King Saud bin Abdul-Aziz University for Health Sciences

College of Nursing
(NURS 302 ) Behavioral Sciences for Nurses
Societal and behavioral health challenges:(Section VII)
Health Literacy (chapter 28)

Presented by :
Dr. Alia Abdullah al Omari
Manager , social service , king Abdulaziz medical city
LISCENCED SENIOR SOCIAL WORKER , COUNCELLING &
REHABLITATION
Objectives
By the end of the lecture, student will be able to:
– Define literacy, health literacy and related terms
– Explain health literacy levels
– Describe how is health literacy measured
– Predict how can health literacy be improved
– Define poverty
– State what is life like when living in poverty.
– Identify the relation between Poverty and Bio
psychosocial Health.
– Identify what are the medical implications of poverty.
– Develop effective interventions in working with the
poor.
 Literacy
Ø In the 19th century, if you could sign your name, you were
considered literate.

Ø Today, literacy means: the ability to read and write as well as

having the knowledge that relates to a specified subject.

Ø Literacy is: understanding, evaluating, using and

engaging with written text to:
§ participate in the society,
§ to achieve one's goals
§ and to develop one's knowledge and potential.
Based on Adult Literacy and Life skills Survey (ALL)
there are four skill domains to measure literacy:
Prose literacy: The ability to understand
information from texts, like news, brochures
and instruction manuals.
Document literacy: The ability to locate and
use information contained in various formats,
including applications, forms, schedules,
maps and charts.
Numeracy: The ability to effectively manage
the mathematical situations.
Problem solving: the ability to think and act
in situations where no routine solution is
available.
Levels of Literacy
In 2003, The American National Assessment of
Adult Literacy (NAAL) introduced the current
method of reporting literacy Using 4 levels:
§ Below basic
§ Basic
§ Intermediate
§ Proficient
Levels of Literacy
ØBelow basic means (the lowest level of
performance) a person may be able to sign a
form.

ØBasic means a person can perform simple

everyday tasks e.g. comparing the ticket price
of two events, or understanding a pamphlet of
medication.
Levels of Literacy
ØIntermediate means a person can do
challenging tasks e.g. calculating the cost of
hospitalization, or identifying a specific
location on a map.

ØProficient means performing complex

activities e.g. comparing viewpoints in two
editorials, or interpreting a table about blood
pressure and physical activity.
 Literacy & health literacy

Mastering health literacy tasks requires:

Ø the use of more than one literacy skill – prose,

document and numeracy – often simultaneously.

Ø critical thinking skills.

Ø involves specialized vocabulary.

Low health literacy is more prevalence
among
• Older adults
• People with low income
• People with limited education
• Minority population
• People with limited Arabic proficiency
• Who else?
 Negative effect of literacy on health:
Ø High prevalence of accidents and diseases.
Ø Children hospitalization is highest in communities with
high prevalence of limited literacy.
Ø Individuals with less than proficient literacy skills find it
difficult to access, understand, and use health
information and services e.g.
§ completing forms, providing informed consent, interacting
with providers etc.
§ Less likely to seek timely interventions, administer
medication, follow treatment regimen, engage in self care,
etc..
 Red flags for low literacy
• Frequently missed appointments.
• Incomplete registration forms.
• Non-compliance with medication.
• Unable to name medications, explain purpose
or dosing.
• Identifies pills by looking at them, not reading
label.
• Unable to give coherent, sequential history.
• Ask fewer questions.
• Lack of follow-through on tests or referrals.
WHO definition of health literacy
The cognitive and social skills which determine
the motivation and ability of individuals to:
§ gain access to,

§ understand and

§ use information in ways

which promote and maintain good health.

 Factors affecting health literacy
Health literacy depends on both individual and systemic factors
including:

1. Communication skills of patients and professionals including

literacy skills (e.g., reading, writing, numeracy), oral
communication skills, and comprehension.
Communication skills are context specific.

Ø Literacy may develop by: increasing specific knowledge of a

subject though social interactions and influenced by cultural and
socioeconomic factors such as class, race , ethnicity, language,
gender, and the value placed on education by any given
community of people. This what makes literacy context-specific.
 Factors affecting health literacy
2. Knowledge of patients and professionals of health
topics:
People with limited or inaccurate knowledge about the body and the
causes of disease may not:
§ Understand the relationship between lifestyle factors (such
as diet and exercise) and health outcomes
§ Cultural practice and home remedies
§ Recognize when they need to seek care
 Factors affecting health literacy
3. Health literacy is dependent on culture:
Ø Culture affects how people:
§ communicate and understand health information
§ think and feel about their health
§ decide when and from whom people seek care
§ respond to recommendations for lifestyle change and
treatment
 Factors affecting health literacy
4. Demands of the healthcare and public health systems:

§ Individuals need to read, understand, and complete many

kinds of forms in order to receive treatment and payment
reimbursement.

§ Individuals need to know about the various types of health

professionals and services as well as how to access care.
§ How ?
 Factors affecting health literacy
5. Demands of the situation/context:
§ Health contexts are unusually compared to other
contexts because of an underlying stress or fear factor.

§ Healthcare contexts may involve unique conditions

such as physical or mental impairment due to illness.

§ Health situations are often new, unfamiliar, and

intimidating.
 Functional literacy
• In 1991, the American National Literacy Act
established the concept of functional literacy.

• In this broader view, adult literacy is

determined by the extent to which a person’s
cognitive and functional capacities enable
them to do as well as know.
 Functional literacy
ØHealth literacy is a type of functional literacy.
Like computer literacy develops with need,
opportunity , and experience.

e.g., few people have the need, opportunity, or

take the time to learn and talk about diabetes
until they or a significant other is diagnosed. It is
only at diagnosis that their health literacy begins
to develop.
 Assessment of health literacy

Currently, 4 tests are commonly used to measure health literacy:

1. Newest Vital 2. REALM 3. SAHLSA 4. S-TOFHLA
sign

Test full name Newest Vital Rapid Estimate The Short The Short Test of
Signs of Adult Literacy Assessment of Functional
in Medicine Health Literacy Health Literacy
for Spanish- in Adults
speaking Adults

Task *Review *Read 66 words *Selected *Fill in missing

nutrition label (scored on meaning of 50 words in 4
*Respond for 6 correct words numerical items
questions pronunciation of (scored on and 2 prose
the words) number of words passages
defined
correctly)
Example
Example
Example
 Using plain language

The governments are required to use the plain

language in documents which is defined as:

ØWriting that’s clear, concise, well- organized,

and follows other best practice appropriate to
the subject or field and intended audience.
 Health literacy impacts on our ability to:

• Make healthy lifestyle choices (nutrition labels)

• Find & understand health & safety information
• Locate appropriate health services
• Communicate with health providers (i.e. sharing
personal information about health history &
symptoms)
• Navigate a complex health care system - from
walking hospital corridors to filling out insurance
forms
 Examples of Health Literacy

1.Listening to news about a health topic

2. Looking for health information on-line
3. Selecting over-the-counter medications
Literacy levels in KSA
• Adult literacy rate of Saudi Arabia increased from
70.82 % in 1992 to 94.84 % in 2015 growing at
an average annual rate of 7.72 %.
Adult literacy level, Age 15+, both genders

DATE VALUE CHANGE, %

2015 94.84 0.44 %

2013 94.43 13.96 %

2004 82.86 4.42 %

2000 79.35 12.04 %

1992 70.82
 Key findings of the research in
KSA
A recent study (2017) was done to assess Health literacy among
Saudi population

• A cross-sectional study was conducted among a randomly

selected population (n=500) in Saudi Arabia.

• The questionnaire comprised of questions pertaining to

demographic characteristics, health literacy and health
information.

• Health literacy was measured by REALM-R test.

 Key findings of the research in KSA

• The majority of the respondents had intermediate (43.8%) and

basic (34.4%) health literacy levels.

• A higher percentage among men had intermediate (59.8%) and

basic (70.93%) health literacy levels compared with women.

• About 30% of respondents had difficulty in understanding health

screening tests and disease treatment.

• More than half (52.4%) of the participants had difficulty in finding

health information.

• The REALM-R test revealed that about 42.6% of individuals with

score of>6 had adequate health literacy, compared with 57.4%
with score of 6 had inadequate health literacy.
 Key findings of the research in KSA
ØThe study results demonstrated that the
majority of Saudi individuals had inadequate
health literacy that associated with poor
knowledge of health information.

ØThe findings highlighted the importance of

understanding the status of health literacy
among Saudis and the need for educational
programs to raise the health literacy
awareness among Saudi population.
 Another studies revealed that
• The prevalence of diabetes increases significantly as
health literacy decreases.
• Health literacy is more complex than general literacy.
• Mastering health-literacy tasks requires the use of
more than one literacy skill – prose, document and
numeracy – often simultaneously.
• In terms of health literacy, the three most vulnerable
populations are: old ages, immigrants and the
unemployed.
 Recent study revealed :
• This study aims to describe the distribution of low health
literacy (HL) in the population in the Kingdom of Saudi Arabia
(KSA), and to analyze factors associated with low HL in KSA. A
cross-sectional national survey using quota sampling,

• population-based of residents of KSA conducted via phone

interviews supplemented by in-person interviews.

• The survey included an overall evidence-based measurement

of HL. Both descriptive statistics of the sample and a
multivariable logistic regression model predicting low HL were
developed. A total of 3557 surveys were available for analysis,

• Almubark R, Basyouni M, Alghanem A, et al. Health literacy in Saudi Arabia: Implications for public health
and healthcare access. Pharmacol Res Perspect. 2019;7(4):e00514. doi:10.1002/prp2.5 14
 Conclusion
• 46% of the respondents were classified as having low HL. In regression
modelling, low HL was associated with older age groups (age 47-56 odds
ratio [OR] 1.60, 95% confidence interval [CI] 1.30-1.97; age 57-66 OR 1.38,
95% CI 0.98-1.94), the regions of Ha’il (OR 0.65, 95% CI 0.5-0.85) and
Najran (OR 1.27, 95% CI 0.99-1.64), having been formerly married,

• lower levels of education (less than elementary OR 3.20, 95% CI 2.10-4.88;

and elementary, OR 1.62, 95% CI 1.14-2.30), lower levels of income, and
having sought healthcare exactly three times in the last year.
Approximately half of KSA has low HL, and risk factors for low HL were
older ages, lower income and education, having been formerly married,
and a moderate pattern of health use.

• Future studies are needed to better characterize the distriution and

determinants of low HL across KSA.
Health Literacy: A Prescription to End Confusion
Recommendations from research studies:

Ø Develop and support programs to reduce the

negative effects of limited health literacy.

Ø Incorporate health knowledge and skills into the

existing curricula of kindergarten through 12th grade
and adult education and community programs.

Ø Develop culturally and linguistically sensitive

programs to promote health literacy and health
education.
Why is health literacy important?
Patients with limited health literacy
may have difficulty:
• Locating providers and services
• Filling out health forms
• Sharing medical history with provider
• Seeking preventive health care
• Managing chronic health conditions
• Understanding directions on medication
• Understanding and acting on health-related news and
information
Low health literacy affects:

• Health outcomes

• Medication errors

• Increased doctor visits and hospitalizations

• Healthcare costs

• Quality of care
What can we do to help?

1. Improve the health literacy of persons with

inadequate or marginal literacy skills.

2. Increase the proportion of persons who report

that their healthcare providers have satisfactory
communication skills.

3. In the patient visit: use plain language and listen

carefully
 What can we do to help?
In the patient visit
Use plain language and listen carefully
§ Use simple language

§ Define technical terms -Avoid medical jargon

§ Use the active voice

§ Break down complex information into understandable pieces

§ Organize information so the most important points come first

§ Use a medically trained interpreter if necessary

§ Check for understanding using the “teach-back” method

§ Ask open-ended questions

§ Use hand signals or visual cues

 What can we do to help?

4. Improve the usability of health forms and instructions

§ Revise forms to ensure clarity and simplicity.

§ Test forms with intended users and revise as needed.

§ Provide forms in multiple languages.

§ Offer assistance with completing forms and scheduling

follow up care.

§ https://youtu.be/A0QTvuupZWc
Dr. Richard Carmona who was recently
the US Surgeon General
• "As a former nurse, trauma
surgeon, and public health director
[I realized] there was a wall
between us and the people we
were trying to serve. Health care
professionals do not recognize that
patients do not understand the
health information we are trying to
communicate. We must close the
gap between what health care
professionals know and what the
rest of America understands."
Poverty
 Introduction
• Social factors are major influences on health
and diseases. Approximately 60% of
premature deaths are attributable to non-
biological causes.

• Poverty is an important factor that have

profound medical consequences.
 Definition of poverty
• The amount of cash income that is required to
support families of various sizes.

• poverty is a multifaceted phenomenon that has

objective and subjective dimensions.
 Definition of poverty
• Objective poverty is defined in economic terms.

• Subjective poverty include the sense of well-being (or its

opposite, a compromised quality of life), social setting,
cultural values, psychological resources, and context of
an individual experience.

• It includes the extent to which people believe they are

empowered or deprived in a society based on the
resources available to them.
World Bank Definition

Poverty is pronounced deprivation in well-being, and

comprises many dimensions. It includes low incomes and the
inability to acquire the basic goods and services necessary for
survival with dignity. Poverty also encompasses low levels of
health and education, poor access to clean water and
sanitation, inadequate physical security, lack of voice, and
insufficient capacity and opportunity to better one's life
Absolute poverty

•The "dollar a day" poverty line was first

introduced in 1990 as a measure to
meet such standards of living. For
nations that do not use the U.S. dollar
as currency, 'dollar a day' does not
translate to living a day on the
equivalent amount of local currency as
determined by the exchange rate
Relative poverty

•Usually, relative poverty is measured as

the percentage of the population with
income.
•Relative poverty views poverty as
socially defined and dependent on
social context. It is argued that the
needs considered fundamental is not an
objective measure and could change
with the custom of society
 Outline

• Millions of people live in extreme

poverty: Who are they?
• We can reduce poverty
• We should reduce poverty
• How can we reduce poverty?
According to the International
Poverty Line, people are considered
to be in 'extreme poverty' if they
live on less than $1.90 per day, or
the equivalent amount after
converting currencies and adjusting
for price differences between
countries. This is the definition used
by the World Bank and many other
international institutions.
About 700 million people in the
world live below this low threshold.
And about 4.7 billion people (more
than half of the global population)
live on less than 10 dollars per day.

(Note: In the interactive version of

this chart you can click on the option
"Change country" to plot numbers
for any country or world region.)
People living in extreme poverty are
concentrated in certain regions.

The country where you happen to

be born makes a huge difference to
your expected living standards.

(Note: In the interactive version of

this map you can use the slider at the
bottom to show estimates for any
year.)
If we focus on the intensity of
poverty, we see a similar pattern:
The countries where a large share
of people live in extreme poverty
are also the countries where people
tend to have the largest shortfall
from the poverty line (i.e. the
'poverty gap' is largest in these
countries).

In other words: People below

the International Poverty Line tend
to have much worse living
standards in low-income countries.

(Note: In our map charts you can

click on any country to display the
time-series estimates in a line chart.)
 Outline

• Millions of people live in extreme

poverty: Who are they?
• We can reduce poverty
• We should reduce poverty
• How can we reduce poverty?
It's important to remember that despite the
magnitude of the challenge, poverty is not
unavoidable
In 1820 there were just under 1.1
billion people in the world, of which
more than 1 billion lived in extreme
poverty.

Over the next 150 years, the decline

of poverty was not fast enough to
offset the very rapid rise of the
world population, so the number of
non-poor and poor people
increased.

Since around 1970, however, we are

living in a world in which the
number of people who are not
living in extreme poverty is rising,
while the number of people who
are living in extreme poverty is
falling.

(Note: You can read more about this

in our article discussing extreme
poverty in a historical perspective.)
 Outline

• Millions of people live in extreme

poverty: Who are they?
• We can reduce poverty
• We should reduce poverty
• How can we reduce poverty?
There is no empirical evidence to support the
romantic idea that people living in extreme
material deprivation are satisfied with their
standards of living
 Outline

• Millions of people live in extreme poverty:

Who are they?
• We can reduce poverty
• We should reduce poverty
• How can we reduce poverty?
 Social policy is important both because it can contribute to promote income
growth, and because it often makes the wait for growth less painful.

“Economists (and other experts) seem to have very little useful to say about why some
countries grow and others do not... Given that economic growth requires manpower
and brainpower, it seems plausible, however, that whenever that spark occurs, it is
more likely to catch fire if women and men are properly educated, well fed, and
healthy, and if citizens feel secure and confident enough to invest in their children,
and to let them leave home to get the new jobs in the city. It is also probably true that
until that happens, something needs to be done to make that wait for the spark more
bearable.”

(Banerjee and Duflo, Poor Economics, Page 270)

Gender & poverty

• In the literature on poverty, one frequently posed question

is:
• are women poorer than men? In these discussions, the
concept of feminization of poverty is used as a short hand
for a variety of ideas.
• It can mean either one or a combination of the following:
• a. Women compared to men have a higher incidence of
poverty.
• b. Women’s poverty is more severe than men’s.
• c. Over time, the incidence of poverty among women is
increasing compared to men
What is meant by poverty from a gender
perspective?
• The interest in analyzing the phenomenon of poverty from a
gender perspective is rooted in the international women’s
movement and it is based on the need to recognize that poverty
affects men and women in a different way.
• It is possible to identify the gender factors that increase or
decrease the probability of individuals experiencing poverty,
and how the characteristics of poverty are different for men and
women.
• Moreover, a gender perspective enhances the conceptualization
of poverty because it goes beyond a descriptive analysis to look
at the causes of poverty. It approaches poverty as a process,
thereby giving it a more dynamic perspective. In addition, a
gender perspective contributes to the design of policies allowing
measures to be directed at the severest poverty and the most
vulnerable populations.
Poverty in Saudi Arabia

•Do we have poverty ?

•What is your personal assumptions
about poverty?
•Which category subject to be poor ?
•Open discussion
Studies of poverty in Saudi Arabia

• Al jazi alshubaiki 2005 women poverty

• "The poverty of women as a singular had its peculiarity,
evident before the modern economic changes of Saudi
society, since the stability of political conditions and the
discovery of oil, and the developments and changes that
followed it in the social environment of the society in terms
of customs, traditions, values, behavioral patterns, and
means of living"
 Studies of poverty in Saudi Arabia

• Suad shadid ( feminization of poverty , 2016)

• This study aimed to investigate the concept of excluding
women by studying the conditions of 20 Saudi women with low
income who do not have the tools that guarantee them
freedom of movement in the social context.
• and to understand how low-income women coexist in a society
characterized by an exclusionary nature of women that
prevents them from possessing the tools that help them to
move In the public space of the Saudi society, where in-depth
interviews were applied with 20 women of low income,
• poverty is seen in this study as a state of socio-
economic deprivation characterized by the
inability to reach an adequate level of important
needs such as food, clothing, housing,
treatment And movement in public space. While
acknowledging the relativity of deprivation as a
concept, its definition varies according to the
social contexts in which it is found.
Nursing Psycho- social assessment
Thank you

amrialia@hotmail.com

@alia amri ( club house )

Further Resources from Our World in Data

• Blog posts and data entries on this topic:

– ourworldindata.org/extreme-poverty
– ourworldindata.org/happiness-and-life-satisfaction

•
Reading list and Teaching Notes for other topics:
ourworldindata.org/teaching-notes
 References
• Healthy People 2015: www.healthypeople.gov
• Healthy People 2015 Health Literacy Action Plan—Communicating
Health: Priorities and Strategies for Progress (2003):
http://odphp.osophs.dhhs.gov/projects/healthcomm/
objective2.htm
• IOM Report—Health Literacy: A Prescription To End Confusion
(2016): www.iom.edu/report.asp?id=19723
• Mohamed M. M. Abdel-Latif and Sherif Y. Saad. Health Promotion
International, 2017, 1–11.
• NIH Improving Health Literacy Web page:
www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htm
• Sahler,o, Carr,J.,Frank,J.and Nunes,F.(2018). The Behavioral Sciences and
Health Care.4th ed .HOGFEFE publishing company.Pg.No:246-253.
• Sahler,o, Carr,J.,Frank,J.and Nunes,F.(2018). The Behavioral Sciences and
Health Care.4th ed .HOGFEFE publishing company.Pg.No:228-236.