Stephan Van den Broucke UC Louvain 4th Asian Health literacy Conference

1. The Expanding Landscape of Health Literacy Research, Policies and Practices : Past, Present And Future Stephan Van den Broucke UC Louvain 4th Asian Health literacy Conference Haiphong, Vietnam, November 7-9, 2016

2. Not a new concept … • The concept of « literacy » • To be literate = being “knowledgeable or educated in a particular field or fields” • Increased attention since the mid 20th century • The ability to identify, understand, interpret, create, communicate, compute and use printed and written materials associated with varying contexts (UNESCO) • Enlarged to a range of competences deemed important to function in the 21st century • Application to the health sector since the 1970s

3. An expanding concept … • Expanding scope and meaning • Expanding scientific research • Expanding geographic coverage • Growing political interest

4. Expanding scope and meaning of health literacy • Frommedical to public healthliteracy • Initial emphasis on individualcompetencies in the context of health care (« medicalhealthliteracy») • Since the last decadeenlarged to a broad set of competenciesthat are relevant for diseaseprevention and health promotion (« public healthliteracy») • From functional to interactive and critical health literacy • Functional HL: the ability to handle words and numbers in a medical context • Interactiveandcritical HL: information seeking, decision making, problem solving, critical thinking, communication, social, personal, and cognitive skills that are necessary to function in the health system

5. Community Individual Conceptual expansion of health literacy Ability to critically analyze and use information to participate in actions that overcome structural barriers to health Critical HL Personal and community empowerment More advanced cognitive literacy and social skills that enable active participation in health care Improved capacity to act on social and economic determinants of health, improved community empowerment Basic skills in reading and writing necessarry for effective functioning in a health context Interactive HL Development of personal skills Improved capacity to influence social norms, and interact with social groups Increased participation in population health programs Functional HL Communication of information Improved capacity to act independently on knowledge, improved motivation and self-confidence Improved individual resilience to social and economic adversity Improved knowledge of health services, better compliance with prescribed actions

6. Healthcompetencies

7. Conceptual model of Health Literacy Sørensen et al., Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80

8. Dimensions of HealthLiteracy

9. Expanding research literature on Health Literacy • First research articles on health literacy published in the late 1970s • Over 5 658 publications on health literacy listed in Pubmed today • 70% published in the last five years • More than 2000 have “health literacy” as a major MeSH term (term introduced in 2010) • 5 317 publications in Scopus • 92 600 records on Google Scholar 10.300 in 2016 alone

10. Number of publications on health literacyincluded in Pubmed 1950-2016

11. Expanding range of Health Literacymeasures A large range of measures available, with important differences in terms of objectives and target groups • Health Literacy Tool Shed lists 128 instruments healthliteracy.bu.edu • HL Screeing in a clinical context: Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy (TOFHLA), Newest Vital Sign (NVS) • Population survey: Health and Adult Literacy Survey (HALS), National Assessment of Adult Literacy survey (NAAL), Health Literacy Questionnaire (HLQ), European Health Literacy Survey (HLS-EU)

12. Increasing availability of data on Health Literacyin populations

13. International comparisons of Health Literacyin populations

14. Geograhicexpansion of health literacy Pleasant A. (2013). Health literacy around the world: Part 1. Health literacy efforts outside of the United States. IOM. 

15. Increasing political recognition of the importance of Health Literacy • Canada: A Vision for a Health Literate Canada (2008) Health Literacy Council of Canada • USA: National Action Plan to Improve Health Literacy (2010) • Germany: Nationales Gesundheitsziel, Gesundheitliche Kompetenz erhöhen (2011) • Scotland Health Literacy Action Plan NHS HealthScotland (2012) • Australia: Communication and Health Literacy Action Plan (2013) • The Netherlands: Report on Health Literacy (NIVEL, 2014) • Austria: Gesundheitskompetenz der Bevölkerung stärken • Israel: Objectives on health literacy included in the National Developmental Goals 2020 • Belgium: Health literacy in the Governmental Declaration (2014) • Singapore: Singapore Action Plan to Improve Health Literacy

16. International recognition of the importance of Health Literacy • UN • ECOSOC Ministerial Declaration of 2009 stressed that “health literacy is an important factor in ensuring significant health outcomes” and calls for the development of appropriate action plans to promote health literacy • Considers HL important for achievement of targets related to SDG 3 on health while advancing a wide range of other SDGs. • WHO • Improvinghealthliteracyis one of the priorities in the strategy document for the EuropeanRegion « Health 2020 » • HealthLiteracy one of the threepriorities of the 9GCHP • EU Healthliteracymentioned as an item for attention in the EU Health Programme « Health for Growth » (2014-2020)

17. Key policy documents with a focus on health literacy Heath Literacy: A Prescription to End all Confusion, Institute of Medicine, National Academy of Sciences. Washington, DC, 2004 (http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx) National Action Plan to Improve Health Literacy Office of Disease Prevention and Health Promotion, USDepartment of Health and Human Services. Washington, DC, 2010 (http://www.health.gov/communication/hlactionplan/) Health literacy and the Millennium Development Goals: United Nations Economic and Social Council (ECOSOC) regional meeting background paper, 2010 (http://www.tandfonline.com/doi/abs/10.1080/.VA7yGVbGDZs) Health Literacy Around the World: Part 1 Health Literacy Efforts Outside of the United States Pleasant A. Institute of Medicine Roundtable on Health Literacy, 2012 http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/2012-SEP-24/WorldHealthLit.pdf Health Literacy: The Solid Facts. Copenhagen: World Health Organization, 2013 http://www.euro.who.int/en/healthtopics/environment-and-health/urban-health/publications/2013/health-literacy.-the-solid-facts) Improving Health Literacy for Older Adults: Expert Panel Report United States Centers for Disease Control and Prevention. Atlanta, 2009 (http://www.cdc.gov/healthliteracy/developmaterials/audiences/olderadults/index.html). Making it Easy: a Health Literacy Action Plan for Scotland NHS Health Scotland, The Scottish Government, 2014 (http://www.scotland.gov.uk/Publications/2014/06/9850/downloads) )

18. Global comparison of attitudes about the State of Health Literacy Pleasant A, Health Literacy Around the World: Part 2. Health Literacy Efforts Within the. United States and a Global Overview. IOM, 2012

19. What further developments regarding health literacy can be expected? • A shift from measuring health literacy to addressing low health literacy (education + workforce development) • A shift from individual health literacy to health literate organizations • A growing attention for digital health literacy and for other literacies • A shift from isolated small scale efforts to partnerships • A shift from local efforts to global policies

20. From measuring to addressing low health literacy Measure the fit of HL competences to demands Measure personal HL competences Measure situational HL demands and support Improve individual and population HL through education and training Compensate for low HL by improving communication and facilitating under-standing Improve organizational HL by reducing situational demands and offering institutional support

21. Compensating for low HL requires Workforce Development • Training of health care providers to identify and address low health literacy • In the basic curriculum • In continued education Example: Project “Building Capacity Among Primary Health Care Providers to Address Literacy and Health”, Nova Scotia • Development of Health Literacy Curricula and Toolkits • Example: http://www.nchealthliteracy.org/toolkit/ developed by the Agency for Healthcare Research and Quality (AHRQ) • LiteracyAssessment Instruments • Health Communication Aids • Principles set out in the Calgary Charter for the Development of Health Literacy Curricula • Certification and accreditation systems Example: IUHPE EU Health Promotion Accreditation System

22. From individual approaches to health literate organizations Create and strengthen health literacy-friendly settings • Has leadership that makes health literacy integral to its mission, structure, and operations. • Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. • Prepares the workforce to be health literate and monitors progress. • Includes populations served in the design, implementation, and evaluation of health information and services. • Meets the needs of populations with a range of health literacy skills while avoiding stigmatization. • Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. • Provides easy access to health information and services and navigation assistance. • Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. • Addresses health literacy in high-risk situations, including care transitions and communications about medicines. • Communicates clearly what health plans cover and what individuals will have to pay for services.

23. Digital health literacy • Refers to the meaning-making of health information mediated by new technologies web resources, smartphone, Wiki, MOOCS, … • Increasing reliance in ITC for health information offers both opportunities and challenges • Opportunities: easy access to information in real time • Challenge: patients with lower health literacy are less likely to use digital health tools than those with high health literacy • Addressing digital health literacy involves: • Building digital skills and knowledge about health information and resources • Designing health IT tools that are navigable for less health literate patients distinction between ease-of-use and usefulness: more health-literate users are able to navigate digital health tools yet appreciate simplicity

24. Other literacies • Health literacy often intersects with other forms of litteracy • educational literacy • digital literacy • media literacy • financial literacy • technological literacy • political literacy • Efforts to reduce disparities in levels of these “litteracies” are mutually reinforcing

25. From isolated efforts to partnerships • Health Literacy challenges can be more effectively addressed by combining efforts • Examples of national partnerships • National Alliance for Health Literacy (Netherlands) Unites more than 60 organizations: patients, providers, health institutions, health insurance providers, academia, industry, business, … • Multistakeholder Collaboration (Ireland) • Well Done Health Literacy Awards (Belgium) • RésauFrancais pour la Littératie de la Santé • Examples of international partnerships • IUHPE Global Working Group on Health Literacy • Health Literacy Europe • Asian Health Literacy Association • International Healthy Literacy Association

26. From local efforts to global policies • Governments can take a strong leadership role in developing and implementing health literacy promotion policies providing sustained funding, setting up special projects, coordinating action across sectors, and conducting health literacy surveillance • SDGs can inform government action on health literacy • International and regional organisations such as WHO can provide moral and political platforms for action

27. Conclusion “Literacy isn't just about reading, writing, and comprehension. It's about culture, professionalism, and social outlook.” ― Taylor Ellwood