Public Health Health Literacy and Non-Communicable Diseases
by
Sandra Vamos, Jim Frankish
  • LAST REVIEWED: 15 December 2016
  • LAST MODIFIED: 30 September 2013
  • DOI: 10.1093/obo/9780199756797-0144

Introduction

Health literacy is an essential capacity for living a healthy life. Limited levels of health literacy are a significant public health issue because of its prevalence and its negative implications for health outcomes, health-care quality, and health-care costs. Given that chronic ill health is the leading global cause of death, having the necessary skills to make daily health-related decisions and the capacity to navigate the health-care system is paramount. Health literacy refers not only to the abilities of individuals but also to the health-related systems and providers of information within those systems. While the concept of health literacy first appeared in the literature more than thirty-five years ago, interest in it has increased dramatically. Until recently, interest in health literacy was concentrated in the United States, led by physicians. However, over the past decade interest in it has grown in other developed countries such as Canada, Australia, and the United Kingdom as well as other European Union countries, led by people with a background in the social sciences and health promotion. Health literacy as an emerging field of research and practice has the potential to increase our understanding of both noncommunicable diseases and health promotion in the global context. This bibliography provides a context for health literacy in relation to noncommunicable diseases (NCDs). It offers a collection of key resources (textbooks, journals, reports, websites, etc.) to provide insight to the concept of health literacy, the relevance and role of NCDs, and evidence of the effectiveness of health literacy interventions in relation to chronic disease prevention and management.

Definitions of Health Literacy

Health literacy involves a broad range of skills needed for everyday life, whereby communication and decision-making skills coupled with an understanding of health and medical concepts and contexts across the life-course are all important. Health literacy can be viewed in many ways in relation to NCDs. Partly as a result of different perspectives (e.g., health care, health promotion, education), different definitions of the concept have been developed. Internationally, the World Health Organization (WHO) introduced the concept in its glossary of health promotion terms (Nutbeam 1998). Nutbeam 2000 further differentiates among three levels of health literacy using this WHO definition. US Department of Health and Human Services 2000 (Healthy People 2010) includes health literacy as a national health promotion objective and includes a definition of health literacy emphasizing individual skills. Nielsen-Bohlman, et al. 2004 puts forth a definition in the US Institute of Medicine landmark report titled Health Literacy: A Prescription to End Confusion, which is seen later in Healthy People 2010. Definitions have been put forth by both organizations and individuals and tend to vary in degree of emphasis regarding health literacy responsibility for individuals, patients, providers, policymakers, and communities. For example, critiques of the commonly cited US Department of Health and Human Services 2000 definition note that public responsibility is highlighted. Zarcadoolas, et al. 2006 views health literacy as a public health issue requiring a broad range of skills and core competencies from individuals. On the other hand, in the European Union, Kickbusch, et al. 2005 offers a definition that emphasizes the responsibility of health literacy by all parties. The most commonly cited Canadian operational definition (Rootman and Gordon-El-Bihbety 2008) also underscores the importance of skills and abilities of all parties involved (e.g., public, patients, providers) and takes into account that health literacy is an interaction between the individual in the system in different settings and highlights that it is a shared responsibility across the life-course. It is likely that the debate on the health literacy definition will continue. This lack of international consensus related to the variety of definitions in existence offers ongoing opportunities for exploration and dialogue related to the complex area of study and application to NCDs. Sorenson and colleagues (Sørensen, et al. 2012), via the European Health Literacy Project Consortium, recently conducted a systematic literature review to identify definitions and conceptual frameworks for health literacy. The review resulted in seventeen definitions and twelve conceptual models. A shared characteristic of earlier definitions is a focus on individual skills to access, process, and understand health information. The following definitions highlight the importance of moving beyond an individual focus and encompass a broader view to consider health literacy as an interaction between the individual and the health system. Key definitions are provided below.

  • Kickbusch, I., S. Wait, and D. Maag. 2005. Navigating health: The role of health literacy. London: Alliance for Health and the Future, International Longevity Centre.

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    Authors emphasize responsibility by all: “The ability to make sound health decision(s) in the context of everyday life—at home, in the community, at the workplace, 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” (p. 8).

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    • Nielsen-Bohlman, L., A. Panzer, and D. A. Kindig, eds. 2004. Health literacy: A prescription to end confusion. Washington, DC: National Academies.

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      The Institute of Medicine’s definition is the same as the definition seen in the US government’s statement of national health objectives Healthy People 2010. Health literacy is “the individual’s capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (p. 37). The text of the report clearly indicates that health literacy is an “interactive” concept.

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      • Nutbeam, D. 1998. Health promotion glossary. Geneva, Switzerland: World Health Organization.

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        The WHO glossary on health promotion authored by Don Nutbeam proposes the following health literacy definition: “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” (p. 10).

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        • Nutbeam, D. 2000. Health literacy as a public goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 15.3: 259–267.

          DOI: 10.1093/heapro/15.3.259Save Citation »Export Citation »E-mail Citation »

          Nutbeam’s definition, which reflects a health promotion perspective, was the same as the definition offered in the WHO Health Promotion Glossary. “Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information to promote and maintain good health” (p. 264). This paper also identified three types of health literacy (functional, interactive, and critical). Available online for purchase or by subscription.

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          • Rootman, I., and D. Gordon-El-Bihbety. 2008. A vision for a health literate Canada: Report of the Expert Panel on Health Literacy. Ottawa: Canadian Public Health Association.

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            This definition encompasses four domains and was the first to note that health literacy (and related information needs and processing) vary across the life-course. Health literacy is “the ability to access, understand, evaluate, and communicate information as a way to promote, maintain, and improve health in a variety of settings across the life course” (p. 11).

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            • Sørensen, K., S. Van den Broucke, J. Fullam, et al. 2012. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12.1: 80.

              DOI: 10.1186/1471-2458-12-80Save Citation »Export Citation »E-mail Citation »

              The authors conducted a systematic review of seventeen health literacy definitions and suggest their own “all-inclusive” definition. Health literacy is “linked to literacy and entails people’s knowledge, motivation, and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course” (p. 3).

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              • US Department of Health and Human Services. 2000. Healthy people 2010. 2 vols. Washington, DC: US Department of Health and Human Services.

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                The US government’s national health objectives titled Healthy People 2010 defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (pp. 11–20). This definition, which reflects the health-care and education perspectives, has been adopted widely. Includes Volume 1, Understanding and Improving Health, and Volume 2, Objectives for Improving Health.

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                • Zarcadoolas, C., A. Pleasant, and D. S. Greer. 2006. Advancing health literacy: A framework for understanding and action. San Francisco: Wiley.

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                  The authors define health literacy as “The wide range of skills and competencies that people develop to seek out, comprehend, evaluate and use health information and concepts to make informed choices, reduce health risks and increase quality of life” (p. 55).

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                  Relevance of Health Literacy for Noncommunicable Diseases

                  Noncommunicable diseases (NCDs) are the leading cause of deaths worldwide. Increasing chronic disease rates are associated with worse health outcomes and higher health-care costs. Low levels of health literacy are also related to poor health outcomes and higher health-care costs. Researchers, scholars, and practitioners in a range of specific disciplines have explored the relevance of health literacy to the broad world of NCDs. Health literacy can be viewed in many ways related to NCDs, such as (a) a determinant of NCDs, (b) a core competency in management of NCDs, and (c) a relationship between general literacy and management of NCDs. A growing body of research over the past several years has indicated that improved health literacy is associated with better health outcomes and is a critical factor in managing NCDs. Systematic reviews, literature reviews, journal articles, books, and reports offer an overview of the evidence on the effectiveness of health literacy interventions.

                  Systematic Reviews

                  The scope of health literacy research developments continues to expand around the globe. Seven relevant systematic literature reviews have been completed, three just recently, whereby possible findings may provide further insight into the “what” and the “how” of the ways interventions may improve health literacy and in relation to chronic disease. Berkman, et al. 2004 and DeWalt, et al. 2004 found limited literacy is related to several adverse health outcomes and incidence of chronic diseases. Pignone, et al. 2005 found most studies have examined the effect of interventions on health knowledge or behaviors. Clement, et al. 2009 centered on interventions focusing on two aspects of health literacy (literacy and numeracy) and found associated interventions to be effective in helping a person to navigate the health-care setting and in health promotion efforts. Sayah, et al. 2013 found low health literacy is consistently associated with poorer diabetes knowledge. Sheridan, et al. 2011 reviewed the effectiveness of intervention designs and found design features and using mixed strategies focusing on self-management improved patient comprehension and reduced disease severity. Sørensen and his colleagues (Sørensen, et al. 2012) reviewed international health literacy definitions and models in order to inform the development of their own applications within the health-care, disease prevention, and health promotion settings. The following major reviews summarize an overview of such recent work linking the evidence of health literacy interventions to chronic disease.

                  • Berkman, N. D., D. A. DeWalt, M. P. Pignone, et al. 2004. Literacy and health outcomes. Evidence Report/Technology Assessment 87; AHRQ Publication 04 –E 007-2. Rockville, MD: Agency for Healthcare Research and Quality.

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                    Berkman and colleagues offer findings from a systematic review (forty-four research articles) that indicate low literacy is associated with increased incidence of chronic disease, less than optimal use of preventative health services, and limited health knowledge.

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                    • Clement, S., S. Ibrahim, N. Crichton, M. Wolf, and G. Rowlands. 2009. Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education and Counseling 75.3: 340–351.

                      DOI: 10.1016/j.pec.2009.01.008Save Citation »Export Citation »E-mail Citation »

                      This systematic review of randomized and quasi-randomized controlled trials focused on complex interventions for people with limited literacy or numeracy. While the review focused only on two specific aspects of health literacy (reading ability and numeracy), these skills were found to be two key components within the broader concept of health literacy. Implementation of literacy interventions may be useful to enable a person navigate a health-care setting. Available online for purchase or by subscription.

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                      • DeWalt, D. A., N. Berkman, S. Sheridan, K. N. Lohr, and M. P. Pignone. 2004. Literacy and health outcomes: A systematic review of the literature. Journal of General Internal Medicine 19.12: 1228–1239.

                        DOI: 10.1111/j.1525-1497.2004.40153.xSave Citation »Export Citation »E-mail Citation »

                        DeWalt and colleagues conclude that low literacy is associated with several adverse health outcomes. Published data showed reading ability is related to knowledge about health and health care, hospitalization, global measures of health, and some chronic diseases.

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                        • Pignone, M. P., D. DeWalt, S. Sheridan, N. Berkman, and K. Lohr. 2005. Interventions to improve health outcomes for patients with low literacy: A systematic review. Journal of General Internal Medicine 20.2: 185–192.

                          DOI: 10.1111/j.1525-1497.2005.40208.xSave Citation »Export Citation »E-mail Citation »

                          This review of research published between 1980 and 2003 on the effect of interventions on the health outcomes of persons with low literacy examined effects on health knowledge, health behaviors, and use of health-care resources; intermediate markers of disease status; and morbidity or mortality. It found most completed studies have examined the effect of interventions on health knowledge or behaviors and focused mostly on short-term knowledge outcomes or health behaviors.

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                          • Sayah, A. F., S. R. Majumdar, B. Williams, S. Robertson, and J. A. Johnson. 2013. Health literacy and health outcomes in diabetes: A systematic review. Journal of General Internal Medicine 28.3: 444–452.

                            DOI: 10.1007/s11606-012-2241-zSave Citation »Export Citation »E-mail Citation »

                            Authors synthesized research evidence (723 citations identified and 23 studies included in review) on the relationships between health literacy (functional, interactive, and critical) or numeracy and health outcomes (e.g., knowledge, behavioral, and clinical) in people with diabetes. Found low health literacy is consistently associated with poorer diabetes knowledge; however, there is little sufficient or consistent evidence suggesting that it is independently associated with processes or outcomes of diabetes-related care. Available online for purchase or by subscription.

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                            • Sheridan, S. L., D. J. Halpern, A. J. Viera, N. D. Berkman, K. E. Donahue, and K. Crotty. 2011. Interventions for individuals with low health literacy: A systematic review. In Special Issue: Health Literacy Research: Looking Forward. Edited by S. C. Ratzan. Journal of Health Communication: International Perspectives 16 (Suppl. 3): 30–54.

                              DOI: 10.1080/10810730.2011.604391Save Citation »Export Citation »E-mail Citation »

                              The authors conducted a systematic evidence review that evaluated the effectiveness of interventions designed to mitigate the effects of low health literacy through either single or multiple strategies. They found design features improved participant comprehension (e.g., adding icons or videos). Studies with intensive mixed-strategy interventions focusing on self-management reduced emergency room visits and hospitalizations. Intensive mixed-strategy interventions focusing on self-care and disease management reduced disease severity.

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                              • Sørensen, K., S. Van den Broucke, J. Fullam, et al. 2012. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12.1: 80.

                                DOI: 10.1186/1471-2458-12-80Save Citation »Export Citation »E-mail Citation »

                                The systematic review resulted in seventeen definitions of health literacy and twelve conceptual models. Based on the content analysis, a new “all-inclusive” comprehensive definition capturing the essence of the seventeen definitions was put forth. Authors also developed an integrative conceptual model containing twelve dimensions referring to the knowledge, motivation, and competencies of accessing, understanding, appraising, and applying health-related information within the health-care, disease prevention, and health promotion setting, respectively.

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                                Literature Reviews

                                The authors of Hauser and Edwards 2006 and King 2007 reviewed the literature on health literacy interventions and their effectiveness and found that few rigorous evaluations exist. Partly because health literacy is affected by so many factors, it can be extremely difficult to evaluate a program to determine its success.

                                • Hauser, J., and P. Edwards. 2006. Literacy, health literacy and health: A literature review. Ottawa: Canadian Public Health Association Expert Panel on Health Literacy.

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                                  Reviewed research on health literacy interventions published prior to 2007. Findings showed that while few rigorous evaluations exist, low literacy was associated with poor management of chronic disease, less use of preventive services, and less knowledge about chronic disease. It also appeared to be associated with higher rates of certain chronic diseases.

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                                  • King, J. 2007. Environmental scan of interventions to improve health literacy: Final report. Antigonish, Canada: National Collaborating Centre for Determinants of Health.

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                                    Scan concluded that the majority of health literacy interventions involve “accessing” and “understanding,” with few focused on appraising or communicating health information. Limited information was found on the effectiveness of health literacy interventions. There was some evidence to support the finding that a participatory educational and empowerment approach is effective for learners in health promotion and disease prevention programs.

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                                    Books

                                    The classic Doak, et al. 1996 targets practitioners and focuses on communication during practice for patient/head education purposes. Nielsen-Bohlman, et al. 2004 is the text version of the report developed by the Institute of Medicine and provides a comprehensive summary of the field of health literacy with a focus on policy implications. Zarcadoolas, et al. 2006 focuses on health literacy as a public health issue. Rootman, et al. 2012 focuses on health literacy as a point of entry for health promotion. Begoray, et al. 2012 is a book about international health literacy perspectives creating bridges in the broad field of health, joining consumers, providers, and all those working in health care, health promotion, chronic disease prevention/management, and many other areas.

                                    • Begoray, D. L., D. Gillis, and G. Rowlands. 2012. Health literacy in context: International perspectives. Hauppauge, NY: Nova Sciences.

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                                      Authors discuss the complexity of health literacy from international perspectives both as users and providers of information in diverse settings and contexts. Health literacy is explored from a clinical, public health, and community point of view, with chapters on timely topics including definitions, healthy lifestyles, health outcomes, lifelong learning, culture and community, and economics.

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                                      • Doak, C. C., L. G. Doak, and J. H. Root. 1996. Teaching patients with low literacy skills. 2d ed. Philadelphia: Lippincott.

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                                        A major resource book for health-care practitioners to provide more user-friendly experiences and methods to simplify health instructions and messages so that they can be better understood by all patients. Guided by behavior and learning theories, practical advice and examples are offered on teaching with visuals and technology, testing literacy skills of patients, and assessing suitability of materials.

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                                        • Nielsen-Bohlman, L., A. M. Panzer, and D. A. Kindig, eds. 2004. Health literacy: A prescription to end confusion. Washington, DC: National Academies.

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                                          This landmark text examines the emerging field of health literacy by providing a definition, and increasing knowledge, awareness, and responsiveness to health literacy among health services providers as well as in the community to reduce problems of limited health literacy.

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                                          • Rootman, I., S. Stachenko, B. A. Riley, et al. 2012. Issues as a point of entry into health promotion. In Health promotion in Canada: Critical perspectives on practice. 3d ed. Edited by Irving Rootman, Sophie Dupéré, Ann Pederson, and Michel O’Neill, 117–137. Toronto: Canadian Scholar’s.

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                                            The authors make a case for the importance of health promotion, articulating both negative and positive framing, focusing on four issues, and avoiding attribution of blame. Health consequences for individuals and populations and costs and issues are framed using negative terms (chronic disease and unsustainable development) as well as positive ones (health literacy and mental health).

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                                            • Zarcadoolas, C., A. F. Pleasant, and D. S. Greer. 2006. Advancing health literacy: A framework for understanding and action. San Francisco: Jossey-Bass.

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                                              This text explores and answers a number of questions related to health literacy principles advancing individual and public health literacy. In doing so, authors discuss the growing complexity of health information in medicine and health and present a series of case studies to illustrate health communications, including NCDs such as diabetes and breast cancer.

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                                              Journal Articles

                                              At this time, there are no journals dedicated specifically to health literacy. However, the number of health literacy publications (based on a focused search of Medline) in peer-reviewed journals grew from 32 prior to 2000 to 1,323 post-2000. Several journals publish health literacy articles regularly, many of which are related to the broad field of NCDs. Some journals have special supplements on health literacy, such as Journal of Health Communication. Such contributions and growing research brings our attention to the fact that individuals with limited health literacy are more likely to have chronic conditions and are less able to manage them effectively (Williams, et al. 1998). On the other hand, studies show improved health literacy is associated with better health outcomes and is a critical factor in managing NCDs (Williams, et al. 1998; Rosenfeld, et al. 2011; Schillinger, et al. 2002; Johnston, et al. 2006). Levin-Zamir, et al. 2011 offers research on target groups such as adolescents and considers associated concepts such as media health literacy as a determining factor of health behavior and as influencing positive health outcomes. Sørenson and Brand 2011 discusses the “Blueprint for Action in Health Literacy,” focusing on increased health literacy and lowering chronic disease as a means to turn the EU into a smart, productive, healthy population and workforce.

                                              • Johnston, L., N. J. Ammary, L. G. Epstein, R. Johnson, and K. Rhee. 2006. A transdisciplinary approach to improve health literacy and reduce disparities. Health Promotion Practice 7.3: 331–335.

                                                DOI: 10.1177/1524839906289378Save Citation »Export Citation »E-mail Citation »

                                                The authors provide concepts and an approach that can be incorporated in health-care settings for effective patient–provider communication, self-management skills, patient education, and cultural competency training to eliminate health disparities and improve health literacy. Available online for purchase or by subscription.

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                                                • Journal of Health Communication: International Perspectives.

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                                                  This journal presents a breadth of research in the field that focuses on communication of health globally related to a range of areas, including health literacy, policy, technology, social marketing, and other topics. Volume 17, Supplement 1 (2012) contains interdisciplinary mHealth-related articles as a useful tool related to health literacy to promote public health with a focus on mHealth evaluation and outcomes. Volume 17, Supplement 3 (2012), a special issue on “Advancing Research in Health Literacy,” discusses innovative research and practice initiatives related to health-care organizations, chronic-disease management, and ethnic groups, among other topics.

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                                                  • Levin-Zamir, D., D. Lemish, and R. Gofin. 2011. Media Health Literacy (MHL): Development and measurement of the concept among adolescents. Health Education Research 26.2: 323–335.

                                                    DOI: 10.1093/her/cyr007Save Citation »Export Citation »E-mail Citation »

                                                    The authors developed the concept and tested a model of media health literacy in schools. They reported sources of health information while analyzing its role in promoting empowerment and health behavior (cigarette/water-pipe smoking, nutritional/dieting habits, physical/sedentary activity, safety/injury behaviors, and sexual behavior). The study found that MHL as a determinant of health behavior identifies groups at risk and may provide a basis for health promotion among youth. Available online for purchase or by subscription.

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                                                    • Rosenfeld, L., R. Rudd, K. M. Emmons, D. Acevedo-García, L. Martin, and S. Buka. 2011. Beyond reading alone: The relationship between aural literacy and asthma management. Patient Education and Counseling 82.1: 110–116.

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                                                      The authors examined the relationship between literacy and asthma issues with a focus on reading, aural (listening), and oral (speaking) exchange. Lower aural literacy skills seemed to complicate asthma management capabilities. The study suggested that listening skills highlighted by aural literacy, as well as other related literacy skills, may help develop strategies for clearer communication related to asthma management. Available online for purchase or by subscription.

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                                                      • Schillinger, D., K. Grumach, J. Piette, et al. 2002. Association of health literacy with diabetes outcomes. Journal of the American Medical Association 288.4: 475–482.

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                                                        This study examined the association between health literacy and diabetes outcomes among patients with type 2 diabetes. The authors found inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy. Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations.

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                                                        • Sørensen, K., and H. Brand. 2011. Health literacy—A strategic asset for corporate social responsibility in Europe. In Special Issue: Health Literacy Research: Looking Forward. Edited by S. C. Ratzan. Journal of Health Communication: International Perspectives 16 (Suppl. 3): 322–327.

                                                          DOI: 10.1080/10810730.2011.606072Save Citation »Export Citation »E-mail Citation »

                                                          The authors present how health literacy can become a strategic asset to help meet the targets of Europe 2020 aimed to turn the EU into a smart, productive, healthy population and workforce. A business case, “Blueprint for Action in Health Literacy,” is offered based on best practices and case studies to help companies devise a framework for prevention, education on healthy choices, and managing chronic diseases in the workplace.

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                                                          • Williams, M. V., D. W. Baker, R. M. Parker, and J. R. Nurss. 1998. Relationship of functional health literacy to patients’ knowledge of their chronic disease: A study of patients with hypertension and diabetes. Internal Medicine 158.2: 166–172.

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                                                            This study examined patients with hypertension or diabetes and the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment. Results confirmed that low-literate patients with chronic disease cannot fully comprehend medical advice using standard patient education methods. The authors suggest that future development and delivery of patient education materials must address these barriers.

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                                                            Reports

                                                            Influential national and global reports have highlighted the importance of health literacy to people’s well-being and recommended actions to promote a health-literate society. Rootman and Gordon-El-Bihbety 2008 provides a comprehensive report of a vision of a health-literate Canada; Mitic and Rootman 2012 builds on these recommendations, provides a detailed blueprint for action, and recommends a set of actions that could be taken at the national, provincial/territorial, and local levels for the purpose of increasing health literacy among Canadians. Pleasant 2012, commissioned by the Institute of Medicine, represents the largest documentation to date of health literacy efforts around the world. Centers for Disease Control and Prevention 2009 identifies public health priorities for improving health literacy among older adults by convening an expert panel consisting of medical practitioners, social-service providers, and diverse researchers, among others.

                                                            Policy

                                                            Many research and policy-related reports note health outcomes are associated with low health literacy such as lack of knowledge about medical care and conditions, poor self-management skills, medication errors, and low understanding and use of preventative services. At the global level, the International Union for Health Promotion and Education (IUHPE), an independent, professional network of people and institutions, has recently formed a global working group on health literacy to support research, action, and policy related to health literacy. These efforts compliment the IUHPE priority action areas, which include NCD prevention and control. United Nations Economic and Social Council 2009 identifies health literacy as an important target area in achieving health related to the Millennium Development Goals. To help reduce the growing burden of chronic disease, the Department of Health developed the Victorian Public Health and Well-Being Plan 2011–2015 (see Department of Health 2011), which aims to develop an effective prevention system combined with a strong and responsive health-care system in Australia. The Office of Minority Health (see Office of Minority Health 2000) developed US national standards on culturally and linguistically appropriate services (CLAS) to be used in health-care organizations and providers. The US Office of Disease Prevention and Health Promotion 2003 and HealthyPeople.gov put forth the US government’s statement of national health objectives (see US Department of Health and Human Services 2000, cited under Definitions of Health Literacy), which defined health literacy, included objectives for the improvement of health literacy, and suggested strategies for progress. The US Office of Disease Prevention and Health Promotion 2010 followed up with a national action plan containing seven goals to improve health literacy and practical strategies to achieve them. The Joint Commission 2007 is a white paper recommending that health-care organizations implement health literacy policies as a patient safety issue.

                                                            • Department of Health. 2011. Victorian public health and wellbeing plan 2011–2015. Melbourne, Australia: Prevention and Population Health Branch, Department of Health.

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                                                              The plan aims to improve the health and well-being of all Victorians by engaging communities in prevention and by strengthening systems for health protection, health promotion, and preventive health care across all sectors and all levels of government. Increasing the health literacy of all Victorians to help them better manage their own health is listed as an area of action.

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                                                              • HealthyPeople.gov.

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                                                                The Healthy People initiative is a comprehensive set of national disease prevention and health promotion objectives developed to improve the health of the nation (see US Department of Health and Human Services 2000, cited under Definitions of Health Literacy). Healthy People 2020 encompasses measures used to track and monitor progress toward promoting health, preventing disease, and eliminating disparities. Objectives 11-2 and 11-6 specifically address health literacy.

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                                                                • IUHPE Global Working Group on Health Literacy.

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                                                                  At the 20th World Conference in Geneva, a formal resolution was presented proposing that the IUHPE address health literacy as a focal point in the strategic priorities. The Global Working Group on Health Literacy was created to support research, action, and policy related to health literacy, and to support the IUHPE priority action areas (including NCDs).

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                                                                  • Joint Commission. 2007. What did the doctor say? Improving health literacy to protect patient safety. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.

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                                                                    This white paper is a call for action to those who influence, develop, and carry out policies, and emphasizes health literacy as a patient safety issue. The commission recommends that health literacy be an organizational priority, that strategies be incorporated to address patients’ communications needs, and that health care professionals pursue policy changes that promote improved practitioner–patient communications.

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                                                                    • Office of Disease Prevention and Health Promotion. 2003. Objective 11-2: Improvement of health literacy. In Communicating health: Priorities and strategies for progress: Action plans to achieve the health communication objectives in Healthy People 2010. Washington, DC: Office of Disease Prevention and Health Promotion.

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                                                                      This plan, developed by the Office of Disease Prevention and Health Promotion, is intended to help achieve the health communication Objective 11-2 in Healthy People 2010 (see US Department of Health and Human Services 2000, cited under Definitions of Health Literacy) as a priority and strategy toward progress: improvement of national health literacy.

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                                                                      • Office of Disease Prevention and Health Promotion. 2010. National action plan to improve health literacy. Washington, DC: Office of Disease Prevention and Health Promotion.

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                                                                        This national plan contains seven goals for action aimed to improved health literacy for patients, providers, and the system while providing practical strategies that various individuals, organizations, and professions at all levels can use to achieve them. One focus area encourages changes in the health-care system to improve health information and communication, informed decision making, and better access to health services.

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                                                                        • Office of Minority Health. 2000. The National CLAS Standards. Washington, DC: Office of Minority Health.

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                                                                          The US Office of Minority Health has developed comprehensive national standards on culturally and linguistically appropriate services (CLAS) in health care. CLAS standards are primarily directed at health-care organizations and encourage individual providers to use the standards to make their practices and services more culturally and linguistically appropriate for diverse patients/consumers, thus improving access to and quality of care.

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                                                                          • United Nations Economic and Social Council. 2009. Regional preparatory meeting on promoting health literacy. Annual Ministerial Review 2009. Geneva, Switzerland: United Nations Economic and Social Council.

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                                                                            Health literacy has been identified as an important target area in achieving health related to the Millennium Development Goals (MDGs). Report recommends ways of scaling up effective health literacy interventions and achievements in health in relation to the MDGs and public health commitments.

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                                                                            Promising Health Literacy Efforts for NCDs

                                                                            Much of the ongoing health literacy effort is triggered by a wish to move away from the original narrow medical concept of health literacy to a much broader concept, which is associated with skills contributing to individual and social empowerment. According to Rudd, et al. 2000 and Rudd, et al. 2007, the number of studies addressing health literacy published between 2000 and 2004 more than doubled compared to those published between 1970 and 1999, and this trend continues. Rudd and colleagues summarize the body of health literacy literature according to four strands of interest regarding the health-related implications of limited literacy and health literacy skills, one of which includes “the development and evaluation of programs designed to improve health literacy.” Health literacy has since become an emerging field of practice, with contributions and activities increasing in scope to reach a larger target population in diverse settings. Consequently, there is a growing awareness of and agreement with the notion that to improve health literacy, we need to improve the knowledge and skills of those who both provide and receive the health information, programs, and services. This transition of moving a health literacy focus outside of primarily health-care settings has the potential to highlight health literacy as an asset and as a preventive public health perspective.

                                                                            • Rudd, R. E., J. E. Anderson, S. Oppenheimer, and C. Nath. 2007. Health literacy: An update of medical and public health literature. In Review of adult learning and literacy. Vol. 7, Connecting research, policy, and practice. Edited by J. P. Comings, B. Garner, and C. Smith, 175–203. Mahwah, NJ: Erlbaum.

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                                                                              Rudd and colleagues summarize health literacy literature according to four strands of interest regarding the health-related implications of limited literacy skills.

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                                                                              • Rudd, R. E., B. A. Moeykens, and T. C. Colton. 2000. Health and literacy: A review of medical and public health literature. In The annual review of adult learning and literacy. Edited by J. Comings, B. Garner, and C. Smith, 158–199. Jossey-Bass Higher and Adult Education Series 1. San Francisco: Jossey-Bass.

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                                                                                Rudd and colleagues’ first review of the literature on health literacy. Represents results from a computer-assisted search from 1990 to 1999 with an annotated bibliography of 241 citations. Findings offer insights into skills needed for navigating health-care environments and managing health problems and may lead to modification in patient health education and training protocols.

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                                                                                Training, Tools, and Techniques

                                                                                The Centers for Disease Control and Prevention, the US federal agency and national public health institute, provides an interactive health literacy website containing the most current activities, resources, and links to health literacy across states (see Health Literacy: Accurate, Accessible and Actionable Health Information for All). Rudd, et al. 2005 presents an overview of Health Literacy Study Circles+, which provides training to adult-education teachers to help their students develop necessary skills required to access and navigate health-care services and systems. Apter, et al. 2008 provides vignettes illustrating challenges to patient–clinician communication related to chronic disease and summarizes best practices and techniques focusing on communication of numerical information between physicians and patients. Health Literacy Embedded Learning Demonstration Project: Learning for Health summarizes embedded learning approaches to enhance the capacity of organizations and partners and includes health literacy learning tools in existing programs for vulnerable individuals and populations. The Canadian Medical Association 2012 and the Centers for Disease Control and Prevention 2011 are accredited online health literacy training modules for public health professionals.

                                                                                • Apter, A. J., M. K. Paasche-Orlow, J. T. Remillard, et al. 2008. Numeracy and communication with patients: They are counting on us. Journal of General Internal Medicine 23.12: 2117–2124.

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                                                                                  Authors recommend a series of techniques (e.g., simplification, clear formatting, omission of distracting information, appropriate framing, use of visuals, and confirmation), which can guide clinicians to improve understanding of quantitative information with their patients when communicating. Available online for purchase or by subscription.

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                                                                                  • Health Literacy: Accurate, Accessible and Actionable Health Information for All. Centers for Disease Control and Prevention.

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                                                                                    The CDC website contains the most current activities, resources, and links to health literacy across states. Health literacy links by state showcase state, community, academic government, and nongovernmental collaborations aligned with the US National Action Plan. Links to training, blogs, and developing state, regional, and/or organizational health literacy plans are included.

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                                                                                    • Health Literacy Course. Canadian Medical Association.

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                                                                                      The Canadian Medical Association with many partners provides an online health literacy module through accredited continuing medical education for physicians and nurses, available in English and French, free of charge. The goal of the online module is to help health professionals understand how health literacy affects their own practice or work setting and introduce some practical tools and strategies to address the health literacy needs of patients.

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                                                                                      • Health Literacy Embedded Learning Demonstration Project: Learning for Health.

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                                                                                        The Learning for Health project is about enhancing the capacity of organizations to include health literacy learning tools in existing programs within community organizations. Examples of health literacy tools include picture stories, videos/DVDs, and websites. Demonstration sites in Canada focused on three different community service organizations with population groups most likely to have low health literacy (seniors, rural families, and immigrants) in three different provinces (Manitoba, Nova Scotia, and Newfoundland).

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                                                                                        • Health Literacy for Public Health Professionals. Centers for Disease Control and Prevention.

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                                                                                          This CDC web-based training course offering accredited continuing education credits is designed to educate a range of public health professionals about health literacy and their role in providing health information and services to promote public health literacy.

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                                                                                          • Rudd, R., L. Soricone, M. Santos, E. Zobel, and J. Smith. 2005. Health Literacy Study Circles+: Introduction: Overview, planning, and facilitation tips. Boston: National Center for the Study of Adult Learning.

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                                                                                            Provides an overview of the planning, structure, and activities of the fifteen-hour Health Literacy Study Circles+, which aims to prepare adult-education teachers to help their students develop necessary skills required to access and navigate health-care services and systems. Health Literacy Study Circles+ includes health care access and navigation, chronic disease management, and disease prevention and screening.

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