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Low health literacy contributes significantly to health disparities for Māori and Pacific peoples. However,
the majority of adult New Zealanders have low health literacy. This has wide ranging implications for people's
well being and the provision of health services. Improving health literacy is about more than enhancing the readability
of information. It is about building the skills and knowledge of individuals, whānau and communities so that they can
evaluate, synthesise and act on the information they receive, to improve their health outcomes.
Why does health literacy matter?
More than half of adults in New Zealand have low health literacy, and they are:
- Less likely to use preventative services
- Less likely to recognise the first signs of medical problems
- Less likely to effectively manage their long-term condition
- Less likely to communicate concerns to health professionals
- More likely to be hospitalised due to a chronic condition
- More likely to use emergency services
- More vulnerable to workplace injury
What is health literacy?
Health literacy is the interaction between the skills and knowledge of individuals and the demands of the health system.1 In many health settings there is a significant mismatch between the skills and knowledge people need in order to meet the health literacy demands they face, and their actual health literacy skills and knowledge.
In New Zealand, good health literacy has been defined as: "the capacity to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions".2
There are three aspects to this definition. Firstly, a person or family has to get the information they need. Secondly, they need to understand the information and decide if it is accurate and sufficient. And finally, they need to act on the information. Patients not acting on information is most commonly cited by health professionals as evidence of non-adherence. But it is equally important to check what happened at the other two stages.
Health professionals need to provide clear, consistent and relevant information and services, where, how and when people need them, and assist people to understand the information and services as required.
People's health literacy skills and knowledge are influenced by:
- Familiarity with the health topic and the system
- Available time and resources
- Confidence levels
- Attitudes, values and beliefs
The literacy and numeracy demands of the health system are influenced by:
- How services are designed and delivered
- Organisational and funding processes
- The complexity of the health issue
- The communication skills of the health workforce
- The complexity of oral and written communication used, e.g. instructions, information, forms, letters, publications, websites, labels
Low health literacy should not be confused with low intelligence. Health care systems are increasing in complexity with a wider range of providers. People are required to be more self-managing, develop new skills to find and manage information, understand and manage their rights and responsibilities and make health decisions for themselves and others.
Health literacy involves:
- Understanding how to navigate and interact with the complex health system
- Understanding what health information is relevant and how to find it
- Developing knowledge and expectations about health and well-being
- Evaluating and understanding health messages, nutrition information, instructions and medicine labels
- Completing medical forms and responding to information requests
- The confidence and ability to talk with health professionals and ask questions
People can have ongoing health literacy needs or episodic health literacy needs. People who have low health literacy will have ongoing difficulties in making informed health decisions, but most people will at some point in their lives experience an episode of low health literacy. Even highly skilled individuals may find the health system too complicated to understand, especially when these individuals are made more vulnerable by poor health.
When a person is diagnosed with a new condition it will take some time to understand the condition, how it is affecting them and what to do about it. It may also require people to prepare for and undergo unfamiliar tests, take new medicines, find clinics and interact with new health professionals. Often people are expected to listen to and read new information, understand and use new vocabulary, speak to new people about new things and monitor results or perform calculations. This is likely to come at a time when people are already feeling ill and stressed.
What can health professionals do about health literacy?
Health literacy is about more than improving the readability of information and the information flow between the public, health professional and the health system. Health literacy is about building the skills and knowledge of individuals, whānau and communities so that they can evaluate and synthesise the information they receive from the health system and others, decide whether they have enough information, and act on the information. This concept of health literacy relies significantly on health professionals, health organisations and the health system not just providing the information but actively building the health literacy skills and knowledge of individuals, whānau and communities.
The health literacy "problem" is not just the responsibility of the patient. The greatest opportunity for the health sector is to reduce the health system's literacy demands and complexity and to improve the health workforce's communication skills.
How to reduce health literacy demands
Reducing health literacy demands does not mean "dumbing down" or reducing information. In some cases it may result in more, rather than less, information being shared with patients.
Health literacy demands can be reduced by:
- Making it easier for patients to navigate health services, systems and processes
- Encouraging health conversations and helping people to identify and ask questions
- Finding out what people know as the starting point of any health conversation
- Tailoring the conversation to take into account what they already know
- Making the amount of information or instructions passed on manageable for the patient and their whānau
- Checking that you have been clear when talking to a patient by asking them to "teach-back"
- Encouraging whānau involvement in health conversations
- Going through written information with patients and whānau rather than handing it out to be read later
- Making medication and treatment information clearer
- Following up and monitoring prescribed medicines and instructions
- Redesigning health education resources, letters and forms so they are clear to the audience
Health literacy statistics in New Zealand
The most recent Adult Literacy and Lifeskills Survey (ALLS)* carried out in 2006, showed that more than half (56.2%) of New Zealand adults have poor health literacy skills. These results are similar to those of Australia, Canada and the United States, which participated in these literacy surveys along with many other OECD countries.
Health literacy skills were measured on a scale of one (very low skills) to five (very high skills). Health literacy skills at level three are considered necessary to cope with the demands of everyday health situations. Only 43% of New Zealand adults have good health literacy, that is, level three and above. This means more than 1.6 million adults in New Zealand have health literacy skills at levels one and two and are limited in their ability to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions.
Elderly people, people with limited education, people with limited income and people with limited language proficiency often have lower health literacy. Māori have much lower health literacy levels than non-Māori, regardless of other demographic factors such as age, gender, income and educational status. However, European New Zealanders comprise the largest group with low health literacy in New Zealand.
* Available from: www.educationcounts.govt.nz
Health literacy is not just providing the information
but actively building the health literacy skills
and knowledge of individuals,
whānau and communities
How to develop peoples' health literacy skills
Every interaction between a patient, whānau and a health professional provides an opportunity to develop people's health literacy knowledge and skills.
For example, a health conversation can be used to check and build understanding about:
- A health condition
- Essential health terminology
- Each aspect of a health process
- Who can provide support and advice
Most people with low health literacy do not know they have an issue and if they do, they are unlikely to reveal the problem. In many situations it is not possible to know what information has previously been provided to a patient and whānau, what is already understood, or what barriers exist for the patient and whānau in relation to acting on information.
Sometimes health professionals may know when a patient has health literacy needs because someone has helped them to fill in forms or understand appointment letters. However, in most cases it will be difficult to readily determine a patient's health literacy skills.
Taking a Universal Precautions approach to health literacy means providing good clear communication (both written and spoken) to all patients and whānau. This approach maintains the mana of the patient and whānau and, when done effectively, benefits all patients and whānau, not just those with low health literacy.
Resources can help to develop health literacy skills and knowledge by including concepts, vocabulary, activities, and information that build on people's existing knowledge and help them to develop the necessary skills and knowledge for understanding and managing their health. For example, someone newly diagnosed with high cholesterol may benefit from a resource that helps them:
- Understand and correctly pronounce new vocabulary about cholesterol
- Learn enough about cholesterol to understand what health professionals are asking them to do, and why
- Plan questions to ask health professionals
- Get support to ask questions and manage their treatment
Written resources to develop health literacy skills and knowledge need to go beyond a "plain language" approach and need to be developed in conjunction with the people using the information, to ensure the resources provide the information people need and want, in an accessible way.
Improving health literacy means people will be better able to take care of their health and engage with the health system. For health professionals, better health literacy will lead to improved patient interactions, and better health outcomes.
- Fakamalolo ke he tau amaamanakiaga, ke mafola ai e tau matakainaga
Strengthen all endeavours and the community will benefit – NIUE
- Toko rangatiratanga na te mana-matauranga
Knowledge and power set me free – MĀORI
- Prescription to End Confusion, Institute of Medicine, 2004
- Kōrero Mārama, Ministry of Health, 2010