An overview of some of the most innovate and person-, practitioner-, and policymaker-centered thinking about health literacy

1. Acknowledgements.
Innovations in Health literacy:
from measurement to intervention Monash'University,'Australia'
.Prof.Rachelle.Buchbinder.
Deakin'University,'Australia'
Richard Osborne
.Mr.Roy.Ba;erham,.Prof.Gerald.Elsworth.
Visiting Professor, Copenhagen University Taiwan'Na8onal'Normal'University,'Taiwan'
Professor of Public Health .Prof.Annie.Chieh@Hsing.Liu.
Director, Population Health Strategic Research Centre Health'Systems'Research'Ins8tute,'Thailand'
Deakin University
.Dr.Charay.Vichathai.
Australia
Victorian'Government,'Department'of'Health,'Australia'
WUN, Southampton, 22nd May2012
© Richard Osborne 2012, Deakin University, Australia.
Components of the
Health Education Impact Questionnaire
(heiQ)
• From the patient, practitioner and policymaker
perspective, what should self-management impact on?
1. Positive and Active Engagement in Life
2. Health-Directed Activities
3. Skill and Technique Acquisition
4. Constructive Attitudes and Approaches
5. Self-Monitoring and Insight
6. Health Service Navigation
7. Social Integration and Support
8. Emotional Distress

2. Health Literacy: several definitions
Use of the Health Education
Impact Questionnaire (heiQ) • Health.literacy.represents.the.cogniFve.and.social.skills.which.determine.
the.moFvaFon.and.ability.of.individuals.to.gain.access.to,.understand.and.
use.informaFon.in.ways.which.promote.and.maintain.good.health ..(World.
Health.OrganizaFon).
• An.individual s.overall.capacity.to.obtain,.process.and.understand.basic.
health.informaFon.and.services.needed.to.make.appropriate.health.
decisions .(US.InsFtute.of.Medicine).
• The.capacity.of.an.individual.to.obtain,.interpret.and.understand.basic.
health.informaFon.and.services.in.ways.that.are.health.enhancing .(UK.
NaFonal.Consumers.Council).
• Health.literacy.is.the.ability.to.make.sound.health.decisions.in.the.context.
of.everyday.life.–.at.home,.in.the.community,.at.the.workplace,.the.
healthcare.system,.the.market.place.and.the.poliFcal.arena .(Kickbusch,.
2001).
• People s.competences.to.access,.understand,.appraise.and.apply.
informaFon.to.make.health.decisions.in.everyday.life.throughout.the.life.
course.(Sorensen.2011).
The association between
Lower health literacy associated with:
Health Literacy and Health Outcomes
– inadequate knowledge about health and
healthcare system
– increased hospitalisation
– poor access and utilisation of health services
• People with lower health literacy ~ 1.5 to 3 times
more likely to experience poor health event
• Based on blunt measures of health literacy
De Walt DA, et al. Literacy and health outcomes: a systematic
review of the literature. J Gen Intern Med 2004:12:1228-39.
© Richard Osborne 2012, Deakin University, Australia. © Richard Osborne 2012, Deakin University, Australia.

3. How has health literacy been measured?
Application of existing
• Mostly.been.assessed.through.measuring.reading. measures of health literacy
ability,.comprehension.and.word.recogniFon.skills.
• Key.tools.used.with.paFents:.
1..Rapid.EsFmate.of.Adult.Literacy.in.Medicine.(REALM). • Prevalence of low health literacy in Australia
2..Test.of.FuncFonal.Health.Literacy.in.Adults.(TOFHLA).
3..Newest.Vital.Sign.(NVS). Barber M, Staples M, Osborne RH, Clerehan R, Elder C, Buchbinder
R. Up to a quarter of the population may have suboptimal health
4..Audit.of.wri;en.materials./.signage.. literacy: a population-based survey. Health Promotion International
5..NaFonal.Literacy.Surveys. 2009; 24:252-261.
Prevalence of low health literacy
(N = 310)
Grade 4-6 May need low-literacy materials; may not be able to read 6 (2%)
prescription labels
Grade 7-8 May struggle with most currently available patient 35 (11%)
education materials
National survey (NAAL)
High school Should be able to read most patient education materials 269 (87%)
suggested that ~60% of
Australians have low (N = 309)
health literacy.
Inadequate May be unable to read and interpret health texts 8 (3%)
Marginal Would have difficulty reading/interpreting health texts 13 (4%)
Adequate Could read and interpret most health texts 288 (93%) Tests fail to meet
Will the real level of fundamental
health literacy please
(N = 308) The definition of measurement
0-1 Suggests highly likely (50% or more) limited literacy 22 (7%) Health Literacy:
stand up?.
does not match
criteria
2-3 Indicates possibility of limited literacy 58 (19%)
what current tools
4-6 Almost always indicates adequate literacy 228 (74%) measure!

4. Steps in instrument development
Development.of.the.
.
Health.Literacy.QuesFonnaire.(HLQ) 1. Purpose and conceptualisation – grounded approach based on
widespread consultation, our preferred method is concept mapping
2. Draft item development – strict item writing rules, cognitive
interviews
3. Administration to a ‘construction sample’ – 600+ general
population, 400 in each special group
4. Psychometric analysis and refinement – structural equation
modelling
(Cluster analysis to identify groups of people with different health
literacy profiles)
5. Administration to a ‘validation sample’ – 600+ general
population, 400 in each special group
6. Finalization of the tool
7. Develop a web of evidence of the value of the tool in target
settings
A grounded approach to
conceptualization health literacy from the
individual’s perspective
• Maximum heterogeneity
• Interviews and Concept Mapping workshops:
If one is truly to succeed in leading a person to a specific place, – Individuals who had taken part in a chronic disease self-
one must first and foremost take care to find him where he is and management program (n=20)
begin there. – General population (n=14)
– Individuals who recently presented to the Hospital
Emergency Department (n=14)
Søren Kierkegaard: “Synspunktet for min Forfatter-Virksomhed. En ligefrem
Meddelelse, Rapport til Historien”, C.A. Reitzels Forlag, 1859.
– International workshop consultation (Borneo)
– Expert clinicians (n=15)
– Expert patients (n=12)
– Community services managers/policymakers (n=10)
– Many other people across fields

5. Concept mapping
Structured conceptualisation process grounded in
the real world of individual
citizens, practitioners and policy makers
Seeding statement:
1. Brainstorming
session
Results
Thinking about your
2. Sorting and rating experiences in trying to
of statements look after your health (or
the health of your family),
3. Multivariate what abilities does a person
analysis (multi-
dimensional scaling and need to have in order to get
cluster analysis)
and to use all of the
4. Interpretation of
information they need?
maps
© Richard Osborne 2012, Deakin University, Australia.
PersonIcentred'health'literacy'
Strongly Agree—Strongly disagree Cannot do—Very easy
1. Healthcare provider support 7. Agency in relationships with
• I have at least one healthcare provider who knows providers
me well • Discuss things with healthcare providers until you
Breadth and depth
• I trust advice I get from healthcare providers understand all you need to
2. Perceived adequacy of health • Feel able to discuss your health concerns with a
information healthcare provider
• I have all the information I need to manage my
health properly
8. Navigating the healthcare system • Each scale is an independent questionnaire and
• Work out what is the best care for you
• When I receive treatments I always understand
what they are for
• Work out how to make an appointment to see a
healthcare provider
has items that measure a wide range of Health
3. Taking responsibility for health
• I set my own goals about health and fitness
9. Ability to access health information Literacy status
• Get health information in words you understand
• There are things that I do regularly to make myself • Find information about health problems
more healthy
10. Reading & writing health
4. Being health focused information
• My health is important to me • Read and understand all the information on
• Despite other things in my life, I make time to be medication labels
healthy • Follow the instructions from healthcare providers
5. Social support properly
• If I need help, I have plenty of people I can rely on
6. Critical appraisal 11. Beliefs and values
• I know which places provide health information that I Getting sick is part of getting old
can trust
A quote from Primary Care…
• When I see new information about health, I check up
on whether it is true or no
“Richard… these are the things that
doctors hate most about their patients” © Richard Osborne 2012, Deakin University, Australia.

6. Scales.of.difficulty….
Find health information from several different places
Find information about health problems .
© Richard Osborne 2012, Deakin University, Australia.
40%.of.
people.
Measurement across the full range of the cannot.do.
this.or.find.it.
construct through carefully written items
very.difficulty..
Item Difficulty
Ability to Access Health Information
1..Find.health.informaFon.from.several.different. 0.60. Hardest
places.
5..Find.informaFon.about.health.problems. 0.78. Easiest
© Richard Osborne 2012, Deakin University, Australia. © Richard Osborne 2012, Deakin University, Australia.

7. 28%.of.
people.
cannot.do.
Distribution of scores
Measurement across the full range of the this.or.have.
construct through carefully written items great.
difficulty..
Item Difficulty
Agency with healthcare professionals
1. Make sure that healthcare providers 0.72 Hardest
understand your problems properly
3. Ask healthcare providers questions to get 0.78
the health information you need
5. Feel able to discuss your health concerns 0.86 Easiest
with a healthcare provider
© Richard Osborne 2012, Deakin University, Australia.
Applications of a comprehensive Applications of a comprehensive
measure of health literacy measure of health literacy
Obtain a profile of an individual’s health literacy Evaluation of an intervention aimed to empower
a disadvantaged group in their self-management
2.'Perceived'
adequacy'of' 4.'Being' 4.'Being'
1.'Healthcare' health' health'focused. health'focused.
provider' informa8on. 3.'Taking' 3.'Taking'
support. responsibility' responsibility'
for'health. for'health.
10.'Reading'&' 5.'Social' 5.'Social'
wri8ng'health' support.. support..
informa8on.
9.'Ability'to'
access'health' 7.'Agency'in' 7.'Agency'in'
6.'Cri8cal'
informa8on. 8.'Naviga8ng' rela8onships' rela8onships'
appraisal.
the'healthcare' with'providers. with'providers.
system.
© Richard Osborne 2012, Deakin University, Australia. © Richard Osborne 2012, Deakin University, Australia.

8. Applications of a comprehensive Applications of a comprehensive
measure of health literacy measure of health literacy
Evaluation of a program to improve communication To understand the needs of individuals through
surveys of target populations
2.'Perceived' 2.'Perceived'
adequacy'of' adequacy'of' 4.'Being'
1.'Healthcare' health' 1.'Healthcare' health' health'focused.
provider' informa8on. provider' informa8on. 3.'Taking'
support. support. responsibility'
We.must.
for'health.
10.'Reading'&' 10.'Reading'&' 5.'Social'
wri8ng'health' understand.needs. support..
wri8ng'health'
informa8on. so.that.the.
informa8on.
9.'Ability'to' 9.'Ability'to'
access'health' access'health' intervenFons.we.
7.'Agency'in' 6.'Cri8cal'
informa8on. informa8on. develop.can.meet.
8.'Naviga8ng' rela8onships' appraisal.
the'healthcare'
these.needs.
with'providers.
system.
© Richard Osborne 2012, Deakin University, Australia. © Richard Osborne 2012, Deakin University, Australia.
Needs assessment But can health
What.about.children?.
education
improve health
The$new$person+centred$health$literacy$
literacy in
Tailoring.of. Strongly Agree—Strongly disagree children?
Cannot do—Very easy
Applications of a comprehensive
measure of health literacy What.are.the.capabiliFes. intervenFons. 1. Healthcare provider support 7. Agency in relationships with
A comprehensive understanding of an individual
and.resources.of.an. to.the.level.of.
I have at least one health provider who
knows me well
providers Equitable.
Discuss things with healthcare providers until
health.
2.#Perceived#
2. Perceived information
4.#Being#
you understand all you need to
adequacy#of#
individual,.and.challenges.
1.#Healthcare# health# health#focused!
health.literacy.
provider# informa=on! 3.#Taking#
responsibility#
adequacy
support!
for#health!
8. Navigating the health system
IntervenFons.healththe information I need to manage
10.#Reading#&# 5.#Social#
Work out what is the best care for you outcomes./.
wri=ng#health# support!!
are.they.experiencing?.. I have all
informa=on!
9.#Ability#to#
of.the.target.
access#health# 7.#Agency#in#
informa=on! 8.#Naviga=ng# rela=onships#
6.#Cri=cal#
appraisal! my properly
to.improve.. Taking responsibility for 9. Ability to access health
the#healthcare#
informed.and.
with#providers!
system!
3.
groups. information
© Richard Osborne 2012, Deakin University, Australia.
health
Health.literacy.my own goals about health and fitness
I set
Get health information in words you
understand empowered.
4. Being health focused
in.children.My health is important to me 10. Reading, writing,
understanding adults.
5. Social support Follow the instructions from healthcare
If I need help, I have plenty of people I can providers properly
rely on
Applications of a comprehensive
Who.are.our.paFents./. Service.re@ 6. Critical appraisal 11. Beliefs and values
These are the
measure of health literacy
organisaFon.to.
I know which places provide health Getting sick is part of getting old
ciFzens?.How.are.they.
A comprehensive understanding of an individual information that I can trust
1.#Healthcare#
2.#Perceived#
adequacy#of#
health#
4.#Being#
health#focused!
be.responsive. skills we need
responding.to.our.
provider# informa=on! 3.#Taking#
support! responsibility#
our children to
for#health!
10.#Reading#&# 5.#Social#
to.diverse.
wri=ng#health# support!!
informa=on!
9.#Ability#to#
services,.educaFon?..
access#health# 7.#Agency#in#
have as they
6.#Cri=cal#
informa=on! 8.#Naviga=ng# rela=onships# appraisal!
the#healthcare# with#providers!
paFent.needs.
system!
© Richard Osborne 2012, Deakin University, Australia.
enter adulthood
© Richard Osborne 2012, Deakin University, Australia.

9. Health promotion: Prevention
evidence pathway in schools (Taiwan) A.health. Is.health.literacy.
‘opportunity’. the.missing.link.
'
➡ Education Need'to'
in.health.
promoFon?.
– Distribution and quality of demonstrate'
school health education causal'links…'
I.have.a.health.
➡ Health literacy change'over'
problem. Choose new behaviour
8me.'
– National survey Data'can'then' .
(n=170,000) inform' I.might.have.a.
➡Risk factor survey health.problem… Choose to not do new behaviour
prac8ce'and'
policy' one.day.
– National surveys .
'
➡Health status
Remain unaware/ unable /
Unaware./. disinterested
– National surveys disinterest.
© Richard Osborne 2012, Deakin University, Australia. © Richard Osborne 2012, Deakin University, Australia.
Why is health literacy important?
1. Clinicians need to know a person’s capacity to process and Thank you
understand health information to be able to communicate with
them effectively Richard.Osborne@deakin.edu.au
2. Policy makers need to understand the community’s capacity to
gain access to and understand health information to be able to
set appropriate policies and provide appropriate resources
3. Researchers need to understand these issues to make correct
judgments about research methods, processes, findings etc
4. Health literacy is a fundamental element of self-care, and Release of HLQ… a matter of weeks!
should be considered when developing and evaluating - enquiries very welcome
interventions
5. We cannot provide complete health education without Development of a e-Health Literacy tool
understanding health literacy - Enquires very very welcome
6. We cannot move the field of health literacy until a web of
evidence is developed based on sound measurement that is
based on sound theory
© Richard Osborne 2012, Deakin University, Australia.