NALA Policy Brief

on
Health Literacy in
Ireland

September 2009

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Contents Page

Position statement 3

Summary analysis 3

Policy Recommendations 5

Implementations 7

References 8

Published by: The National Adult Literacy Agency 2009

NALA © 2009

The National Adult Literacy Agency (NALA) was established in 1980 and is an independent
membership organisation, concerned with developing policy, advocacy, research and offering
advisory services in adult literacy work in Ireland. NALA has campaigned for the recognition of,
and response to, the adult literacy issue in Ireland.

Contact NALA at: National Adult Literacy Agency

76 Lower Gardiner Street

Dublin 1
Tel: +353 1 8554332
Fax +353 1 8555475
Email: literacy@nala.ie
Web: www.nala.ie

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Position Statement

NALA’s health literacy policy

NALA 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 wishes to see health literacy as a fundamental consideration in health policy and
programme planning. Health literacy is a relatively new subject area worldwide. In Ireland we
do not have any studies documenting the literacy skills demanded of the Irish health service or
quantifying health literacy.

Definition of health literacy

The USA Institute of Medicine (IOM) and the Department of Health and Human Services offer
the most relevant definition of health literacy. It emphasises the dual responsibility for health
literacy and takes into consideration issues of access and context.

“Health literacy emerges when the expectations, preferences and skills of individuals seeking
health information and services meet the expectations, preferences and skills of those providing
information and services.” (IOM 2004)

NALA’s efforts in this area come from the view that a large section of the Irish population may
not have the skills to fully understand and benefit from our health service. 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 (NALA 2002).

Summary Analysis
The first Irish literacy survey took place in 1995 with results published in 1997. It was called the
International Adult Literacy Survey (IALS) and was sponsored by the Organisation for Economic
Co-operative Development (OECD). It took place across a number of international countries
thus allowing for international comparisons. It used everyday reading material such as a train
timetable and a packet of Aspirin. It used a five Level scale with Level three considered the
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minimum level needed to actively engage in Irish society. Results showed that 25% of the Irish
population, or at least 500,000 adults scored, at the lowest level, Level one. This means that a
large percentage of the population experience difficulty with everyday reading material.

Numeracy is a very important issue in healthcare. Risk, probability, likelihood and norm are
difficult mathematical concepts and yet are commonly used in the healthcare contexts. The
IALS 1997 found that 25% of adults could not answer correctly the simplest of numerical
questions.

While Irish people are living longer, they are also developing more chronic conditions, which call
for a greater degree of self management (CSO 2006). The IALS showed that 44% of people
aged 55-65 scored at Level one compared to 17% of people aged 16-25. It also found that over
40% of respondents aged 56-65 could not answer correctly the simplest of numerical questions.
It is possible to conclude that older people are struggling to a greater extent with reading and
numerical material in healthcare settings.

Evidence also shows that healthcare systems in industrial nations, such as Ireland, are getting
more complex and therefore more demanding for all patients (OECD, 2005).

Irish Health Policy

In terms of health policy documents literacy was cited in the Department of Health’s Health
Promotion Strategy 2000-2005 (DOHC, p20)

“Poor literacy skills are a barrier to many opportunities in our information-based society and this
also limits access to health information and health services.”

Since this time, the Health Promotion Unit has 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.

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Health literacy defined too narrowly

Currently health literacy initiatives are funded by the Population Health Section of the HSE,
which drives initiatives for health promotion practitioners. While this work is appreciated, health
literacy needs to be developed in a range of settings and from a number of perspectives. The
Department of Health are responsible for devising policy which permeates through the Health
Service Executive’s (HSE) work. Public health services are delivered at a local level by the
HSE. Therefore, it would be useful for the Department of Health to devise a policy statement,
which could guide future work by the HSE and stimulate research funding.

Other policy domains

Health literacy is not a feature of national health strategies and national on-going population
based surveys such as SLAN. Health literacy is not included directly or indirectly in any Irish
healthcare accreditation process and so is limited to the health promotion sector which is driving
this area. It is not recognised and researched as a health issue. It needs to be tackled from a
number of perspectives such as:

research,

communications,

policy, and

healthcare accreditation.

Recent developments

Ireland has recently agreed to partake in the first European health literacy survey as a full
partner (April 2009). This project will develop a measure of health literacy and results in 2010
will give a clear picture of the literacy skills of Irish people. It will allow the Department of
Health to compare the Irish results with European countries. For health literacy to advance,
comprehensive and timely Irish data is required and the European survey will be an important
source of such information.

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Policy Recommendations

Development of communication principles

NALA wishes to see health literacy explored as a communication issue. Health communication
is the study and use of communication strategies to inform and influence individual and
community decisions that enhance health.

Communication principles should be included as evaluation criteria regarding all national health
initiatives by the Department of Health. This would mean that materials are written in plain
English, use images frequently and are tested with focus groups. It would also involve
considering the numeracy demands of materials, an area often overlooked. The Canadian
Public Health Association for example has mandated that all materials geared for the general
public use plain language and avoid the jargon, scientific vocabulary and complex sentences
that make materials difficult to read.

People who do not experience literacy difficulties in other areas of life might easily run into
trouble in healthcare settings because they are not used to the setting or indeed the vocabulary
used. Attention needs to be given to the design and complexity of healthcare systems. Health
care settings could be encouraged to conduct literacy audits such as NALA’s health literacy
audit, which helps organisations and individuals to find literacy barriers and respond to them.

The 2008 HSE National Intercultural Health Strategy recognises that a greater emphasis on
visual and spoken messages will be required. It also advocates the provision of information in
clear understandable language to facilitate access to health services for people from minority
ethnic groups as well as those experiencing literacy difficulties.

Funding

There needs to be a specific health literacy budget in place to research and develop this area.
Currently the health promotion department fund this area but money is project based and not
guaranteed each year. There is no guarantee that this fund will continue. Also, there is no
guarantee that literacy will feature in any future health promotion strategies. It is hoped that
results from the European Health literacy survey will lead to a specific health literacy
programme.

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Healthcare accreditation

Health literacy could also be part of any ongoing efforts to improve healthcare systems i.e.
accreditation system. In the US Accreditation committees are increasingly encouraging
hospitals and health centres to examine and redesign their documents and procedures for
informed consent.

Training issue

With a health literacy policy statement, the Department of Health needs to encourage
professional organisations to develop a position on health literacy and issue policy statements
and papers. They could also provide a training framework for administrative and medical
practitioners.

Literacy included in all national surveys and initiatives

Health literacy should also be included in all national population surveys. It was included in the
1999 National Health and Lifestyle Survey (SLAN) but was not included in follow up surveys. In
addition, national health screening initiatives should follow good adult literacy practice. This
would mean that literacy is taken into account at design, operational and evaluation stage. It
could also offer the opportunity for programmes to develop a relationship with their local literacy
for training and referral purposes. Breastcheck is a government funded programme providing
breast screening. Breastcheck is an example of a national programme that recognised the
value of using plain English, integrating visuals and making front line staff literacy aware.

Implementation

The Department of Health needs to develop a health literacy policy. This would guide
the HSE to develop a response to this issue. This development could lead to HIQA
acknowledging health literacy.
A Department of Health literacy budget could be used to develop a health literacy
training programme for HSE staff. This programme could access supports from NALA to
develop innovative tools such as the NALA/HSE literacy audit and health literacy
awareness DVD (2009).

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Health literacy needs to be researched in Ireland. Lack of Irish research has hindered
the development of initiatives and also hindered this area being included in specific
curricula.

The Department needs to include health literacy as an area to include in future national
surveys.

A co-ordinated media campaign needs to be undertaken to increase awareness of the

issue of health literacy among the public and specific audiences.

Lack of literacy awareness amongst Irish medical practitioners is a barrier that needs to
be addressed (NALA 2002). Health literacy needs to be a mandatory component of
health curricula and professional continuing training.

Targets for health literacy need to be set and monitored.

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References
Central Statistics Office (CSO) 2006 http://www.cso.ie/statistics/lifexpect.htm Accessed 4/9/09

Department of Health and Children, (2000) National Health Promotion Strategy

2000- 2005, Dublin Stationery Office.

Health Services Executive, 2008. National Intercultural Health Strategy 2007-2010.

Kildare:HSE.

Institute of Medicine, 2004 Health Literacy: A Prescription to End Confusion. Washington, DC:
National Academies of Science.

NALA 2002 Health Literacy Policy and Strategy Report. Dublin: NALA.

OECD, 2005. Learning a Living: First Results of the Adult Literacy and Life Skills Survey. Paris:
Statistics Canada:OECD Publishing.

Tassi, A., 2004. The Emergence of Health Literacy as a Public Policy Priority. Literacy Harvest
Autumn.

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