1. Approaches to improving health literacy in Thailand
Professor Don Nutbeam
School of Public Health, Prevention Research Collaboration, University of Sydney

2. General literacy matters
Low literacy in a population is associated with a range of poor health outcomes of relevance to NCD prevention and management.
Those with lower levels of literacy are less responsive to health education, the use of disease prevention services, and less able to successfully self-manage of non-communicable diseases (NCDs).
Literacy is not a fixed asset. It is both content and context specific.
Improving access to education and achieving high levels of literacy in a population is not only a key sustainable development goal in its own right, but will also produce substantial public health benefits.

3. Literacy Rate of Thai People Between 1970 – 2010
Percentage
Literate
Illiterate
A.D.
1970
1980
1990
1994
1995
2006
2007
2000
2001
2003
2005
2010

4. Health education is important
Health literacy can be improved through education, enabling greater autonomy in decision-making, as well as engagement in a wider range of health actions.
BUT – message, medium and context matter
Observable differences in health literacy emerge as a consequence of differential exposure to different forms of heath information content, and communication media.
Individual responses to information and education will be moderated by the environment in which they occur.
Health literacy is also content and context specific. A person’s ability to access health information and their motivation and skills to use information is greatly influenced by their age and stage in life, and the context in which information might be applied.

5. Situational demands and complexity
Health literacy is a product of personal skills and situational context
Adapted from Ruth Parker, Measuring health literacy: what? So what? Now what? In Hernandez L, ed. Measures of health literacy: workshop summary, Roundtable on Health Literacy. Washington, DC, National Academies Press, 2009:91–98
Personal skills
and abilities
Health literacy
Situational demands and complexity
Personal skills
and abilities

6. Health literacy matters
Health literacy is an observable, measurable outcome from health education
Higher levels of health literacy can support a wide range health actions to prevent illness and better manage existing conditions, including
changed personal behaviours,
Improved health system use
and the capability of influencing others towards healthy decisions
Health education is most likely to improve health literacy when the messaging and delivery are tailored to the specific needs of individuals and populations across their life course

7. Figure 1: Health education and improved health literacy need to be viewed in the wider context of a comprehensive and integrated set of actions
Health Promotion
Outcomes
(intervention impact measures)
Health Promotion
Actions
Intermediate
Health Outcomes
(modifiable
determinants)
Primary Health Outcomes
With individuals
School education, media
communication
patient education
Health Literacy
Improved health-related knowledge,
attitude, motivation,
behavioural intentions, personal skills, self-efficacy
Healthy Lifestyles
Non smoking use,
physical activity,
food choices (salt)
alcohol use
Health Outcomes
reduced metabolic disorders (HBP, obesity) disability,
avoidable mortality
With families and communities
community
engagement and mobilisation,
family education
Effective health services
Universal access to primary health services, preventative screening, access to specialist treatment and rehab.
Social action & influence
community participation,
public opinion
Social Outcomes
quality of life,
functional
independence,
equity
Healthy
Environments
Safe physical environment,
nutritious food supply tobacco control measures.
By National and local government
policy development, resource allocation
Healthy public policy
Public policy,
legislation, regulation,
organisational practices

8. Communication is good, education is better
Health literacy can best be improved through a structured educational programs or through well designed on-line/mobile learning programs.
Community health education for NCD prevention has been considerably strengthened by the development of a new generation of more sophisticated, theory-informed interventions
These theories have helped to identify and explain the complex relationships between knowledge, beliefs, and perceived social norms, and provide practical guidance on the content of health education programs to improve interactive and critical health literacy
Successful interventions tend to be based on more interactive and personalized forms of communication and messaging

10. Clinicians in the health system have a vital role to play
In clinical practice, there is good evidence that comprehension of health information among individuals with low health literacy can be improved through modifications to communication, and changes to the clinical environment
These produce produce improved health outcomes including
Improved medication use
Improved self-management of conditions
Reduced reported disease severity,
Reduced unplanned emergency department visits, and
reduced hospital use

11. Adopting and adapting interventions that work in health care settings
2011Review reports on the outcomes of 38 intervention studies (Sheridan et al 2011*).
Broadly consistent evidence that comprehension of health information and advice among individuals with low health literacy can be improved
Requires modifications to communication, and mixed-strategy interventions (for example combining adapted communications with behavioural skills coaching)
an emphasis on skill building, and delivery by a health professional.
use of simplified text and teach-back methodologies that have been shown to be effective in other literacy interventions
Delivers improved health outcomes including reduced reported disease severity, unplanned emergency department visits and hospitalizations.
* Sheridan et al. (2011). Interventions for individuals with low health literacy: a systematic review. Journal of Health Communication, 16(s3):

12. Teach-back – four steps to improving patience adherence with medicine prescription*.
1. Clinicians must accept the burden of communication - “I have covered a lot of information today and I want to make sure I did a good job of explaining this.” 2. The communication should focus on a specific behaviour “Can you tell me when and how you will take this medicine?” 3. The patient should be reassessed and instructions should be explained again in a different manner as needed 4. Clinicians should continue to explain until both they and the patient agree that the information has been understood.

13. Tackling health literacy in the health care system*
Health literacy assessment -
Health-related reading fluency, numeracy, prior knowledge
Organizational practice sensitive to health literacy
*Nutbeam D The evolving concept of health literacy. Social Science and Medicine
See also Paasche-Orlow MK, Wolf MS. The causal pathway linking health literacy to health outcomes.
American Journal of Health Behaviour; 2007; 31 (Supplement 1): S19-26

14. Tackling health literacy in the health care system*
Tailored health/patient communication and education
Improved access to health care, and productive interaction with health care professionals
Health literacy assessment -
Health-related reading fluency, numeracy, prior knowledge
Organizational practice sensitive to health literacy
*Nutbeam D The evolving concept of health literacy. Social Science and Medicine
See also Paasche-Orlow MK, Wolf MS. The causal pathway linking health literacy to health outcomes.
American Journal of Health Behaviour; 2007; 31 (Supplement 1): S19-26

15. Tackling health literacy in the health care system*
Improved clinical outcomes
Enhanced capability for self management, improved compliance
Tailored health/patient communication and education
Improved access to health care, and productive interaction with health care professionals
Health literacy assessment -
Health-related reading fluency, numeracy, prior knowledge
Organizational practice sensitive to health literacy
*Nutbeam D The evolving concept of health literacy. Social Science and Medicine
See also Paasche-Orlow MK, Wolf MS. The causal pathway linking health literacy to health outcomes.
American Journal of Health Behaviour; 2007; 31 (Supplement 1): S19-26

16. Health, development and health literacy – priorities for Thailand?
Health literacy has been adopted by several countries as a population measure of human capacity and development – is this right for Thailand?
Health literacy is monitored in countries and specific populations in a variety of ways that are practical and relevant to local circumstances – WHO has recommended population monitoring of health literacy as a key measure of health development – is this right for Thailand?.
Several countries have developed national targets to improve health literacy and/or related policies across the spectrum of health care and public health education. These targets and related policies guide both clinical and public health practice – is this right for Thailand?.

17. Health, development and health literacy – priorities for Thailand?
Health literacy can best be improved through structured, theory-informed educational programs, or through similarly designed on-line learning programs – do current health communication and education strategies in Thailand reflect this?
Interventions that are context and content relevant - linked to critical life stages (eg adolescence, parenthood, aging and retirement) and events (eg diagnosis of chronic disease) - are likely to be more successful in producing sustainable change – do current priorities reflect this in Thailand?.
We know that organisational context is important – do current health system policies and regulations in Thailand support health literacy?
We know that clinicians are important in supporting health literacy – is this reflected in current education and training strategies?

18. Health literacy in Australia – it’s not a new idea

19. 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 Harris E, Leeder S on Health Literacy in Goals and Targets for Australia’s Health, Canberra, AGPS 1993