Health Literacy

Health literacy as a discrete form of literacy is becoming increasingly important for social, economic and health development. The positive and multiplier effects of education and general literacy on population health, particularly women's health, are well known and researched. However, a closer analysis of the current HIV/AIDS epidemics, especially in Africa, indicates a complex interface between general literacy and health literacy. While general literacy is an important determinant of health, it is not sufficient to address the major health challenges facing developing and developed societies. As a contribution to the health literacy forum in Health Promotion International, this paper reviews concepts and definitions of literacy and health literacy, and raises conceptual, measurement and strategic challenges. It proposes to develop a set of indicators to quantify health literacy using the experience gained in national literacy surveys around the world. A health literacy index could become an important composite measure of the outcome of health promotion and prevention activities, could document the health competence and capabilities of the population of a given country, community or group and relate it to a set of health, social and economic outcomes.

Health Education

Health researchers and health care professionals, from both the developed and developing worlds, have long been concerned about the link between health and education (Evans et al., 1994; Health Canada, 1999; World Bank, 2000). Education and literacy rank as key determinants of health, along with income and income distribution, employment, working conditions and the social environment, although the interrelationships and weighting of these various determinants demand further research. The second Canadian health report ‘Towards a Healthy Future’ states:

... literacy levels, which are usually, but not always, related to levels of education, are important predictors of employment, active participation in the community and health status. They are also important predictors of the success of a nation (Health Canada, 1999).

The report mentions in various chapters how Canada's high ranking in the UNDP Human Development Index (UNDP, 1998) drops when parameters such as income distribution and literacy are factored in.

Reports abound from developing countries that highlight the positive impact of education and literacy on population, health and, in particular, womens' health and the health of children (Caldwell, 1986; Bledsoe et al., 1999; Sen, 1999; Nussbaum, 2000). The recent report on the State of the World's Mothers by Save the Children (Save the Children, 2000) has identified the adult female literacy rate (the percentage of women over the age of 15 years who can read and write), as one of the 10 key indicators to assess ‘women’s well-being'. It is estimated that two-thirds of the world's 960 million illiterate adults are women. All countries ranked in the top 10 for ‘women’s well-being' have a female literacy rate of 90% and higher. Latin America has an 80% female literacy rate—the highest among developing nations. In contrast, Africa has the lowest rate with wide disparities. For example, South Africa and Zimbabwe have a literacy rate close to 80%, while in some of the poorest countries, such as Niger and Burkina Faso, only 10% of women can read and write. A mother's level of education correlates closely with a child's risk of dying before age 2 years. Developing countries that have achieved a female literacy rate ranging from 70 to 83% have also achieved an infant mortality rate of 50 (per 100 000) or lower (Save the Children, 2000). Income for women rises by 10–20% for each additional year of schooling. Educated women are more likely to postpone marriage and childbirth, give better health care to their families, and send their children to school and contribute to overall economic growth (Filmer, 1999). The strong relationship between women's educational level and the total fertility rate of the society is well documented. The insufficiently considered impact of improved educational levels among women of childbearing age is beginning to disprove the dire predictions of an impending population explosion.

Much of the research on health and education has focused on population health effects. Recently, however, re-analysis of epidemics such as that of HIV/AIDS has brought new issues and relationships to the fore (Crawley, 2000; UNICEF, 2000). While Zimbabwe and South Africa have some of the highest literacy rates in Africa, they are also the countries most severely challenged by HIV/AIDS. It is estimated that in Zimbabwe, up to 25% of the population is infected, the majority of them women (UNAIDS/WHO, 1999). UNICEF's recent Progress of Nations Report 2000 highlights that there is a disproportionately high incidence of HIV/AIDS among sub-Saharan African teachers (UNICEF, 2000). In 1999, at least 860 000 elementary students in sub-Saharan Africa lost a teacher to HIV/AIDS. The rate was particularly high in Kenya, where ~1400 teachers died in 1999, affecting some 95 000 primary students (compared to only 10 teachers in 1993). Consider the 1999 data for other African countries: in South Africa 100 000 students lost a teacher to HIV/AIDS, in Zimbabwe it was 86 000, and in Nigeria 85 000. The high death rate of teachers shows clearly that general literacy and health literacy do not necessarily go hand in hand. It illustrates that literacy and health literacy are moving targets and must be viewed in context. For example, the high death rate in teachers can partly be explained by the fact that many teachers are women and in most of these cultures, women do not have much power in relation to their family roles and their husbands' sexual demands. It demonstrates drastically the impact of low health literacy on other policy sectors, in this case education. Hard-won gains in school, health and general literacy in the African countries are being seriously endangered, with increasing effects on social and economic development. These effects open up an avenue for a common agenda between health and education, focusing on the interrelationship and the interdependence between investing in both literacy and health literacy, in schools and in society overall (Harrison, 1997).

While education and literacy are important determinants of health, health literacy as a discrete form of literacy is becoming increasingly important for social and economic development. The challenges we face are to:

• develop reliable measures of the health literacy of societies and population groups;
• quantify scientifically its impact on health and quality of life outcomes; and
• propose public health interventions that significantly increase health literacy along its various dimensions.

The next step is to revisit some definitions and measurements of general literacy, and discuss to what extent they can be applied to the specific challenges of health literacy.

Source: Health Promotion International