Health Literacy – the agenda we cannot afford to ignore

Health Literacy – the agenda we cannot afford to ignore
A briefing from the Community Health & Learning Foundation
May 2014
This briefing provides an overview of the important agenda of health literacy and outlines
the extent of the level of need and its economic impact. It concludes with six key priority
policy actions.
Foreword by Health Literacy Group UK
As Co-Chairs, on behalf of the Health Literacy Group, we are delighted to support this policy briefing
paper. We know from extensive published research from the US, Europe and the UK, that health
literacy has a significant impact on morbidity and mortality – specifically, low health literacy has
been linked to increased risk of hospitalisation, lower uptake of preventative services and screening,
poorer self-management and medication adherence. Low health literacy is central to health
inequalities as marginalised groups, those from with lower socio-economic status and lower
education levels are most at risk.
Dr Joanne Protheroe PhD FRCGP
Dr Gillian Rowlands MD FRCGP
Co-Chairs Health Literacy Group, UK
What is health literacy?
For this briefing we use the World Health Organisation embracing definition:
Health literacy implies the achievement of a level of knowledge, personal skills
and confidence to take action to improve personal and community health by
changing personal lifestyles and living conditions. Thus, health literacy means
more than being able to read pamphlets and make appointments. By improving
people’s access to health information, and their capacity to use it effectively,
health literacy is critical to empowerment.i
Health literacy is a pivotal feature in the complex links between health inequalities, income
and skills and is critical to inclusive growth for local and national policy as the economy
moves out of the recessionii. It recognises a shared responsibility between government,
local institutions, employers and people in addressing the socio/economic factors that
impact on health.
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Three areas are key for effective health literacy, these are summarised as:
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system change:
o in which local strategies recognise the multiple impacts on health inequalities
across public services;
o in which all health practitioners tailor communications effectively to everyone,
including those with limited health literacy.
prevention:
o alongside a changing system, the skilling of young people and adults in the
essential empowerment literacies of health, digital, numeracy and literacy.
self management:
o providing people with the skills and information to manage long term and life
limiting conditions.
The scale of the problem
Recent research on the mismatch between the population’s health literacy and the skillsiii
needed to navigate and understand the system shows that 43 per cent of people aged 16
– 65 are unable to effectively understand and use health information, this rises to 61
per cent if maths is involved. This means that between 15 and 21 million people of
working age population in the UK may not be able to access the information they need to
become and stay healthy.
This is significantly higher than those who lack basic literacy and numeracy skills and
highlights the multi-dimensional nature of health literacy. The 2011 Skills for Life surveyiv
reported that 24 per cent of adults aged 16-65 (8.1 million people) lack functional numeracy
skills (below Entry level 3 numeracy) and 15 per cent (5.1 million) lack functional literacy
skills (below level 1 literacy).
The 2013 OECD International Survey of Adult Skillsv (ISAS) assessed the literacy,
numeracy and problem solving in technology-rich environments skills of adults aged 16-65
from 24 countries and sub-national regions. The survey only included England and
Northern Ireland within the UK. England is ranked 15 in literacy and 17 in numeracy levels.
In England and Northern Ireland, parents’ educational attainment has a stronger-than
average impact on adults’ proficiency in both literacy and numeracy, even after taking
account of other factors, such as age, gender, and type of occupation. On average across
participating countries, adults with low levels of education and whose parents also
have low levels of education are nearly five times more likely to have poor
proficiency in literacy than adults whose parents had higher levels of education; in
England and Northern Ireland, the likelihood is eight times greater.vi
The OECD report also states that in all countries individuals with lower proficiency in
literacy are more likely than those with better literacy skills to report poor health, to believe
that they have little impact on political processes, and not to participate in associative or
volunteer activities. On average across countries, adults who score at or below Level 1
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on the literacy scale have over two times the odds of reporting fair to poor health
than those who score at Level 4 or 5. Adults scoring at Level 2 are also markedly more
likely, on average, to report fair to poor health even when other factors are taken into
account.
Researchvii using data from the British Cohort born in 1970 examined the association
between adult basic skills and health of adults. It found that low adult literacy and
numeracy are associated with worsening health limiting conditions. In particular, low
numeracy was associated with worsening health limiting conditions for men and women
and low literacy was associated with worsening health limiting conditions for women only.
The economic implications
Health services budgets are under crisis from demographic changes, the changing nature
of preventative care and the pressure on public spending. A strategic and consistent
approach to improving the health literacy of the population and those who deliver services
is a simple and cost effective method of change.
American research shows that the cost of poor health literacy is between 3-5 per cent of
the health budget a yearviii. It found that at a patient level the additional expenditures per
year for each person with limited health literacy as compared to an individual with adequate
health literacy range from $143 to $7,798.
In England, the NHS budget is £95.6 billionix - a saving of 3-5 per cent from effective health
literacy would be in the range of £2.87 billion to £4.78 billion – equivalent to the whole of
the current skills budget for England and Wales.x
The Patients Information Forum make a compelling case xi for a better and more
empowered approach for health information, including health literacy. It reports that patients
with low health literacy:
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have poorer health status;
experience higher rates of hospitalisation and emergency admissions, and have
longer stays;
are less likely to adhere to treatments and self-care plans;
have more medication and treatment errors;
make less use of preventative services and more use of unplanned services;
have less knowledge of disease management and healthy living behaviours;
have decreased ability to communicate with health professionals and participate
in decision-making;
are less able to make appropriate health decisions
incur substantially higher health costs.
Health, equalities and education are interlinked, but it is more complex than a set of simple
inputs and outputs – this means that a collaborative and cross organisational approach is
needed both at a national and a local level.xii For example, research highlights that men and
women who left school with no qualifications may be able to “catch up” to some extent with
more qualified people in terms of lowered coronary heart disease risk.xiii
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What needs to change?
At the Community Health & Learning Foundation we have identified six priority actions
needed at a national and local level to ensure effective health literacy:

a cross-government strategic approach to recognise the economic and social impact
of health literacy and its role in addressing health inequalities and wellbeing;
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the integration of health literacy into social inclusion funding strategies;
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a government review of how preventative actions for health literacy can be funded
from future long-term savings, particularly those realised through improved patient
understanding and self-management of long-term health conditions;
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a review of how savings from improved health literacy can flow back into the local
areas;
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the integration and adoption of health literacy as a core literacy within education and
skills policies alongside digital, numeracy and literacy, with joint funding between
DoH, DfE and BIS;
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the development of a health literate system with clinical commissioning groups
prioritising practitioner awareness.
i
World Health Organisation (1998) Health Promotion Glossary:
http://www.healthliteracypromotion.com/upload/hp_glossary_en.pdf
ii
For a detailed discussion see Benzeval M et al. (2014) How does money influence health? JRF
http://www.jrf.org.uk/publications/how-does-money-influence-health
iii
Rowlands et al (2012) Defining and describing the mismatch between population health literacy and
numeracy and health system complexity2014 submitted for publication – a note of interim findings available at
http://www1.lsbu.ac.uk/php5c-cgiwrap/hscweb/cm2/public/news/news.php?newsid=115
iv
TNS-BMRB and AlphaPlus Consultancy Ltd. (2012) 2011 Skills for Life survey: a survey of Literacy,
Numeracy and ICT Levels in England, BIS research report 81, available online at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/36000/12-p168-2011-skills-forlife-survey.pdf
v
OECD (2013) OECD Skills Outlook 2013: first results of the survey of adult skills,
http://skills.oecd.org/skillsoutlook.html
vi
For a more detailed analysis on this point see Green et al (2014) Why are Literacy and Numeracy Skills in
England so Unequal? LLAKES Research paper 47
http://www.llakes.org/wp-content/uploads/2014/01/Inequality-paper.pdf
vii
Sabates R. & Parsons S. (2012) The Contribution of Basic Skills to Health Related Outcomes During
Adulthood: Evidence from the BCS70 BIS Research Paper 91
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/34667/12-1239-contributionbasic-skills-to-health-outcomes.pdf
viii
Eichler, K., Wieser, S., Brugger, U. (2009). The costs of limited health literacy: a systematic review.
International Journal of Public Health, http://www.springerlink.com/content/n7327r1tl81665t3/fulltext.pdf
ix
http://www.england.nhs.uk/allocations-2013-14/
x
Total for adult learning and skills in 2013-14 is 3.1 billion in England and Wales https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/278529/bis-14-p172a-skillsfunding-statement-2013-2016.pdf
xi
Patients Information Forum (2013) Making the case for information: the evidence for investing in high quality
health information for patients and the public http://www.pifonline.org.uk/wp-content/uploads/2012/09/PiF-
4
Case-for-Information-full-report-FINAL-Sept2013.pdf http://www.pifonline.org.uk/wpcontent/uploads/2012/09/PiF-Case-for-Information-full-report-FINAL-Sept2013.pdf
xii
See Kings Fund (2013) Improving the public’s health: an overview for local authority leaders
http://www.kingsfund.org.uk/sites/files/kf/field/field_related_document/improving-publics-health-overviewdec2013.pdf
xiii
Chandola T et al (2011) Is adult education associated with reduced coronary heart disease risk?
International Journal of Epidemiology 2011;40:1499–1509
http://ije.oxfordjournals.org/content/40/6/1499.full.pdf+html
About the Community Health & Learning Foundation
The Community Health & Learning Foundation is a leading innovative organisation,
pioneering and promoting health literacy and general health related learning. We
specialise in delivering health literacy courses for people with low basic skills and health
literacy training for the practitioners working with them. Our aim is to help people make
informed decisions about their own and their families’ health and to get the most from all
the contacts that they have with health services.
For more information see www.chlfoundation.org.uk or contact: [email protected]
or contact Jonathan Berry on 07525347269 or [email protected]
About the Health Literacy Group UK
The Health Literacy Group UK is a group of people interested in building the evidence
base for Health Literacy and its impact on people and their lives, and in supporting national
policy to reduce health inequalities. We are a special interest group of the Society for
Academic Primary Care. We work together to discuss and develop new research ideas,
run research projects, write reports and research papers, and support implementation of
research findings into practice. We have regular face-to-face meetings and also discuss
ideas and work together through our website.
For more information please see our website, www.healthliteracy.org.uk
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