Health literacy

Health literacy relates to how people access, understand and use health information in ways that benefit their health. People with low health literacy are at higher risk of worse health outcomes and poorer health behaviours.

The idea of health literacy is dynamic and evolving. While there are many published definitions, there is no consensus on its meaning (Sørensen et al. 2012). Health literacy initially focused on the ability of individuals to read and understand medical information, however the way information is delivered by health care professionals and organisations is equally important. Therefore, health literacy has 2 main components:

• Individual health literacy—these are individual skills, such as the ability to find, understand and use health information; for example, to complete health care forms or understand and use the health care system.
• The health literacy environment—these are the health system-based elements, such as policies, processes, and materials, which affect the way the individual engages with the health system (ACSQHC 2014a).

Why is health literacy important?

People with low health literacy are more likely to have worse health outcomes overall (Berkman et al. 2011) and adverse health behaviours, such as:

• lower engagement with health services, including preventive services such as cancer screening (Kobayashi et al. 2014)
• higher hospital re-admission rates (Mitchell et al. 2012)
• poorer understanding of medication instructions (for example, non-adherence, improper usage) (Marvanova et al. 2011; Miller 2016)
• lower ability to self-manage care (Geboers et al. 2016).

In contrast, better levels of health literacy are associated with increased patient involvement in shared decision making (de Oliveira et al. 2018; Seo et al. 2016), which is important in patient-centred care. Improving health literacy is therefore a key element in allowing people to partner with health professionals for better health.

At the population level, low health literacy may be a contributing factor to health inequalities among certain groups (Kickbusch et al. 2006). There is a strong association between some social determinants of health, such as lower levels of education and socioeconomic status, older age, and being from a culturally and linguistically diverse background, and low health literacy (Adams et al. 2009; Heijmans et al. 2015; Rowlands et al. 2015). Targeting health literacy programs at these groups has the potential to reduce health inequalities.

The COVID-19 pandemic highlights the importance of health literacy in the wider community, as whole populations are asked to understand and rapidly digest complex health concepts relating to infection, immunity and use of the health care system—for example, ‘flattening the curve’—to produce a coordinated response to try and slow the spread of disease. Understanding health literacy levels among the population (and vulnerable sub-populations) helps the development and delivery of consumable and effective population health messages during such large-scale outbreaks.

See Health promotion.

Measuring health literacy

Data generated by measuring health literacy can inform policy decisions and assist health organisations to tailor services appropriately to particular groups of people. The Organisation for Economic Co-operation and Development (OECD) identified that addressing gaps in health literacy measurement is an important way to remove barriers to health literacy (Moreira 2018). However, the ability to measure health literacy is hampered by the broad range of definitions, a lack of consensus on what to measure, and the multiple approaches to measuring it (Osborne et al. 2013; Poureslami et al. 2017). This makes it difficult to provide comparable reporting on health literacy over time.

Health Literacy Survey

In 2018, the Australian Bureau of Statistics (ABS) conducted the Health Literacy Survey (ABS 2019), using the Health Literacy Questionnaire (HLQ) (Osborne et al. 2013). The HLQ is a validated tool that has been used in a range of settings, in Australia and abroad (ABS 2019; Bo et al. 2014; NZ Ministry of Health 2018).

The benefits of the Health Literacy Survey data are that they report a larger range of health literacy characteristics and can therefore be used to improve health service provision. The HLQ does not give a total score of health literacy, nor does it state whether health literacy levels are high or low. Rather, it assesses health literacy across 9 domains that encompass both individual and health environment measures and so provides information about gaps or strengths in the health literacy of the population (Beauchamp et al. 2017).

Selected estimates from the ABS Health Literacy Survey are:

• the majority of people (97%) agreed or strongly agreed that they have sufficient information to manage their health (Figure 1a)
• the majority of people (96%) felt that they are understood and supported by health care providers (Figure 1a)
• the majority of people (92%) agreed or strongly agreed that they are actively managing their health (Figure 1a)
• while the majority of people (83%) felt they are able to appraise health information, as many as 1 in 6 (17%) people disagreed or strongly disagreed that they are able to do so (Figure 1a)
• almost 2 in 5 people (39%) find it always easy to understand health information well enough to know what to do, with a further 54% stating that they usually find this easy (Figure 1b).
   

The findings from the ABS Health Literacy Survey also showed that for some domains there was variation by age group. Younger people aged 18–24 were almost twice as likely to strongly agree that they have access to social support compared with older people aged 65 and over (39% compared with 20%). In contrast, navigating the health care system appears to be more difficult for younger age groups. Nearly 1 in 5 (19%) people aged 18–24 stated that they found navigating the health care system difficult, and this decreased to 7.9% for those aged 65 and over.

There was also some variation in the results according to main language spoken in the home (figures 1a and 1b). Overall, the proportion of people who disagreed or strongly disagreed that they feel understood and supported by health care providers was similar for people who spoke English in the home (4.2%) and those who did not (5.2%). However, a higher proportion of people who spoke English in the home strongly agreed they feel understood and supported by health care providers (33%) than those who did not speak English in the home (20%).

Additionally, those who spoke English in the home were more likely to always find it easy to actively engage with health care providers (34%) than those who spoke a language other than English in the home (26%).

How can health literacy be improved?

The National Statement on Health Literacy (ACSQHC 2014b) acknowledges the importance of health literacy in enabling effective partnerships in health, and proposes actions that can be implemented within the health system to improve health literacy levels. This has been a driver for health literacy at the local level, with Local Health Networks, Primary Health Networks and community organisations designing and implementing locally appropriate health literacy interventions.

Some examples of activities being undertaken at the national and community levels to improve health literacy are provided below.

National initiatives

The National Strategic Framework for Chronic Conditions (Australian Health Ministers’ Advisory Council 2017) and the National Safety and Quality Health Service Standards (ACSQHC 2017) are 2 national initiatives that acknowledge and integrate health literacy as an important component of the health system.

Community initiatives

The Centre for Culture, Ethnicity and Health works closely with community, government and health professionals to represent people from culturally diverse backgrounds, particularly migrants and refugees. It provides a range of resources to address health literacy across all audiences, including:

• health literacy training courses—including the first health literacy course in Australia
• health translations directory—an online library of health information translated into more than 100 languages (in conjunction with the Victorian Government)
• Drop the Jargon day—a national day encouraging health professionals to think about using simple language with their clients, in place of medical terms and acronyms.

Where do I go for more information?

For more information on health literacy, see:

• Australian Bureau of Statistics National Health Survey: Health Literacy, 2018
• Australian Commission on Safety and Quality in Health Care National Statement on Health Literacy—Taking action to improve safety and quality
• Centre for Culture, Ethnicity and Health Resources in Health literacy

References

ABS (Australian Bureau of Statistics) 2019. National Health Survey: health literacy, 2018. ABS cat. no. 4364.0.55.014. Canberra: ABS.

ACSQHC (Australian Commission on Safety and Quality in Health Care) 2014a. Health literacy: taking action to improve safety and quality. Sydney: ACSQHC.

ACSQHC 2014b. National statement on health literacy. Sydney: ACSQHC.

ACSQHC 2017. National safety and quality health service standards2nd edn. Sydney: ACSQHC.

Adams RJ, Appleton SL, Hill CL, Dodd M, Findlay C & Wilson DH 2009. Risks associated with low functional health literacy in an Australian population. Medical Journal of Australia 191(10):530–534.

Australian Health Ministers’ Advisory Council 2017. National Strategic Framework for Chronic Conditions. Canberra: Australian Government.

Beauchamp A, Batterham RW, Dodson S, Astbury B, Elsworth GR, McPhee C et al. 2017. Systematic development and implementation of interventions to optimise health literacy and access (Ophelia). BMC Public Health 17:230

Berkman ND, Sheridan SL, Donahue KE, Halpern DJ & Crotty K 2011. Low health literacy and health outcomes: an updated systematic review. Annals of Internal Medicine 155(2):97–107.

Bo A, Friis K, Osborne RH & Maindal HT 2014. National indicators of health literacy: ability to understand health information and to engage actively with healthcare providers—a population-based survey among Danish adults. BMC Public Health 14:1095.

De Oliveira GS, Errea M, Bialek J, Kendall MC & McCarthy RJ 2018. The impact of health literacy on shared decision making before elective surgery: a propensity matched case control analysis. BMC Health Services Research 18:958.

Geboers B, de Winter AF, Spoorenberg SLW, Wynia K & Reijneveld SA 2016. The association between health literacy and self-management abilities in adults aged 75 and older, and its moderators. Quality of Life Research 25(11):2869–2877.

Heijmans M, Waverijn G, Rademakers J, van der Vaart R & Rijken M 2015. Functional, communicative and critical health literacy of chronic disease patients and their importance for self-management. Patient Education and Counseling 98(1):41–48.

Kickbusch I, Wait S & Maag D 2006. Navigating health: the role of health literacy. London: Alliance for Health and the Future, International Longevity Centre UK (United Kingdom).

Kobayashi LC, Wardle J & von Wagner C 2014. Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing. Preventative Medicine 61:100–105.

Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper JL & Kripalani S 2011. Health literacy and medication understanding among hospitalized adults. Journal of Hospital Medicine 6(9):488–493.

Miller TA 2016. Health literacy and adherence to medical treatment in chronic and acute illness: a meta-analysis. Patient Education and Counseling 99(7):1079–1086.

Mitchell SE, Sadikova E, Jack BW & Paasche-Orlow MK 2012. Health literacy and 30-day postdischarge hospital utilization. Journal of Health Communication 17 (Supplement 3):S325–338.

Moreira L 2018. Health literacy for people-centred care. Where do OECD countries stand? OECD Health Working Papers no. 107. Paris:OECD Publishing.

NZ (New Zealand) Ministry of Health 2018. Content Guide 2017/18: New Zealand health survey. Wellington: NZ Ministry of Health.

Osborne RH, Batterham RW, Elsworth GR, Hawkins M & Buchbinder R 2013. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health 13:658.

Poureslami I, Nimmon L, Rootman I & Fitzgerald MJ 2017. Priorities for Action: recommendations from an international roundtable on health literacy and chronic disease management. Health Promotion International 32:743–754.

Rowlands G, Protheroe J, Winkley J, Richardson M, Seed PT & Rudd R 2015. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice 65:e379–e386.

Seo J, Goodman MS, Politi M, Blanchard M & Kaphingst KA 2016. Effect of health literacy on decision-making preferences among medically underserved patients. Medical Decision Making 36(4):550–556.

Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. 2012. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health 12:80.