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4233.0 - Health Literacy, Australia, 2006  
Latest ISSUE Released at 11:30 AM (CANBERRA TIME) 25/06/2008   
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SUMMARY OF FINDINGS


INTRODUCTION

This publication discusses the distribution of health literacy among the Australian population aged 15-74 years. The publication focuses on the findings of the Adult Literacy and Life Skills Survey (ALLS), which was conducted in Australia in 2006.

The methodology underpinning the ALLS draws on the fact that different situations, including the home, community and work, impose skill demands on individuals at all stages and in all aspects of their lives. This is especially true with health, which every Australian makes decisions about and takes action on, ranging from diet and fitness to seeing a health professional about a health concern. It is noteworthy that research, the bulk of which has been undertaken in Canada and the United States of America (USA), has found that individuals' health related decisions and actions are strongly associated with their level of education and literacy skills.

According to the Canadian Council on Learning (2007), education and health literacy have an integral relationship with the overall health of a society's population as well as disparities within the population. Literacy is important on many levels, but it is increasingly being seen as important for an individual's ability to participate fully in modern society.

The ALLS assessed respondents' prose and document literacy, numeracy and problem solving. From these data, information relating to respondents' health literacy was derived, using specific questions related to health issues.


THE ADULT LITERACY AND LIFE SKILLS SURVEY

The ALLS was conducted in Australia in 2006 as part of an international literacy study coordinated by Statistics Canada and the Organisation for Economic Co-operation and Development (OECD). The first wave of the survey, conducted in 2003, included the USA, Bermuda, Canada, Italy, Mexico (state of Nuevo Leon), Norway and Switzerland. Australia participated in the second wave along with Hungary, the Netherlands, New Zealand and South Korea. The ALLS is a follow up of the International Adult Literacy Survey (IALS), which was conducted in Australia in 1996 as the Survey of Aspects of Literacy (SAL). The IALS was the first internationally comparable survey of adult literacy, with three rounds of data collection between 1994 and 1998.

The ALLS in Australia was co-funded by the ABS, the former Australian Government Department of Education, Science and Training and the former Australian Government Department of Employment and Workplace Relations. The Australian Government Department of Health and Ageing provided funding for the additional calculation of the health literacy scale. As health literacy is a new addition to the 2006 ALLS, no time series information is available.

The ALLS is designed to identify and measure literacy which can be linked to the social and economic characteristics of people both within and across countries. Currently, the Australian health literacy domain is only directly comparable to that of Canada. Although the United States of America also derived health literacy from their National Assessment of Adult Literacy, comparing the two collections must be done with caution since collection and derivation methods differ. In the future, other internationally comparable data on health literacy may become available, as the ALLS second wave countries complete their data collection activities.

For more information on the ALLS, refer to Adult Literacy and Life Skills Survey, Australia, Summary Results (cat. no. 4228.0) and the Adult Literacy and Life Skills Survey, User Guide (cat. no. 4228.0.55.002).


DEFINITION OF HEALTH LITERACY

Health literacy is a widely used term that encompasses a range of ideas and definitions. The USA Institute of Medicine (2004) stated that health literacy is a shared function that is dependent on social and individual factors, including an individuals' health and literacy skills and capacities. As levels of education and literacy are now acknowledged by policy researchers and policy makers as being important determinants of health, health literacy is perceived as being increasingly important for social and economic development (Kickbusch, 2001).

When considered in such a broad context, the most commonly cited definition of health literacy is one that emphasises the skills of individuals: 'The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions' (USA Department of Health and Human Services, 2000). This definition acknowledges the fact that health literacy operates within the 'complex group of reading, listening, analytical and decision making skills' and is dependent upon 'the ability to apply these skills to health situations' (National Network of Libraries, 2007). It is this interaction between ability and application that is the focus of the ALLS assessment tasks.

Health literacy in the ALLS is defined as: the knowledge and skills required to understand and use information relating to health issues such as drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid, emergencies, and staying healthy.


THE DEVELOPMENT OF THE HEALTH LITERACY SCALE

The USA Educational and Testing Service (ETS) report Literacy and Health in America, which was released in 2004, was the first research paper to analyse population-based health literacy skills among adults. The report used 191 health-related assessment tasks that formed part of the 1992 National Adult Literacy Survey to create a Health Activities Literacy Scale. This scale was improved and updated for use in the Canadian Adult Literacy and Skills Survey and the USA National Assessment of Adult Literacy in 2003. The health literacy scale used in the Canadian survey was subsequently used in the Australian 2006 ALLS.

The report compiled by the ETS (2004), together with a report by the USA Institute of Medicine (Health Literacy: A Prescription to End Confusion, 2004), encouraged researchers and academics to move beyond a medical perspective of health literacy to adopt a more comprehensive overview of the concept. As such, the concept of health literacy was expanded to include activities that not only occur in the formal health care system, but a range of health activities that take place in the home, the workplace and the community.

This broader perspective of health literacy is integral to the concept underpinning measurement in the ALLS. Before the emergence of large-scale surveys, researchers had not considered the systematic investigation of health tasks in everyday settings, nor had they examined the materials that adults are expected to interpret and understand in order to achieve these tasks. Research has shown that health outcomes are influenced by a person's ability to use a wide range of health-related materials which may include package labels on food and over-the-counter medicines (Kickbush, 2001).


United States of America

The USA was the first country to use a health literacy scale, the Health Activities Literacy Scale (HALS), which was developed by the ETS. The HALS was linked to the 1992 National Adult Literacy Survey (NAL), one of the first large scale population-based surveys on literacy (Educational Testing Service, 2004). The NAL was followed by the 2003 National Assessment of Adult Literacy (NAAL) survey, which with help from the USA Department of Health and Human Services and the USA Department of Education, included a component that analysed health literacy. This component measured 28 items and materials related to health, each of these items following the same format and structure as the other literacy domains (prose, document and quantitative) in the survey. However, the health literacy scale used in NAAL is not comparable to the health literacy scale used in the Canadian International Adult Literacy and Skills Survey (ALL) or the health literacy scale used in the Australian ALLS. This is due to differences in the analytical process, such as the sampling parameters, performance levels used, and the probability level set for doing a task correctly (Canadian Council on Learning, 2007: 17).


Canada

The Canadian ALL was enumerated in 2003, and incorporated a health literacy domain. The scale used to measure health literacy was an improved and updated version of the 1992 HALS, although it was different in terms of methodology to the NAAL. As such, the Canadian ALL was the first to use this particular health literacy scale, which was developed in conjunction with the ETS. This health literacy scale is the same scale that the Australian ALLS used, and is therefore directly comparable.


Australia

In the ALLS, health literacy was derived as a by-product of the objectively assessed prose and document literacy, numeracy and problem-solving domains. The following is a brief description of the four domains:

  • Prose literacy: the ability to understand and use information from various kinds of narrative texts, including texts from newspapers, magazines and brochures.
  • Document literacy: the knowledge and skills required to locate and use information contained in various formats including job applications, payroll forms, transportation schedules, maps, tables and charts.
  • Numeracy: the knowledge and skills required to effectively manage and respond to the mathematical demands of diverse situations.
  • Problem solving: goal-directed thinking and action in situations for which no routine solution is available.

The ALLS contained 191 health-related items across these four domains. Each of the items related to one of the following five health-related activities: health promotion (60 items), health protection (64 items), disease prevention (18 items), health care maintenance (16 items), and systems navigation (32 items). The five health-related activities are defined below:
  • Health promotion: the ability to enhance and maintain health (e.g. plan an exercise regime or purchase health foods) by locating and using health-related articles in magazines and brochures, or information contained on charts of food or product-safety labels.
  • Health protection: the ability to safeguard individual or community health (e.g. the ability to select from a range of options) by reading newspaper articles, information about health and safety, or air and water quality reports, or participating in referenda.
  • Disease prevention: the ability to take preventive measures and engage in early detection (e.g. determine risks, seek screening or diagnostic tests and follow up on courses of treatment) by understanding health alerts on TV or in newspapers or understanding letters about test results.
  • Health care maintenance: the ability to seek and form a partnership with health care providers, including providing health history forms or following directions on medicine labels, or being able to understand and discuss the merits of alternative forms of treatment with a health professional.
  • Systems navigation: the ability to understand and to access needed health services by completing application forms, reading maps to locate appropriate facilities or understanding health benefits packages.

(Canadian Council on Learning, 2007)

These health-related activities were used to code and analyse health tasks such as purchasing food and products, using products at home or at work, interpreting information about air and water quality, using medicine, applying for insurance, and offering informed consent. A list of these categories is provided below with selected examples of materials and tasks.

CATEGORIES OF HEALTH ACTIVITIES, Selected examples

Health activities Focus Examples of materials Examples of tasks

Health promotion Enhance and maintain health Articles in newspapers, magazines, booklets and brochures; charts, graphs, lists; food and product labels Purchase food; plan exercise regime
Health protection Safeguard health of individuals and communities Articles in newspapers and magazines; postings for health and safety warnings; air and water quality reports Decide among product options; use or avoid products
Disease prevention Take preventive measures and engage in early detection News alerts such as TV, radio, newspapers; postings for inoculations and screening; letters related to test results; graphs and charts Determine risk; engage in screening or diagnostic tests; follow up
Health care maintenance Seek care and form a partnership with health-care providers Health history forms; medicine labels; discharge instructions; education booklets and brochures; health information on the Internet Describe and measure symptoms; follow directions on medicine labels; calculate timing for medicine; collect information on merits of various treatment regimes for discussion with health professionals
Systems navigation Access needed services; understand rights Maps; application forms; statements of rights and responsibilities; informed consent; health benefit packages Locate facilities; apply for benefits; offer informed consent

Source: Canadian Council on Learning (2007)


For each literacy domain, proficiency was measured on a scale ranging from 0 to 500 points. To facilitate analysis, these continuous scores were grouped into 5 skill levels (only 4 levels were defined for the problem solving scale), with Level 1 being the lowest measured level of literacy and 5 the highest. The relatively small proportion of respondents who actually reach Level 5 often results in unreliable estimates of the number of people at this level. For this reason, whenever findings are presented by skill level, Levels 4 and 5 are combined. Skill Level 3 is regarded by the survey developers as the 'minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge-based economy' (Statistics Canada, 2005).

The score ranges for each level of proficiency for health literacy were:
  • Level 1: 0-225
  • Level 2: 226-275
  • Level 3: 276-325
  • Level 4: 326-375
  • Level 5: 376-500

For a full description of the levels please refer to Appendix 1. A summarised version of the framework used in the ALLS can be found in an ETS monograph, The International Adult Literacy Survey: Understanding What Was Measured (2001).


AUSTRALIA'S HEALTH LITERACY

Age and sex

Consistent with other literacy domains (prose and document literacy, numeracy and problem solving), health literacy generally increased from the 15 to 19 years age group up to the 35 to 39 years age group, and then generally decreased for those aged 40 years and over. Ageing causes physical, psychological and social change, and dependence on health care services and personal health care often increases. In such circumstances, the ability to effectively care for oneself, interact and communicate with health services, requires a reasonable level of health literacy. The graph below indicates that 83% of those aged 65 to 74 years did not achieve Level 3 or above on the health literacy scale. It is important to note that the steep decline in the older age groups may also be associated with the lower education levels of these older cohorts (American Council of Education, 2007), and may not necessarily be associated with a decline in health literacy over time for any individuals.

HEALTH LITERACY BY SKILL LEVEL, by Age
Graph: HEALTH LITERACY BY SKILL LEVEL, by Age


Both males and females achieved similar levels of health literacy overall, with 40% and 41% respectively achieving skill Level 3 or above. When examined by age, 48% of females aged 15 to 44 years achieved a health literacy of Level 3 or above, compared to 43% of males in the same age group. In contrast, 35% of males aged 45 and over achieved a health literacy Level 3 or above, compared to 32% of females of the same age.


Comparison between literacy domains

It is interesting to look at how health literacy compares to the other literacy domains. Approximately 59% of Australians aged 15 to 74 years achieved scores below Level 3 for the health domain. In comparison, 46% scored below Level 3 for the prose domain, 47% for the document domain, 53% for the numeracy domain, and 70% for the problem solving domain.

PROPORTION AT EACH SKILL LEVEL
Graph: PROPORTION AT EACH SKILL LEVEL


All literacy domains, including health literacy, were found to have similar relationships with characteristics such as educational participation and attainment. For example, those respondents who had completed a greater number of years of formal education achieved higher literacy scores across all literacy domains.


Health literacy by states and territories

There were no outstanding differences in skill levels for health literacy between the states and territories of Australia. The exception to this was the Australian Capital Territory, where there were significantly more people at skill Level 3 or above (56%) than other states and territories. The proportions at skill Level 3 or above in the other states and territories ranged from 43% in Western Australia to 37% in the Northern Territory and Tasmania. This is consistent with the findings for the other literacy domains.

HEALTH LITERACY SKILL LEVEL 3 OR ABOVE, by states and territories, by sex
Graph: HEALTH LITERACY SKILL LEVEL 3 OR ABOVE, by states and territories, by sex



Educational attainment

Research has shown that people in lower socioeconomic groups are on average less healthy than those in higher socioeconomic groups (Australian Institute of Health and Welfare, 2004). Links have been established in American, Canadian and European research between health and markers of socioeconomic status such as educational attainment. In common with other literacy domains, people with higher formal educational attainment achieved higher levels of health literacy. Among those with 16 years or more of formal education, 69% achieved Level 3 or above. Of people with a Bachelor degree or above, 55% achieved Level 3, and 15% achieved Level 4/5, while 30% of those with an Advanced diploma/diploma or below achieved Level 3 and 3% achieved Level 4/5.

HEALTH LITERACY, by Level of highest non-school qualification
Graph: HEALTH LITERACY, by Level of highest non-school qualification


Completing Year 12 is also associated with achieving higher health literacy levels. Among people who had completed Year 12 or equivalent, 58% achieved Level 3 or above, and if a non-school qualification was also completed, 61% achieved Level 3 or above. In comparison, if Year 12 was completed but a non-school qualification was not completed, 50% achieved a health literacy Level 3 or above.


Educational participation

There were approximately 13.4 million people who reported participating in learning in the 12 months prior to the survey. Learning includes formal learning which is participating in an educational program to obtain a formal qualification. In addition, learning includes informal learning (but not as part of a course) which involves activities such as visiting trade fairs, professional conferences or expos, attending lectures, seminars or workshops, reading manuals or reference books or using computers or the Internet.

For health literacy, people who participated in informal learning (45%) in the 12 months prior to the survey were more likely to achieve scores at Level 3 or above than those who did not participate (13%). When considering formal learning in relation to health literacy, of the 6.7 million people who undertook an educational qualification and/or course in the previous 12 months, 54% achieved scores at Level 3 or above. In contrast, of the people who did not undertake an educational qualification and/or course in the previous 12 months, 30% achieved scores at Level 3 or above.


Parental education

There are many studies on intergenerational relationships and the effects on development, health and various adult behavioural outcomes (Chevalier, 2004), which support a positive relationship between parental educational attainment, especially the mother's highest educational qualification, and the child/ren's educational outcomes (Behrman,1997; Behrman and Rosenzweig, 2002). In Australia, of adults whose parents' or guardians' highest educational attainment was a Bachelor degree or above, 68% achieved a health literacy Level 3 or above. This is compared to 58% of adults whose parents or guardians completed an Advanced diploma/diploma or below.

HEALTH LITERACY, by Parental educational attainment
Graph: HEALTH LITERACY, by Parental educational attainment



Labour force status and income

In Australia a significantly greater proportion of employed people achieved a health literacy skill Level 3 or above (47%), compared to those who were unemployed (25%) or not in the labour force (25%). It is also interesting to note the differences between the sexes based on labour force status. A higher proportion of employed females (50%) achieved Level 3 or above than males (44%). Among the unemployed, 27% of males achieved a health literacy Level 3 or above, while 23% of females achieved a health literacy Level 3 or above. For those not in the labour force, there was little difference between the proportion of females and males (both 25%) who achieved a health literacy Level 3 or above.

HEALTH LITERACY, SKILL LEVEL 3 OR ABOVE, by Labour force status and sex
Graph: HEALTH LITERACY, SKILL LEVEL 3 OR ABOVE, by Labour force status and sex


People who achieved higher health literacy levels were more likely to live in households with higher mean equivalised gross household incomes. When comparing people who achieved a health literacy skill Level 1 and those who achieved skill Level 3, there was approximately a $34,400 difference in their equivalised household incomes.

HEALTH LITERACY BY SKILL LEVEL, by Income (a)
Graph: HEALTH LITERACY BY SKILL LEVEL, by Income (a)



Health literacy by industry/occupation

Health literacy skills varied across the different industries and occupations in which people were employed. While these results are of interest, it is important to be aware of the differing roles and skills required across the range of industries and occupations. Each requires different qualifications and skill sets, such as particular academic or technical qualifications, or specialised skills.

In Australia, 72% of those employed in the Education and Training industry achieved a skill Level 3 or above in health literacy, and 68% in the Professional, Scientific and Technical Services industry. In comparison, 29% of those employed in the Transport, Postal and Warehousing industry achieved Level 3 or above for health literacy.

Differences are also apparent when examining occupations, where a high proportion of Professionals achieved Level 3 or above (71%). In contrast, 21% of Machinery Operators and Drivers achieved a health literacy Level of 3 or above.

HEALTH LITERACY BY SKILL LEVEL, by Occupation of main job
Graph: HEALTH LITERACY BY SKILL LEVEL, by Occupation of main job



Health literacy by self-assessed health status

Self-assessed health is commonly used to provide insight into health status in the absence of other measurement tools. While it is not equivalent to health status as assessed by a medical professional, self-assessed health does provide a measure of an individual's health at a given point in time. When analysing self-assessed health with other characteristics, insights can be provided into how people perceive their own health in relation to being overweight or obese, high risk drinking, smoking or having a sedentary lifestyle (ABS, 2007). The 2006 ALLS used the SF-12, a multipurpose short-form (SF) question module to measure self-assessed health. The 12 self-assessment questions related to mental, physical and social well being (please see the Glossary for more information).

Half (50%) of those who reported that they had a lot of energy a good bit of the time in the 4 weeks prior to the survey achieved a health literacy Level 3 or above. About half (48%) of those who reported that they felt calm and peaceful for a good bit of the time in the last 4 weeks achieved a Level 3 or above.This was in contrast to people who reported that they felt calm and peaceful for none of the time, only 19% of whom scored Level 3 or above. For people who felt that physical health or emotional problems interfered with social activities only some of the time in the last 4 weeks, 31% achieved health literacy skill Level 3 or above.


Health literacy by social participation

Social participation is another dimension associated with health literacy. Social participation incorporates many characteristics, with two being included in the ALLS: participation in a group or organisation and participation as an unpaid volunteer.

For people participating in different types of groups or organisations, over half (55%) of those who participated in a political organisation achieved Level 3 or above for health literacy. Of those people who volunteered in coaching, teaching or counselling, 56% achieved a health literacy Level 3 or above.

Of those who participated in any type of group or organisation, 48% achieved health literacy Level 3 or above. In contrast, of people who did not participate in any type of group or organisation, 30% achieved a health literacy Level 3 or above. Similarly, of those who did not participate as an unpaid volunteer, 33% achieved a health literacy Level 3 or above. However, of people who did participate as an unpaid volunteer, 51% achieved a health literacy Level of 3 or above. Those with high health literacy levels also had high levels of satisfaction with life. For those who were extremely satisfied with life, 50% achieved a health literacy of Level 3 or above, while 21% of those who were extremely dissatisfied with life achieved at this level.


Health literacy by migrant characteristics

A key social characteristic within migrant studies is country of birth, and more specifically, whether a person was born in an English speaking country. A similar proportion of people born outside of Australia in mainly English speaking countries (46%) scored at Level 3 or above on the ALLS health literacy scale as those born in Australia (44%). In comparison, of those born overseas in a mainly non-English speaking country, only 26% achieved Level 3 or above.

HEALTH LITERACY SKILL LEVEL 3 OR ABOVE, by Country of birth(a)
Graph: HEALTH LITERACY SKILL LEVEL 3 OR ABOVE, by Country of birth(a)



Health literacy by Remoteness

For people living in major cities in Australia, 42% achieved a health literacy skill Level 3 or above, with similar proportions of people living in remote regions and inner regions achieving at this level (39% and 38% respectively). For those people living in outer regions of Australia, 36% achieved a health literacy skill Level 3 or above. Note that the survey was not conducted in very remote parts of Australia. See paragraph 8 of the Explanatory notes for more information.

HEALTH LITERACY BY SKILL LEVEL, by Remoteness(a)
Graph: HEALTH LITERACY BY SKILL LEVEL, by Remoteness(a)



Comparison to Canada

It is possible to compare health literacy results between Australia and Canada. For each of the literacy domains in the ALLS, Australia and Canada were found to have very similar results, including health literacy. In the health literacy domain, 45% of Canadians achieved a health literacy Level 3 or above, compared to 43% in Australia.

HEALTH LITERACY BY SKILL LEVEL, Australia and Canada(a)
Graph: HEALTH LITERACY BY SKILL LEVEL, Australia and Canada(a)


It should be noted that the Canadian survey scope was for those aged between 16 and 65 years. For the purpose of the above comparison, Australian data was restricted to those aged 16 to 65 years. International results should also be interpreted with caution as different levels of non-response could impact on the comparisons. For Canada, the response rate of eligible dwellings was 66%, compared to Australia's 81%. Refer to paragraphs 12 and 13 in the Explanatory notes for further information on response rates.


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