Reading you loud and clear

02 May 2018

When almost half of the working-age adults in England cannot decipher everyday health information, journalist Juliette Astrup examines health literacy in the UK, and what is being done to improve it


Health literacy is defined by WHO as ‘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’ (WHO, 2014).

Simply put, health literacy enables people to understand and use health information and services well enough to actively take care of their health. And while it is largely dependent on literacy levels in the population, health literacy is a two-way street, with the onus on healthcare providers to present information in a clear and comprehensible fashion.


Why is health literacy important?

Fundamentally, poor health literacy leads to poorer health. WHO recognises it as ‘a critical determinant of health’ (WHO, 2016) requiring investment for its development, and the American Medical Association (AMA) concluded that health literacy is a stronger predictor of health status than age, income, employment status, education level, race or ethnic group (AMA, 1999).

Limited health literacy is linked with unhealthy behaviours and poorer health outcomes; those with limited health literacy are more likely to use emergency services, and less likely to successfully manage long-term health conditions (Public Health England (PHE), 2015). And it is more likely to be an issue for disadvantaged groups, and those with poorer general literacy and numeracy (PHE, 2015).

Not only does it have a potentially devastating impact on individuals who are at risk of problems such as misusing medications or exacerbating chronic conditions such as diabetes, but it also drains NHS resources: the economic cost of poor health literacy in England is estimated at between £2.95bn and £4.92bn a year (PHE, 2015).


How health literate are we?

Poor health literacy is surprisingly common. The European Health Literacy Survey found almost one in two respondents had insufficient or problematic health literacy (Sørensen et al, 2015). A study in England showed 43% of working-age adults in England were unable to understand and make use of everyday health information (Rowlands et al, 2015).

Professor Jo Protheroe, chair of Health Literacy Group UK, who co-authored that study, says it included a range of health-related information, including reading instructions on the side of medicine packaging and directions on how to fit a car seat, to assess how well subjects matched the literacy and numeracy skills of the working-age population in England.

‘What we found was a mismatch,’ she says. ‘The information out there is too difficult to comprehend for nearly half of working-age adults. And if you include numbers – say, on the side of a bottle of Calpol to calculate the number of millilitres appropriate for a child – that rises to 61%. That equates to between 15 and 21 million working-age people across the country.’


What can be done?

Professor Protheroe believes health literacy is not solely down to the skills of the individual, but about the balance between their skills and the environment – the health, education and care systems they navigate.

She insists the onus must be on healthcare professionals to ensure that they communicate with patients in ways that can be understood.

‘We have consistent evidence that low health literacy can be improved through moderating communication and making changes to the clinical environment,’ she says.

‘And if you improve health literacy, you improve outcomes. You improve medication use, you improve self-management of conditions, reduce mortality, reduce unplanned emergency visits, reduce hospital use and improve screening.’


Policy and practice

With NHS services under unprecedented pressure, the drive towards increased patient participation, self-care and self-management shows no sign of abating – but, as experts have pointed out, if health literacy isn’t also addressed, that policy goal could actually worsen health inequalities (Protheroe et al, 2009).

So what is being done to ensure UK populations are properly empowered to manage their own health and wellbeing?

Health literacy is already embedded in policy across the four nations, with scoping studies and action plans highlighting the issue: for example, Scotland’s Making it easier, published last year, which set out strategies to embed health literacy in policy and practice throughout health and social care services (Scottish Government, 2017).

In England the latest advance was the launch, in December last year, of a health literacy toolkit, developed by Health Education England (HEE) in partnership with PHE, NHS England and the Community Health and Learning Foundation (HEE, 2017).

It includes a number of strategies to help healthcare workers adapt their practice, including the much-lauded teach-back method, which works by asking people to repeat back to health professionals what they have just heard as a way of confirming understanding.

There is also a dedicated toolkit for school nurses, produced by the Association for Young People’s Health (AYPH) with the support of PHE (AYPH, 2016).

Among the notable initiatives in Northern Ireland are those taking place within Belfast Healthy Cities, part of the WHO global Healthy Cities project, where work has included creating online resources and health literacy training. Belfast also hosted the Health Literacy: Making Life Better UK conference in February this year.

Top health literacy tips

  • Don’t make any assumptions about literacy levels and understanding.
  • Use the teach-back technique – asking someone to repeat back what they have just been told to assess their level of understanding.
  • Make use of diagrams and pictures.
  • Stick to three points rather than overloading someone with information.
  • If you have to give more information, use the ‘chunk and check’ technique, giving a small amount of information, then checking that it has been understood before moving on.
  • Look out for ‘red flags’ in patients such as body language, missing appointments, being slow to fill in forms or questionnaires, finding it difficult to give a coherent history or not asking many questions.
  • Make sure you use everyday language and not medical terminology.

Next steps

Louise Hales, chair of the CPHVA in Northern Ireland and a lecturer at Queen’s University Belfast, says efforts are still very much focused on raising awareness.

‘I think until the message is out there that this is a significant public health issue, things won’t improve. It’s in policy documents, but I don’t think it’s reached practice yet.’

She adds: ‘It is something we really need to be more mindful of when having any interaction with patients – whether we are providing them with information or asking them to participate in their own care, make decisions about treatment or follow a regime.

‘We need to recognise that we can’t leave it all down to the individuals. Yes, measures need to be taken to improve people’s education and literacy levels, but organisations, governments and practitioners have a responsibility to ensure they make the information understandable, and that includes everything from signs in hospitals to information leaflets. And there are things that can be done in appointments, such as the teach-back technique.’

Louise is also a member of the intersectoral Health Literacy Working Group, which aims to raise the profile of health literacy across all sectors in Northern Ireland. This work is supported by the Belfast Healthy Cities project, which also delivers communication training focused on health literacy to community agencies and health professionals, including community pharmacists, GPs and dentists.

‘We need to be training all staff to recognise whether there could be issues with somebody’s health literacy, as well as working with the community and the voluntary sector to raise their awareness, so that they can initiate programmes to support people,’ she says.

‘And we as practitioners need to make sure we are working in a person-centred way.’ 



Making it easier health literacy action plan 

Health Education England’s health literacy toolkit 

Public Health Wales’ scoping document 

Belfast Health Cities’ health literacy toolkit 


American Medical Association. (1999) Health literacy: report of the Council on Scientific Affairs. JAMA 281(6):552–7. See: https://jamanetwork.com/journals/jama/article-abstract/188749?redirect=true (accessed 16 April 2018).

Association for Young People’s Health. (2016) School nurse toolkit. See: http://www.youngpeopleshealth.org.uk/wp-content/uploads/2016/10/AYPH_NursesToolkit_interactive.pdf (accessed 16 April 2018).

Health Education England. (2017) Health literacy toolkit. See: https://www.hee.nhs.uk/our-work/health-literacy (accessed 16 April 2018).

Protheroe J, Nutbeam D, Rowlands G. (2009) Health literacy: a necessity for increasing participation in health care. British Journal of General Practice 59(567): 721-3.

Public Health England. (2015) Local action on health inequalities: improving health literacy to reduce health inequalities. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/460709/4a_Health_Literacy-Full.pdf (accessed 13 April 2018).

Rowlands G, Protheroe J, Richardson M, Seed P, Winkley J, and Rudd R. (2015) A mismatch between population health literacy and the complexity of health information; an observational study. British Journal of General Practice 65(635): e379-86.

Scottish Government. (2017) Making it easier: a health literacy action plan for Scotland 2017-2025. See: gov.scot/Publications/2017/11/3510 (accessed 16 April 2018).

Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, Fullam J, Kondilis B, Agrafiotis D, Uiters E, Falcon M, Mensing M, Tchamov, van den Brouke S, Brand H. (2015) Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). European Journal of Public Health 25(6): 1053-8.

WHO. (2016) Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development. See: who.int/healthpromotion/conferences/9gchp/shanghai-declaration.pdf?ua=1 (accessed 13 April 2018).

WHO. (2014) Health literacy toolkit. See: http://apps.searo.who.int/PDS_DOCS/B5148.pdf (accessed 13 April 2018).

Picture credit | Shutterstock

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