Health Literacy and Sustainable Development

Many of us wonder what exactly literacy is and the role it plays in improving the lives of people on a daily basis. Literacy is a human right and can be considered a tool of personal empowerment: a means for social and human development. Educational opportunities depend on literacy. Thus, literacy is essential for eradicating poverty, improving the socio-economic status of communities, reducing child and maternal mortality rates, curbing population growth, achieving gender equality and promoting sustainable development at the local, regional and national levels.1

According to a report released by the United Nations Educational, Scientific and Cultural Institution (UNESCO) in 2007, the countries of South and South-West Asia have the highest number of illiterate adults in the world: an estimated 388 million. While literacy rates in Central Asia are not as high, the gender gap is of concern, as 72.5 per cent of the illiterate population are women.2 The lack of education and literacy among women and children is manifold causing a direct and indirect impact on their sense of empowerment, low socio-economic status, health care and ultimately poor health.

To improve literacy rates, 2003-2012 has been designated as the United Nations Literacy Decade. In this context, unesco has been partnering with UN agencies and other organizations to promote literacy and teach basic health literacy, through formal and informal educational programmes in many countries.

Health literacy and the pivotal role it plays has been defined by the World Health Organization as follows:

Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people's access to health information, and their capacity to use it effectively, health literacy is critical to empowerment. Health literacy is itself dependent upon more general levels of literacy. Poor literacy can affect people's health directly by limiting their personal, social and cultural development, as well as hindering the development of health literacy.3

Health care providers often face challenges when catering to the needs of the communities they serve. One of the important barriers which needs to be addressed is the lack of compliance due to the low levels of health care literacy worldwide. As a health care provider, public health practitioner and health educator working with global communities, I have found that certain groups of populations, such as women, those living in rural areas and immigrants are vulnerable to serious health disparities. Unfortunately, they experience significantly worse health outcomes such as higher rates of morbidity and mortality due to a lack of health literacy levels. Some of the health risks faced by these groups include a higher incidence of cancer, diabetes, high blood pressure and hiv/aids. These health risks demand effective communication between the providers and the target population -- to help them recognize, minimize and respond effectively and in a timely fashion to potential health problems. It is ironic that while there is such a compelling need for effective communication, the process is extremely complicated and often poorly developed. Language, socio-political, economic and cultural barriers and time constraints pose challenges to health care providers.

Incorporating health literacy into educational programmes for youth and adult learners is vital. An example of a groundbreaking health literacy project is the collaboration between UNESCO, the Joint United Nations Programme on hiv/aids (UNAIDS) and other stakeholders resulting in the launching of EDUCAIDS in 2004 -- the Global Initiative on Education and HIV&AIDS. The two primary goals of this initiative are:

1. To prevent the spread of HIV through education; and

2. To protect the core functions of the education system from the worst effects of the epidemic.4

This ground breaking initiative has been launched at various levels (partnering with local, national and international stakeholders) in many countries throughout the world.

Country Snapshots
The following are a few projects and initiatives illustrating the efforts made by UN agencies, local and national governments, non-governmental organizations and foundations partnering at the grass-roots level to increase health literacy rates and improve the health status of communities:

Angola: Since 2007, UNESCO has been partnering with the Ministry of Education in Angola to offer mainstream education on HIV and AIDS throughout the school curriculum as part of the ongoing process of education reform. As a result, HIV and AIDS prevention is being integrated into education materials for primary and secondary schools across the country. UNESCO has been working with The Virginio Bruni Tedeschi Foundation to educate children about HIV/AIDS by enhancing the capacity of the Ministry of Education to deliver in-service training to teachers. The programme is designed to improve the quality of primary and secondary school teacher-training in the area of HIV and AIDS, evaluate its outcomes and impact through consultations with stakeholders to ensure ownership, and produce harmonized guidelines and approaches to in-house teacher-training on HIV and AIDS prevention, care and support. The programme also aims to support the Ministry of Education in developing a strategy and an implementation plan for rolling-out in-service teacher training across the country.5

An ongoing project evaluation and assessment was conducted in mid-2008. One of the important lessons learned was that coordination of efforts among the stakeholders and support for the Government's education sector in response to HIV and AIDS is critical to achieving maximum impact of interventions in the post-conflict and transition phase in Angola.

Viet Nam: EDUCAIDS was launched in 2006 in Viet Nam; UNESCO has partnered with the United Nations Population Fund, the United Nations Children's Fund (UNICEF) and the School Health HIV and Education Working Group, which supports the Ministry of Education and Training (MoET). The project goals in Viet Nam were to institutionalize a policy framework to mandate reproductive health and HIV/AIDS education in schools, thereby mainstreaming prevention education in the school curriculum and promoting capacity-building for educational personnel through pre-service and in-service teacher training.6 The establishment of an interdepartmental coordination mechanism in MoET to manage and implement comprehensive responses to HIV and AIDS. This partnering also led to the development of guidelines for implementation of recent legislation on HIV/AIDS in Viet Nam's education sector. The programme seeks to address the various forms of discrimination faced by people living with HIV/AIDS and to protect their rights to health care access and equal employment opportunities.

Moldova: UNESCO launched the EDUCAIDS project in Moldova in 2006 after consultations with MoET, UNAIDS, the United Nations Development Programme, UNICEF, the World Bank, and community-based organizations. The EDUCAIDS project team identified the need for advocacy to mobilize support from decision makers as well as gaps in educator training and support. To address these specific needs, UNESCO in liaison with UNICEF and the Education for All-Fast Track Initiative, has organized life skills-based education seminars for educators from child and family community centres. In Moldova's sensitive environment, and by adhering to the country's prevailing cultural and religious beliefs, EDUCAIDS has been useful in promoting a coordinated approach among UN agencies and other partners in addressing the challenges posed by HIV/AIDS.7

Mexico: In June 2007, EDUCAIDS was launched in Mexico as a collaborative partnership between the Ministry of Education, UN agencies, civil society and youth. The main objective of EDUCAIDS in Mexico is to develop a national strategy to promote HIV and sex education in schools.8 Launching the project was instrumental in providing UNESCO with the opportunity to profile its initiatives and share lessons learned, advocate and network with relevant stakeholders, and learn about the latest developments and experience related to the AIDS epidemic at the XVII International AIDS Conference in Mexico City in August 2008.

In addition to these activities, UNESCO's Regional Office for Culture in Latin America and the Caribbean, in collaboration with several United Nations agencies and institutions under the umbrella of the Cuban Ministries of Culture and Public Health, launched a series of cultural events with an underlying focus on promoting health literacy, especially HIV/AIDS education and prevention. One such activity was a workshop created as a multidisciplinary space for the exchange of experiences and the assessment of arts-based approaches to HIV and AIDS, with a particular emphasis on theatre and audiovisual productions. A multimedia approach was used to consider the impact of arts, creativity and literacy on changing attitudes, as well as behaviour modification -- both on the individual and collective level -- regarding the pandemic.9

Non-governmental organizations have recently been partnering with national and international agencies to incorporate informal health literacy programmes in developing countries, so as to improve health care access and safe motherhood initiatives. The White Ribbon Alliance for Safe Motherhood (WRA) in India, for example, has been working closely with the Partnership for Maternal and Child Health and the Government of India to educate and empower women to make the right choices and improve their health status. In the state of Orissa, women have an unfortunately low socio-economic status, low literacy levels, high incidences of early marriage, and a maternal mortality rate of 358, (considerably higher than the national average of 301). One contributing factor to this dismal picture is the high incidence of anaemia among pregnant Indian women. Studies also indicate that more than 53 per cent of women living in the state of Orissa are not involved in making decisions about their own health. In order to address these challenges, the above-mentioned stakeholders are working at the grass-root level to reach out to women, community leaders and policy makers to improve the levels of health literacy in the state. Efforts so far have resulted in the implementation of WRA-Orissa launching in 12 districts, a campaign entitled "Deliver Now for Women and Children: Advocacy for Maternal, Newborn and Child Health in India". The campaign centres around the creation of community demand for quality maternal and child health, bringing about political will and making policy changes for better delivery of maternal and child health care, with an underlying theme of health literacy.10

Recommendations to promote and improve health literacy among populations
* Health professionals need to be aware of the levels of education and health literacy among the populations they serve.

* Disseminated health information needs to be user-friendly and efforts should be made to keep verbal and written information simple. The increased use of charts and pictures may be more beneficial in improving communication: this also includes the development and testing of alternative and text-free educational methods.

* A neutral and friendly atmosphere between the providers and the clients will help to increase the level of communication and understanding, as well as to improve patient compliance.

* Training and educating health care professionals, teachers, social workers and community volunteers about the importance of health literacy and effective health communication is of vital importance. This can be achieved by a periodic review of the materials and processes in use by the various stakeholders, and by training in both verbal and written communication skills.

* Local cultural beliefs and customs need to be considered when developing interventions or programs to improve health literacy rates in the target population.

* If needed current programmes can be redesigned or adapted, based on the recommendations made as a result of monitoring and evaluating project outcomes.

* Working with and supporting the adult education sector at various levels will also help improve the health literary levels among communities.

* If necessary, existing policies at the national, state and local levels can be modified or redesigned to improve health literacy outcomes.11

In conclusion, health literacy is a valuable tool in empowering women and communities to improve their health status and achieve sustainable development by reaching the indicators of the Millennium Development Goals 1-6.

Notes
1. Literacy Portal (http://portal.unesco.org/education/en/ev.php-URL_ID=54369&URL_DO=DO_TOPIC&URL_SECTION=201.html)

2. Fourth UNESCO Regional Literacy Conference to open in New Delhi (http://portal.unesco.org/education/en/ev.php-URL_ID=54831&URL_DO=DO_TOPIC&URL_SECTION=201.html)

3. Health Promotion Glossary (http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf)

4. EDUCAIDS -- the Global Initiative on Education and HIV & AIDS (http://portal.unesco.org/en/ev.php-URL_ID%3D36400&URL_DO%3DDO_TOPIC&URL_SECTION%3D201.html)

5. EDUCAIDS -- Angola (http://unesdoc.unesco.org/images/0016/ 001610/161028E.pdf)

6. EDUCAIDS -- Viet Nam (http://unesdoc.unesco.org/images/0016/ 001626/162629E.pdf)

7. EDUCAIDS -- Moldova (http://unesdoc.unesco.org/images/0015/001538/153884E.pdf)

8. EDUCAIDS -- Mexico (http://unesdoc.unesco.org/images/0015/ 001569/156997E.pdf)

9. Theatre and Visual Arts: A New Approach to HIV and AIDS in Latin America and the Caribbean (http://portal.unesco.org/en/ev.phpURL_ID=38930&URL_DO=DO_TOPIC&URL_SECTION=201.html)

10. Brief Report on Safe Motherhood Rally-cum-Public Hearing 25th November 2008, Boudh District, Orissa (http://www.who.int/pmnch/events/20081125_dnpubhearing_orissa.pdf)

11. Health Literacy Studies (http://www.hsph.harvard.edu/healthliteracy/overview.html)