governmental policy is reported to address health literacy in many ways, but a participant noted that the government does not use the term/concept to organize policy. As a result, a participant noted that aspects of patient centered care and the country’s health targets embed many aspects of health literacy without explicitly indicating a focus on health literacy.

Participants did report that regional health providers have received government funding to support research investigating health literacy in their regions, indicating at least some level of governmental policy support for health literacy. Others reported that they are not aware of formal governmental policies on health literacy per se, but one participant does note that New Zealand Ministry of Health Requests for Proposals for resources or projects that involve interventions are increasingly asking that health literacy be addressed. As a result, this participant suggests that more people in the health sector in New Zealand are becoming aware of and using health literacy in both policy and practice.

A search of the phrase “health literacy” on the New Zealand Ministry of Health’s website produces multiple “hits,” again indicating that there is some support within the governmental policy structure to support health literacy work.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

New Zealand is reported by participants to have joined the small number of nations in the world that has made the attempt to evaluate the level of health literacy of residents. The government sponsors a report on health literacy statistics in New Zealand, “Korero Marama,” that is freely available online at http://www.health.govt.nz/publication/korero-marama-health-literacy-and-maori-results-2006-adult-literacy-and-life-skills-survey

Participants reported that in producing this report, New Zealand has sufficiently sampled the indigenous population so that statistical analysis can make a valid distinction between Maori and non-Maori participants. The data collection process is based upon the 2006 Adult Literacy and Lifeskills Survey. The study found that “Maori have much poorer health literacy skills compared to non-Maori across all of the measured variables. Eighty per cent of Maori males and 75 per cent of Maori females were found to have poor health literacy skills. On average, New Zealanders have poor health literacy skills. The report presents findings by gender, rural and urban location, age, level of education, labour force status, and household income” (Ministry of Health, 2010).

In no small part as a result of this national data set, a respondent reported that there is an “increasing call for services—including health services—to empower people and their whanau8 rather than see them as mere service users, the need to understand current levels of health literacy and how those might be improved is becoming even more important in New Zealand,” according to one participant.

Participants reported that there are a large number of health literacy research projects going on at the University of Auckland. For example, one project (with the University of Waikato) investigated health literacy and palliative care for Maori. Another project (an international indigenous collaborative with Australia and Canada) is investigating health literacy about cardiovascular disease medicines among indigenous people. The New Zealand Ministry of Health is reported to also be currently sponsoring three health literacy projects at the University of Auckland that focus on the Maori population with specific foci on gout among older Maori men, skin infections for children under 14 years of age, and diabetes in pregnancy in mothers under age 25. Participants indicate that there are

___________

8 Whanau, according to multiple online sources, is a Maori-language word for extended family—comprised of the elders, the pakeke (senior adults such as parents, uncles, and aunts), and the sons and daughters, together with their spouses and children. Some report the word is now increasingly entering New Zealand English, particularly in official documents.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

multiple other health literacy projects ongoing, for instance, one focusing on health literacy and caregivers for people living with disabilities.

A nonprofit organization—Health Navigator—promoting health literacy in New Zealand has developed a website at http://healthliteracyorg.nz. The site offers multiple resources and definitions of health literacy from around the world. The site also offers access to the Waipanu statement, which is a “brief paper encouraging health organisations, health professionals, patients, media and communities to take action about improving health literacy right across the health system” (Health Navigator New Zealand, 2011).

Another health literacy resource in New Zealand is Workbase (http://www.workbase.org.nz). Workbase is a national, nonprofit organization working in partnership with business, the education sector, and government to raise the literacy, English, and numeracy skills of the New Zealand population (Anonymous, 2001). The organization includes a focus on health literacy (http://www.healthliteracy.org.nz) that includes definitions of health literacy, statistics on health literacy in New Zealand, resources for addressing health literacy, and health literacy consulting services.

BOX A-4
How Did You First Learn About Health Literacy?

“I am not aware how and when I became involved in health information literacy. I never thought about it, it just came in a natural way, as when you learn about caring for yourself, or use the personal computer. May this be an answer?”

—Italian participant

A participant reported this range of efforts is making inroads from a systems point of view.

A conference in May 2012 that featured U.S. health literacy scholar Rima Rudd as a keynote speaker is reported to have generated further interest in health literacy in New Zealand. Others reported that part of that growing success in informing governmental policy and practices in New Zealand is attributed to an Associate Minister of Health, Minister Tariana Turia, who is Maori and who understands that Maori have low levels of health literacy. So although most all of the projects funded by the government are reportedly focused on Maori and other Pacific peoples (also experiencing very low literacy and numeracy levels), there seems to be a shared understanding among some participants that interventions

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

for Maori and Pacific people will also successfully inform interventions targeting other populations in New Zealand. Sir Peter Gluckman, the New Zealand Prime Minister’s Chief Scientific Advisor, is also reported to be addressing health literacy.

Participants also reported that the New Zealand Health Quality and Safety Commission has initiated some projects on health literacy but some also comment that those efforts are based upon a “limited understanding of health literacy.” For example, participants asserted that within that organization the concept is solely related to patients’ understanding and educational materials (http://www.hqsc.govt.nz/home/SearchForm?Search=health+literacy+&Programme-clone=0&Programme=0). In September 2011, this governmental organization produced a report on an “environmental scan” of health literacy activities ongoing within the nation that is freely available at http://www.hqsc.govt.nz/assets/Consumer-Engagement/Publications/FINAL-NZGG-HQSC-Health-literacy-environmental-scan.pdf. That report on health literacy efforts, appropriately, reports on more specific efforts within New Zealand than is contained within this summary of efforts within the nation.

The New Zealand Ministry of Health is also reported to have published a revised version of its guide to developing health education materials titled “Rauemi Atawhai: A Guide to Developing Health Education Resources in New Zealand” that includes a section on health literacy. The full report is available at http://www.health.govt.nz/publication/rauemi-atawhai-guide-developing-health-education-resources-new-zealand.

Health Workforce New Zealand (http://www.healthworkforce.govt.nz) is reported to have commissioned a health literacy literature review, but that project is not yet published.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

The New Zealand Ministry of Health via Health Workforce New Zealand has launched an online cultural competency tool that includes a basic module on health literacy that can be seen at http://www.healthworkforce.govt.nz/news/2012/06/20/minister-releases-online-cultural-competency-training.

HOW IS HEALTH LITERACY DEFINED IN NEW ZEALAND?

Health literacy in New Zealand, some participants note, is a widely used term that encompasses a range of ideas and definitions.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

The New Zealand Ministry of Health on its website and in reports such as “Korero Marama” defines health literacy “as the ability to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions” (Ministry of Health, 2010). The Ministry also expresses that knowing and understanding the extent to which people are able to read and comprehend health instructions and messages is an important part of tailoring appropriate population and personal health services (Ministry of Health, 2010).

The Health Navigator New Zealand website defines health literacy as “the ability to read, understand and effectively use basic medical instructions and information.” Their website adds that “For health providers, health literacy includes the capacity of professionals and institutions to: communicate effectively so that community members can make informed decisions and take appropriate actions to protect and promote their health” (Health Navigator New Zealand, 2012).

The New Zealand Tertiary Education Commission is reported to define literacy as the “written and oral language people use in their everyday life and work; it includes reading, writing, speaking and listening” (Ministry of Health, 2010). Thus, literacy is the skills people need in order to function at an optimal level in society.

Participants add that the approach to health literacy in New Zealand acknowledges that health literacy operates within a complex group of reading, listening, analytical, and decision-making skills and is dependent upon a person’s ability to apply these skills to health situations. Health literacy, one participant added, is essentially the skills people need to find their way to the right place in hospital, fill out medical and insurance forms, and communicate with their health providers.

One participant reported that the understanding of health literacy within the New Zealand health sector seems to this person to be limited to conceptualizing health literacy as solely being about the educational process and that health literacy is a problem solely of individuals versus a health system and larger societal issue. This participant reported that efforts to broaden that limited conceptualization of health literacy are occurring within the health sector in New Zealand.

Finally, another respondent summed up what seems to reflect a consensus: that health literacy is generally defined either by the WHO definition or the definition from the Ministry of Health in New Zealand reported above, but that there is not a truly standardized definition of health literacy in New Zealand.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Pakistan

GOVERNMENTAL POLICY

The government of Pakistan’s health policy is reported to be almost silent about health literacy. There are multiple reports that the government of Pakistan has abolished the national Ministry of Health, handing off those services to individual provinces versus a national agency (Nishtar and Mehboob, 2011).

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

A participant from Pakistan notes that occasionally there are government led immunization promotions, family planning promotions, and responses to epidemics like the dengue virus but that there is not a formal or regular program focusing on health literacy. Another participant who works as a social worker reported that “I receive a lot of people from the rural areas with health issues. Some cases get complicated only due to lack of awareness. Timely help is not sought and patients end up in precarious condition and even death. We tried to run a lot of awareness and treatment camps in rural areas, but the challenge was too big to be physically everywhere. With the advent of the technological revolution that we are experiencing, my approach changed. I am now developing all kinds of mass communication tools and content to convey to the un-served and under-served. It’s a slow process but I feel that over a decade things will definitely be different. A lot of pain will be reduced and a lot of lives will be saved.”

See the Business section of the forthcoming report for other efforts in Pakistan.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

A participant reported that international NGOs do fund the government to promote awareness in relation to specific health issues, but that there is not a long-term methodical plan for health literacy education and training.

HOW IS HEALTH LITERACY DEFINED IN PAKISTAN?

In the Pakistan National Health Policy, there is not a definition for health literacy at either the patient or public level according to a participant. Another participant reported that NGOs define health literacy as

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

providing information on personal hygiene, diseases of different ages and geographies, different sexes and ages, chronic diseases, and epidemics.

Peru

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

In Peru, a participant reported, there is a group called Iniciativa Contra la Desnutricion Infantil (Initiative Against Child Malnutrition) that is made up of NGOs and international agencies that has the purpose of informing and influencing public policy on the subject of infant malnutrition, including stunting and anemia. The group shares information and attempts to present a coherent interpretation and messages in relation to the main nutrition and health problems facing the country (http://www.iniciativacontradesnutricion.org.pe). Peru also has a program to provide health insurance for all children—Seguro Integral de Salud that a participant reported is being expanded to include all members of the poorest families.

Another organization, “La Mesa de Concertación para la Lucha contra la Pobreza” (The Board for Consensus Building in the Fight Against Poverty), is organized to reduce poverty in Peru. Reflecting health literacy, two of the group’s aims are to enhance participation of citizens in the design, decision making, and oversight of government policy; and to maximize transparency in programs addressing poverty.

Another participant from Peru reported that there are many projects and programs in Peru that address health literacy. The “Arts for Behavior Change” program is a study that evaluates an arts intervention to improve home hygiene practices in a peri-urban area of Lima. This project in Peru is created by Canyon Ranch Institute, implemented in Peru by local partners Instituto de Investigacion Nutricional and KALLPA. The program developed and tested a new methodology, Theater for the Arts, which improved household hygiene behaviors in the participating community. The Clorox Company funded the program that also included partners from Boston University College of Fine Arts and the University of Arizona’s Mel and Enid Zuckerman College of Public Health. For more information on this effort see the International Nongovernmental Organization section of this report.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN PERU?

The Arts for Behavior Change program in Peru is based on a definition of health literacy based on the Calgary Charter that defines health literacy as allowing “the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improve the ability of people to act on information in order to live healthier lives. These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills” (Coleman et al., 2008). In addition, the Charter fairly uniquely suggests that health literacy applies to both individuals and to health systems, explaining that a system is health literate when it provides equal, easy to use, and shame-free access to and delivery of health care and health information.

Singapore

GOVERNMENTAL POLICY

A participant reported that the Singapore government has only recently begun efforts to promote health literacy by recognizing its importance in promoting the health of the nation. Reportedly, the government through the Health Promotion Board is implementing plain language guidelines to ensure that all material produced are health literate.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The government is reported to be embarking on an effort to establish a baseline of the levels of health literacy in Singapore by administering an adapted and validated version of the S-TOFHLA (Short Test of Functional Health Literacy in Adults).

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

The Health Promotion Board of the Singapore government is spearheading all health literacy efforts in the nation. This organization is reported to be undertaking a capacity building effort targeting health care professionals, and nursing and pharmacy students, and other allied

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

health professionals. The Health Promotion Board is also reported to be working with educational institutions—schools of medicine, pharmacy, and nursing—to introduce health literacy into their curriculum.

HOW IS HEALTH LITERACY DEFINED IN SINGAPORE?

None reported.

Slovenia

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

A participant reported working on a Slovenian Chemical Safety Literacy project with the Slovenian government to raise the health literacy of the public and professionals related to chemical safety. The government is reported to have declared a chemical safety week and the project’s method to stimulate action on the local level was to train “catalysts” to create awareness raising events through a training course for national and local government officials, NGOs, academics, and private-sector communication people on advocacy.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN SLOVENIA?

None reported.

South Africa

GOVERNMENTAL POLICY

Participants note that while the South African government does have a variety of health programs, they are not aware of any governmental policies or programs explicitly focused on health literacy or health com-

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

munication. The National Drug Policy for South Africa (The National Deparment of Health, 1996) is an example of a policy, published 2 years after the first democratic elections, when the new government was beginning to address changes in the health care system. A respondent reported that a section on rational drug use that includes making literature understandable to the public but nothing is said about “health literacy,” but the policy does indicate an awareness that much effort is required to facilitate understanding by patients. The National Department of Health (2011) has a Policy on Language Services that stipulates that the responsibility lies with the provider to ensure the availability of information and documentation in at least two of the official languages. This is critically important in South Africa, a nation with 11 official languages, a respondent noted.

The Constitution of South Africa does include guarantees for access to health care services and sufficient food and water as well as the right to a basic education, including adult basic education (South African Government, 2009). Other relevant rights addressed within the South African constitution include the right to use the language and to participate in the cultural life of their choice, the right of access to information held by the state, and that people belonging to a cultural, religious or linguistic community may not be denied the right to enjoy their culture, practice their religion and use their language; and to form, join, and maintain cultural, religious, and linguistic associations and other organs of civil society (South African Government, 2009).

HEALTH LITERACY INTERVENTIONS (GOVERNMENTAL AND NONGOVERNMENTAL)

To help set the stage for an understanding of health literacy efforts in South Africa, a respondent noted that “the real literacy problems in South Africa—and hence health literacy problems—have been a constant issue in the healthcare landscape here forever, and apply to the majority of the population, rather than the ‘ethnic minorities’ so often reported about as lacking literacy and health literacy in the literature from Britain, U.S.A., or Europe.” Reportedly, about 18 percent of South Africans have no schooling, 41 percent have only primary school (including the 18 percent), 31 percent have some secondary school, and only 20 percent have completed secondary school. South Africa is reported to consistently perform near the bottom of all international benchmark literacy tests, for example, in the 2006 Progress in International Reading Literacy Study (PIRLS), South Africa was ranked 40 out of 40 countries (Mullis et al., 2007).

According to participants, the one disease that has had a vast influence on the way patients are treated in South Africa is HIV/AIDS. One participant reported that “Healthcare in South Africa, as a result, has

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

definitely shifted from having focused on a purely biomedical approach to a much more all-inclusive biopsychosocial approach where the patient is acknowledged as being part of a particular community and social structure. Interestingly, though, the term health literacy has still not become a prominent one. In a way, ‘health literacy’ is tacitly acknowledged as being a component of every consultation, as all health care providers are aware of the lack of relevant background knowledge required to fully comprehend complex health conditions, e.g., a knowledge of the workings of the body, what a heart is, what lungs are, the way food is digested. One of our rural asthma patients declared, ‘I knew that sheep and cows have lungs, but I did not know I had them!’”

Other participants reported that some of the best known HIV/health communication campaigns in South Africa such as LoveLife (http://www.lovelife.org.za) and Soul City (http://www.soulcity.org.za) address health literacy according to a participant. These efforts are reported to have some government involvement (via individuals), but they are not government-funded programs or a government initiative. A participant reported that the edutainment program Soul City was developed specifically for the highest target market on South Africa’s Broadcasting Corporation (SABC) television channel 2 (viewers aged 15 and older), explores themes related to health, including gender-based violence, alcohol use, HIV/AIDS, and stigma to improve the health literacy of viewers through the dramatic series. Soul City’s work is evidence-based, pre-tested, and evaluated after every series. Another series aimed at children called Soul Buddyz has the same objectives for children (http://www.soulcity.org.za).

A participant reported that perhaps the most useful application of the health literacy work done over the years in South Africa in terms of developing and testing pictograms is currently being applied on the Phelophepa Healthcare Train (see http://www.transnetfoundation.co.za/CSIPortfolios/Pages/Health.aspx#aboutphelophepa or http://www.trainofhope.org). The two trains travel around the rural areas of South Africa that are the poorest most underserved areas, offering a diverse range of primary health care. There is also a dispensary on the train. Ros Dowse, a lecturer in Pharmaceutics at the Faculty of Pharmacy, Rhodes University, South Africa, reported that “a couple of years I met up with the pharmacists on the Train and offered the use of the materials I had developed. As the Train travels around all areas of the country, patients speaking a huge variety of languages are tended to. A selection of our pictograms are now used as stickers which are attached to the medicine boxes or bottles and which provide a valuable communication tool, facilitating the interaction between provider and patient. It is extremely rewarding to see the outcome of many years of research impacting positively on patient care.”

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Another participant notes that there are national, provincial, and district health promotion and education programs focusing on healthy lifestyles, HIV and AIDS, nutrition, child and maternal health, and youth health, among other issues, but this individual did not report on any specifically based on or addressing health literacy. For example, a participant reported that the government offers health services at provincial hospitals and local clinics—and may hand out information pamphlets from time to time—but this individual was not aware of any efforts specifically focusing on health literacy.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN SOUTH AFRICA?

Participants reported that they are not aware of health literacy being formally defined as a public policy issue in South Africa. A participant reported that the term “health literacy” is not a commonly used term in South Africa. The expectation in the public health care system is that the vast majority of patients will be able to comprehend only very basic health information. Thus, this participant reported that there is almost no point in measuring health literacy, because no test exists that is simple enough to differentiate between the low levels of health literacy seen in South Africa.

Spain

GOVERNMENTAL POLICY

None reported.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The AIDS Research Institute IrsiCaixa is reported by participants to work with countries all over the world regarding research, but in regard to the field of health literacy the organization is only active in Spain. IrsiCaixa and the La Caixa Foundation conduct the Scientific Dissemination and Prevention Programme on AIDS. This program is reported to include multimedia tools offered via the IrsiCaixa Outreach website

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

(http://www.irsicaixa.es/outreach), participative dissemination and reflection workshops, experiment workshops where youngsters can perform real research experiments, and scientific updating sessions for teachers at the museums CosmoCaixa Barcelona and CaixaForums in other cities of Catalonia. Youth are encouraged to actively participate in the program, producing their own communication tools and/or disseminating the information using social networking, as well as in local communities within their environment.

Proyecto LIS España (http://lisic.isciii.es) is a search engine focused on providing health information that is selected through established quality criteria. The initiative is the result of technical cooperation between the National Library of Health Sciences of Spain and the Latin American and Caribbean Center on Health Sciences which is an agency of the Pan American Health Organization/WoHO.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

SIPES (Sistema de Información de Promoción y Educación para la Salud) is an effort to enhance communication between professionals and health institutions related to health promotion and education. Key objectives of the network include the exchange of information and experiences between professionals and various government institutions, organizations, social groups, and organizations working on issues related to health promotion and education; facilitating management initiatives and demands of existing health education to improve decision making in health promotion; providing evidence-based information on health promotion, accessible and professional schools, including implications for health services, education, and social services system; and improving the quality and accessibility of health information aimed at the general public, professionals, social groups, and organizations (http://sipes.msps.es/sipes2/indexAction.do).

HOW IS HEALTH LITERACY DEFINED IN SPAIN?

None reported.

Switzerland

GOVERNMENTAL POLICY

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The network of Swiss Public Health, Health Promotion Switzerland, the Careum Foundation, the Swiss Medical Association FMH, and MSD created Alliance Compétences en matière de santé. The goal of this organization is to significantly increase the health literacy of Swiss citizens and enable them to positively influence the determinants of health, risk assessment, and move independently within the health system. The organization has completed an assessment of health literacy in 22 of the 26 cantons of Switzerland. This report is available, in French, at http://www.alliance-competences-en-sante.ch/logicio/client/allianz/file/Projekte/20120222_Competences_en_sante_F_FINAL-001.pdf. The report found that health literacy was generally known, but not a public health priority. The organization also offered a prize for the most innovative projects in health literacy.

(See the Business section of the forthcoming report for other efforts in Switzerland.)

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

One training session in the Swiss Master of Public Health training was reported to be on the topic of health literacy. No further information was provided or available.

HOW IS HEALTH LITERACY DEFINED IN SWITZERLAND?

The Alliance Compétences en matière de santé defines health literacy as the ability to make decisions with a positive impact on health in everyday life. The organization states that health literacy is, among other things, knowledge and skills that allow an individual to behave favorable to health. The concept of “health literacy” has many facets. It is not only the case of the health system. Skills development in health is a cross-cutting theme that should include not only health insurance, medical, patient organizations but also the education sector, the food industry, and sport as well as retailers (http://www.alliance-competences-en-sante.ch/logicio/pmws/indexDOM.php?client_id=allianz&page_id=home&lang_iso639=fr).

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

Turkey

GOVERNMENTAL POLICY

A participant from Turkey noted that “First, I wanted to participate to your study and then I declined because in fact nothing has been done in terms of health literacy in Turkey. The efforts of the Turkish Ministry of Health in this field could not be named as health literacy but as health education and public awareness programs.” This participant noted that in Turkey illiteracy is an important social problem and around 5,000,000 cannot read and write. Among them 4,500,000 are women.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

While not specifically targeting or based on health literacy, a participant reported that in the 1980s, together with the Johns Hopkins University Center for Communication Programs and School of Public Health, the Turkish Ministry of Health launched a campaign for family planning based on the Enter Education approach; this was followed by efforts focusing on use of oral rehydration salts, vaccination against preventable communicable diseases, and AIDS prevention. In the 1990s, campaigns for public awareness against smoking, washing hands, preventing the flu were conducted. In the 2000s, antismoking campaigns are still occurring along with campaigns targeting obesity and the importance of physical exercise. All these campaigns were performed by showing short films and awareness spots on television, distributing pamphlets and posters, and through face-to-face interviews between health care providers and people.

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED IN TURKEY?

None reported.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

United Kingdom (Great Britain, Scotland, Wales, and Northern Ireland)

GOVERNMENTAL POLICY

Participants agreed that health literacy appears only in policy at the national level; there is not a United Kingdom wide policy on health literacy.

According to participants, the most developed strategy is that of Scotland. A participant from Scotland reported that while there is no national policy addressing health literacy, a scoping exercise was conducted with funding through the Health Improvement Strategy Division of the Scottish Government to assess the effects of poor health literacy on accessing local support and managing long-term conditions (http://www.scotland.gov.uk/Resource/Doc/296717/0092261.pdf). This report, released in 2009, states that

There is no appetite for, or requirement for a “health literacy strategy” for Scotland. This is mainly because the ideas underpinning health literacy are complex and diffuse. Pursuing a separate policy on health literacy would be counterproductive, and would not achieve the aim of improving health literacy across the population of Scotland. (The Scottish Government, 2009)

Instead, the recommendation is to “focus on the practical integration of the ideas underpinning health literacy into existing programmes, projects and initiatives.” Another participant reported that health literacy now has a prominent role in health policy development in regard to the Scottish government’s Person Centred Health and Care Program. This participant reported that the Scottish government has developed a national health literacy action group that brings together policy, practice, research, and education sectors to develop a National Health Literacy Action Plan (http://nhlag.wordpress.com).

In England, participants reported that health literacy is part of the health inequalities strategy report, Health Inequalities: Progress and Next Steps, available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085307. However, a participant noted that the government has changed since the publication of this report and health literacy does not appear in current government documents or reports.

Another participant noted that current government policy on the National Health Service is reflected in the report, Equity and Excellence: Liberating the NHS (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353). In particular, health literacy–related references in this policy document include

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

entries on shared decision making. These sections report that “we want the principle of ‘shared decision-making’ to become the norm: no decision about me without me” (Department of Health, 2010). Also, that the “new NHS Commissioning Board will champion patient and carer involvement, and the Secretary of State will hold it to account for progress. In the meantime, the Department will work with patients, carers and professional groups, to bring forward proposals about transforming care through shared decision-making” (Department of Health, 2010).

In Wales, health literacy is reported to be a part of the public health strategy, Our Healthy Future, a strategic action plan for reducing health inequity. As part of that strategy, the report Fairer Health Outcomes for All: Reducing Inequities in Health Strategic Action Plan directly addresses health literacy (http://wales.gov.uk/docs/phhs/publications/110329working2en.pdf). Health literacy is one of the seven action areas indicated in this report.

There is no report of a health literacy policy in Northern Ireland.

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

Health Literacy Group UK is a Special Interest Group of the Society for Academic Primary Care that participants reported is committed to raising the profile of health literacy as a remediable cause of health inequalities in England, and to developing and undertaking research to achieve that. The group allows membership for individuals outside of the United Kingdom as well (http://www.healthliteracy.org.uk).

Reflecting the level of policy involvement noted above, the Scottish government is reported by participants to have funded several health literacy projects. Education Scotland maintains a database of these efforts at http://www.educationscotland.gov.uk/communitylearninganddevelopment/adultlearning/adultliteracies/adultliteraciesinpractice/health.asp. This includes many examples of partnerships in Scotland between adult-learning providers and the health sector and also features a Communities of Practice forum, a segment of which is focused on health literacy efforts.

In England, participants reported that the Skilled for Health (SfH) program is the national learning program that embeds Skills for Life learning into health improvement topics. SfH courses and workshops address both the low skills and health inequalities prevalent within traditionally disadvantaged communities. This program uses an embedded approach to add to our understanding of how these issues can be addressed (http://www.continyou.org.uk/what_we_do/skilled_health). This approach is reflected in the use of an innovative national partnership

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

to run the program, consisting of the Department of Health, the Department for Business, Innovation and Skills (formerly the Department for Innovation, Universities and Skills) and the learning and health charity ContinYou, which has overseen SfH since its inception (ContinYou, 2011b). ContinYou is one of the United Kingdom’s leading education charities that provide services in partnership with schools for children and young people across the country, particularly those from the most disadvantaged communities (ContinYou, 2011a).

Another national project in health literacy in England reported by participants included a national curriculum focusing on personal, social, health, and economic education in the school system (http://www.education.gov.uk/schools/teachingandlearning/curriculum/secondary/b00198880/pshee).

The “Expert Patients Programme” (EPP) is a self-management effort for people who are living with a chronic (long-term) condition. The aim is to support people by increasing their confidence, improving their quality of life, and helping them manage their condition more effectively (NHS, 2012). An expert patient is described as an individual who, “feels confident and in control of their life, aims to manage their condition and its treatment in partnership with healthcare professionals, communicates effectively with professionals and is willing to share responsibility for treatment, is realistic about how their condition affects them and their family, and uses their skills and knowledge to lead a full life” (NHS, 2012).

The Welsh Government, a participant reported, has commissioned work on developing a strategic approach to health literacy in Wales from Public Health Wales, which is the national organization that leads on public health. Participants reported the policy efforts in Wales draw on an effort, produced in 2010, Health Literacy in Wales: A Scoping Document for Wales. This report provides context on the health literacy situation and activities in Wales and is available at http://www.google.co.uk/url?sa=t&rct=j&q=wales%20health%20literacy%20osborne&source=web&cd=1&ved=0CFIQFjAA&url=http%3A%2F%2Fwww2.nphs.wales.nhs.uk%3A8080%2Fcommunicationsgroupdocs.nsf%2F61c1e930f9121fd080256f2a004937ed%2Fa2588bc62b678a5b802578c70032b10e%2F%24FILE%2FHealth%2520Literacy%2520Scoping%2520Document%2520FINAL%2520Sarah%2520Puntoni.pdf&ei=FJPfT5iJNsTOtAbB4viDCQ&usg=AFQjCNHjju67ttRRPdCJzXkQrXgbHKy46w.

Participants reported that ongoing work in Wales includes efforts to create a program of work related to raising awareness of functional health literacy and health, including guidelines and standards for public health information and translation and validation of measurement tools for use in the Welsh language.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

In Wales, a participant reported that aspects of health literacy are included within the Personal and Social Education Curriculum and the Skills Development Curriculum (http://wales.gov.uk/topics/educationandskills/schoolshome/curriculuminwales/arevisedcurriculumforwales/pse/?lang=en) and that the Welsh Government also supports self management programs for those with chronic conditions (http://www.eppwales.org).

Participants note that the Scottish Government funded several projects on health and numeracy, many concentrating on drug calculation for nurses and others focusing on raising awareness within health sector staff (http://www.educationscotland.gov.uk/communitylearninganddevelopment/adultlearning/adultliteracies/adultliteraciesinpractice/health.asp).

BOX A-5
How Did You First Learn About Health Literacy?

“Several years ago I got a call for papers [in an] e-mail from a scientific journal concerning studies about health literacy. This was the first time that I heard the term of health literacy and I searched for the meaning. I read many scholarly articles about health literacy and most of them were from USA. Together with my colleagues we planned to perform a study on this subject and we did.”

—Participant from Turkey

The Patient Information Forum (http://www.pifonline.org.uk) is a membership organization for consumer health information producers and providers in the United Kingdom. The organization is reported to campaign to ensure that health information is central to high-quality, patient-centered care and helps producers and providers to develop high-quality information for their patients and the public. The organization offers health literacy resources, meetings and seminars, reports, and group sessions.

HOW IS HEALTH LITERACY DEFINED IN THE UNITED KINGDOM?

One participant reported that health literacy is defined in the United Kingdom as representing “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand,

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

and use information in ways which promote and maintain good health. Health literacy means more than being able to read pamphlets and successfully make appointments. By improving people’s access to health information and their capacity to use it effectively, health literacy is critical to empowerment.”

On a rather similar note, the Department of Health in England’s report on Health Inequalities defines health literacy as “the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways that promote and maintain good health. This means much more than transmitting information and developing skills to undertake basic tasks. It is also necessary to improve people’s access to, and understanding of, health information and their capacity to use it effectively supports improved health.”

Another participant reported that health literacy is operationalized in the United Kingdom mainly in terms of health care, shared decision making, and successful management of long-term conditions.

In Wales, according to multiple participants, health literacy has been recently defined as “the ability and motivation level of an individual to access, understand, communicate, and evaluate both narrative and numeric information to promote, manage, and improve their health status throughout their lifetime.” Participants note that this is a modification of a definition prepared by a Canadian Expert panel in order to demonstrate the role of both narrative and numeracy abilities and to reflect a motivational dimension to health literacy.

Participants reported that in Scotland, multiple definitions are stated in policy documents and no single definition is widely accepted or used.

Zimbabwe

GOVERNMENTAL POLICY

The Ministry of Health and Child Welfare in Zimbabwe reported that the government has shown commitment to increasing health literacy levels through supporting health promotion activities over the past several years. The Ministry points to a decline in HIV prevalence as evidence that individuals are translating their HIV literacy into action (Ministry of Health and Child Welfare, 2009).

The 2009 Assessment Survey of Primary Health Care in Zimbabwe (“Health where it matters most”) found that information is fundamental in disease prevention and control. The assessment found that people in Zimbabwe “have a reasonable knowledge of common health conditions, but lack the specific knowledge needed to act in an informed way to promote

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
×

and protect their health (such as how to make and use sugar salt solution (SSS) to manage dehydration)” (Ministry of Health and Child Welfare, 2009).

The Ministry reports that the assessment data is supporting efforts to ensure that communities to have consistent, regular, specific information flows and recommends that ad hoc and one-off information to communities needs to be integrated into a more comprehensive health literacy program, as is currently being implemented in the districts supported by the Community Working Group on Health (CWGH). Support for the functioning of Village Health Workers and other community-based health workers, person-to-person health information and mass media also provide a means to improved health information flows (Ministry of Health and Child Welfare, 2009).

HEALTH LITERACY INITIATIVES (GOVERNMENTAL AND NONGOVERNMENTAL)

The CWGH is a network of approximately 30 civic/community-based organizations that aim to collectively enhance community participation in health in Zimbabwe. The CWGH was formed in early 1998 to take up health issues of common concern and was registered as a trust in 2002 (http://www.cwgh.co.zw).

Health literacy is one of the four programmatic areas of the CWGH, the other being adolescent reproductive health, advocacy and lobbying, and community home-based care.

The Health Literacy program is reported to have grown out of a civic education on health program that, in turn, arose out of concern about the deterioration of key social indicators during the 1990s. Demand for information and participation from civic groups in 1998 on a range of public health, health systems, and organizational issues saw the birth of this program. The Health Literacy Program aims to consolidate the work done through the Civic Education program, identifying and filling gaps, as well as to introduce innovative processes and concepts into the work. It is a regional program of work in East and Southern Africa being coordinated by TARSC Zimbabwe.

The health literacy effort is reported to be operating in Zimbabwe, Malawi, and Botswana to support the development and use of participatory health education materials for health civil society. Health facilities are realizing the importance of health literacy and are starting to develop health literacy programs to address the difficulties that patients have in obtaining and understanding health information, to equip civil societies in selected communities with the skills they need to assess quality of service delivery at their health institutions. For example, the effort is

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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reported to have partnered with the Zimbabwe Association of Church-related Hospitals (ZACH) to build health literacy in health centre committees in clinics in two ZACH districts. This program hopes to increase level of knowledge of communities around health facilities on quality health services responsive to their needs. The work also facilitates and supports the establishment of mechanisms of community participation, such as Health Centre Committees, district chapters and Health Advisory Boards. The effort is reported to have trained a total of 60 facilitators from the Northern and Southern Regions of Zimbabwe that are implementing health literacy community programs in 20 districts in Zimbabwe.

The CWGH Zimbabwe has also started work around resuscitating community health committees in districts through reviving the Health Centre Committees and linking them with the Health Literacy facilitators in the districts under the program “Strengthening Health Centre Committees: Enhancing Community Participation in Health.” Health Centre Committees are vehicles through which communities can participate in primary health care and district health systems. The work being done under the health literacy program facilitates and supports the establishment of mechanisms of community participation. Health literacy campaigns have been held at both the district and national level while the community health literacy trainings have reportedly reached more than 3,500 people and have the capacity to multiply. CWGH has campaigned for health literacy as a means to attaining some of the Millennium Development Goals, in improving primary health care, and in organizing people’s power for health at the CWGH 15th annual conference held in October 2008 (CWGH, 2012).

EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

The CWGH efforts described above include specific components targeting Village Health Workers and other community-based health workers.

HOW IS HEALTH LITERACY DEFINED IN ZIMBABWE?

The CWGH defines literacy as an individual’s ability to read and write and the degree to which a person can apply these skills to function in society, learn and achieve goals. Health literacy specifically refers to one’s ability to obtain, process, and understand health information and services to make appropriate health decisions (CWGH, 2012).

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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European Union (EU)

EU POLICY

The white paper “Together for Health: A Strategic Approach for the EU 2008–2013” puts forth, first, a justification for policy efforts at the EU level. “Member States have the main responsibility for health policy and provision of healthcare to European citizens. The EC’s role is not to mirror or duplicate their work. However, there are areas where Member States cannot act alone effectively and where cooperative action at Community level is indispensable. These include major health threats and issues with a cross-border or international impact, such as pandemics and bioterrorism, as well as those relating to free movement of goods, services and people” (Commission of the European Communities, 2007). The document continues by laying out core values held by members of the European community related to health policy. These core values are, in part, extrapolated from the report Council Conclusions on Common Values and Principles in European Union Health Systems (http://eurlex.europa.eu/LexUriServ/site/en/oj/2006/c_146/c_14620060622en00010003.pdf). That report states, for example, that “The overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different EU institutions,” and that “All health systems in the EU aim to make provision, which is patient-centred and responsive to individual need” (The Council of the European Union, 2006). Building upon that basis, the White Paper identified a core value of “Citizen’s Empowerment.” This value is described as meaning that “Community health policy must take citizens’ and patients’ rights as a key starting point. This includes participation in and influence on decision-making, as well as competences needed for wellbeing, including ‘health literacy’” (Commission of the European Communities, 2007).

EU HEALTH LITERACY INITIATIVES

Health literacy efforts seem to be increasing in number across the European Union. Perhaps most often reported is the European Health Literacy Survey (HLS-EU). The objectives of the initial effort, from 2009 to 2011, were to

  • establish a European Health Literacy Network;
  • adapt a model instrument for measuring health literacy in Europe;
  • generate first-time data on health literacy in European countries, providing indicators for national and EU monitoring;
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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  • make comparative assessment of health literacy in European countries; and
  • create National Advisory Boards in countries participating in the survey and to document different strategies to establish an economic basis for health literacy efforts in differing national structures and priorities (Maastricht University 2011).

The effort has successfully conducted a health literacy assessment in eight countries—Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland, and Spain. Initial results collected during the summer of 2011 provide first-time data on health literacy across eight European countries (http://www.health-literacy.eu). The results of the HLS-EU were first reported at the European Health Literacy Conference in November 2011. The event, held in Brussels, attracted more than 150 participants from more than 20 countries (http://www.maastrichtuniversity.nl/web/Institutes/FHML/FHML/DepartmentsCAPHRI/InternationalHealth/ResearchINTHEALTH/Projects/HealthLiteracyHLSEU/Events.htm).

Although health literacy is not mentioned specifically in the EU 2020 strategy, the European Commission has launched the program “Health for Growth” in the context of the EU2020 strategy to increase productivity and to meet the challenges of an aging population and chronic diseases (http://ec.europa.eu/health/programme/docs/prop_prog2014_en.pdf). Health literacy, however, is not explicitly mentioned as part of the effort.

A respondent reported that growing interest in health literacy across the European Union is, in part, due to a panel discussion held as part of the 8th European Health Forum Gastein (2005) where a panel of international experts discussed health literacy and its importance and impact on Europeans. The report Navigating Health: The Role of Health Literacy is reported to have laid the foundation for EU recognition of health literacy as a critical empowerment strategy for European citizens and a pillar of both health and lifelong learning (http://www.emhf.org/resource_images/NavigatingHealth_FINAL.pdf).

More recently, The Collaborative Venture on Health Literacy is one of the priority initiatives of Enterprise 2020 of CSR Europe (http://www.csreurope.org). The effort was launched in 2010 and is jointly led by Edenred, Microsoft, MSD, Nestlé, Maastricht University, and Business in the Community UK with the support of CSR Europe. The effort produced a report, “Blueprint for Action on Health Literacy: Creating Value for Employees, Businesses and Indirectly the Wider Communities.” This report essentially provides a toolbox for businesses to strengthen the health literacy of their employees by laying out the business case for health literacy and the justification for health literacy as the basis for corporate social responsibility activities (http://www.csreurope.org/data/

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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files/HL_Blueprint_/Final_Draft_HL_Blueprint_14_March_2012_FINAL.pdf).

A participant also reported on an EU project “Xplore Health” which targets youth from 15 to 18 years old with the aim to improve health literacy, to inspire future researchers in this area, and to bridge the gap between biomedical research and education (http://www.xplorehealth.eu). The initiative is reported to be an educational portal on cutting-edge health research that offers innovative multimedia and hands-on experiences to young people through the Internet, schools and science centers and museums (XploreHealth, 2010). The portal offers videos, computer games, virtual experiments, card games to promote dialogues on ethical, legal, and social aspects, and protocols of experiments linked to current research and activities for the classroom.

A brief roundup of health literacy efforts and policies across EU is offered at EurActiv.com where the issue is framed as moving forward as, “The first half of 2012 is set to see the Council and Parliament debate the Commission’s new proposals for updating the directive on information to patients on medicines. The debate will take place against a backdrop of statistics showing that almost half of Europe’s patients are ‘health illiterates’” (Health Literacy: Helping Patients Help Themselves, 2012).

EU EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

None reported.

HOW IS HEALTH LITERACY DEFINED BY THE EUROPEAN UNION?

Respondents reported that health literacy is defined as the ability to make sound health decisions in the context of everyday life, at home, in the community, at the workplace, in the health care system, the market place, and the political arena. It is a critical empowerment strategy to increase people’s control over their health, their ability to seek out information and their ability to take responsibility. Others reported that health literacy is defined as the ability to read, filter, and understand health information in order to form sound judgments.

The European Health Literacy Survey (HLS-EU) effort is reported to have adopted an integrated definition of health literacy, which was developed from a review of more than 15 definitions found in scientific literature. This approach posits that health literacy is based on general literacy and entails people’s knowledge, motivation, and competences to access, understand, appraise, and apply health information to make

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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judgments and take decisions in terms of health care, disease prevention, and health promotion in order to maintain and improve quality of life throughout the life course (Sørensen et al., 2012).

As reported from several nations, other respondents reported that they are not able to accurately offer a single definition of health literacy in the European Union, as there is variation within the member states.

United Nations (UN)

UN POLICY

In 2011, the UN General Assembly adopted the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. In part, this resolution asserts that in order to reduce the risk of noncommunicable diseases and create health promoting environments, measures shall be taken to “Develop, strengthen and implement, as appropriate, multisectoral public policies and action plans to promote health education and health literacy, including through evidence-based education and information strategies and programmes in and out of schools, and through public awareness campaigns, as important factors in furthering the prevention and control of non-communicable diseases, recognizing that a strong focus on health literacy is at an early stage in many countries” (UN, 2011).

Also in 2011, the WHO Regional Office for Europe released a report, “Patient Engagement in Reducing Safety Risks in Health Care,” which explicitly “aims to improve patient safety by enhancing patient empowerment and health literacy” (WHO, 2011). The same WHO office produced an earlier report in 2010, “Patient safety and rights: Developing tools to support consumer health literacy.” In particular, this report asserts that “Both the topics of patient safety and patient rights are high on the health agendas of countries in the European region. This project aims to bridge the two approaches by trying to look at the links between patient rights and patient safety and more particular at means to improve patient safety by enhancing patient empowerment and health literacy.” Specific foci of the project include blood transfusion, hospital infections/hand hygiene, and communication during patient handovers (WHO, 2010).

Earlier, in July of 2009, the UN Economic and Social Council (ECOSOC) issued a Ministerial Declaration that paid explicit attention to health literacy, which was “seen as an important factor in ensuring significant health outcomes,” and included a call for appropriate action plans to promote health literacy (WHO, 2009).

More recently, in 2001 the United Nations Educational, Scientific

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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and Cultural Organization (UNESCO) hosted the International Conference on Women’s Literacy for Inclusive and Sustainable Development. While the conference highlighted the role of literacy, no explicit mention was made of health literacy (http://portal.unesco.org/geography/en/files/14476/13190177885Outcome_Document.pdf/Outcome%2BDocument.pdf).

In the UN Convention on Rights of People with Disability of 2006, Article 2 described the breadth of communication modes, Article 9 addresses issues of accessibility, and Article 21 addresses issues related to freedom of expression and opinion and access to information. Further discussion can be found in Basterfield (2009).

UN HEALTH LITERACY INITIATIVES

The WHO’s 7th Global Conference on Health Promotion in 2009, held in Nairobi, Kenya, featured a specific track focusing on health literacy. A working document on health literacy was prepared to inform the discussion on health literacy, available at http://www.who.int/healthpromotion/conferences/7gchp/Track1_Inner.pdf.

Another member of the UN family of organizations, UNESCO, held a 2009 Regional Ministerial meeting on “Promoting Health Literacy” in Beijing, China. A summary report of the meeting is available at http://www.un.org/Docs/journal/asp/ws.asp?m=E/2009/104.

The WHO Healthy Cities Network includes efforts in more than 1,000 cities around the world and in every WHO region. The effort is reported to undertake a wide variety of projects addressing health literacy, health promotion, social marketing, and education (http://www.who.int/healthy_settings/types/cities/en).

The UNESCO Institute for Education produced a report on the follow-up to the Fifth International Conference on Adult Education (CONFINTEA V), held in Hamburg in 1997. The report specifically highlights health literacy as a tool for policy development and that it is necessary to identify indicators for the health literacy of individuals and society. Additionally, the report recommends that strategies to increase health literacy need to be developed (UNESCO, 1999).

An article in the UN Chronicle links health literacy with sustainable development. The article specifically relates information on UN projects ongoing in Angola, Mexico, Moldova, and Vietnam (http://www.un.org/wcm/content/site/chronicle/home/archive/issues2009/wemustdisarm/healthliteracyandsustainabledevelopment).

United Nations Children’s Fund (UNICEF) is also reported to conduct health literacy–related efforts around the world. For example, the 2010 UNICEF annual report on efforts in China reports that the organization’s

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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Health and Nutrition program will follow a health systems approach to reach the overall objective to support China’s health sector reform so that “poor and vulnerable children and women will enjoy a better health and nutrition status, and protection from disease and impoverishment due to ill health, in line with 2011–2015 United Nations Development Assistance Framework (UNDAF) outcome two” (UNICEF, 2010). Objectively improving levels of health literacy among leaders and beneficiaries is a key expected result of that outcome.

Other efforts reported by participants to be related to health literacy at the UN level include

UN EDUCATIONAL EFFORTS TARGETING HEALTH PROFESSIONALS

UNESCO is reported to have provided training for health care providers in Africa on doctor patient communication. No other information was reported.

HOW IS HEALTH LITERACY DEFINED BY THE UNITED NATIONS?

In 1998, the WHO Health Promotion Glossary defined health literacy as, “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” (WHO, 1998).

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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The UNESCO 2009 meeting discussed above defined health literacy as “the ability to gain access to, understand and use health information for promoting and maintaining good health” (UNESCO, 1999).

WHO is also reported to have defined health literacy as “the achievement of a level of knowledge, personal skills, and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment. Health literacy is itself dependent upon more general levels of literacy. Poor literacy can affect people’s health directly by limiting their personal, social and cultural development, as well as hindering the development of health literacy” (European Health Management Association, 2008).

International Nongovernmental Organizations (in alphabetical order)

Participants in the data-gathering process that helped create these reports on health literacy efforts around the world identified several NGOs that are conducting efforts in more than one nation. In this section, those health literacy efforts conducted by NGOs working in multiple countries are reported in alphabetical order.

The Asia-Europe Foundation—Health on Stage Program

The Asia-Europe Foundation program (http://www.asef.org/index.php/projects/themes/public-health/1987-10th-asia-europe-young-volunteers-exchange-health-on-stage). This program aimed to involve young people in tackling key global public health issues. Twenty-seven young participants from 14 countries in Asia and Europe gathered in three cities in India: Bangalore, Chennai, and Mysore. They identified crucial health issues in these areas and put together a series of plays from August to October 2011, which reached out to more than 3,000 people from the local communities. The forum theatre format was chosen as it allowed interaction and engagement between the audience and volunteers and thereby created opportunities for a meaningful dialogue on cultural and health issues (Wongjarin, 2012). Health on Stage aimed to enhance cultural competencies and creative thinking of young volunteers in fostering dialogue on public health, focusing on water-related health issues. The initiative was a response to the recommendations of the Connecting Civil Society Conference 4 (CCS4), an official side-event of the 8th Asia-Europe

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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Meeting Heads of State and Government Summit, which took place in Brussels, Belgium, in 2010. At the Summit, the role of youth in promoting public health was emphasized.

Canyon Ranch Institute

Canyon Ranch Institute (http://www.canyonranchinstitute.org) is a 501(c)3 nonprofit public charity based in the United States and has, to date, conducted health literacy programs in Peru and the United States. In Peru, the organization developed the “Arts for Behavior Change” program, a study that developed and tested a new methodology, “Theater for Health,” that used the arts to advance health literacy and, as a result, improved knowledge, home hygiene behaviors, and reduced microbiological risk factors among residents of a low-income community in Lima, Peru. In the United States, the organization has 14 active partnerships with a broad range of organizations in business, education, health care, and policy. The partnerships range from focusing on improving health policy to creating active community-based health literacy efforts like the Canyon Ranch Institute Life Enhancement Program and Time to Talk CARDIO.

European Patients Forum

The European Patients Forum (EPF) is based in Brussels and works European-wide. A participant reported that the EPF holds health literacy high on the agenda in terms of patients’ rights and safety. The group organized a conference with health literacy as a theme in 2008 and partner on the issue in European Union matters as they strive to raise awareness of health literacy and integrate it into policies (http://www.eu-patient.eu).

BOX A-6
How Did You First Learn About Health Literacy?

“I believe that the first time I learned about health literacy was in 1989 when I had dinner with Scott Ratzan in Toronto after he had done a presentation for the Health Communication Unit which was part of the Centre for Heath Promotion at the University of Toronto that I directed at the time.

That encounter led me to be invited to a meeting on health literacy in Washington sponsored by Pfizer. A subsequent meeting with Rima Rudd when I joined the Institute of Medicine Board on Health Promotion cemented my interest in the topic and ultimately led me to do research using this concept and to participate in the Institute of Medicine Committee on Health Literacy and Co-Chair the Canadian Expert Panel on Health Literacy.”

—Canadian participant

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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International Union of Health Promotion and Education (IUHPE)

The IUHPE established a Global Working Group on Health Literacy in 2011 (http://iuhpe.org/index.html?page=661&lang=en). The group has established a 3-year work plan for promoting healthy literacy policy, practice, and research. Members of the working group are from different regions of the world. IUHPE has designated health literacy as one of the central topics for sub-plenary sessions in the upcoming world conference and a priority area. Multiple presentations and workshops on health literacy have been organized at previous international conferences.

Sisters of Mercy of the Americas

Sisters of Mercy of the Americas is reported by a participant to have been carrying out their mission in the following eight countries (year efforts started in each nation are in parenthesis): Argentina (1856), Belize (1883), Chile (1965), Guatemala (1971), Guyana (1894), Honduras (1959), Panama (1959), and Peru (1962). Ministries in the eight countries range from formal education and health care to empowerment of women, care of children, aid to those suffering from poverty, literacy education, and pastoral responses to spiritual and temporal hungers. The participant reported that the organization’s tradition of formal education is continuing at Colegio Santa Ethnea in Argentina, Muffles Junior College and St. Catherine Academy in Belize as well as Instituto Maria Regina in Honduras. Literacy and alternative educational programs are ongoing in Argentina, Guyana, Panama, and Peru. All the educational endeavors give particular attention to women and children suffering from poverty (http://www.sistersofmercy.org).

The What to Expect Foundation

On June 14, 2012, U.S. Secretary of State Hillary Clinton announced what is perhaps the newest health literacy initiative that will be ongoing in multiple nations—specifically in Bangladesh, Brazil, and Liberia. The U.S. Office of Global Women’s Issues is partnered with The What to Expect Foundation (http://www.whattoexpect.org) to implement their Baby Basics Program in these three nations. The Women’s Health Innovation Program will expand the Foundation’s work to the international arena, and will be piloted in Bangladesh, Brazil, and Liberia. Building on more than 10 years of successful implementation across the United States, the international program aims to empower vulnerable and expectant mothers with evidence-based, culturally appropriate pregnancy information, education, and social support, in an effort to improve maternal and

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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child health and literacy. The Foundation will develop innovative materials inspired and informed by their Baby Basics book and prenatal health literacy program. Work will be implemented with local partners and government agencies. The partnership will support and coordinate the work of front-line health care providers and policy makers by fostering collaboration, increasing capacity and ensuring that health information is accurate, comprehensive and readily available and accessible. The goals of the program are

  • To provide evidence-based, culturally appropriate pregnancy and parenting materials to underserved families that are attractive, comprehensive and easy to read, and serve as a catalyst for learning and family literacy;
  • To empower and educate low-income expecting women so they have the skills and the support they need to advocate for themselves, their babies, families and communities;
  • To teach health care providers, educators and communities how to respectfully engage, communicate and educate low-income mothers during their pregnancy and childbirth; and
  • To build initiatives to bring communities together to support pregnant and new mothers’ learning, and ensure families receive compassionate information and timely care.

A small grants component will be awarded to local grassroots organizations to implement the program using the country-specific Baby Basics tools and curriculum.

World University Network (WUN)

The WUN held a Global Public Health Conference held in May 2012, where their Health Literacy Network held their first workshop to generate ideas about collaborative projects. This initial meeting resulted in five working research groups, centered on the following themes (http://www.wun.ac.uk/research/wun-global-health-literacy-network):

  • Health literacy conceptual and priority issues
  • Health literacy in an age of digital communication
  • Health literacy and health inequalities
  • Integrating health literacy into health professional training
  • Participatory approaches to health literacy research
Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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PRELIMINARY SUMMARY AND CONCLUSIONS

This discussion paper details the responses received regarding health literacy efforts outside of the United States as well as efforts reported in the European Union and the United Nations. A forthcoming paper will detail responses about health literacy efforts occurring within the United States. That forthcoming paper will also report on efforts sponsored by the business community around the world. Additionally, that forthcoming paper will include information on what participants in this process suggest as the best next steps for the field of health literacy and their quantitative assessments of the state of the field of health literacy.

Essentially, these two planned discussion papers make up two parts of a larger whole. The decision to separate the information was based on a desire to not create an appearance that health literacy efforts in the United States were any more advanced than in other nations. The amount of data from one nation compared to another or several nations is simply an indication of quantity, not necessarily quality. Additionally, given the vast amount of information collected in this effort, combining the information into one document would have produced a discussion paper that was quite simply impractical in length. Thus, given the amount of information to come in the forthcoming report, the conclusions and recommendations in this initial paper on health literacy activities occurring outside of the United States are necessarily preliminary and constrained.

Much of these data could perhaps have been subsumed in analysis versus reported, but there is a certain obligation to participants in such an effort to report their data as accurately and completely as possible from a non-critical perspective. The central aspiration is that this and the forthcoming discussion paper on efforts in the United States will provide a baseline that can and should be used for future study and comparison. The hope is that this effort uncovered a sufficient sample of activities to give an adequate—though incomplete—“taste” of how health literacy is being put to use and diffusing around the world. Clearly, however, the population of interest remains under-sampled—especially in nations where English is not the primary language.

Turning to analysis of the information that was gathered and reported, several points seem worth highlighting. First, the reports received from many nations clearly indicate the vital importance of leadership within a governmental structure. When leadership clearly adopts health literacy as an important factor, the results are significant. The vast body of evidence about health literacy supports the active promotion of health literacy by governmental, social, and cultural leaders, but nonetheless uptake among policy makers around the world seems delayed in many—but certainly not all—instances. To those policy makers remaining on the edge of the field as spectators, hopefully this key finding will suggest the presence

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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of a clear opportunity. You will create a positive effect if health literacy is made central to your platform.

Second, the importance of engaging broad-based multidisciplinary partnerships is equally clear across the spectrum of information and sources that this effort encountered. A best practice of health literacy is to involve people early and often in order to better engage with their entire life. That inherently requires an integrative approach to be successful, and that is something many health care organizations are just coming to appreciate and embrace. Often, health care facilities may not have the personnel on hand to create an integrative, multidisciplinary effort—but rarely is it the case that an entire community does not have the resources to do so. Thus, creating partnerships across organizations may well be a critically important key to successful health literacy policy and practice efforts. Embracing both those approaches—adopting health literacy at the highest levels of leadership and creating multidisciplinary partnerships between organizations—seems likely to produce even greater progress in addressing health disparities around the world.

Several other lessons to policy makers and advocates should be clear as a result of this discussion paper. First, there is more than sufficient technical knowledge in the world to resolve many of the health issues that continue to plague the human population. What has been lacking is the means to effectively translate that knowledge into universal and precautionary action. The primary challenges seem to lie in how robust health literacy is conceptualized and the ability and willingness to engage a diverse group of stakeholders.

Next, it seems increasingly clear as a result of this data collection and reporting process that when governments have collected data on the status of health literacy among the populations they serve, they have also created health literacy policies and intervention projects. This project’s design is limited in its ability to determine whether the data collection prompts policy development, or whether policy development causes data collection efforts, but a relationship clearly exists. A long history of research into health policy and efforts to inform practice with evidence confirms the importance of robust data to support the policy creation processes. Still, that remains a complex relationship that is neither unidirectional nor unidimensional. The causality, effectiveness, and outcomes of that relationship will, and should, be subject to continuing analysis. For example, a very promising area for future analysis of this relationship for the field of health literacy is to observe the outcomes to the recently completed survey of health literacy in eight European nations. Many of those nations are not among the leaders in creating health literacy policy to date, according to the results of this effort. The future outcomes of that effort shall help the field discover the direction and strength of the

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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relationship between empirical data collection and policy activity in a variety of geopolitical and social contexts, but only if adequate resources are directed to the evaluation of the outcomes of that measurement effort.

Some, however, may question if an emphasis on policy making is warranted in a field that focuses so strongly on empowering individuals and communities to take action. Ironically, an emphasis on individual empowerment could lead to a logical fallacy that health literacy is not a policy-related field, as “top-down” efforts are not the primary or initial goal. However, a primary goal of empowering individuals and communities through advancing their health literacy is, in fact, to change or develop policies that produce healthier outcomes for all people. Thus, a monitoring of policy progress is a key indicator of the effectiveness of the field of health literacy and should remain a consideration of those designing health literacy interventions.

The information gathered in this effort does point out a critically important area for reflection and a strategic choice that faces the field of health literacy. Health literacy efforts are likely under way in every nation around the world. However, many may not have adopted the phrase “health literacy.” An open-ended definition of the concept that accepts all comers has certainly helped the field of health literacy to rapidly grow. This discussion paper makes that growth increasingly clear. However, this effort has also found indications of cracks at the foundation to the field—especially as efforts to introduce health literacy into governmental policy move forward. Despite multiple policy initiatives, there remains to date a lack of a clear and effective approach to incorporating health literacy into policy that moves beyond rhetoric and into regulation that requires health literacy as a universal precaution. The one possible exception that may be emerging is plain language requirements, but those seem to be often either voluntary or not stringently enforced. Further, plain language in and of itself is unlikely to reach the level of effect that can be achieved through a focus on a more robust conceptualization of health literacy.

Health literacy, even more clearly as a result of this data collection process, is a socially constructed concept that nearly everyone agrees is important. However, very few seem to agree on what the concept actually represents. The risk to continuing that situation seems clear. If there is not a broadly shared consensus about the definition of health literacy, then the measurement and identification of health literacy remain problematic—and that puts into risk the adoption and effectiveness of policy formulations addressing health literacy.

Health literacy may well be a field on the verge of needing to make a major, collective decision. One path is to continue with the current status quo that does not demand a certain level of consensus or rigor regarding what is or is not health literacy. This approach, as demonstrated in this

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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discussion paper, has attracted a broad range of interest and activity. A second path is to collectively agree on a core definition of health literacy that makes a distinction between a health literacy effort and, for example, efforts in health education or health communication. Those efforts are certainly not unrelated, but a core definition of the constructs can be delineated, measured, evaluated, and formulated into policy constructs if the will to do so is present.

One possible approach to making that distinction, should the field decide to move in that direction, is by defining health literacy as a theoretical cause of behavior change that produces positive health outcomes. That path would necessitate that studies of health literacy not stop data collection efforts at documenting the acquisition of knowledge or at the change of attitudes. Those outcomes have been historically true of much of health communication and health education—and much of health literacy to date. A more rigorous approach would demand that to be truly health literacy, efforts must demonstrate that the health literacy intervention caused behavior changes that produced health effects. In that sense, health literacy could use strategies from health communication and health education, but in many instances those strategies (or theories) would in and of themselves be insufficient to be identified as health literacy. That, in fact, is a very high bar that may even be unattainable. For instance, if this effort had initiated criteria for inclusion such that the collection and reporting of data about changes in health behavior and health status were requisite, at least half—if not vastly more—of the initiatives reported in this and the forthcoming discussion paper would likely have been excluded. Such criteria would have also demanded a nearly universal exclusion of the policy efforts reported around the world as they, by and large, have not been evaluated for outcomes.

Looking forward to the completion and distribution of the forthcoming discussion paper, it is important to note in closing that there should be much room for optimism given the clear expansion of health literacy that is documented in this initial discussion paper and will continue in the forthcoming paper. Awareness of and use of health literacy has diffused into some of the most remote regions of the world. Health literacy has also diffused into the heart of many of the most populous and connected locations on earth. Both are locations where people can and do experience some of the greatest inequities in health and where a rigorous application of health literacy’s best practices—which we continue to develop—can have a tremendous and positive effect. That reality and the growing awareness of health literacy around the world are outcomes that clearly should be celebrated.

Suggested Citation:"Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States." Institute of Medicine. 2013. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18325.
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Next: Appendix B: Speaker Biosketches »
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The roots of health literacy can be traced back to the national literacy movement in India under Gandhi and to aid groups working in Africa to promote education and health. The term health literacy was first used in 1974 and described as "health education meeting minimal standards for all school grade levels". From that first use the definition of health literacy evolved during the next 30 years with official definitions promulgated by government agencies and large programs. Despite differences among these definitions, they all hold in common the idea that health literacy involves the need for people to understand information that helps them maintain good health.

Although the United States produces a majority of the research on health literacy, Europe has strong multinational programs as well as research efforts, and health literacy experts in developing countries have created successful programs implemented on a community level. Given these distinct strengths of efforts worldwide, there are many opportunities for collaboration. International collaboration can harness the United States' research power, Europe's multilingual and multinational experience, and developing nations' community-based programs to create robust programs and research that reach people—not based on language or nationality but on need and value.

A workshop on international health literacy efforts that feature presentations and discussion about health literacy interventions from various countries as well as other topics related to international health literacy was held as the basis for this report. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World summarizes the findings and discussions at the workshop.

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