In a spooky coincidence, 31 October heralded both Halloween and the end of health literacy month.
To support health literacy month, Seeside Advisory social media posts have focused on the role of health literacy in the advertising of medicines and medical devices. In particular, how complying with the Australian therapeutic goods advertising laws supports health literacy—especially for people with lower levels of health literacy. And now, to wrap up health literacy month (mummy style), Seeside has prepared an eerie blog post to unravel these themes further.
Key points
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What is health literacy?
The United States of America’s Institute for Healthcare Advancement (IHA), which brings us health literacy month, defines the concept of health literacy in two ways:
- Personal health literacy is how well a person can find, understand, and use information and services to make decisions about their own health and the health of others.
- Organizational health literacy is how well organizations equitably help all people find, understand, and use information and services to make decisions about their own health and others.
The Australian Commission on Safety and Quality and Healthcare and the Australian Institute of Health and Welfare similarly recognise that health literacy is not solely about a person’s abilities to find, understand and use health information, recognising that the environment influences one’s health literacy and actions.
There are recognised subsets of health literacy, including mental health literacy, death literacy, digital health literacy, oral health literacy and sexual/reproductive health literacy.
Why health literacy is important
Health literacy is recognised as a key specific determinant of health, just as biological factors (like body weight and blood pressure), health behaviours (e.g., smoking, alcohol use) and socioeconomic factors are.
Health literacy can be thought of as the lens through which people view and interpret health and medical information. If the lens is coloured, patchy, thin or warped, people’s interpretations of health and medical information will be adversely affected. As such, a person’s health literacy is integral to their ability to engage with health information and access appropriate health care in a timely fashion.
The Australian Institute of Health and Welfare notes that poor health literacy is linked to poor health outcomes:
People with low health literacy are more likely to have worse health outcomes overall (Berkman et al. 2011) and adverse health behaviours, such as:
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Strong health literacy has also been found to be important in enabling people to identify and reject medical misinformation, as experienced during the COVID-19 pandemic.
Health literacy in Australia
So, how do Australians rate when it comes to health literacy? In short, not very well.
The Australian Bureau of Statistics (ABS) conducted an Adult Literacy and Life Skills (ALLS) survey of Australians aged 15 to 74 years in 2006. This survey graded the proficiency of participants’ health literacy as Level 1 (lowest level of health literacy proficiency) through to Level 5 (highest level), with Level 3 representing the minimum level of proficiency needed to effectively engage with health information.
Overall, there was little variation between males and females across all age groups, with 40% and 41% respectively demonstrating a Level 3 or higher proficiency. However, this indicates that some 60% of the Australian adult population have limited health literacy.
In 2018, the ABS conducted a National Health Survey on Health Literacy. Consistent with the IHA’s definition of health literacy, this survey moved away from assessing the health literacy proficiency of Australians to collecting data that can “…be used to improve health service provision”. This survey found that 91% of Australians felt they could actively manage their health but the results indicated that their certainty declined with their health:
People who considered themselves to be in excellent health were more likely to strongly agree that they could actively manage their health (34%), compared with 11% who considered their health to be good and 9% of people who considered their health to be fair or poor.
A 2019 scoping review by Choudhry et al considered 27 health literacy studies conducted on Australians after the ALLS survey. This review concluded that Australian consumer health literacy levels remained very low, including in indigenous populations.
Factors that influence personal health literacy
A person’s health literacy is not static.
Just like other kinds of literacy, it evolves. The degree to which it grows is dependent on a range of factors, including the level of education the person attains, the impact of disabilities, their socioeconomic group, as well as whether they come from a culturally and linguistically diverse background or live in a remote community. However, health literacy can also be depleted or eroded.
The ALLS survey showed health literacy tends to decline after age 40, with a steep decline occurring from age 60. The survey notes this may reflect generally lower levels of education in these cohorts, rather than age-related cognitive decline. In contrast, the findings of a 2023 study of Australians aged 65 years or over ‘…suggest increasing age is associated with greater confidence in engaging with [health] providers, accessing information and navigating services, particularly for those living with chronic illnesses’.
But the researchers also noted lower health literacy skills in people with poor English or people experiencing psychological distress. Stress and mental illness (including anxiety and depression) are known to impair focus, comprehension, motivation and decision-making abilities, which would affect a person’s ability to interpret and act on health-related information.
As indicated by the 2018 ABS survey, chronic illnesses can also adversely impact health literacy. Some illnesses, like diabetes and cardiovascular disease, can cause cognitive impairment, which in turn, will deplete health literacy. Chronic pain and fatigue, such as that caused by arthritis and fibromyalgia, can make it difficult to focus, creating health literacy challenges. Pregnancy, menopause and cancer are all associated with cognitive impairment (including ‘brain fog’), again creating health literacy challenges. And chronic conditions in general can increase the risk of mental illness, especially depression.
A person’s health literacy may also be challenged by the stress of the chronic health conditions of their child or someone else they care for.
How health literacy impacts on the ability to interpret advertising
Advertising for medicines or medical devices is just another type of health-related information. Like other health information, people will rely on their health literacy to read and interpret it. For those with low health literacy, the advertising may:
- cause confusion (and not achieve its intended purpose), or
- mislead them into thinking the advertised good is suitable for them (when it isn’t), including inferring the good has properties that it doesn’t have.
In Australia, consumer advertising for therapeutic goods must comply with the Therapeutic Goods Act 1989 and the Therapeutic Goods Advertising Code (Code). The Objects of the Code state:
The objects of this Code are to specify requirements for advertisements about therapeutic goods so that advertisements:
(a) promote the safe and proper use of the therapeutic goods by minimising misuse, overuse or underuse; and
(b) are ethical and do not mislead or deceive the consumer or create unrealistic expectations about the performance of the therapeutic goods; and
(c) support informed health care choices; and
(d) are not inconsistent with current public health campaigns.
In other words, the Code requirements exist to help people correctly interpret and understand therapeutic goods advertising to support making informed health care choices, thereby imposing health literacy obligations on advertisers.
The Code foreshadows that health literacy, and a range of other factors, can impact on how people interpret advertising. To address this, the Code specifies that:
This Code applies, in relation to a particular advertisement, by reference to its likely impact on a reasonable person to whom the advertisement is directed.
Therefore, if an advertisement is directed to a particularly vulnerable group of people who are known to have limited health literacy, extra care will be needed to ensure the advertisement is clear and does not mislead.
Unlike in the United States of America, prescription medicines cannot be advertised to Australian consumers, unless it is done by (or on behalf of) the Australian Government or a state or territory government. An example is the government advertising for the COVID-19 vaccines to build Australians’ health literacy around where to get vaccinated and the benefits of getting vaccinated.
However, prescription medicine sponsors can lawfully disseminate disease education advertising to consumers that encourages them to talk to their doctor or other health practitioner about a particular disease or condition to explore prevention or treatment (which might include a prescription medicine). Such advertisements are another important contribution to Australian health literacy.
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