Health Literacy Review Paper 2018 Part A

Sep 21, 2023

Primary Author: Kelly Naughton - Outer East Primary Care Partnership

“Health literacy refers to the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health. Health literacy includes the capacity to communicate, assert and enact these decisions.” - Dodson, Beauchamp, Batterham, & Osborne, 2014

Health literacy is about how people understand information about health and health care, and how they apply that information to their lives, use it to make decisions and act on it (ACSQHC, 2014). A person’s individual health literacy needs to be considered in the context of the demands that they will face when accessing and using our complex health system.

Individual health literacy: the skills, knowledge, motivation and capacity of a person to access, understand, appraise and apply information to make effective decisions about health and health care and take appropriate action.
The health literacy environment: the infrastructure, policies, processes, materials, people and relationships that make up the health system and have an impact on the way in which people access, understand, appraise and apply health-related information and services (ACSQHC, 2014)

Just over 1/3 of Victorians aged 15-74 have an adequate level of individual health literacy (ACSQHC, 2014). Essentially, this means that the majority of people do not have sufficient skills, knowledge, motivation and capacity to access, understand, appraise and apply information to make effective decisions about their health and take appropriate action.

Health literacy is important because it shapes people’s experience of the services and healthcare they receive and contributes to the safety and quality of their health care. A person’s ability to access, understand and use information about their condition will influence the action they take and the decisions they make about treatment and management.

The evidence base exploring health literacy has grown drastically, with a ten-fold increase in the number of journal articles published between 1997 and 2007 (Chinn, 2011). Despite this interest there is no unanimously accepted definition, however the concept generally involves abilities, actions, information, objective, context and time – See Card below (Sørensen, et al., 2012).

It is also difficult to assign a single definition of health literacy, as it can be used to explain similar concepts including health education, health communication, consumer participation, empowerment and health promotion (ACSQHC, 2014). Health literacy can also be viewed as either a personal ‘asset’ in health promotion and health education, or as a ‘risk’ that needs to be managed to reach optimal health (Jordan, Osborne, & Buchbinder, 2011).

The key concepts of a health literacy definition

The six clusters identified when condensing the definitions from the literature review - Sørensen, et al. (2012)

1. Competence/ skills/abilities

Skills, Possession of requisite skills/Constellation of skills/Wide range of skills, Cognitive skills, Social skills, Personal skills, The ability, The capacity, The knowledge, The competencies, Motivation, Comprehension, Communication.

2. Action

To gain access, To understand, To use, To perform basic reading and, numerical tasks, To obtain, To process, To seek out, To comprehend, To evaluate, To read, To filter, To find, To appraise, To communicate, To interpret, To identify, To perform arithmetic operations, To embrace or disregard actions, To derive meaning, To act, To make sound decisions/to make health-related decisions, To take responsibility, To pertain interactions, To attain capacity, comprehension and communication.

3. Information

Information, Health information, Information relating to health, Basic health information, Health-related print-material, Information presented in graphical form, Health information in written, spoken or digital form, Different forms of communication, Concepts, Services.

4. Objective

Promote and maintain good health, To function in the health care environment, To make appropriate health decisions, A critical empowerment strategy to increase people’s control over their health, To make informed choices, Reduce health risks, Increase quality of life, To form sound judgments, To engage in demands of different health contexts, To promote health, To enhance health, To improve health, To make appropriate health and care decisions, To accomplish health related objectives, To make public health decisions that benefit the community.

5. Context

Variety of settings, The health care environment, Different health contexts, Health care setting, Health related contexts, The everyday life at home, in the community, at the workplace, within the healthcare system, at the market place and within the political arena, HL always related to the context of the specific tasks needed to be accomplished.

6. Time

Across the life course, Evolves over lifetime.

Individual Health Literacy

An individual approach to health literacy focuses on the skills and abilities of the consumer (Jordan, Osborne, & Buchbinder, 2011) and is seen as a process involving four related types of competencies:

Access - an individual’s ability to locate, find and obtain health information

Understand - an individual’s ability to comprehend the health information that has been accessed

Appraise - an individual’s ability to consider, interpret, and evaluate the health information that has been accessed

Apply - an individual’s ability to communicate and use the information to make decisions to maintain and improve health (Sørensen, et al., 2012).

Individual health literacy is dynamic and can vary from day to day. Personal factors like an individual’s previous experience and knowledge of health and illness, as well other contexts such as fatigue, mood, being unwell or stressed can affect a person’s capacity to understand, use, apply and act on information at that time (ACSQHC, 2014). Some individuals may prefer their healthcare provider to make decisions and action, whereas others prefer an active role in their care.

Consumer motivation and decision-making are also essential components. An individual may possess healthcare knowledge, have the capacity to process and retain information and be provided with understandable information, but if they are not motivated they may not act on the information or make the decision needed (ACSQHC, 2014). This lack of motivation could be from either the consequences of no actions haven’t been communicated well, or the consumer may surrender their right to choose to their healthcare provider – whichever way, consumer motivation will influence the transformation of information into action (ACSQHC, 2014).

By improving the capacity to take control over health, health literacy is critical to empowerment (WHO, 1998). A delicate balance is needed between the two concepts, as high health literacy levels without a high degree of empowerment leads to an unnecessary dependence on health professionals; while a high degree of empowerment without the corresponding degree of health literacy increases the risk of dangerous health choices (Schulz & Nakamoto, 2013).

Consumer participation

Consumer participation in health-care refers to the mutually beneficial partnerships between healthcare providers, consumers, carers and their families around the planning, delivery, and evaluation of their health care. Research has shown that those who actively participate in healthcare decisions shown to achieve better health outcomes compared to those who do not (Kaplan, Greenfield, & Ware, 1989). Poor health literacy can lead to a significant variation in an individual's ability to access, apply and communicate health information, impacting their opportunity and capability to interact with health professionals and participate in their health care. Consumer participation in health-care may therefore unintentionally increase inequalities in health by favouring certain population groups as a consequence of their higher health literacy (Thomson, Murtagh, & Khaw, 2005).

Literacy

Literacy refers to having or showing a range of abilities, competencies and knowledge about a particular subject. To effectively function throughout life, an individual needs to possess a wide number of literacies (ACSQHC, 2012). These literacies can be subject-specific such as cultural, technology, media and scientific literacy, but subject-specific literacies build on the foundation of general literacy (ACSQHC, 2013).

Some researchers do not consider health literacy to be a separate concept, viewing it simply as general literacy in the health context (Reeve & Basalik, 2014); whereas some view the two as completely separate and different concepts (Canadian Public Health Association, 2008). This resource views health literacy as a distinct, separate concept to general literacy, as although general literacy is an important determinant of health; individuals need more than those abilities to manage the health issues that arise throughout the life course (ACSQHC, 2013).

Literacy is an enabler to action and not just a measure of achievement (Nutbeam, 2000); therefore poor general literacy impacts the development of health literacy by limiting personal, social and cultural development (ACSQHC, 2013). While health literacy is dependent on general literacy (WHO, 1998), high general literacy does not directly lead to high health literacy (ACSQHC, 2013).

Health Literacy Environment

A person’s individual health literacy needs to be considered in the context of the demands that they will face when accessing and using our complex health system. Our complex health system places many demands on individuals, carers, families and communities. Decreasing these demands will lead to improved health literacy.

The Health Literacy Environment is the infrastructure, policies, processes, materials, people and relationships that make up the health system and have an impact on the way that people access, understand, appraise and apply health related information and service. A Health Literate Organisation is one that recognises the impacts on the health literacy environment and makes it easier for people to navigate, understand, and use information and services to take care of their health.

The 10 Attributes of A Health Literate Organisation

The Institute of Medicine in the United States of America released a paper in 2012 that identified ten aspirational attributes that characterise a health literate organisation. These attributes are a list of qualities that organisations can strive to achieve to ensure services provided are easy for people to navigate, understand and use (Brach, et al., 2012).

A Health Literate Organisation:

Has leadership that makes health literacy integral to its mission, structure and operations.
Integrates health literacy into planning, evaluation measures, service user safety and quality improvement.
Prepares the workforce to be health literate and monitors progress.
Includes consumers in the design, implementation and evaluation of health information and services.
Meets the needs of consumers with a range of health literacy skills while avoiding making assumptions about individual health literacy levels.
Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.
Provides easy access to health information, services and navigation assistance.
Designs and distributes print, audio-visual 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 treatments and medicines.
Communicates clearly the costs that funding schemes may cover (e.g. Medicare, private health insurance) and what individuals may have to pay for services.

The universal precautions approach to health literacy is also recommended for those in the health sector as providers won’t always know which consumers have limited health literacy (DeWalt, et al., 2010). In taking this approach, it is assumed there will be barriers to understanding and it will be necessary to reduce the complexity of the information and services that are provided; not just for those who appear to have literacy issues but for all.

Cultural competence is explained as the capacity to interact and communicate with people across different cultures to support and empower consumers to engage in their health and health care. This requires knowledge of cultural practices and differences, a positive attitude towards these practices and differences; and cross-cultural communication skills. Australia’s growing multicultural society requires healthcare providers and organisations to understand and address cultural barriers to health literacy and provide culturally competent services. (ACSQHC, 2014)

Strategic & Legislative Context

Health literacy is becoming a core concept of many systems including legislation, policies and plans, standards, funding mechanisms, incentives and curricula. This section outlines a select few documents at international, national and Victorian levels that impact and guide the interpretation and intervention into Health Literacy.

International

A number of countries around the world have progressed significantly in the strategic and legislative context of health literacy. A global approach has been taken by the World Health Organisation with its 2013 release The Solid Facts: Health Literacy (World Health Organization , 2013). WHO considers health literacy an essential component of pursuing health and wellbeing in a modern society, and as a determinant of health. The Solid Facts advocates a wider, whole-of-society approach to health literacy that takes into account an individual’s level of health literacy and also recognises the importance of different health contexts within which people live. Focus is placed on how actions in a range of settings and sectors can combine to empower and enable people to make sound health decisions and carry them out in the context of everyday life.

The Calgary Charter on Health Literacy from the Centre for Literacy in Canada (Coleman, et al., 2009) is intended to support the development of new health literacy curricula and evaluation tools for both the public and health professionals. The Charter reflects a two-way-street approach to health literacy, showing how the concept applies to both information seekers (patients, adult learners, etc.) and information givers (health care providers, the public health system, etc.). The interactive resource encourages those involved in developing or evaluating health literacy curricula to incorporate their approaches into the Charter. Beyond its value of curriculum development, the Charter specifically avoids specifying any particular groups, assuming that health literacy affects all individuals and health systems, expressed differently in different contexts and always based on the same underlying skills and abilities.

The National Action Plan to Improve Health Literacy from the US Department of Health and Human Services (U.S. Department of Health and Human Services, 2010) aims for a multi-sector effort to create a health literate society. The Plan identifies seven overarching goals with highest priority strategies to achieve each, and many of the strategies highlighting actions that particular organizations or professionals can take to further these goals.

Making it Easy - A Health Literacy Action Plan for Scotland (NHS Scotland, 2014) positions the task of dealing with health literacy not just with those who experience the issue, but as an issue for health services and practitioners to respond to; setting out specific actions that can be taken at each level to help address the issue. The Plan recognises health literacy as ‘people having enough knowledge, understanding, skills and confidence to use health information, to be active partners in their care, and to navigate health and social care systems’ and maintains that when individuals health literacy needs are not met, the person-centeredness of care is undermined as ineffective communication decreases the capacity to make decisions.

Healthy People comes from the United States Department of Health and Human Services (National Centre for Health Statistics, 2012) with nationwide health-promotion and disease-prevention goals. Goals are set in each program for the following decade, and subsequently updated for Healthy People 2000, Healthy People 2010, and Healthy People 2020. Healthy People 2010 comprised of two overarching goals - increase quality and years of healthy life and eliminate health disparities – achieved through 467 specific objectives organized into 28 focus areas. One such focus area was ‘Health Communication’ with the goal to ‘use communication strategically to improve health’ and corresponding objectives to monitor the availability of Internet access, health literacy, and the characteristics of health communication campaigns and health-related websites. The focus area was expanded for Healthy People 2020 to Health Communication and Health Information Technology (IT) to strategically combine health IT tools and effective health communication processes, and additional objectives aimed at increasing health literacy skills and delivering accurate, accessible, and actionable health information that is targeted or tailored.

National

The National Health and Hospitals Reform Commission identified improving health literacy as a national health reform direction for Australia in its 2009 report A Healthier Future For All Australians (NHHRC, 2009). The report, contains more than 100 recommendations for reform, advising action on three areas - tackle the major access and equity issues that affect people now, redesign our health system to meet emerging challenges in the future; and create an agile, responsive and self-improving health system. Within this third area of reform Health Literacy is recognised as a lack of knowledge and skills to understand and use information about how to stay healthy or how to navigate the health system. The report recommends health literacy be included in the national curriculum and incorporated in national skills assessment throughout primary and secondary school. The NHHRC also propose targeted approaches to improve health literacy in particular domains, with the need to help ‘make healthy choices easy choices’ apply at all ages and groups in the population.

The Australian Safety and Quality Framework for Health Care (ACSQHC, 2010) from the Australian Commission on Safety and Quality in Health Care (ACSQHC) sets out the actions needed to achieve safe, high quality care for all Australians. The Framework was endorsed by Health Ministers as the national safety and quality framework for Australia in November 2010, and specifies three core principles, that care be: consumer centred, driven by information, and organised for safety. Health literacy is recognised within the first core principle, consumer centred care, and viewed as a specific area for action to reach the principle, rather than an issue itself. The Framework provides tools, resources, and examples to assist in implementing this action. However, this was the first ACSQHC publication mentioning health literacy and as such did not outline specifically what the concept meant and how to tailor action effectively.

Outlining overarching principles for safe and high quality care in Australia, the Australian Safety and Quality Goals for Health Care from ACSQHC (ACSQHC, 2012) supports care which is consumer centred, driven by information and organised for safety. The publication, released in 2012, describes specific priority areas in which a coordinated approach to improvement can be taken to achieve better outcomes for patients and provide a more efficient health system. Health literacy is viewed in the Goals not as a health issue itself, but as a means or tool to achieving safe and high quality healthcare. Health literacy is considered in the context of healthcare organisations, aiming for healthcare organisations to be designed in a way that makes it easier for consumers to navigate, understand, and use their information and services, organisations undertaking improvement projects based on partnerships with consumers and improvement in the design of the physical environment and information produced by healthcare organisations. This was the second ACSQHC publication referencing health literacy, building on the last document and recognising organisations as a vessel for acting on health literacy. Goal 3 of the Australian Safety and Quality Goals for Health Care - ‘Partnering With Consumers’ – explicitly outlines ‘Healthcare organisations are health literate organisations’ as an objective.

Translation Standards - Royal District Nursing Service (Michael, Aylen, & Ogrin, 2013)

The Royal District Nursing Service has undertaken a project to develop a translation standard as a means of driving improvement in the quality of translation in health care. The standard was released in 2013 and identifies 10 components as necessary to ensure a minimum standard of translation that is of high quality and caters to the health literacy levels of the target audience. These are:

Develop the English text and/or test the translation with members of the target languages other than English-speaking (LOTE) communities.
Undertake a cultural and linguistic assessment of the English text in preparation for its translation.
Undertake a subject matter expert assessment of the English text, as appropriate.
Organise for the English text to be translated by an accredited translator.
Undertake a cultural and linguistic assessment of the translation.
Organise for the translation to be proofread by an accredited translator.
Include the title of the text in English on the translation.
Include the name of the target language in English, on both the English text and the translation.
Distribute the translation in bilingual format (English and LOTE).
Date, monitor, evaluate and update the English text and the translation as part of an ongoing review program.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) released their National Statement on Health Literacy (ACSQHC, 2014) in 2014 to highlight the importance of health literacy, emphasise the need for collaboration to systematically address health literacy and inform decision-making around health literacy for individuals and organisations. The ACSQHC separates health literacy into two concepts; individual health literacy as the skills, knowledge and capacity of a person to access, understand, appraise and apply information to make effective decisions about health and health care and take appropriate action, and the health literacy environment as the infrastructure, policies, processes, materials, people and relationships that make up the health system and have an impact on the way that people access, understand, appraise and apply health-related information and services. To address health literacy in a coordinated way in both individual and environmental contexts, the Statement advises actions to be taken across three approaches:

Embedding health literacy into systems - developing and implementing organisational and societal level systems and policies, including funding to encourage awareness and action on health literacy, policies that prioritise health literacy in program planning, and designing easier healthcare organisations.

Ensuring effective communication - providing print, electronic or other communication that is appropriate for the needs of consumers; supporting effective partnerships, communication and interpersonal relationships between consumers, healthcare providers and other staff.

Integrating health literacy into education - educating consumers and healthcare providers through population health programs, formal education, training of healthcare providers, health promotion and education strategies, school health education, and social marketing campaigns.

The Statement also describes possible actions that can be taken to address health literacy, detailed by each role in the health system – consumers, healthcare providers, organisations providing local healthcare, organisations supporting healthcare providers and government bodies.

Victorian

The Public Health and Wellbeing Act 2008 (Public Health and Wellbeing Act 2008, 2008) identifies the principles and importance of prevention, collaboration and evidence-based decision making as key to future directions in public health and wellbeing. Particularly relevant to health literacy is the principle of collaboration, which states that public health and wellbeing in Victoria and at a national and international level can be enhanced through collaboration between all levels of government and industry, business, communities and individuals; acknowledging that client-centred care and the ability of individuals to take ownership and make decisions for their health can improve health and wellbeing.

Recognising the rights of patients and consumers utilising the Australian healthcare system, the Australian Charter of Healthcare Rights in Victoria (Department of Health Victoria, 2010) ensures that any and all healthcare that is provided is safe and of high quality. The Charter outlines that patients, consumers, families, carers and providers need to share an understanding of the rights of people receiving health care. The rights recognised in the Charter include:

Access: a right to access health care
Safety: a right to receive safe and high quality health care
Respect: a right to be shown respect, and to be treated with dignity and consideration
Communication: a right to be informed about services, treatment, options and costs in a clear and open way
Participation: a right to be included in decisions and to make choices about your health care
Privacy: a right to privacy and confidentiality of your personal information
Comment: a right to comment on your health care, and to have your concerns addressed

Of the Australian Charter of Healthcare Rights, communication, participation and comment all recognise the basic components health literacy and the importance of improving health through ensuring individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decision.

Doing it with us not for us: Strategic direction 2010-13 is the Victorian Government’s policy on consumer, carer and community participation in the health care system (Department of Health Victoria, 2011). The publication recognises that ‘participation occurs when consumers, carers and community members are meaningfully involved in decision making about health policy and planning, care and treatment, and the wellbeing of themselves and the community’. By advocating for increasing health literacy through the following individual care level priority actions, the document aims to improve health policy and planning, care and treatment, and the wellbeing of all Victorians.

For those working in the public health sector, the 2015-2019 Victorian Public Health and Wellbeing Plan (VPHWP) was released on September 1st 2015 and articulates the government’s vision for a Victoria free of the avoidable burden of disease and injury so that all Victorians can enjoy the highest attainable standards of health and wellbeing at every age, and aims to reduce inequalities in health and wellbeing. The 2015-2019 VPHWP explicitly discusses health literacy within the three major ‘Platforms for Change’ through which much of the implementation of the plan will occur; being healthy and sustainable environments, place-based approaches and people-centred approaches.

The Victorian Health Priorities Framework 2012-2022: Metropolitan Health Plan (Department of Health Victoria, 2011) outlines the long-term planning and development priorities for Victoria’s health services for the next decade, detailing the directions and actions that will improve the State’s health system. The Plan predicts that by 2022 Victorians will have improved health literacy, possess the knowledge they need to make choices about their health management, and will be able to access high quality information and targeted local health programs. It also recognises that those who are health literate are healthier, empowered to make more informed decisions and to take greater responsibility for their health. The Health Plan establishes seven priority areas, with the ‘Improving every Victorian’s health status and experiences’ area being most relevant to health literacy.

The priority area states that improving the health status of the Victorian population requires action to improve health literacy among the whole community, to engage them in maintaining the best health status for themselves and their families. To improve health literacy, the Plan mentions the need for the development and implementation of a metropolitan wide strategy for improving people’s health knowledge and supporting patient choices; particularly for those whom English is not their first language. High priority is also placed on ensuring that these diverse communities receive high-quality, culturally sensitive healthcare, and that support services such as interpreters should be available where needed. Accurate and up to date information is also recognised as a requirement for Victorians, and a commitment is made to ensuring that information is accessible to patients and to carers.

The Department of Human Services Language Services Policy (Department of Human Services, 2013) identifies that effective communication between service providers and clients is essential to the delivery of high quality services and outlines the requirements needed to enable those with no English, or with limited English, those who are deaf or use sign language, assistance with communication when making significant life decisions and where essential information is being communicated. The Policy assists those with low health literacy by providing aid when essential information needs to be communicated, they are required to make significant decisions concerning their lives or they need to give informed consent. It ensures individuals can make informed decisions about their lives and their health and their ability to access services and to participate in decision making processes which have consequences for their lives are not limited.

Accreditation Standards

The following information outlines a range of common State and National health accreditation standards mapped against the 10 Attributes of a Health Literate Organisation. This information was collected and mapped by the Gippsland Primary Care Partnerships and reported in their ‘Gippsland Guide to becoming a Health Literate Organisation’ report, released in 2015 (Gippsland Primary Care Partnerships, 2015).

The standards that have been mapped against the 10 Attributes include:

Aged Care – Australian Council on Healthcare Standards (ACHS) and EQUIP
Community - Care Common Standards (CCCS), Home and Community Care Standards (HACC) and National Respite Carers Program (NRCP)
Department of Human Services (DHS) Community Standards
General Practice Standards Royal Australian College of General Practitioners (RACGP) and Australian General Practice Accreditation Limited (AGPAL)
National Mental Health Standards
National Standards for Disability Services (NSDS)
National Safety and Quality Health Service Standards (NSQHS)
Palliative Care – National Standards Assessment Program (NSAP)
Quality Improvement Council (QIC).

Accreditation Standards

The Gippsland PCPs have undertaken an audit of the accreditation standards their member agencies are required to meet. A compilation of the common standards was developed and then each standard mapped against the 10 Attributes of a Health Literate Organisation. This mapping was completed by a qualified accreditation and quality coordinator.

What?

The standards that have been mapped against the 10 Attributes include:

Aged Care – Australian Council on Healthcare Standards (ACHS) and EQUIP
Community Care Common Standards (CCCS), Home and Community Care Standards (HACC) and National Respite Carers Program (NRCP)
Department of Human Services (DHS) Community Standards
General Practice Standards Royal Australian College of General Practitioners(RACGP) and Australian General Practice Accreditation Limited (AGPAL)
National Mental Health Standards
National Standards for Disability Services (NSDS)
National Safety and Quality Health Service Standards (NSQHS)
Palliative Care – National Standards Assessment Program (NSAP)
Quality Improvement Council (QIC)

Why?

By using this document, organisations will be able to align their work in health literacy to their existing quality standards. Aligning with organisational quality standards provides a mechanism to collect evidence and celebrate the progress and success of moving toward being a Health Literate Organisation.

How?

All staff can contribute to the collection of evidence for accreditation reporting. By being aware of the relevant standards, all staff can assist their quality improvement team/worker in moving towards achieving organisational accreditation.

Impacts & Outcomes

Poor health literacy can have an impact on people’s health and wellbeing. These challenges affect the individual and the community more broadly. Research has found low health literacy to be associated with:

Increased hospitalisation and readmissions, greater use of emergency care and unnecessary emergency room presentation and longer stays in hospital.
Fragmented access to care and reduced use of preventive health services.
Poor management of chronic conditions and ability to demonstrate appropriate medication taking, and poorer knowledge about own diseases or conditions.
Less knowledge and understanding of medical conditions and their preventability.
Misdiagnosis from poor communication between providers and patients, low rates of guidance and treatment compliance.
Poorer ability to interpret labels and health messages.
Less engagement in health-promoting behaviours and poorer overall health status.
Lower participation in screening programs (Canadian Public Health Association, 2008), lower use of mammography and lower uptake of the influenza vaccine.
Higher incidence of chronic disease conditions such as diabetes, cardiac disease and stroke (Adams, et al., 2009).

Lower levels of health literacy can also have an impact on the stage at which a consumer engages with the health system and the types of conditions they present with. Avoidable mortalities such as diabetes, stroke, skin cancer, Ischaemic Heart Disease (IHD) and Chronic Obstructive Pulmonary Disease (COPD) all typically have improved health outcomes when treated early (Western Health, 2012).

Alarmingly, prospective studies have suggested a strong relationship between low health literacy and high mortality rates, particularly in the elderly. Those with poor health literacy levels have a 50% higher mortality rate over a five-year period; and low reading proficiency is the top predictor of mortality after smoking (Baker, et al., 2007) (Sudore, et al., 2006). Even when other factors such as age, sex, education, income, ethnicity and health status are considered the links between level of individual health literacy and outcomes remain (Bush, et al., 2010).

Broader Impacts

A limited amount of data exists around health literacy, health care utilization, and health care cost. Determining the cost of low health literacy to the individual, healthcare organisations and the system as a whole is difficult, as separating the effects of health literacy and other related concepts that influence behaviour is challenging (Eichler, Wieser, & Brügger, 2009).

From the limited US publications available, data has shown that those with poor health literacy incur higher medical costs individually, spending between US$143 and US$7,798 more per person per year compared to those with higher health literacy; and at a system level, additional costs corresponded to roughly 3-5% of total healthcare spending (Howard, Gazmararian, & Parker, 2005) (Eichler, Wieser, & Brügger, 2009). Though the economic costs of limited health literacy sound substantial, few rigorous studies are available and results are often mixed.

Paper continues in Part B

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