Vulnerable groups and

Health literacy

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• Module duration: 1 ½ – 2 hours
• Material: Theoretical report
• References cited in the module are found in the theoretical report.

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Learning objectives
• Able to explain what health literacy is
• Understanding who is more vulnerable to having low health literacy
• Explain how health disparities are related to low health literacy
• Able to explain the difference between personal health literacy and
organisational health literacy
• Give examples of factors that can impact negatively on health care
research
• Have practical knowledge about basic communication

Reference number: 2020-1-SE01-KA202-077806

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Exercise
• Does everyone has equal access • Group discussion
health care? • 20 - 30 min
• Who does not? • 5 min feedback from each
• Who belongs to vulnerable group
groups
• How does it impact your work?

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 Vulnerable groups
• Individuals that belong to vulnerable groups are at significant risk to
have low health literacy and the impact is considerable both health
wise and socially.
• Factors that influence the health literacy level include, but are not
limited to education, disability, socioeconomic status, ethnicity,
gender and age.

Reference number: 2020-1-SE01-KA202-077806

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cannot be held responsible for any use, which may be made of the information contained therein.
Reference number: 2020-1-SE01-KA202-077806
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cannot be held responsible for any use, which may be made of the information contained therein.
EU High Level Group of Experts on
Literacy. Executive Summary,
September 2012
Luxembourg: Publications Office of the
European Union. ISBN 978-92-79-
25499-4

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What is health literacy?
Health literacy represents 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
Nutbeam, D. (1998) Health promotion glossary. Health Promotion International, 13, 349–364.

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Santana, Stephanie MPH; Brach, Cindy MPP; Harris, Linda PhD; Ochiai, Emmeline MPH; Blakey, Carter BS; Bevington, Frances MA; Kleinman, Dushanka DDS, MScD; Pronk, Nico PhD, MA,
FASCM, FAWHP Updating Health Literacy for Healthy People 2030: Defining Its Importance for a New Decade in Public Health, Journal of Public Health Management and Practice:
November/December 2021 - Volume 27 - Issue - p S258-S264
doi: 10.1097/PHH.0000000000001324
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 Illiteracy rate
• Approximately 7 million
Australian adults (46%) had
literacy scores below the
minimum level needed to
function fully in life and work.

http://cit.edu.au/partnerships/industry_connection/2010_june/literacy_and_numeracy_
holding_australia_back
http://www.abs.gov.au/AUSSTATS/abs@.nsf/Previousproducts/4228.0Main%20Features2
2006%20(Reissue)?opendocument&tabname=Summary&prodno=4228.0&issue=2006%2
0(Reissue)&num=&view
=

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MEASURES OF LITERACY
• Level 1 – lowest
• Level 3 = "minimum required for individuals to meet the complex
demands of everyday life and work in the emerging knowledge-based
economy”
• Level 5 – highest

http://www.abs.gov.au/AUSSTATS/abs@.nsf/Previousproducts/4228.0Main%20Features22006%20(Reissue)?opendocument&tab
name=Summary&prodno=4228.0&issue=2006%20(Reissue)&num=&view
=

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 Health literacy
• Health literacy is defined • Approximately 9 million
as the knowledge and (60%) Australians
skills required to attained scores at Level 1
understand and use or 2
information relating to
health issues such as
drugs and alcohol, disease
prevention and
treatment, safety and
accident prevention, first
aid, emergencies, and
staying healthy
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“Health literacy refers to people’s knowledge, motivation and
competence to access, understand, appraise and apply health
information in order to make judgments and take decisions
about health care, disease prevention and health promotion to
maintain or improve quality of life throughout their lives” 

Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H (2012). Health literacy and public
health: a systematic review and integration of definitions and models. BMC Public Health 12(80): 1-13.
doi:10.1186/1471-2458-12-80. 

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“Survey results from Europe and north America show that
around half of all patients cannot understand basic health care
information, which indicates that health literacy is not simply
a minority problem.” 

Expert Panel on effective ways of investing in Health (EXPH), Report on Access to Health Services in the
European Union, 3 May 2016 
 

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cannot be held responsible for any use, which may be made of the information contained therein.
Reference number: 2020-1-SE01-KA202-077806
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cannot be held responsible for any use, which may be made of the information contained therein.
Exercise
• Who is at risk for low health • Group discussion
literacy? • 15 - 20 min
• What is the impact for these • 5 min feedback from each
individuals? group
• Medical treatment
• Health
• Psychosocial

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Impact of low health literacy
• Contributes to increased hospitalisation (Ngoh, 2009),
• More frequent use of emergency departments (Griffey et al., 2014)
• Increased mortality (Bostock and Steptoe, 2012).
• Impacts parent and caregiver behaviour negatively (DeWalt and Hink,
2009)
• Influences health outcomes adversely for children, not only in the
short-term, but in a long-term perspective as well (DeWalt et al.,
2007).

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Impact of low health literacy
• The health impact is also evident for young people with low health
literacy since they become more prone to engage in risky health
behaviours (for example; substance abuse, unsafe sex), unhealthier
diet, heavier weight, underuse of health prevention services and
more likely to self-report lower general health (Park et al., 2017,
Chang, 2011).

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Impact of low health literacy
• Education is clearly linked to health literacy outcomes and in 2019,
10,2% of EU citizens in the age group 18 – 24 years old had completed
at the lowest secondary education but were no longer in education
and training (Eurostat, 2020b).

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Impact of low health literacy
• For older adults (those ≥65 years old) with low health literacy, the
impact might be more severe than for any other group. Studies
indicates that they experience more pain, lower physical functioning,
limitations of daily activities, and worse mental health status (Wolf et
al., 2010).
• Currently, more than one fifth (20.3 %) of the EU-27 population was
aged 65 and over in 2019 and it is predicted that in 2050, 29,5% will
be aged 65 and over (Eurostat, 2020c).

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Progresses in health practice that tackle low
health literacy are needed to diminish health
disparities in the European population.

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 Levels of health literacy

Don Nutbeam, Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st
century, Health Promotion International, Volume 15, Issue 3, September 2000, Pages 259–267, https://doi.org/10.1093/heapro/15.3.259

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 Exercise
• How would you engage someone • Talk in groups for 20 – 30 min.
with low health literacy? • Group discussion
• How do you identify someone • Each group feedback their
• How would you talk and convey discussions.
information • 10 min
• What are the challenges at your
work (organisational) to engage
someone with low health
literacy
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Communication
• Use Plain Language
• Organizing information so the most important points come first
• Breaking complex information into understandable chunks
• Using simple language and defining technical or medical terms
• Using the active voice
• Example: I threw the ball (active).
• Example: The ball was thrown by me (passive).

https://acpdecisions.org/four-simple-strategies-for-improving-your-patients-health-literacy/

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Communication
• Ask open-ended questions to assess a patient’s understanding of written materials,
including prescription labels.
• Use the Teach Back communication method to determine if a patient has understood
your instructions and can repeat the information in their own words.
• Use “Show Back” when teaching a patient to use a device or perform a task, to
demonstrate correct use.
• Speak more slowly when providing instructions, with an emphasis on being respectful
and clear without being patronizing.

https://acpdecisions.org/four-simple-strategies-for-improving-your-patients-health-literacy/

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• Europe faces significant health challenges, for example; that over
790'000 deaths per year are due to risk factors such as smoking,
drinking, physical inactivity, and obesity (OECD/EU, 2018).
• However, it is the individuals that are at risk for belonging to a
vulnerable group that are at most risk for inadequate levels of health
literacy, which makes this group the most affected.
• At the same time, our scientific community lacks a harmonised
strategy to address these problems.

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Reference number: 2020-1-SE01-KA202-077806
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 Impact in relation to research
• Failure to acquire medical research data which accurately replicates the whole
population generates a number of methodological shortcomings such as
external validity and the ability to generalise
• Blocking the disadvantaged groups from any health benefits of trial
participation
• Incapability to analyse the safety of health promotion, provision of care and
innovations with sub-groups in the population
• Failing to detect groups that have the highest burden of illness and
consequently not being able to generate an understanding of why these
differences exist.
BONEVSKI, B., RANDELL, M., PAUL, C., CHAPMAN, K., TWYMAN, L., BRYANT, J., BROZEK, I. & HUGHES, C. 2014. Reaching the hard-to-reach: a systematic review of strategies for
improving health and medical research with socially disadvantaged groups. BMC Med Res Methodol, 14, 42.

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COVID-19
• In the current pandemic, there is evidence that those individuals
occupying lower socioeconomic positions and/or lower education are
more prone to developing severe COVID-19 or dying from it (de
Lusignan et al., 2020, Drefahl et al., 2020, Williamson et al., 2020), but
it is not understood why this is occurring.

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• This can be reflected in that many HCPs and researchers are not
aware of the challenges to engage with this specific target group,
based upon their numerous studies that has omitted this group in
their research (Bonevski et al., 2014).
• This then results in unintentional discrimination and non-access to
preventive health interventions and general healthcare, which results
in poor health outcomes for our European population.

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