1. Don Nutbeam University of Sydney
Literacy, health education, health literacy and health outcomes – How do they fit?
Don Nutbeam
University of Sydney

2. What is literacy? What is it?
Functional literacy is a measure of a person’s ability to read basic text and write a simple statement relevant to everyday life
Why do we care?
Those who are functionally literate are able to participate more fully in society, and are able to exert a higher degree of control over everyday events
Literacy levels are related to public health outcomes

3. Distribution of Global Adult Illiterate Population (15 and over)
by Region, (Total Number of Adult Illiterate Population: 775 millions)
"More than two-thirds of the world's adult illiterates live in Asia and the Pacific Region"

4. Distribution of adult illiterate population (15 and over)
by sub-region and gender, (Total Number of Adult Illiterate Population: 775 millions)
Rates of illiteracy are higher in S&W Asia, especially in India, Bangladesh and Pakistan
Women continue to constitute the majority of the illiterate.
Source: Asia-Pacific Literacy database -

5. As Female Literacy Rates Climb, Total Fertility Rate Drops
List of country codes
Afghanistan AFG
Bangladesh BGD
Bhutan BTN
Cambodia KHM
China CHN
India IND
Indonesia IDN
Iran   IRN
Lao LAO
Malaysia MYS
Maldives MDV
Mongolia MNG
Myanmar MMR
Nepal NPL
Pakistan PAK
Papua NG PNG
Philippines PHL
Sri Lanka LKA
Thailand THA
Viet Nam VNM
NB. Total fertility rate is the number of children that would be born per woman
if she were to live to the end of her child-bearing years and bear children at each age
in accordance with prevailing age specific fertility rates.
Source: Asia-Pacific Literacy database -

6. As Mothers Learn to Read, More Children Survive
List of country codes
Afghanistan AFG
Bangladesh BGD
Bhutan BTN
Cambodia KHM
China CHN
India IND
Indonesia IDN
Iran   IRN
Lao LAO
Malaysia MYS
Maldives MDV
Mongolia MNG
Myanmar MMR
Nepal NPL
Pakistan PAK
Papua NG PNG
Philippines PHL
Sri Lanka LKA
Thailand THA
Viet Nam VNM
NB. Under-5 mortality rate is probability of dying between birth and exactly five years of age
expressed per 1,000 live births.
Source: Asia-Pacific Literacy database -

7. Literate People Tend to Live Longer
Life expectancy at birth is the number of years newborn children would live
if subject to the mortality risks prevailing for the cross-section of population at the time of their births
Source: Asia-Pacific Literacy database -

8. Commission on Social Determinants of Health
Education and the life-course
“Removing the numerous barriers to achievement of primary education will be a crucial part of action on the social determinants of health”
Literacy has “central role in health equity” in countries rich and poor

9. Literacy and health
Relationship between low literacy and a range of health related outcomes well established
Some indirect effects
Employment
Income
Some direct effects
Engaging in preventive health practices
Early detection of disease
Access to health care
Management of chronic disease
Key messages:
Literacy is a public health goal
Achieving the MDGs in relation to literacy will have major public health benefits
Dewalt DA et al Literacy and health outcomes: a systematic review of the literature.
Journal of General Internal Medicine,

10. A brief history of health education (1)
A central component of efforts to promote health an prevent disease throughout this century
Evolved from health propaganda campaigns focused on eradication of infectious disease into healthy lifestyle programs
Found to be most effective in reaching and influencing the most literate, best educated and economically advantaged in the community

11. Contemporary health education – how to maximise impact on health outcomes
New generation of health education focussed on the social context of health decision-making, the development of personal skills and capabilities
Informed by evolving psycho-social theory
Supported by more sophisticated understanding of media, and adaptation of social marketing techniques to health campaigns
Greater understanding of the need to contextualise communication, making it relevant to defined target populations, and needs of low literacy populations
Well documented successes in improving knowledge and health related skills, and in changing health behaviours relevant to the MDGs, for example in relation to smoking, food choices, physical activity and sexual practices

12. The emergence of the concept of health literacy
Literacy is context and content specific – more accurate to talk about literacies for example:
financial literacy,
consumer literacy,
IT literacy and,
health literacy
Even where a person has advanced literacy skills their ability to obtain, understand and apply information about health may be poor – hence findings indicating high prevalence of poor health literacy from US, Australian and Canadian studies.

13. What is health literacy?
“Health literacy represents 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”
“Health literacy means more than being able to read pamphlets and make appointments. By improving peoples’ access to health information and their capacity to use it effectively, health literacy is critical to empowerment”
*Nutbeam D. Health Promotion Glossary. Health Promotion International, 13(4): (also - WHO/HPR/HEP/98.1)

14. Health literacy – public health origins in Australia

15. Australia’s health literacy goals 1993
To achieve the goals of the Australian Language and Literacy Policy
To enhance knowledge and improve health literacy to enable people to make informed choices about their health
To enhance knowledge and improve health literacy to enable people to take an active role in bringing about changes in the environments that shape their health
Nutbeam D, Wise M, Bauman A et al on Health Literacy in Goals and Targets for Australia’s Health, Canberra, AGPS 1993

16. Established population literacy – reading fluency, numeracy,
Improved health outcomes,
healthy choices
and opportunities
Changed health
behaviours and
practices
Improved
Health Literacy
Developed
knowledge
and capability
Health education – directed to knowledge improvement and compliance with pre-determined actions
Established population literacy –
reading fluency, numeracy,
existing knowledge
Developing functional health literacy – a simple linear model

17. Established population literacy – reading fluency, numeracy,
Improved health outcomes,
healthy choices
and opportunities
Changed health
behaviours and
practices
Improved
Health Literacy
Skills in
social organization
and advocacy
Skills in
negotiation and
self management
Developed
knowledge
and capability
Health education directed to knowledge and personal skills development to promote active engagement in health decision-making
Established population literacy –
reading fluency, numeracy,
existing knowledge
Developing interactive health literacy skills

18. Established population literacy – reading fluency, numeracy,
Improved health outcomes,
healthy choices
and opportunities
Engagement in
social action/advocacy
for health
Participation in
changing social
norms and service
practices
Changed health
behaviours and
practices
Improved
Health Literacy
Skills in
social organization
and advocacy
Skills in
negotiation and
self management
Developed
knowledge
and capability
Health education directed to knowledge and personal skills development to promote active engagement in health decision-making
Established population literacy –
reading fluency, numeracy,
existing knowledge
Developing interactive and critical health literacy skills

19. How would this look in practice?
Schools and health literacy – strong and consistent evidence exists for:
providing a comprehensive and integrated health education program for students, based on:
Content that includes both basic personal health information, and exposure to the influence of social, economic conditions, and the role of the media
Teaching and communication methods based on well researched psycho-social theory and effective classroom interaction
Outcomes focus on enhanced health literacy through improved knowledge and development of personal and social skills

20. Schools and health promotion
Efforts to promote health literacy will be greatly enhanced by:
Adopting organisational practices which complement and support the teaching program
Offering a supportive social environment for students
Fostering links with health resources in the community, including optimal use of school health services
creating a safe an secure physical environment

21. Summary remarks – What is the state of the science
Good research in health care settings linking poor health- related literacy with range of clinical outcomes
Some intervention trials in health care settings demonstrate potential effectiveness and cost savings
Good research on the efficacy of modern health education in schools and other settings, but less developed research on the intermediate concept of health literacy in these settings (eg adult education, E-learning)
Progress in development of measures of health-related literacy in clinical settings, but limited progress in development of comprehensive measures

22. Summary remarks – where to from here in practice development
Health literacy fundamentally dependent upon levels of basic literacy in the population – essential to make policy and practical program links between these MDGs,
Developing self confidence to act on knowledge and the ability to support others requires more personal, and community-based educational outreach – incorporation of adult learning principles and health promotion concepts
Promoting greater critical health literacy and well informed independent decision-making requires recognition of social and environmental context to decision-making, enabling individuals to address structural barriers to health

23. Summary remarks – What needs to be done first?
Develop programs that are context and content specific in priority areas in relation to MDGs:
Improving capability to obtain, understand and apply relevant information through
Maternal and child health programs
School Health programs
Cross-sectoral collaboration on adult literacy programs

24. Skilled for Health (UK)
Integrates goals of health improvement with improving literacy, language and numeracy (LLN) skills of adults
Cross government-voluntary sector initiative combines adult LLN learning with people’s wish for a better understanding of health