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The European Health Literacy Survey: Results from Ireland

Authors:
April 2012
THE EUROPEAN HEALTH LITERACY
SURVEY: RESULTS FROM IRELAND.
Dr Gerardine Doyle (Principal Investigator)
Dr Kenneth Cafferkey (Postdoctoral Researcher)
Mr James Fullam (PhD Student)
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Contents
Table of Figures ....................................................................................................................................... 5
List of Tables ........................................................................................................................................... 6
ABOUT THE AUTHORS ............................................................................................................................. 7
Executive Summary ................................................................................................................................. 8
Introduction ........................................................................................................................................ 8
Method ............................................................................................................................................... 8
Findings: Health Literacy ..................................................................................................................... 8
Findings: Functional Health Literacy ................................................................................................... 9
European Findings............................................................................................................................... 9
Recommendations .............................................................................................................................. 9
SECTION 1: HEALTH LITERACY ............................................................................................................... 11
What is Health Literacy? ................................................................................................................... 11
Why are we concerned about health literacy? ................................................................................. 11
Health Literacy and Chronic Disease................................................................................................. 13
Health literacy in Ireland ................................................................................................................... 15
SECTION 2: THE HLS-EU ........................................................................................................................ 19
The HLS-EU Consortium .................................................................................................................... 19
The HLS-EU-C: A Conceptual Model of Health Literacy .................................................................... 20
From the HLS-EU-C to an Instrument for Measuring Health Literacy .............................................. 23
SECTION 3: METHODOLOGY ................................................................................................................. 25
Data Collection .................................................................................................................................. 25
Sampling ............................................................................................................................................ 25
Recruitment ...................................................................................................................................... 26
The Health Literacy Index ................................................................................................................. 26
Technical Properties of the HLS-EU Indices .................................................................................. 26
The Fixation of Thresholds for the European Health Literacy Index ............................................ 29
Conclusion of Validity and Reliability Analyses and General Remarks ......................................... 30
SECTION 4: RESULTS.............................................................................................................................. 33
Introduction ...................................................................................................................................... 33
Respondent Profiles .......................................................................................................................... 33
Descriptive analysis of demographics ............................................................................................... 34
Health Behaviours and Outcome Related Descriptives ........................................................................ 41
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Self-Rated Health .............................................................................................................................. 41
Health Service Use ............................................................................................................................ 42
Health behaviours ............................................................................................................................. 43
SECTION 5: A DESCRIPTIVE OVERVIEW OF HEALTH LITERACY .............................................................. 46
Notable findings ................................................................................................................................ 50
Cure and Care ................................................................................................................................ 50
Disease Prevention ....................................................................................................................... 53
Health Promotion .......................................................................................................................... 55
Newest Vital Sign .............................................................................................................................. 58
Health Literacy .................................................................................................................................. 59
Regional differences in Health Literacy ............................................................................................ 60
Gender and Health Literacy .............................................................................................................. 62
Age and Health Literacy .................................................................................................................... 62
Education and Health Literacy .......................................................................................................... 64
Income and Health Literacy .............................................................................................................. 65
Self- Perceived Social Class and Health Literacy ............................................................................... 67
Predicting Health Literacy ................................................................................................................. 69
SECTION 6 THE RELATIONSHIP BETWEEN HEALTH LITERACY AND HEALTH OUTCOMES ..................... 70
Section 7 European Results ................................................................................................................... 74
Overview ........................................................................................................................................... 74
Correlation Analyses ..................................................................................................................... 75
SECTION 8: CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS .............................................. 79
Recommendations ............................................................................................................................. 79
REFERENCES .......................................................................................................................................... 81
Appendix 1: The European Health Literacy Survey ........................................................................... 85
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ACKNOWLEDGEMENTS
The authors would like to acknowledge the funding contribution of the Department of
Health.
The authors would like to acknowledge the funding contribution of the Executive Agency for
Health and Consumers (EAHC) Grant Number 2007 113 HLS _EU in making this research
possible.
The authors would like to acknowledge the participation of The National Adult Literacy
Agency in the development of the HLS.EU.
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Table of Figures
Figure 1 Health literacy, a personal for patients. ................................................................................. 15
Figure 2 The HLS-EU Conceptual Model of Health Literacy, the HLS-EU-C. .......................................... 21
Figure 3 Design matrix for HLS-EU Health Literacy Items. .................................................................... 24
Figure 4 Identity of Sample ................................................................................................................... 35
Figure 5 Marital Status .......................................................................................................................... 35
Figure 6 Household Living Situation ..................................................................................................... 36
Figure 7 Educational Attainment .......................................................................................................... 37
Figure 8 Ability to pay for medication. ................................................................................................. 39
Figure 9 Self-Perceived Social Class ...................................................................................................... 40
Figure 10 Household Net Income ......................................................................................................... 41
Figure 11 Health Insurance ................................................................................................................... 42
Figure 12 Hospital Service Use .............................................................................................................. 43
Figure 13 Smoking Behaviour ............................................................................................................... 43
Figure 14 Alcohol Consumption Index .................................................................................................. 44
Figure 15 Community Involvement ...................................................................................................... 45
Figure 16 Newest Vital Sign .................................................................................................................. 58
Figure 17 Average Health Literacy by Region. ...................................................................................... 61
Figure 18 Average Newest Vital Sign Score by Region. ........................................................................ 61
Figure 19 Health literacy on health in general ...................................................................................... 70
Figure 20 Health literacy on visits to the doctor ................................................................................... 70
Figure 21 Health literacy on use of hospital services............................................................................ 71
Figure 22 Health literacy on smoking ................................................................................................... 71
Figure 23 Health Literacy on exercise ................................................................................................... 71
Figure 24 Health Literacy on community involvement ......................................................................... 72
Figure 25 Health literacy on alcohol consumption ............................................................................... 72
Figure 26 Percentages of different levels of the General Health Literacy Index, for 8 countries and the
total sample. ......................................................................................................................................... 74
Figure 27 Distribution of Levels of and Means of NVS Scores .............................................................. 75
Figure 28 General Health Literacy Index, Mean Scores by Age and Country ....................................... 75
Figure 29 General Health Literacy Index, Mean Scores by Education (ISCED) and Country................. 76
Figure 30 General Health Literacy Index, Mean Scores by NVS scores and Country ............................ 76
Figure 31 General Health Literacy Index, Mean Scores by Self-Rated Social Status and Country........ 77
Figure 32 General Health Literacy Index, Mean Scores by Financial Deprivation and Country ........... 77
Figure 33 General Health Literacy Index, Mean Scores by Self-Assessed Health and Country ............ 78
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List of Tables
Table 1 The 12 dimensions of health literacy. ...................................................................................... 24
Table 2 Recruitment Results Wave One HLS.EU. .................................................................................. 26
Table 3 General and specific health literacy scales and their respective items; minimum number of
valid answers necessary for index calculation; minima and maxima of scale metric. ......................... 28
Table 4 Regional Distribution of Surveys .............................................................................................. 33
Table 5 Employment Status: What is your current “main” status of employment? ............................ 38
Table 6 Frequency Table for Health Literacy Items .............................................................................. 46
Table 7 Regional Mean Scores for Health Literacy and Newest Vital Sign ........................................... 60
Table 8 Determinants of Health Literacy .............................................................................................. 69
Table 9 Beta Values for Health Literacy Outcome Regression Models................................................. 73
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ABOUT THE AUTHORS
Dr. Kenneth Cafferkey
Kenneth Cafferkey is a postdoctoral researcher at University College Dublin. Kenneth holds
a PhD from NUI Galway. His research interests include healthcare management, health
literacy and high performance work systems. Kenneth is presently working on the European
Health Literacy Survey (HLS-EU), with responsibility for valorisation activities.
Dr. Gerardine Doyle
Gerardine is a chartered accountant and lecturer in accounting at University College Dublin.
Gerardine's research interest in health care management combines her science degree in
pharmacology (UCD) with her qualification and experience as a chartered accountant with
KPMG. Gerardine was academic director of the Executive MBA (Health Care Management)
programme at the UCD Michael Smurfit Graduate Business School (2005 2009).
In 2008, Gerardine secured funding for a four year PhD study in the area of health literacy
with MSD Ireland. The study is a part of the European Health Literacy Survey (HLS-
EU) aimed at measuring health literacy in Ireland and performing comparative analyses with
other European countries. Gerardine is responsible for the work package on valorisation for
HLS-EU. The cost effectiveness of a variety of health literacy interventions and studies of the
economic implications of limited health literacy are other research interests that Gerardine is
pursuing. Gerardine has been chairperson of the judging panel for the Crystal Clear MSD
Health Literacy Awards (healthliteracy.ie, crystalclearawards.ie) since their inception in
2007.
James Fullam
James Fullam is PhD student researching health literacy in Ireland. Specifically James is
attempting to assess the effect of health literacy on health outcomes and health behaviours
among the general public and within specific patient groups. James has worked closely with
the European Health Literacy Survey (HLS-EU) consortium, particularly on the conceptual
foundations and piloting of the survey instrument. James’ work is supervised by Dr.
Gerardine Doyle and is based in the UCD Michael Smurfit Graduate Business School and the
UCD School of Public Health, Physiotherapy and Population Science. His PhD scholarship is
supported by MSD Ireland.
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Executive Summary
Introduction
This is the first European Health Literacy Survey (HLS.EU). It represents the first attempt to
measure health literacy in eight European countries. The objectives of the study were
fivefold:
1. To develop a model instrument for measuring health literacy in Europe.
2. To generate first-time data on health literacy in European countries, providing
indicators for national an EU monitoring.
3. To make comparative assessment of health literacy across European countries.
4. To create National Advisory Bodies in countries participating in the survey and to
document different valorization strategies following national structures and
priorities.
5. To establish a European Health Literacy network
This is the report of the Irish study of the HLS.EU project. The report is divided into eight sections as
follows:
1. Health Literacy
2. The HLS.EU
3. Methodology
4. Results
5. A descriptive overview of health literacy
6. The relationship between health literacy and health outcomes
7. European results
8. Conclusions, implications and recommendations
Method
The Irish sample involved 1005 respondents (response rate 69%). Data was collected in July
2011. The sample was representative of the general population. The Newest Vital Sign (UK
version) was also administered to respondents as part of the HLS-EU Questionnaire
(HLS.EU.Q) to measure functional health literacy. Findings were analysed descriptively and
also by predictor and outcome variables as designated by a conceptual model of health
literacy developed by the HLS.EU consortium(Sorensen et al., 2012).
Findings: Health Literacy
Of the respondents in Ireland, 10.3% had inadequate health literacy, 29.7% had problematic
health literacy, 38.7% had sufficient health literacy and 21.3% had excellent health literacy.
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Findings: Functional Health Literacy
Of the respondents, 19.9% showed a high likelihood of limited functional health literacy,
22.5% showed a possibility of limited functional health literacy and 57.6% had adequate
functional health literacy.
European Findings
Of the eight participating countries, Ireland had the second highest level of health literacy,
after the Netherlands. All countries displayed positive correlations between health literacy
and education, health literacy and self-assessed social status, health literacy and the Newest
Vital Sign score. All countries displayed negative correlations between health literacy and
financial deprivation, health literacy and self-assessed health. With regard to age, all
countries except the Netherlands displayed a negative correlation between health literacy
and age.
Recommendations
Recommendations from the study are presented at both the national level and the European level.
Recommendations for Ireland
Health care professionals in Ireland should adjust their expectations in assuming the levels
of health literacy and literacy of their patients. Health literacy should be included in the
education and evaluation of health care practitioners.
Health education and its assessment needs to be integrated into the school curricula from
the earliest years to school leaving age.
Efforts must be made to identify individuals with poor functional literacy at the point of
entry to the health system and steps should be taken to counter this risk factor immediately.
Further research is needed into the barriers to accessing information on mental health.
Health literacy should be considered in the development of all health promotion initiatives
at all levels/settings, i.e. primary care, hospital settings, residential care and national health
promotion campaigns. Plain language should be the foundation of all new materials but the
cognitive ability required to understand and process the information presented should also
be taken into account.
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The study recognises the efforts made by the pharmaceutical industry to produce
information leaflets that take into account consultation with target patient groups, a process
that is required by legislation (Directive 2001.83 EC as amended 07/11). However in light of
the findings of the extent of low levels of functional literacy in Ireland and given that 17.5%
of those surveyed still have difficulty understanding medication leaflets, the industry is
encouraged to investigate ways to further incorporate principles of health literacy into the
information they provide.
In the media, standards of reporting should be considered to aid people in their
interpretation of health information.
At a European level the HLS-EU consortium has proposed the following policy
recommendations which are also relevant to Ireland, as a member of the EU:
Define concrete objectives and ways to empower citizens and increase health literacy, which
should become a priority in the European Commission’s new programme, and promote
concrete cross-sector, multi-stakeholder collaboration.
Feature health literacy prominently in the new European health strategy, following the
White Paper (European Commission, 2007).
Fund projects to promote health literacy in the context of the new seven year health
programme, and ensure that the impact on health literacy will be one of the selection
criteria for funding of any project put forward in this programme.
Develop a comprehensive health information and literacy strategy that goes beyond the
current Directive on Information to Patients.
Conduct further research to inform policies and help measure the impact of health literacy
across Europe.
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SECTION 1: HEALTH LITERACY
What is Health Literacy?
Health literacy as a concept is defined as:
The degree to which individuals have the capacity to obtain, process and understand basic
health information and services needed to make appropriate health decisions (Institute of
Medicine, 2004).
Or
Health literacy encompasses people’s capacities, skills, and motivation to access, understand,
appraise, and apply health information (Sorensen et al. 2011).
An adequate level of health literacy enables an individual to make judgments and informed
decisions with regard to healthcare, disease prevention and health promotion.
Health literacy is a shared function of social and individual factors, which emerges from the
interaction between the individual and the health care system. At first glance health literacy
may appear to be primarily concerned with the comprehension of reading materials, and there
is indeed a clear and established link between reading skills and health literacy (Baker 2006;
Kwan et al. 2006). However there is much more to being health literate than simply the
ability to read. Much of the health information that people are expected to comprehend is in
the form of one-on-one interactions with health professionals and health information
presented through various forms of media. At its core the health literacy issue is one of a
mismatch between people’s skills and the demands of the healthcare system. Modern
healthcare requires more participation of the individual, both in the clinical setting and in
lifestyle choices, than ever before.
Why are we concerned about health literacy?
Nutbeam (2008) has proposed two distinct ways to view health literacy, as a clinical risk
factor or as a personal asset. From the health professional’s perspective, it is the notion of
clinical risk factor that is relevant. Ireland is regarded as having a well educated population;
however this assumption obscures the fact that nearly half of the population has low literacy
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skills, half of these having difficulty with the most basic reading tasks (OECD 1997; NALA,
2009). Recent research in the UK (Weinman et al. 2009) found that many patients and the
general public do not know the location of key body organs, even those in which their
medical problem is located (e.g. only half of cardiac patients could identify the heart organ on
a simple body diagram). Research has also demonstrated that patients recall and comprehend
as little as half of what they are told by their physician (Roter, 2000, Rost and Roter, 1987,
Crane, 1997, Bertakis, 1997). Clearly many members of the public are at serious risk of
misunderstanding health communications. Evidence from a recent survey carried out in
Ireland found that over two thirds of Irish GPs do not realise the extent of literacy problems
amongst Irish patients (Health Service Executive and NALA, 2009). International research
has highlighted that doctors commonly overestimate patients' literacy levels and rarely
consider limited literacy skills in their assessment of whether patients understand what they
need to do to manage their illness (Bass et al. 2002; Powell and Kripalani, 2005). These
findings suggest that there are important consequences for doctor-patient communication and
there are clear issues to do with patient safety. As research in the field has progressed, well
designed studies that have controlled for factors such as education and income have found
alarming links between limited levels of health literacy and health outcomes in different
groups. A sample of these include:
Inadequate health literacy independently predicts all-cause mortality and
cardiovascular death among community dwelling elderly persons (Baker et al. 2007).
Inadequate health literacy is independently associated with poor glycaemic control
and higher rates of retinopathy in type 2 diabetics (Schillinger et al. 2002).
Individuals with inadequate functional health literacy have a higher risk of hospital
admission (Baker et al. 1998, Baker et al. 2002).
Health literacy is a predictor of medication adherence in different patient groups
including cardiovascular disease (Murray et al. 2004) and HIV (Waite et al. 2008).
Asthmatic children with parents of low literacy have higher rates of hospitalizations
and emergency department visits (Dewalt et al. 2007).
Caregivers with limited literacy are likely to use a non-standard dosing instrument
when administering liquid medication to infants (Yin et al. 2007).
Mothers with limited literacy are less likely to continue breast feeding for more than
two months (Kaufman et al. 2001).
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Angner et al. 2009, found that happiness and health literacy were positively
correlated, a link likely to be mediated by a sense of personal control, the loss of
which is likely when presented with information that cannot be understood or used
adequately.
These findings are also useful to illustrate the value of health literacy as a personal asset for
patients. Health literacy is a resource for a patient that allows them to understand and engage
in the management of their own and their families’ illness, particularly in the management of
chronic disease. Empowering patients through increasing their health literacy should be an
objective of all stakeholders in healthcare.
At this point numerous studies have established links between vulnerable groups and poor
health literacy. These include groups such as the elderly, minority ethnic groups and those in
the lower socioeconomic ranks of society. This makes it clear that health literacy is also an
issue associated with equality in modern healthcare.
The ever more apparent relationship between health literacy levels and health outcomes
suggest that health literacy based intervention may offer a relatively cost effective, easily
initiated pathway for improving health outcomes and patient safety and satisfaction.
Health Literacy and Chronic Disease
One area in which the value of health literacy has been much advocated is the management of
chronic disease. Chronic diseases have traditionally included the following: cardiovascular
disease, diabetes, asthma and chronic obstructive pulmonary disease (COPD). As survival
rates and durations have improved, this type of disease now also includes many varieties of
cancer, HIV/AIDS, mental disorders (such as depression, schizophrenia and dementia) and
disabilities such as sight impairment and forms of arthritis (Busse et al. 2010). With the
incidence of many chronic diseases rising, notably, diabetes and dementia, health literacy will
play an increasingly important role in the impact of these diseases on individuals, health
systems and society.
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Much of the self-management of these diseases is performed by individual patients outside of
any medical setting. In many cases this care is of such complexity that it represents a
significant burden to the patient. Presented below is some of the evidence on links between
chronic disease and health literacy and also some examples and suggestions for ameliorating
poor health literacy in those with chronic disease.
Diabetes
Low health literacy has been significantly associated with worse glycaemic control and
poorer disease knowledge in patients with type 2 diabetes (Powell et al. 2007; Williams et al.
1998). Patients with limited health literacy have been identified as being especially
vulnerable to significant hypoglycaemia in type 2 diabetes patients using anti-hyperglycaemic
therapies (Sarkar et al. 2010). Efforts to reduce hypoglycaemia and promote patient safety
may require self-management support that is appropriate for those with limited health
literacy. Patients with inadequate health literacy have been shown to have lower rates of
keeping a record of blood glucose testing results (Mbaezue et al. 2010). The same study
found that patient education classes in diabetes management care were positively related to
self-testing.
Asthma
Paasche-Orlow et al. 2005, found that inadequate health literacy was associated with a greater
likelihood of hospitalization for asthma exacerbations, significantly less knowledge of asthma
medication and improper metered-dose inhaler (MDI) technique. The same study found that
tailored education (e.g. combined use of oral and written instruction, one-on-one personalized
training, teach-to-goal until mastery, exhibiting appropriate MDI technique), could surmount
low health literacy as a barrier to learning and remembering key asthma self-management
skills. Rosenfeld et al. 2011, found a significant association between those participants with
lower aural literacy skills and less successful asthma management. The authors recommend
greater attention to the oral exchange, in particular the listening skills highlighted by aural
literacy, as well as other related literacy skills to achieve clear communication.
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Cardiovascular Conditions
A study by Gazmararian et al. 2006, suggests that low health literacy predicts medication
adherence in patients with cardiovascular related conditions. Peterson et al. 2011 found that
among patients with heart failure, low health literacy was significantly associated with all-
cause mortality. Dewalt et al. 2004, showed that heart failure patients with limited literacy
could achieve better outcomes than those with adequate literacy when they used a reliable,
sustainable self-care system, in this case doctors helped them organize the information they
needed to manage their condition into a few simple directions. The resulting booklet included
simple, clear graphics, easy-to-follow steps, daily instructions, and charts to fill out.
Figure 1 Health literacy, a personal for patients.
Health literacy in Ireland
Health
Literacy
Empowerment
Disease Self-
Management
Effective Use of
Health Services
Health
Promotion
Self Efficacy
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Health literacy is a concept that developed in the United States and has gained prominence
within academia and in public health promotion in the US, Canada and Australia over the last
two decades. In the US a national action plan for health literacy has been developed and the
implementation of health literacy programs is now on-going in many US states. There are
also strong media interests in the US around health literacy issues. Europe has lagged behind
in adopting the concept of health literacy but this situation is changing fast, with researchers
and practitioners recognising its validity for inclusion in health promotion and healthcare
strategies.
In Ireland the National Adult Literacy Agency (NALA), has been working on the area of
health literacy since 2000. In 2002 NALA interviewed 78 adult literacy students to ascertain
how weak literacy skills impact on dealing with the health service. These adults expressed
frustration at being given so much reading material and described reading materials as dense
and hard to read due to the degree of technical medical language. These results formed part of
their published Health Literacy Policy and Strategy Report in 2002 (McCarthy 2002).
Market research commissioned by NALA and MSD in 2007 found the following:
20% of respondents are not fully confident in their comprehension of information they
receive from their medical healthcare professional.
20% of respondents do not fully understand information and instructions that appear
on medical packaging.
20% of respondents were unable to correctly identify which part of the body
‘Cardiology Department’ related to.
15% of respondents could not explain what the term ‘Outpatients’ meant.
57% of respondents said they would only sometimes seek clarification if they did not
understand instructions from a healthcare professional.
10% of respondents admitted taking the wrong dose of medication because of failure
to understand instructions.
66% of respondents have difficulty understanding signs and directions in Irish
hospitals some of the time, 20% stated they have difficulty most of the time.
60% of respondents were unable to correctly define the term ‘Prognosis’.
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(Health Service Executive and NALA, 2009)
Over the years NALA has worked closely with the Health Service Executive Health
Promotion Unit who have supported NALA’s health literacy initiatives. Initiatives have
included:
· health research;
· literacy friendly teaching packs;
· family literacy model developed and evaluated;
· literacy audit for healthcare settings; and
· a health literacy awareness DVD.
In NALA’s updated policy document in 2009, their health literacy policy ‘seeks to make the
Irish health service literacy friendly where both the skills of individuals and the literacy
demands of the health service are analysed. It wants to see a health service where literacy is
not a barrier to treatment. It will work to influence the health service in every context:
promotion, protection, prevention, access to care and maintenance’ (NALA 2009).
In 2009 NALA developed the health literacy audit with the Health Service Executive (HSE).
The Audit was produced as a health literacy tool for health settings. It allows people to
identify possible literacy barriers in their workplace. It does this by comparing current
practice to established communication best practice. The audit is also designed to highlight
good practice in communication. In 2010 NALA received a grant from MSD to conduct a
research project using the NALA/HSE Audit. This project introduced four Irish health
settings to the NALA/HSE audit. It identified the following action areas, training, health
literacy policy, lack of knowledge about local VEC literacy services, skills involved in
healthcare and use of health literacy audits internationally (NALA 2010).
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These findings, according to Coughlan (2010) will have serious implications for the
healthcare system especially as health literacy problems are strongly associated with older
people, and the number of older people in Ireland is rising.
Also in Ireland, attention has been focused on raising awareness of the issue of health literacy
through the Crystal Clear MSD Health Literacy Awards, which recognise and reward
excellence in programs for health literacy. These awards commenced in 2007 with an
increasing number of entrants each year. The awards are a collaboration between NALA and
MSD (see www.healthliteracy.ie for details).
The HLS-EU will, for the first time, provide data on health literacy in a representative sample
of the Irish population. It is hoped that this data will promote the adoption of health literacy
in policy formation, increase the profile of health literacy among Irish researchers and the
Irish media, and also give indications of what influences health literacy in Ireland and how it
may be affecting health service use and health behaviours.
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SECTION 2: THE HLS-EU
The European Health Literacy Survey (HLS-EU) is a project which aims to help establish the
issue of health literacy in Europe. The objectives of the HLS-EU are to:
Establish a European Health Literacy Network.
Create an instrument for measuring health literacy in Europe.
Generate first-time data on health literacy in European countries, providing indicators
for national and EU monitoring.
Make comparative assessment of health literacy in European countries.
Create National Advisory Panels in countries participating in the survey and to
document different valorisation strategies following national structures and priorities.
The HLS-EU Consortium
The HLS-EU project is carried out in cooperation with partners in eight European project
partners, and a number of collaborating partners. The consortium brings together members
from various backgrounds including public health, psychology, education, sociology,
accounting, and medicine. The project partners are:
Maastricht University, the Netherlands
National School of Public Health, Greece
University College Dublin, National University of Ireland
Ludwig Boltzmann Gesellschaft GmbH, Austria
Instytut Kardiologii, Poland
University of Murcia, Spain
Medical University - Sofia, Bulgaria
Landesinstitut für Gesundheit und Arbeit des Landes Nordrhein-Westfalen
Furthermore there are several organisations and institutes supporting the project as
collaborating partners:
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Deakin University, Melbourne, Australia
Health Literacy Missouri
ECDC, Stockholm, Sweden
MSD Europe; MSD Ireland and Switzerland
Public Health Institute, Ljubljana, Slovenia
National School of Public Health, Lisboa, Portugal
Centre for Health Policies and Services, Bucharest, Bulgaria
European Patient's Forum, Brussels, Belgium
Instituto di Ricerche Farmacologieche Mario Negri, Milan, Italy
University Hospital of North Norway, Tromsoe, Norway
University of Adelaide, Australia
Ministry of Health and Children, Dublin, Ireland
National Consumers Council, United Kingdom
Institute of Public Health in Crakow, Poland
Chinese Academy of Medical Sciences & Peking Union Medical College, China
Scientific Institute of Public Health, Brussels, Belgium
National Adult Literacy Database, Canada
Bavarian Health and Food Safety Authority, Germany
Institute for Medical Informatecs, Biostatistics and Epidemiology, Germany
The HLS-EU-C: A Conceptual Model of Health Literacy
At the outset of the HLS-EU project it was agreed that existing models did not fully elucidate
the concept of health literacy as envisioned by the project partners. Therefore the consortium
proposed a new integrated model of health literacy. This model aims to capture the main
dimensions of existing conceptual models. In addition it includes the full range of input and
output factors identified in two independent literature reviews that focused on the
conceptualisation of the concept of health literacy. This new model the HLS.EU.C (Figure 2)
is discussed in detail below.
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Figure 2 The HLS-EU Conceptual Model of Health Literacy, the HLS-EU-C.
(Adapted from Sorensen et al. 2012)
The model combines the qualities of a conceptual model outlining the main dimensions of
health literacy (represented in the concentric oval shape), and of a logical model showing the
proximal and distal factors which impact on health literacy, as well as the pathways linking
health literacy to health outcomes. The core of the model shows the main competencies
necessary to be considered health literate, namely the abilities to;
(1) Access (refers to the ability to seek, find and obtain health information)
(2) Understand (refers to the ability to comprehend health information)
(3) Appraise (describes the ability to interpret, filter, judge and evaluate health information)
(4) Apply (refers to the ability to communicate and use the information to maintain and
improve health).
These competencies can easily be linked to the levels of functional, interactive and critical
health literacy. Effectively employing these four competencies enables a person to navigate
three domains of the health continuum: being ill or as a patient in the health care setting, as a
person at risk of disease in the disease prevention system, and as a citizen in relation to health
22
promotion efforts in the community, work place, and educational system. The capacity to
navigate this health continuum depends on cognitive and psychosocial development as well
as on previous and current experiences, meaning that a person’s health literacy is constantly
evolving with life experience. Health literacy is also obviously context dependent.
The model incorporates a progression from an individual towards a population perspective.
As such, the model integrates the “medical” conceptualisation of health literacy with the
broader “public health” perspective. Placing greater emphasis on health literacy outside of
health care settings has the potential to impact on preventative health and reduce pressures on
health systems.
In addition to the components of health literacy proper, the model also shows the main
antecedents and consequences of health literacy. Among the factors which impact on health
literacy, a distinction is made between more distal factors, including personal characteristics
(e.g., age, gender, race, education, socioeconomic status, occupation, employment, income),
and factors in the social and physical environment (e.g., demographic situation, social
support, culture, language, political forces, media use, family and peer influences and
physical environment), and proximal factors, which are more concerned with personal
competencies and other forms of literacy. Literacies can be divided into (1) fundamental (i.e.
competence in comprehending and using printed and spoken language which affects a wide
range of cognitive, behavioral, and societal skills and abilities) (2) science literacy (i.e. the
ability to comprehend technical complexity, understanding of common technology, and an
understanding that scientific uncertainty is to be expected), (3) cultural literacy (i.e.
recognizing and using collective beliefs, customs, world-views, and social identity
relationships) and, (4) civic literacy (i.e. knowledge about sources of information and about
agendas and how to interpret them, enabling citizens to engage in dialogue and decision-
making).
Moving to the outcomes associated with health literacy, it is shown to influence health
behavior and the use of health services, and thereby will also impact on health outcomes and
on the health costs in society. At an individual level, ineffective communication due to poor
health literacy will result in poorer health, poor quality of self-care/self-management in
23
disease, ineffective use of health services and a decreased ability to advocate for oneself in
the health arena. At a population level, health literate societies are better able to participate in
ongoing public and private dialogues about health, medicine, equity and sustainability in
public health. Advancing health literacy can be seen as a part of individual and societal
development towards improved quality of life. Consequently, low health literacy can be
addressed by educating persons to become more resourceful (i.e. increasing their personal
health literacy), and by making the task or situation less demanding, (i.e. improving the
“readability of the system”).
From the HLS-EU-C to an Instrument for Measuring Health Literacy
The combination of the four dimensions referring to health information processing within the
three domains of the HLS-EU-C yields a matrix with 12 dimensions of health literacy (Table
1). This matrix served as a template in choosing and designing questions for the health
literacy section of the HLS-EU, questions 1- 47 (Figure 3).
24
Table 1 The 12 dimensions of health literacy.
Access/obtain
information
relevant to health
Understand
information
relevant to health
Process/appraise
information
relevant to health
Apply / use
information
relevant to health
Cure and care
Ability to access
information on
medical or clinical
issues
Ability to
understand medical
information and
derive meaning
Ability to interpret
and evaluate
medical information
Ability to make
informed decisions
on medical issues
Disease prevention
Ability to access
information on risk
factors for health
Ability to
understand
information on risk
factors and derive
meaning
Ability to interpret
and evaluate
information on risk
factors for health
Ability to make
informed decisions
on risk factors for
health
Health promotion
Ability to update
oneself on
determinants of
health in the social
and physical
environment
Ability to
understand
information on
determinants of
health in the social
and physical
environment and
derive meaning
Ability to interpret
and evaluate
information on
health
determinants in
the social and
physical
environment
Ability to make
informed decisions
on health
determinants in
the social and
physical
environment
Figure 3 Design matrix for HLS-EU Health Literacy Items.
HLS.EU
Survey
Design
Matrix
Access/Obtain
information
relevant to
health
Understand
information
relevant to
health
Process/Appraise
information relevant
to health
Apply/Use
information
relevant to
health
Cure and
Care
Disease
Prevention
Health Literacy Scale
Total 47 questions
Health
Promotion
25
SECTION 3: METHODOLOGY
Data Collection
Between the 4th of July and the 27th of July 2011, TNS Opinion & Social, a consortium
created between TNS Plc and TNS Opinion, carried out the first wave of the HLS-EU, on
request of the HLS-EU consortium. This survey covered a sample of the population of the
respective nationalities of 8 European Union Member States (in Germany only the region
North Rhine-Westphalia was interviewed and in Greece interviews took place in Athens),
resident in each of the Member States and aged 15 years and over.
Sampling
A multi-stage, random sampling design was used to conduct the data collection in all the
participating countries / states. In each country / state, a number of sampling points was
drawn with probability proportional to population size (for a total coverage of the country /
state) and to population density. The sampling points were drawn systematically from each of
the "administrative regional units", after stratification by individual unit and type of area.
They thus represent the whole territory of the countries surveyed according to the
EUROSTAT NUTS II (or equivalent) and according to the distribution of the resident
population of the respective nationalities in terms of metropolitan, urban and rural areas. In
each of the selected sampling points, a starting address was drawn, at random. Further
addresses (every Nth address) were selected by standard "random route" procedures, from the
initial address. In each household, the respondent was drawn, at random (following the
"closest birthday rule”). All interviews were conducted face-to-face in people's homes and in
the appropriate national language. As far as the data capture is concerned, CAPI (Computer
Assisted Personal Interview) was used in all the listed countries except in Bulgaria and
Ireland where PAPI (Paper Assisted Personal Interview) was used.
26
Recruitment
Recruitment results are summarised in Table 2 below.
Table 2 Recruitment Results Wave One HLS.EU.
IRELAND
Number of sampling points
255
Number of starting points
255
Number of addresses
1869
Number of individuals contacted
1459
1st visit
1869
2nd visit
67
3rd visit
19
4th visit
4
Number of interviews stopped underway
0
Number of net interviews
1005
Number of refusals
454
Response rate (%)
69%
Number of interviewers
54
Average interview length (in minutes)
22
Shortest interview (in minutes)
12
Longest interview (in minutes)
41
The Health Literacy Index
This section of the report is an extract from the Report Technical Details of the HLS-EU-Q
for Measuring Health Literacy Across Countries. (Rothlin & Pelikan, 2012, forthcoming).
Technical Properties of the HLS-EU Indices
Eight scales representing the structure of the HLS-EU conceptual model were created:
1 A general HL scale comprising all items and providing a general picture and
overview,
2-4 Three dimension-specific scales covering healthcare, prevention and health
promotion, and
27
5-8 Four information-processing specific scales covering the different stages of
information processing.
Scales are based on the inverted categories of the items (thus a higher value denotes better
health literacy) with the following numerical values: 1=very difficult; 2=difficult; 3=easy;
4=very easy. See Table 3 which sets out the items which apply to each of the scales.
28
Table 3 General and specific health literacy scales and their respective items; minimum number of valid
answers necessary for index calculation; minima and maxima of scale metric.
Scale
General
Health Care
Disease
Prevention
Health
Promotion
Find
Information
Understand
Information
Evaluate
Information
Apply
Information
Q1.1
Q1.2
Q1.3
Q1.4
Q1.5
Q1.6
Q1.7
Q1.8
Q1.9
Q1.10
Q1.11
Q1.12
Q1.13
Q1.14
Q1.15
Q1.16
Q1.17
Q1.18
Q1.19
Q1.20
Q1.21
Q1.22
Q1.23
Q1.24
Q1.25
Q1.26
Q1.27
Q1.28
Q1.29
Q1.30
Q1.31
Q1.32
Q1.33
Q1.34
Q1.35
Q1.36
Q1.37
Q1.38
Q1.39
Q1.40
Q1.41
Q1.42
Q1.43
Q1.44
Q1.45
Q1.46
Q1.47
Minimum number of valid answers for scale calculation
Item Number
43
15
14
14
12
10
11
11
Convenient metric of scales
Minimum
0
0
0
0
0
0
0
0
Maximum
50
50
50
50
50
50
50
50
29
To have a scale computed, a given respondent had to have answered validly at least 80% of
the items representing the scale in question. The number of items an individual had to answer
to be part of the calculation for the different scales can be seen in the item number row of 3.
To allow meaningful and convenient calculations with indices and for comparisons between
sub-indices, all eight scales were set to a metric between 0 and 50, using the following
formula:
Formula:
Where:
Index…... is the specific scale calculated
mean….. is the mean of all participating items for each Individual
1 ……… is the minimal possible value of the mean (leads to a minimum Value of the Index
of 0)
3 …… is the range of the mean
50……. is the chosen maximum value of the desired scale
The Fixation of Thresholds for the European Health Literacy Index
It is common and useful practice for literacy and health literacy measures to define limited or
problematic levels of literacy, since it is this kind of simplification that makes health literacy
measures on the level of general populations practicable and valuable for decision making in
health policy. For that purpose, thresholds have to be defined, and justified. We opted for 4
categories: “inadequate”, “problematic” (which together also define “limited” health
literacy), “sufficient” and “excellent”, and thus had to introduce three different thresholds.
Thresholds have been fixed just for the four most important indices (general, healthcare,
30
disease prevention, health promotion) by a technical decision of the team in Vienna. The
guiding criterion for the fixation of thresholds was the assessment of the likelihood of an
individual to be confronted with excessively demanding situations, where appropriate
decision making and information processing cannot be expected. Thresholds were then
internally validated to the general distribution of the scales and externally validated with
regard to their validation patterns to external criteria.
As a threshold for “inadequate” health literacy, scores below 26 have been chosen, i.e.
individuals with inadequate health literacy have at least rated 50% of the items as difficult or
very difficult. It again has to be stated that this threshold is based on technical decisions of
the project statistical team and was a relatively arbitrary decision. The border between
sufficient and problematic health literacy was fixed by a score value of 33, i.e. below 2/3 of
the possible points to be reached. This score coincides with the modus, median and mean of
the distributions of the four indices which lie between 33 and 34 points. Thus the cutting
point between problematic and sufficient health literacy approximates to the point estimators
of the distribution. The skewed normal distributions indicate that the HLS-EU Indices are
more sensitive and provide more information for lower literacy scores, especially regarding
the three domain related indices. For the cut point between “sufficient” and “excellent” health
literacy, 42 was designated, which marks the bottom 80%, top 20% of the population shares.
Furthermore, categorized indices were tested according to their co-variation patterns with
their corresponding indices, as well as with other important covariates (to prove if the
correlation patterns of the categorized indices are similar to the correlation patterns of the
original scales) like self-perceived health, health care use, demographic variables or the NVS.
We chose the same numerical scores as thresholds for the four indices, and did not adjust for
somewhat different means and degrees of skewness, to keep the differences in difficulty of
the four indices comparable.
Conclusion of Validity and Reliability Analyses and General Remarks
While the high values of Cronbach´s alphas can be regarded as evidence of appropriate
internal consistency of the indices, and as an indicator for scale reliability, they would be
misinterpreted, if used, as evidence for uni-dimensionality. Therefore confirmatory factor
31
analysis was used as a means to test for underlying dimensions and the appropriateness and
validity of the theoretical model.
The analysis so far only confirmed that the HLS-EU items have scale properties only to a
certain extent. While they can be combined to internally consistent indices (partly because of
the length of the indices) there are some problems regarding the covariance structure of the
items. So far we didn´t find a Confirmatory Factor Analysis (CFA) model that represented
the covariance structure of the items to our complete satisfaction. The best fitting CFA model
was furthermore a model that allowed items to load on more than one factor. This has to be
expected with regard to the theoretical matrix we used for item construction. Every item of
the matrix has at least two background factors (one domain factor and one information
processing factor). This leads to some serious problems for the psychometric assumption of
unidimensionality of items. Following our analyses, we therefore don´t assume that the HLS-
EU items can be combined to psychometric scales (at least not in the transnational European
sample).
We therefore use simple index building as comparison strategy. As opposed to scales, indices
cannot be assumed to be unidimensional measures. Both contextual circumstances and
individual competencies have to be considered for the interpretation of results. We feel
confident to use at least 4 health literacy indices for further comparative analyses, the General
HL index, and three content specific indices for HCHL (Health Care HL), DPHL (Disease
Prevention HL) and HPHL (Health Promotion HL). These indices follow assumptions of the
conceptual model, show high internal consistencies, and to a sufficient degree (for indices)
are confirmed by confirmatory factor analysis.
It is important to understand the relational nature of the HLS-EU-Q items. Health literacy as a
relational concept not only depends on personal competences, but also on context specific
variables like national health cultures, the complexity or readability of national health care
systems, the history of national information and media campaigns and the foci of national and
regional health policies. Different values on HL indices can therefore be interpreted as an
individual assessment of the complexity/uncertainty/manageability of health relevant
situations and tasks. This means that in a cross-national context, comparing HLS-EU health
literacy measures is actually comparing the perceived manageability of health relevant
situations and tasks. The type and nature of the health relevant tasks/situations was decided
32
according to the HLS-EU measurement model and within the international HLS-EU expert
community. Because of this, we are confident that the items in the HLS-EU-Q are reasonably
important for all participating countries to provide balanced and relevant information on
national differences.
Since the HLS-EU-Q is still in a first phase, we want to note that a number of items in the
instrument could be developed in future studies in order to improve scaleablity as a whole.
33
SECTION 4: RESULTS
Introduction
The HLS-EU was conducted between 4th of July and the 27th of July 2011 by TNS Opinion
& Social at the request of the HLS-EU consortium. In Ireland there were 255 sampling points
in total and 54 professional interviewers conducted the research. In total 1459 individuals
were contacted to participate in the research, 1005 accepted representing a response rate of
69%. Interviews ranged in length from 12 to 41 minutes with an average interview length of
22 minutes (see Table 2).
Table 4 below presents the regional distribution of interviews conducted in each region,
proportional to population size.
Table 4 Regional Distribution of Surveys
Population
Target interviews
Observed interviews
Dublin
973,000
276
279
Rest of Leinster
935,000
265
263
Munster
974,000
277
280
Connacht/ Ulster
640,000
182
183
TOTAL
3,552,000
1000
1005
Respondent Profiles
The survey elicited descriptions of the following
Gender
Age
Height and Weight
Identity
Socio- economic status
Social deprivation and economic barriers
Health promotion (Managing resources for health and well-being)
Disease prevention (Managing risk factors for health)
34
Cure and care (Managing symptoms, complaints, illness and treatments)
Personal health
Health service use
Health behaviour
Social interaction
Newest Vital Sign
Descriptive analysis of demographics
Gender
In total 1005 individuals were interviewed in the Republic of Ireland, 431 (42.9%) were male
and 574 (57.1%) were female.
Age
The age profile of respondents ranged from 15 years of age to 91 years of age, with an
average respondent age of 45 years.
Height and Weight
Respondents’ height ranged from 139 to 200cm with an average height of 168.5cm. Weight
ranged from 38 to 170 kg with an average weight of 73.8 kg. Height and weight were used to
calculate Body Mass Index (BMI).
Identity
Figure 4 presents the breakdown of identity of the population sample. In relation to
respondents’ identity 913 (91.7%) of respondents indicated that both their parents were born
in Ireland. 32 (3.2%) indicated that one of their parents was born in Ireland and the other was
born within the EU. In 39 (3.9) cases both parents were born in an EU state outside of
Ireland, and in 6 (.6%) cases one parent was born in Ireland and the other was born outside
the EU. In 5 (.5%) cases the respondent indicated that both parents were born outside the EU,
and in a single case (.1%) the respondent indicated that one of their parents was born in
another EU state while the other was born outside the EU.
35
Figure 4 Identity of Sample
Marital Status
Figure 5 depicts the marital status of respondents to the survey. Of the participant surveyed
334 (33.3%) indicated they were not married, while 536 (53.4) indicated that they were
married, 62 (6.2%) were separated/ divorced and 71 (7.1%) were widowed.
Figure 5 Marital Status
36
Household Living Situation
In relation to household living situation (Figure 6), 262 (26.2%) of respondents stated that
they were single/ living alone, 726 (72.2%) indicated that they were living together/ shared
household, whereas 10 (1%) suggested that they were in a serious relationship but not living
together.
Figure 6 Household Living Situation
Parenting
In relation to parenting, 649 (64.6%) respondents indicated that they had children under the
age of 15 years, compared to 356 (35.4%) who did not have children. Concerning children
over the age of 15 years, 622 (61.9%) indicated that they had no children compared with 383
(38.1%) who indicated that they did have children over the age of 15 years.
Educational Attainment
In relation to the highest level of educational attainment of respondents, 7 (.7%) have only
pre-primary education, 65 (6.5%) have only primary education, 190 (19.1%) have lower
secondary, 261 (26.2%) have upper secondary education, 165 (16.6%) have post-secondary
non-tertiary education, 130 (13.1%) have first stage tertiary education, and 178 (17.9%) have
attained the second stage of tertiary education (Figure 7).
37
Figure 7 Educational Attainment
Employment Status
Table 5 presents the main status of employment from the population sample. In terms of
employment 41.4% of respondents were in either full or part-time employment, 11.9% were
unemployed, 13.6% were in retirement, 21.1% were homemakers/ fulltime parent/ carer and
4.9% were students.
38
Table 5 Employment Status: What is your current “main” status of employment?
Frequency
Valid
Percent
Carries out a job or profession, including unpaid work
for a family business or holding, including an
apprenticeship or paid traineeship etc.
15
1.5%
Full-time
274
27.3%
Part-time
142
14.1%
Unemployed
119
11.9%
Pupil, student, further training, unpaid work experience
49
4.9%
In retirement or early retirement or has given up
business
137
13.6%
Permanently disabled
17
1.7%
In military or community services
1
.1%
Full-time homemaker, parent or carer
212
21.1%
Inactive
26
2.6%
Other (SPECIFY)
11
1.1%
Don’t Know
1
.1%
Total
1004
100.0
Ability to Pay for Medication
In total, 28.6% of participants said they found it ‘very easy’ to pay for medication needed,
40.1% found it ‘fairly easy’, 20.6% found it ‘fairly difficult’ and 10.6% found it very
difficult (Figure 8).
39
Figure 8 Ability to pay for medication.
Ability to pay to see a doctor
Of the respondents, 75.1% found it very easy or fairly easy to pay to see a doctor, compared
with 24.1% who had some degree of difficulty in paying to attend a doctor.
Self-perceived social class
Figure 9 below shows the distribution of social classes (self-rated) in the sample.
40
Figure 9 Self-Perceived Social Class
Household Net Income
In relation to household income (Figure 10), 10.2% of households have less than €800
income per month, 25% have €800 to under €1,350, 18.8% have €1,350 to under €1,850,
13.7% have €1,850 to under €2,400, 11.5% have €2,400 to under €2,950, and 21.9% of
respondents had in excess of €2,950 in income.
41
Figure 10 Household Net Income
Health Behaviours and Outcome Related Descriptives
In relation to outcomes, information was collected on perceptions of one’s personal health,
health service use, health behaviour, social interaction and a previously validated short
measure of functional literacy (Newest Vital Sign).
Self-Rated Health
In relation to personal health 79.3% of respondents rated their personal health as good or
very good, in comparison to 3.7% of respondents who rated their personal health as bad or
very bad. Regarding long term illness 30.2% of respondents indicated that they had one or
more long term illness. Of those with health problems 24.8% indicated that they were
severely limited by their illness, 43.2% said they were limited but not severely by their
health problems.
42
Health Service Use
With regards to health insurance (Figure 11) 29.4% of participants have public insurance,
43% have private insurance, 4.8% have public and private insurance and 22.9% have no
insurance.
Figure 11 Health Insurance
In terms of emergency service usage 75.6% of participants did not use any emergency service
in the previous two years, 19.6% used the service 1-2 times, 3.5% used the service 3-5 times
and 1.3% used the emergency services more than 6 times. In terms of hospital usage (Figure
12), 55.2% of respondents did not use any hospital service in the past year, 33.5% attended
hospital 1-2 times, 6.6% attended 3-5 times, and finally 4.8% attended more than 6 times.
43
Figure 12 Hospital Service Use
Health behaviours
Smoking
With regards to smoking (Figure 13), 51% of respondents have never smoked, 27.12% smoke
every day, 20.72% previously smoked but have now stopped, and 0.66% smoke occasionally.
Figure 13 Smoking Behaviour
44
Alcohol Consumption
In relation to alcohol consumption, an alcohol consumption index was used (Garretsen 1983).
37.6% respondents were classified as having light alcohol consumption, 20.2% had moderate
alcohol consumption, 8.3% had excessive alcohol consumption, and 2.2% had very excessive
alcohol consumption.
Figure 14 Alcohol Consumption Index
45
Exercise
In relation to exercise 36.6% exercise every day, 30.6% exercise a few times per week,
10.9% exercise a few times per month, 18.5% do not exercise at all and 3.4% are unable to
exercise.
Social interaction
Of the respondents 85.8% indicated that they had a family member or a friend available to
take them to the doctor. Concerning community involvement (Figure 15) 3.1% are involved
almost every day, 9.6% a few times per week, 12% a few times per month, 12% a few times
per year and 63.4% who are not involved in their community at all.
Figure 15 Community Involvement
46
SECTION 5: A DESCRIPTIVE OVERVIEW OF HEALTH LITERACY
This section presents a descriptive overview of the responses to the newly developed Health
Literacy measure in terms of Cure and Care, Disease Prevention, and Health Promotion
(Table 6).
Table 6 Frequency Table for Health Literacy Items
Health Literacy Section of The HLS.EU
Frequencies
Total (n)
Very Easy (%)*
Fairly Easy (%)*
Fairly Difficult
(%)*
Very Difficult
(%)*
No Answer
Cure and Care
Evaluate
information to
manage disease
(symptoms,
complaints,
illness and
treatments)
No.
On a scale from very easy to
very difficult, how easy
would you say it is to:
6
…understand the leaflets that
come with your medicine?
977
372
(38.1)
434
(44.4)
124
(12.7)
47
(4.8)
28
(2.8)
9
…judge how information
from your doctor applies to
you?
986
365
(37)
517
(52.4)
91
(9.2)
13
(1.3)
19
(1.9)
10
…judge the advantages and
disadvantages of different
treatment options?
957
206
(21.5)
446
(46.6)
226
(23.6)
79
(8.3)
48
(4.8)
11
…judge when you may need
to get a second opinion from
another doctor?
941
195
(20.7)
407
(43.3)
238
(25.3)
101
(10.7)
64
(6.4)
12
…judge if the information
about illness in the media is
reliable?
(Instructions: TV, Internet or
other media)
904
126
(13.9)
383
(42.4)
278
(30.8)
117
(12.9)
101
(10)
13
…use information the doctor
gives you to make decisions
about your illness?
967
268
(27.7)
561
(58)
107
(11.1)
31
(3.2)
38
(3.8)
Understand
information to
manage disease
(symptoms,
complaints,
illness and
treatments)
5
…understand what your
doctor says to you?
992
440
(44.4)
443
(44.7)
83
(8.4)
26
(2.6)
13
(1.3)
8
…understand your doctor’s or
pharmacist’s instruction on
how to take a prescribed
medicine?
997
519
(51.1)
431
(43.2)
38
(3.8)
9
(0.9)
8
(0.8)
14
…follow the instructions on
997
519
435
38
5
8
47
medication?
(51.6)
(43.6)
(3.8)
(0.5)
(0.8)
15
…call an ambulance in an
emergency?
995
626
(62.9)
327
(32.9)
32
(3.2)
10
(1.0)
10
(1.0)
16
…follow instructions from
your doctor or pharmacist?
1000
570
(57)
392
(39.2)
32
(3.2)
6
(0.6)
5
(0.5)
Access
information to
manage disease
(symptoms,
complaints,
illness and
treatments)
3
…find out what to do in case
of a medical emergency?
974
371
(38.1)
435
(44.7)
121
(12.4)
47
(4.8)
31
(3.1)
4
…find out where to get
professional help when you
are ill?
(Instructions: such as doctor,
pharmacist,
psychologist)
984
421
(42.8)
472
(48)
63
(6.4)
28
(2.8)
21
(2.1)
7
…understand what to do in a
medical emergency?
972
361
(35.9)
423
(43.5)
139
(14.3)
49
(4.9)
33
(3.3)
1
…find information about
symptoms of illnesses that
concern you?
989
345
(34.9)
481
(48.6)
116
(11.7)
47
(4.8)
16
(1.6)
2
…find information on
treatments of illnesses that
concern you?
966
288
(29.8)
507
(52.5)
132
(13.7)
39
(4.0)
39
(3.9)
Disease Prevention
Ability to access
information on
risk factors for
health
17
…find information about how
to manage unhealthy
behaviour such as smoking,
low physical activity and
drinking too much?
967
418
(43.2)
442
(45.7)
81
(8.4)
26
(2.7)
38
(3.8)
19
…find information about
vaccinations and health
screenings that you should
have?
(Instructions: breast exam,
blood sugar test, blood
pressure)
957
276
(28.8)
494
(51.6)
135
(14.1)
52
(5.4)
48
(48)
20
…find information on how to
prevent or manage conditions
like being overweight, high
blood pressure or high
cholesterol?
981
379
(38.6)
479
(48.8)
100
(10.2)
23
(2.3)
24
(2.4)
21
…understand health warnings
about behaviour such as
smoking, low physical
activity and drinking too
much?
977
459
(47)
445
(45.5)
59
(6)
14
(1.4)
28
(2.8)
24
…judge how reliable health
warnings are, such as
969
397
499
58 (6)
15
36
48
smoking, low physical
activity and drinking too
much?
(41)
(49.7)
(1.5)
(3.6)
Evaluate
information to
manage risk
factors for health
22
…understand why you need
vaccinations?
969
347
(35.8)
470
(48.5)
109
(11.2)
43
(4.3)
36
(3.6)
23
…understand why you need
health screenings?
(Instructions: breast exam,
blood sugar test,
blood pressure)
973
363
(37.3)
492
(50.6)
93
(9.6)
25
(2.6)
32
(3.2)
25
…judge when you need to go
to a doctor for a check-up?
1000
494
(49.4)
409
(40.9)
82
(8.2)
15
(1.5)
5
(0.5)
26
…judge which vaccinations
you may need?
958
264
(27.6)
443
(46.2)
196
(20.5)
55
(5.7)
47
(4.7)
27
…judge which health
screenings you should have?
(Instructions: breast exam,
blood sugar test,
blood pressure)
967
257
(26.6)
441
(45.6)
212
(21.9)
57
(5.9)
38
(3.8)
29
…decide if you should have a
flu vaccination?
962
361
(37.5)
429
(44.6)
125
(13)
47
(4.9)
43
(4.3)
Make decisions to
manage risk
factors for health
18
…find information on how to
manage mental health
problems like stress or
depression?
929
245
(26.4)
394
(42.2)
176
(18.9)
114
(12.3)
76
(76)
28
…judge if the information on
health risks in the media is
reliable?
(Instructions: TV, Internet or
other media)
919
169
(18.4)
412
(44.8)
241
(26.2)
97
(10.6)
86
(8.6)
30
…decide how you can protect
yourself from illness based on
advice from family and
friends?
970
283
(29.2)
513
(52.9)
146
(15.1)
28
(2.9)
35
(3.5)
31
…decide how you can protect
yourself from illness based on
information in the media?
(Instructions: Newspapers,
leaflets, Internet or other
media?)
949
191
(20.1)
433
(45.6)
245
(25.8)
80
(8.4)
56
(5.6)
Health
Promotion
Access
information to
manage resources
for
health and
33
…find out about activities
that are good for your mental
well-being?
(Instructions: meditation,
exercise, walking, pilates
981
329
(33.5)
455
(46.4)
125
(12.7)
72
(7.3)
24
(2.4)
49
wellbeing +
Evaluate
information to
manage resources
for health and
wellbeing
etc.)
34
…find information on how
your neighbourhood could be
more health-friendly?
(Instructions: Reducing
noise and pollution, creating
green spaces, leisure
facilities)
935
196
(21)
391
(41.8)
200
(21.4)
148
(15.8)
70
(7.0)
35
…find out about political
changes that may affect
health?
(Instructions: legislation,
new health screening
programmes, changing of
government, restructuring of
health services etc.)
921
164
(17.8)
355
(38.5)
202
(21.9)
200
(21.7)
84
(8.4)
36
…find out about efforts to
promote your health at work?
785
223
(28.4)
390
(49.7)
108
(13.8)
64
(8.2)
220
(21.9)
41
…judge how where you live
affects your health and well-
being?
(Instructions: Your
community, your
neighbourhood)
977
279
(28.6)
470
(48.1)
133
(13.6)
95
(9.7)
28
(2.8)
42
…judge how your housing
conditions help you to stay
healthy?
971
298
(30.7)
484
(49.2)
105
(10.8)
84
(8.7)
34
(3.4)
43
…judge which everyday
behaviour is related to your
health?(Instructions:
Drinking and eating habits,
exercise etc.)
979
306
(31.3)
504
(51.5)
107
(10.9)
62
(6.3)
26
(2.6)
Understand
information to
manage resources
for health and
wellbeing
32
…find information on healthy
activities such as exercise,
healthy food and nutrition?
991
423
(42.7)
479
(48.3)
69
(7)
20
(2)
14
(1.4)
37
…understand advice on
health from family members
or friends?
983
334
(34)
542
(55.1)
92
(9.4)
15
(1.5)
22
(22.2)
38
…understand information on
food packaging?
989
255
(25.8)
413
(41.8)
185
(18.7)
136
(13.8)
16
(1.6)
39
…understand information in
the media on how to get
healthier?
(Instructions: Internet,
newspapers, magazines)
960
252
(26.1)
515
(53.3)
139
(14.4)
60
(6.2)
39
(3.9)
50
40
…understand information on
how to keep your mind
healthy?
972
267
(27.5)
480
(49.4)
142
(14.6)
83
(8.5)
33
(3.3)
Make decisions to
manage resources
for health and
wellbeing
44
…make decisions to improve
your health?
997
407
(40.8)
479
(48)
87
(8.7)
24
(2.4)
8
(0.8)
45
join a sports club or
exercise class if you want to?
988
438
(44.3)
433
(43.8)
74
(7.5)
43
(4.4)
17
(1.7)
46
…influence your living
conditions that affect your
health and well-being?
(Instructions: Drinking and
eating habits, exercise etc.)
974
332
(34.1)
501
(85.5)
93
(9.5)
48
(4.9)
31
(3.1)
47
…take part in activities that
improve health and well-
being in your community?
983
316
(32.1)
529
(53.8)
88
(9.0)
50
(5.1)
22
(2.2)
*Percentage given is valid percentage of cases where an answer was given. Unanswered cases are
excluded.
Notable findings
Cure and Care
(Q 6) 17.5% of people have difficulty understanding leaflets that accompany medicines.
There was no significant difference evident between males and females in understanding
medical leaflets, similarly differences between age groups were also insignificant. There is a
significant difference between education groups and the ability to understand leaflets that
accompany medicine (F= 5.511, p .01) with those with lesser education indicating greater
difficulty. There is also a significant difference between income groups and the ability to
understand medical leaflets (F= 7.983, p .01), in this instance those with average income
indicated a marginally better ability to understand medical leaflets than those with high
incomes and finally those with low incomes had the most difficulty. A significant difference
was also evident between alternative social classes and one’s ability to understand leaflets
that accompany medicine (F= 20.807, p .01), those self-rated as being in lower social class
had most difficulty, followed by middle class followed by upper class who had least
difficulty.
51
(Q 12) 43.7% of respondents find it difficult to judge the reliability of health
information from the media. There was no significant difference evident between males
and females, and no differences were evident among different age groups. There is a
significant difference between education groups and the ability to judge the reliability of
health information from the media (F= 2.356, p .05). Again those with most education had
a greater ability to comprehend health information. There is also a significant difference
among income groups and the ability to appraise the reliability of health information received
(F= 5.289, p ≤ .01) with the lowest level of ability ranging from those with lowest to highest
incomes. Differences were also evident between ones perception of social class and one’s
ability to judge the reliability of health information in the media (F= 8.983, p .01), lower
class people had most difficulty, followed by middle class people, followed by upper class
people.
(Q13) 85.7% of people find it easy to use information given to them by a doctor to make
decisions about their health. There was no significant difference evident between males and
females, or among different age groups. There was no significant difference between
education groups and the ability to use information provided by a doctor. Similarly there was
no significant difference between income and the ability to make decisions regarding one’s
health. There is a significant difference among ones perception of social class and one’s
ability to use information by their doctor (F= 17.254, p .01), lower class people had most
difficulty, followed by middle class people followed by upper class people.
(Q5) 89.4% of find it easy to understand what the doctor says to them. There was no
significant difference evident between males and females, while differences between age
group were also insignificant. A significant difference between education groups and the
ability to understand what a doctor says was evident (F= 3.723, p .01), with those above
level 2 education having a significant ability to understand their doctor above those who have
attained less than level two education. There is a significant difference among income groups
and the ability to comprehend what a doctor says (F= 3.358, p ≤ .05), those on average
incomes scored highest, followed by those on high incomes and finally those on low incomes.
52
A significant difference was also found among ones perception of social class and one’s
ability to comprehend what a doctor says (F= 10.184, p .01), lower class people had most
difficulty, followed by middle class people, and finally upper class people.
(Q8) 94.3% of people understand instructions from doctors and pharmacists on how to
take prescription medications. No significant difference was found between males and
females, while differences between age group were also insignificant. There is a significant
difference between education groups and the ability to understand instructions from both
doctors and pharmacists on how to take medicine (F= 5.320, p .01) with those with lower
education predominantly expressing lesser ability in comprehension terms. There is also a
significant difference among income groups and the ability to take instructions regarding how
to correctly take medication (F= 8.842, p ≤ .01), those on most income scored highest,
followed by those on average incomes and finally those on low income. A significant
difference was also found between ones perception of social class and one’s ability to
understand instructions from doctors and pharmacists on how to take medicines (F= 7.796, p
≤ .01), middle class people had most difficulty, followed by lower class people, followed by
upper class people.
(Q7) 19.2% of people would find it difficult to understand what to do in a medical
emergency. There was no significant difference evident between males and females.
Differences between age groups were also insignificant. There is a significant difference
between education groups and the ability to know what to do in an emergency situation (F=
3.767, p .01). Interestingly those with most education (Levels 4, 5 and 6) and those with
least education (Levels 0 and 1) displayed the greatest ability in understanding what to do in
an emergency, compared to those with level 2 and 3 education. There is a significant
difference among income groups and the ability to understand what to do in a medical
emergency (F= 7.487, p .01), the best score ranged from those with the highest incomes to
those with the lowest. There is a significant difference between ones perception of social
class and one’s ability to understand what to do in an emergency (F= 9.509, p .01), lower
class people had most difficulty, followed by middle class people, followed by upper class
people.
53
(Q11) 36% of people would find it difficult to judge if they needed to get a second
opinion from a doctor. There was no significant difference evident between males and
females or between age groups. There is a significant difference among income groups and
the ability to judge whether a second medical opinion is needed (F= 5.294, p ≤ .01), the best
score ranged from those with the highest incomes to those with the lowest. There is also a
significant difference between ones perception of social class and one’s ability to judge
whether they need a second opinion (F= 14.427, p ≤ .01), lower class people had most
difficulty, followed by middle class people, followed by upper class people.
Disease Prevention
(Q17) 11.1% of people find it difficult to find information about how to manage
unhealthy behaviour such as smoking, low physical activity and drinking too much.
There is a significant difference between mean scores on Q17 between males (1.78) and
females (1.65) at the level t = 2.619, p ≤ .01. Differences between age groups were
insignificant. There is a significant difference among education groups and the ability to find
information on unhealthy behaviour (F= 3.892, p ≤ .01) as those with less education
progressively find it more difficult to access information. There is a significant difference
among income groups and the ability to find information on how to manage unhealthy
behaviour (F= 12.261, p ≤ .01), again the highest score ranged from those with the highest to
the lowest incomes. There is also a significant difference between ones perception of social
class and one’s ability to manage unhealthy behaviour (F= 8.237, p ≤ .01), lower class people
had most difficulty, followed by middle class people, followed by upper class.
(Q18) 31.2% of people find it difficult to find information on mental health issues such
as stress and depression. There was no significant difference between males and females.
Differences between age groups were also insignificant. There is a significant difference
among education groups and the ability to find information on mental health issues (F=
2.670, p .05) those with less education finding it more difficult to access information on
54
mental health related issues. There is also a significant difference between income groups and
the ability to find information on mental health issues (F= 8.431, p.01), scores for average
and high incomes were the same and were significantly different from low incomes. There is
a significant difference between ones perception of social class and one’s ability to find
information on mental health issues (F= 16.766, p ≤ .01), lower class people had most
difficulty, followed by middle class people, followed by upper class.
(Q19) 19.5% of people find it difficult to find information about vaccinations and health
screenings that they require. There is a significant difference between mean scores on Q19
between males (2.05) and females (1.90) at the level t = 2.829, p ≤ .01. Differences between
age groups were insignificant. There was no significant difference among education groups
and the ability to find information about vaccinations and health screenings. There is a
significant difference among income groups and the ability to locate information about
vaccinations and health screenings (F= 10.510, p .01), the best score ranged from those
with the highest income to those with the lowest. There is also a significant difference
between ones perception of social class and one’s ability to find information about vaccines
and health screenings (F= 16.010, p .01), lower class people had most difficulty, followed
by middle class people, followed by upper class.
(Q26) 26.2% of people find it difficult to judge which vaccinations they require. There is
a significant difference between mean scores on Q26 between males (2.14) and females
(1.97) at the level t = 3.141, p ≤ .01. Differences between age groups were insignificant.
There is a significant difference among education groups and the ability to judge which
vaccinations they require (F= 3.954, p .01), with those with lesser education more likely to
have difficulty judging such information. There is a significant difference among income
groups and the ability to judge which vaccinations they require (F= 13.106, p ≤ .01), the best
score ranged from those with the highest income to those with the lowest. There is a
significant difference among ones perception of social class and one’s ability to judge which
vaccinations they require (F= 15.866, p ≤ .01), lower class people had most difficulty,
followed by middle class people, followed by upper class.
55
(Q33) 20% of people find it difficult to find out about activities that are good for their
mental health. There was no significant difference between males and females or between
age groups. There was no significant difference among education groups and the ability to
find out information on activities that are good for one’s mental health. There is a significant
difference among income groups and the ability to find out information on activities that are
good for one’s mental health (F= 10.943, p ≤ .01) with those on average incomes scoring the
best results, followed by those on high incomes and finally those on low incomes. There is
also a significant difference between one’s perception of social class and one’s ability to find
information about activities that are good for one’s mental health (F= 24.200, p ≤ .01), lower
class people had most difficulty, followed by middle class people, followed by upper class.
Health Promotion
(Q34) 37.2% find it difficult to find information on how to make their neighbourhood
more health friendly (e.g. in relation to noise and pollution, creating green spaces and
leisure facilities) There was no significant difference evident between males and females or
among different age groups. There is a significant difference between education groups and
the ability to make ones neighbourhood more health friendly (F= 2.53, p .05), with those
with least education expressing greater difficult in accessing such information. There is a
significant difference among income groups and the ability to make ones neighbourhood
more health friendly (F= 7.055, p ≤ .01) with those on average incomes scoring the best
results, followed by those on high incomes and finally those on low incomes. There is a
significant difference between one’s perception of social class and one’s ability to make their
neighbourhood more health friendly (F= 25.622, p ≤ .01) lower class people had most
difficulty, followed by middle class people, followed by upper class.
(Q35) 43.6% of people find it difficult to get information on political matters which
affect healthcare (e.g. legislation, new health screening programmes, changes in
government, or the restructuring of the health service). There was no significant
difference evident between males and females or among different age groups. There was no
significant difference among education groups and the ability to find out information of
56
political matters which affect healthcare, however it is important to note that this was
marginally insignificant and in general those with less education expressed the greatest
difficulties. There is also a significant difference among income groups and the ability to
obtain information on political matters that affect healthcare (F= 5.468, p ≤ .01) with those on
average incomes scoring the best results, followed by those on high incomes and finally those
on low incomes. There is a significant difference among ones perception of social class and
one’s ability to find information on political matters which affect healthcare (F= 32.650, p
.01), lower class people had most difficulty, followed by middle class people, followed by
upper class.
(Q32) 91% of people find it easy to get information on healthy activities such as
exercise, healthy food and nutrition. There was a significant difference between mean
scores on Q32 between males (1.74) and females (1.64) at the level t = 2.267, p ≤ .05.
Differences between age groups were insignificant. There was no significant difference
among education groups and the ability to find out information on healthy activities (F=
3.963, p ≤ .01), again those with most education were more likely to find it easy to get
information on healthy activities. There is a significant difference among income groups and
the ability to obtain information on healthy activities (F= 9.832, p ≤ .01), the best scores
ranged from those with the highest income to those with the lowest. There is a significant
difference among one’s perception of social class and one’s ability to find information about
healthy activities (F= 9.942, p .01), lower class people had most difficulty, followed by
middle class people, followed by upper class.
(Q38) 32.5% of people find it difficult to understand the information on food
packaging. There is a significant difference between mean scores on Q38 for both males
(2.33) and females (2.11) at the level t = 3.562, p .01. There is a significant difference
between age groups and understanding food packaging (F= 7.943, p .01) where there is a
progressive decline in the ability to understand food packaging as one grows older. There is
also a significant difference among education groups and the ability to understand
information on food packaging (F= 11.114, p .01) where those with most education found
57
information on packaging easier to understand. A significant difference among income
groups and the ability to understand information on food packaging was evident (F= 13.538,
p ≤ .01) the best scores ranged from those with the highest income to those with the lowest,
however the difference between those on high incomes and those on average incomes was
minimal. Another significant difference was found among ones perception of social class
and one’s ability to understand information received on food packaging (F= 43.336, p ≤ .01),
lower class people had most difficulty, followed by middle class people, followed by upper
class.
(Q39) 20.6% of people find it difficult to understand information in the media on how to
improve their health (e.g. internet, newspapers and magazines). There is a significant
difference between mean scores on Q39 between males (2.12) and females (1.93) at the level
t = 3.645, p ≤ .01. There is also a significant difference between age group and the ability to
understand information in the media on health (F= 4.247, p ≤ .01). Older and younger people
had most difficulty in understanding information in comparison to those aged between 25-
49. There is also a significant difference among education groups and the ability to
understand media information regarding health improvements (F= 5.326, p ≤ .01) where
one’s ability progressively increased with education. There is a significant difference among
income groups and the ability to understand media information on health improvements (F=
11.583, p .01), the best score ranged from those with the highest income to those with the
lowest. Another significant difference was evident between ones perception of social class
and one’s ability to understand information in the media on how to improve one’s health (F=
22.040, p ≤ .01), lower class people had most difficulty, followed by middle class people,
followed by upper class.
(Q44) 89.6% of people find it easy to make decisions that improve their health. There is
a significant difference between mean scores on Q44 between males (1.78) and females
(1.69) at the level t = 2.004, p .05. Differences between age groups were insignificant. A
significant difference was found among education groups and the ability to make decisions
that will improve their health (F= 8.110, p .01) with those with less education more likely
58
to find it difficult to improve their health. There is also a significant difference among income
groups and the ability to make decisions to improve their health (F= 19.144, p ≤ .01) the best
scores ranged from those with the highest income to those with the lowest. There is a
significant difference between one’s perception of social class and one’s ability to make
decisions to improve their health (22.844, p .01), lower class people had most difficulty,
followed by middle class people, followed by upper class.
Newest Vital Sign
The Newest Vital Sign is a validated measure of functional health literacy. The results
indicate (Figure 16) that 19.9% of people have a high likelihood of limited functional health
literacy, 22.5% of respondents may be at risk of low functional health literacy and 57.6%
have adequate functional health literacy.
Figure 16 Newest Vital Sign
59
Health Literacy
Of the respondents 10.3% had inadequate health literacy, 29.7% had problematic health
literacy (these categories may be grouped together and described as limited health literacy),
38.7% had sufficient health literacy and 21.3% had excellent health literacy.
60
Regional differences in Health Literacy
Table 7 presents the regional differences in relation to health literacy, general literacy and the
three core aspects that make up health literacy namely, cure and care, disease prevention and
health promotion. In relation to health literacy (Figure 17) Munster had the highest levels of
health literacy (37.13), followed by Connacht/ Ulster (36.04), the rest of Leinster (35.85) and
finally Dublin (33.31). In relation to general literacy (Newest Vital Sign Table 13, Figure 18)
again Munster scored best (3.68) followed by Connacht/ Ulster (3.57), Dublin (3.56) and
finally the rest of Leinster (3.51). With regards to the components of health literacy Munster
scored best in all three, while Dublin scored the lowest.
Table 7 Regional Mean Scores for Health Literacy and Newest Vital Sign
Health Literacy Index
Newest Vital Sign
Score
Region
Dublin
33.23
3.62
Rest of Leinster
35.30
3.60
Munster
36.68
3.76
Connacht/ Ulster
35.75
3.56
61
Figure 17 Average Health Literacy by Region.
1 = Dublin, 2 = Rest of Leinster, 3 = Munster, 4 = Connaught/Ulster.
Figure 18 Average Newest Vital Sign Score by Region.
62
1 = Dublin, 2 = Rest of Leinster, 3 = Munster, 4 = Connaught/Ulster.
Gender and Health Literacy
There is a significant difference between mean scores on health literacy between males
(34.36) and females (35.92) at the level t = - 3.115, p .01. Similarly there is a significant
difference in relation to the Newest Vital Sign for both males (3.51) and females (3.78) t = -
2.033, p ≤ .05. Females appear to have higher health literacy and better functional literacy.
Age and Health Literacy
In terms of health literacy, 10-year age groups (Figure 19), the means were as follows; < 25
years of age (mean = 35.095), 26-35 years (mean = 34.65), 36-45 years (mean = 35.58), 46-
55 (mean = 35.45), 56-65 (mean = 35.67), 66-75 (mean = 34.56) and >76 (mean 34.29).
There was no significant difference found between the age groups (F= .534, p = .783).
Figure 19. The Relationship between Age and Health Literacy
63
In terms of the Newest Vital Sign, the means were as follows, < 25 years of age (mean =
3.76), 26-35 years (mean = 4.12), 36-45 years (mean = 4.03), 46-55 (mean = 3.38), 56-65
(mean = 3.56), 66-75 (mean = 2.69) and >76 (mean 1.95). There were significant differences
between the groups (F= 11.707, p ≤ .01). This is shown in Figure 20.
Figure 20. The Relationship between Age and Newest Vital Score
64
Education and Health Literacy
Regarding education and health literacy (Figure 15), those at Level 0 had the lowest level of
health literacy (Mean = 26.02), followed by Level 2 (Mean = 32.76), Level 1 (34.24), Level 4
(35.14), Level 3 (Mean = 35.24), Level 5 (Mean = 35.87), and finally Level 6 (Mean =
37.46). There are significant differences between the groups (F= 7.23, p ≤ .01).
Figure 21. The Relationship between Education and Health Literacy
Regarding education and the Newest Vital Sign (Figure 16), those at Level 0 had the lowest
level of functional health literacy (Mean = 2.00), followed by Level 1 (Mean = 2.40), Level 2
(2.59), Level 3 (3.45), Level 4 (Mean = 3.97), Level 5 (Mean 4.05) and finally Level 6 (Mean
= 4.84). There are significant differences between the groups (F= 26.25, p ≤ .01).
65
Figure 22. The Relationship between Education and Newest Vital Sign Score
Income and Health Literacy
Regarding income level those with least income (€1- €1,850) had the lowest health literacy
scores (Mean = 32.94), followed by those with average incomes (€1850- €4,400) with an
average score of 36.90, and finally those on high incomes (€4,400+) had an average score of
37.30 (Figure 23). The average score for the population sample was 34.94, and analysis of
variance suggests a significant difference between income levels and health literacy (F=
21.429, p ≤ .01).
66
Figure 23. The Relationship between Income and Health Literacy
Regarding income and the Newest Vital Sign (Figure 22), those on the lowest income had the
lowest score (2.86) followed by those on average incomes (4.02) and finally those on high
incomes (4.49). The significant differences among income groups (F= 33.00, p .01)
suggests that income is a good determinant of literacy.
Figure 24. The Relationship between Income and Newest Vital Sign Score
67
Self- Perceived Social Class and Health Literacy
Regarding self-perceived social class, there was an obvious progression in health literacy
score from lower class to higher (Figure 25), the means of each class were as follows, very
low = 29.99, low = 33.09, lower middle = 33.09, middle = 35.76, upper middle = 36.66, high
= 39.72, very high = 41.21. There was a significant difference among the class categories (F=
20.436, p ≤ .01).
Figure 25. The Relationship between Social Class and Health Literacy
Regarding social class and the Newest Vital Sign (Figure 26), there was an obvious
progression in NVS score from lower class to higher, the means of each class were as
follows, very low = 1.99, low = 2.98, lower middle = 3.24, middle = 3.98, upper middle =
4.23, high = 4.46, very high = 4.53. There was a significant difference among the class
categories (F= 17.06, p ≤ .01).
68
Figure 26. The Relationship between Social Class and Newest Vital Sign Score
69
Predicting Health Literacy
Table 8 summarises the determinants of health literacy. In this instance the determinants
explain 7.2% variance in health literacy. However only income and social class reach the
appropriate level of significance at the level p ≤.05 and in both instances the variables
positively predict health literacy.
Table 8 Determinants of Health Literacy
Variables
Gender
β = .028
Age
β = .024
Education
β = .052
Income
β = .138**
Social class
β = .149**
Parent
β = -.005
R2
.072
ANOVA
F = 7.163**
*p ≤ .05; ** p ≤ .01
70
SECTION 6 THE RELATIONSHIP BETWEEN HEALTH LITERACY AND
HEALTH OUTCOMES
This section presents an analysis of demographics and health literacy on health outcomes.
Gender
Age
Education
Income
Social class
Parent
Figure 19 Health literacy on health in general
Figure 19 presents the model of health literacy on one’s health in general (Table 9, Model 1).
Of the demographics, gender positively predicts health in general (with females expressing
higher instances of self-rated health in general than males), as age increases ones health in
general increases, as education increases ones health in general decreases, as social class
increases ones health in general decreases. Finally being a parent increases self-rated health
in general. Health literacy also has a significant negative impact on ones health in general,
indicating that higher instances of health literacy relate to lower instances of health in
general.
Gender
Age
Education
Income
Social class
Parent
Figure 20 Health literacy on visits to the doctor
Figure 20 presents the model of health literacy and the amount of times one visits the doctor
(Table 9, Model 2). Of the demographics gender positively predicts doctor visits, as age
increases visits to the doctor increase, as social class increases visits to the doctor decrease.
Being a parent increases ones visits to the doctor. Health literacy does not significantly
predict visits to the doctor.
Health Literacy
Health in general
Health Literacy
Visits to the doctor
71
Gender
Age
Education
Income
Social class
Parent
Figure 21 Health literacy on use of hospital services
Figure 21 presents the model of health literacy and the amount of times one uses hospital
services (Table 9, Model 3). Of the demographics gender positively predicts the use of
hospital services (females using hospital services more often), as age increases the instances
of the use of hospital services increases. Health literacy does not significantly predict use of
hospital services.
Gender
Age
Education
Income
Social class
Parent
Figure 22 Health literacy on smoking
Figure 22 presents the regression model of health literacy on smoking (Table 9, Model 4). Of
the demographics as ones age increases smoking decreases, as education increases smoking
decreases. Health literacy also has a significant negative impact on smoking, indicating that
higher instances of health literacy relate to lower instances of smoking.
Gender
Age
Education
Income
Social class
Parent
Figure 23 Health Literacy on exercise
Figure 23 presents the regression model of health literacy on exercise (Table 9, Model 5). Of
the demographics, an increase in social class predicts lower instances of exercise. Health
Health Literacy
Use of hospital
services
Health Literacy
Smoking
Health Literacy
Exercise
72
literacy also has a significant negative impact on exercise, indicating that higher instances of
health literacy relate to lower instances of exercise.
Gender
Age
Education
Income
Social class
Parent
Figure 24 Health Literacy on community involvement
Figure 24 presents the regression model of health literacy on community involvement (Table
9, Model 6). Of the demographics, gender positively predicts community involvement (with
females more likely to be actively involved in their community), as social class increases
community involvement decreases, also being a parent positively increases community
involvement. Health literacy does not significantly predict community involvement.
Gender
Age
Education
Income
Social class
Parent
Figure 25 Health literacy on alcohol consumption
Figure 25 presents the regression model of health literacy on alcohol consumption (Table 9,
Model 7). Of the demographics, gender negatively predicts alcohol consumption (with males
consuming more than females, as age increases alcohol consumption decreases, as education
increases alcohol consumption decreases and finally as social class increases alcohol
consumption decreases. Health literacy does not significantly predict alcohol consumption.
Health Literacy
Community involvement
Health Literacy
Alcohol consumption
*p ≤ .05, **p≤ .01
Table 9 Beta Values for Health Literacy Outcome Regression Models
Model 1
Model 2
Model 3
Model 4
Model 5
Model 6
Model 7
HL → Health
in general
HL Visits to
the doctor
HL Use of
hospital
services
HL
Smoking
HL
Exercise
HL Community
involvement
HL drinking
Gender
β = .083*
β = .160**
β = .170**
β = -.051
β = .021
β =.090*
β =-.240**
Age
β = .216**
β = .230**
β = .087*
β =-.173**
β =.070
β =.032
β =-.219**
Education
β = -.187**
β = -.030
β = -.001
β =-.209**
β =-.036
β =-.025
β =-.158**
Income
β =-.062
β = -.072
β = -.029
β =-.016
β =-.090
β =-.012
β =-.006
Social Class
β = -.101*
β = -.130**
β = -.045
β =-.083
β =-.095*
β =-.169**
β =-.115*
Parent
β = .099*
β = .083*
β =-.047
β = -.023
β =-.004
β =.104*
β =.073
R2
.186
.118
.046
.085
.040
.046
.151
Change in R2
.186
.118