Reducing Hospital Mortality: Programmatic and Policy Interventions

**3**

**Chapter 1**

LMICs

Introductory Chapter: Mortality

Mortality data is a key indicator of the health of a population, with life expectancy being a commonly reported measure. Most recent estimates (2015) place global life expectancy at birth at 71.4 years but with significant regional differences. Improvements in life expectancy over the last few decades are reflected in the 55% of global deaths which occurred among older persons 65 years and over (moving from 41% in 1990). This development is a marker of socioeconomic development

In 2017 approximately 56 million deaths were recorded and of that number non-communicable diseases (NCDs); communicable, maternal, neonatal and nutritional diseases; and injuries accounted for 72.3, 19.3, and 4.6% of deaths, respectively [2]. Cause-specific mortality for the top 10 leading causes of death was attributed to cardiovascular diseases (32.26%), cancers (16.32%), respiratory diseases (6.48%), diabetes (5.83%), dementia (4.36%), lower respiratory infections (4.35%), neonatal deaths (3.16%), diarrheal diseases (3.03%), road incidents

Globally, the predominant risk factors for mortality are preventable and include high blood pressure, smoking, high blood sugar, high body mass index (obesity), high cholesterol, outdoor air pollution, alcohol use, household air pollution, low fruit diets, and low vegetable diet. While both men and women have metabolic and behavioral risk factors for early death and disability, the leading behavioral risk factors for men were smoking and alcohol consumption, while for women metabolic risk factors were predominant (e.g., high systolic blood pressure, glucose, and body mass index) [2]. The association between nutrition and NCDs may have arguably originated in utero [3], and an increased awareness of epigenetics has thickened the discussion around NCDs and associated mortality. Discussions on health disparities and NCDs have also become increasingly relevant, especially given global economic disparities and social risks which directly impact on the poor, marginalized and other vulnerable populations. This is oftentimes compounded by deficiencies in health literacy and inadequate integration of evidence-based models in health care. While non-communicable diseases have largely accounted for global deaths, acute and chronic respiratory conditions remain the major threats to survival. In 2016, the top two leading causes of death in low-income countries were noncommunicable diseases—lower respiratory infections and diarrhoeal diseases [2].

and Quality of Care Systems in

*Jasneth Mullings, Affette McCaw Binns,* 

**1. Mortality and risk factors: the global picture**

and progress in the reduction of premature deaths [1].

(2.45%), and liver disease (2.3%) [2].

*Antoinette Barton-Gooden and Tomlin Paul*

*Camille-Ann Thoms-Rodriguez,* 

#### **Chapter 1**

## Introductory Chapter: Mortality and Quality of Care Systems in LMICs

*Jasneth Mullings, Affette McCaw Binns, Camille-Ann Thoms-Rodriguez, Antoinette Barton-Gooden and Tomlin Paul*

#### **1. Mortality and risk factors: the global picture**

Mortality data is a key indicator of the health of a population, with life expectancy being a commonly reported measure. Most recent estimates (2015) place global life expectancy at birth at 71.4 years but with significant regional differences. Improvements in life expectancy over the last few decades are reflected in the 55% of global deaths which occurred among older persons 65 years and over (moving from 41% in 1990). This development is a marker of socioeconomic development and progress in the reduction of premature deaths [1].

In 2017 approximately 56 million deaths were recorded and of that number non-communicable diseases (NCDs); communicable, maternal, neonatal and nutritional diseases; and injuries accounted for 72.3, 19.3, and 4.6% of deaths, respectively [2]. Cause-specific mortality for the top 10 leading causes of death was attributed to cardiovascular diseases (32.26%), cancers (16.32%), respiratory diseases (6.48%), diabetes (5.83%), dementia (4.36%), lower respiratory infections (4.35%), neonatal deaths (3.16%), diarrheal diseases (3.03%), road incidents (2.45%), and liver disease (2.3%) [2].

Globally, the predominant risk factors for mortality are preventable and include high blood pressure, smoking, high blood sugar, high body mass index (obesity), high cholesterol, outdoor air pollution, alcohol use, household air pollution, low fruit diets, and low vegetable diet. While both men and women have metabolic and behavioral risk factors for early death and disability, the leading behavioral risk factors for men were smoking and alcohol consumption, while for women metabolic risk factors were predominant (e.g., high systolic blood pressure, glucose, and body mass index) [2]. The association between nutrition and NCDs may have arguably originated in utero [3], and an increased awareness of epigenetics has thickened the discussion around NCDs and associated mortality. Discussions on health disparities and NCDs have also become increasingly relevant, especially given global economic disparities and social risks which directly impact on the poor, marginalized and other vulnerable populations. This is oftentimes compounded by deficiencies in health literacy and inadequate integration of evidence-based models in health care.

While non-communicable diseases have largely accounted for global deaths, acute and chronic respiratory conditions remain the major threats to survival. In 2016, the top two leading causes of death in low-income countries were noncommunicable diseases—lower respiratory infections and diarrhoeal diseases [2]. Among the many respiratory conditions that contribute to hospital mortality, infectious causes are reported to account for the largest proportion [4]. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study (2015) reported in the Lancet Infectious Diseases (2017) that, worldwide, the fifth cause of death overall was attributable to lower respiratory tract infections [4]. Over 50% of these deaths (totaling 1,517,388) in all ages were attributable to pneumococcal pneumonia. The impact of this was disproportionately seen among various age groups with the greatest impact in childhood [4]. Vaccination, proper nutrition and a reduction in exposure to contaminated air were important strategies that resulted in a reduction in mortality in children [3]. Other important infectious agents associated with significant morbidity and mortality include *Haemophilus influenzae* serotype B, *Mycobacterium tuberculosis* complex (MTBc), influenza virus, and the respiratory syncytial virus with MTBc infections being among the top 10 causes of death globally [5]. Tuberculosis has had a resurgence in recent times, associated with the HIV/ AIDS epidemic. Management of these conditions has been further complicated by the development of multidrug-resistant strains which further contribute to significant morbidity and mortality [5].

#### **2. Health disparities and the growing burden in LMICs**

Health disparities between high- and low-income countries are reflected in the leading causes of death in low-income countries being communicable, maternal, neonatal, and nutritional diseases compared to non-communicable diseases (e.g., ischemic heart disease, stroke, and lung cancer) in high-income countries. Lower-middle, upper-middle and high-income countries all reported ischemic heart disease and stroke as the top two leading causes of death. Notably, however, ischemic heart disease was the third leading cause of death in low-income countries, signaling an epidemiological transition [6] (**Table 1**).

The prevalence of chronic non-communicable diseases (CNCD) in lower middle-income countries (LMICs) is burdensome. Currently, three out of four people die from a CNCD, and 40% are premature, occurring between 30 and 69 years [7]. The drivers of these diseases are well documented and include both behavioral and biological factors, which are challenging to address when compounded with needed health system strengthening. Notwithstanding, the latter may be easier to address strategically through policy implementation, while the former will need an ecological approach that addresses cultural and economic nuances that are inherent in LMICs.

The economic fallout from the global NCD burden over the next 20 years is estimated at a cumulative loss output of US\$ 47 trillion, representing a value of 75% of global gross domestic product at 2010. The forces of population growth and ageing are expected to increase the number of persons affected by NCDs, thereby increasing healthcare costs and reducing productivity globally. Cardiovascular disease and mental health conditions are the major contributors to the economic burden. The largest share of the burden will be borne by high-income countries. However, the scale of the impact in developing countries will increase as a result of population growth and economic challenges [8]. LMICs are increasingly being challenged by the lack of resources and inadequate infrastructure and health systems to effectively respond to the NCD epidemic, while many are simultaneously battling emerging and re-emerging communicable diseases. Jamaica and Burkina Faso are among two of the countries classified as LMICs, albeit at different ends of the spectrum, but facing grave economic and social challenges. Experiences from both countries are shared in this book.

**5**

diseases [11].

**Table 1.**

*Introductory Chapter: Mortality and Quality of Care Systems in LMICs*

**Upper-middle income countries**

Ischemic heart disease

2 Stroke Stroke Stroke Diarrhoeal

Chronic obstructive pulmonary disease

Trachea, bronchus, lung cancers

Lower respiratory infections

Alzheimer disease and other dementias

8 Diabetes mellitus Road injury Pre-term birth

**Lower-middle income** 

Lower respiratory infections

Chronic obstructive pulmonary disease

Diabetes mellitus Diabetes mellitus Tuberculosis

complications

Tuberculosis Stroke

Diarrhoeal diseases Malaria

Ischemic heart disease Lower respiratory

**Low-income countries**

infections

diseases

HIV/AIDS

Ischemic heart disease

Pre-term birth complications

and birth trauma

**countries**

Burkina Faso in Africa has a population of 18,450,000 and life expectancy at birth of 60 years. Communicable diseases account for 5 of the top 10 causes of death, the top 3 of which are lower respiratory infections (14%), malaria (10%) and diarrheal disease (6%) [9]. These data reflect a country in what Omran described as the second stage of the epidemiological transition—'Age of Receding Pandemics' [10]—characterized by a shift from primarily infectious diseases to include noncommunicable diseases such as stroke (6%), ischemic heart disease (4%), and road injury (3%) [9]. Burkina Faso is classified as a low-income country by the World Bank, with an economy which is heavily reliant on agriculture and vulnerable to external shocks and internal political instability. Ranked 144 out of 157 countries on the new World Bank Human Capital Index, Burkina Faso is severely challenged by the impact of the twin epidemics of communicable and non-communicable

9 Kidney disease Liver cancer Cirrhosis of the liver Birth asphyxia

10 Breast cancer Stomach cancer Road injury Road injury

Home to 2.9 million persons, Jamaica, the largest island in the English-speaking Caribbean, has a life expectancy at birth of 76 years and is classified as an upper middle-income economy. In spite of this, the country has struggled with low growth, high public debt and vulnerability to external shocks from global economic forces and natural disasters such as floods and hurricanes [12]. Across the Caribbean, governments are paying increased attention to the impact of NCDs on sustainable development. In the case of Jamaica, GDP output loss due to the four leading NCDs (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) and mental health conditions is projected at US\$ 18.45 billion over the 2015–2030 period. As a singular factor, cardiovascular disease is expected to account for 20% of this loss [13]. Furthermore, NCDs and mental health conditions

*DOI: http://dx.doi.org/10.5772/intechopen.86804*

disease and other dementias

pulmonary disease

**Rank High-income countries**

1 Ischemic heart disease

3 Alzheimer

4 Trachea, bronchus, and lung cancers

5 Chronic obstructive

6 Lower respiratory infections

7 Colon and rectum cancers

*Source: World Health Organization [6].*

*Top ten causes of death by income group, 2016.*


*Introductory Chapter: Mortality and Quality of Care Systems in LMICs DOI: http://dx.doi.org/10.5772/intechopen.86804*

#### **Table 1.**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

Among the many respiratory conditions that contribute to hospital mortality, infectious causes are reported to account for the largest proportion [4]. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study (2015) reported in the Lancet Infectious Diseases (2017) that, worldwide, the fifth cause of death overall was attributable to lower respiratory tract infections [4]. Over 50% of these deaths (totaling 1,517,388) in all ages were attributable to pneumococcal pneumonia. The impact of this was disproportionately seen among various age groups with the greatest impact in childhood [4]. Vaccination, proper nutrition and a reduction in exposure to contaminated air were important strategies that resulted in a reduction in mortality in children [3]. Other important infectious agents associated with significant morbidity and mortality include *Haemophilus influenzae* serotype B, *Mycobacterium tuberculosis* complex (MTBc), influenza virus, and the respiratory syncytial virus with MTBc infections being among the top 10 causes of death globally [5]. Tuberculosis has had a resurgence in recent times, associated with the HIV/ AIDS epidemic. Management of these conditions has been further complicated by the development of multidrug-resistant strains which further contribute to signifi-

cant morbidity and mortality [5].

**2. Health disparities and the growing burden in LMICs**

signaling an epidemiological transition [6] (**Table 1**).

Health disparities between high- and low-income countries are reflected in the leading causes of death in low-income countries being communicable, maternal, neonatal, and nutritional diseases compared to non-communicable diseases (e.g., ischemic heart disease, stroke, and lung cancer) in high-income countries. Lower-middle, upper-middle and high-income countries all reported ischemic heart disease and stroke as the top two leading causes of death. Notably, however, ischemic heart disease was the third leading cause of death in low-income countries,

The prevalence of chronic non-communicable diseases (CNCD) in lower middle-income countries (LMICs) is burdensome. Currently, three out of four people die from a CNCD, and 40% are premature, occurring between 30 and 69 years [7]. The drivers of these diseases are well documented and include both behavioral and biological factors, which are challenging to address when compounded with needed health system strengthening. Notwithstanding, the latter may be easier to address strategically through policy implementation, while the former will need an ecological approach that addresses cultural and economic nuances that are inherent

The economic fallout from the global NCD burden over the next 20 years is estimated at a cumulative loss output of US\$ 47 trillion, representing a value of 75% of global gross domestic product at 2010. The forces of population growth and ageing are expected to increase the number of persons affected by NCDs, thereby increasing healthcare costs and reducing productivity globally. Cardiovascular disease and mental health conditions are the major contributors to the economic burden. The largest share of the burden will be borne by high-income countries. However, the scale of the impact in developing countries will increase as a result of population growth and economic challenges [8]. LMICs are increasingly being challenged by the lack of resources and inadequate infrastructure and health systems to effectively respond to the NCD epidemic, while many are simultaneously battling emerging and re-emerging communicable diseases. Jamaica and Burkina Faso are among two of the countries classified as LMICs, albeit at different ends of the spectrum, but facing grave economic and social challenges. Experiences from both countries are

**4**

shared in this book.

in LMICs.

*Top ten causes of death by income group, 2016.*

Burkina Faso in Africa has a population of 18,450,000 and life expectancy at birth of 60 years. Communicable diseases account for 5 of the top 10 causes of death, the top 3 of which are lower respiratory infections (14%), malaria (10%) and diarrheal disease (6%) [9]. These data reflect a country in what Omran described as the second stage of the epidemiological transition—'Age of Receding Pandemics' [10]—characterized by a shift from primarily infectious diseases to include noncommunicable diseases such as stroke (6%), ischemic heart disease (4%), and road injury (3%) [9]. Burkina Faso is classified as a low-income country by the World Bank, with an economy which is heavily reliant on agriculture and vulnerable to external shocks and internal political instability. Ranked 144 out of 157 countries on the new World Bank Human Capital Index, Burkina Faso is severely challenged by the impact of the twin epidemics of communicable and non-communicable diseases [11].

Home to 2.9 million persons, Jamaica, the largest island in the English-speaking Caribbean, has a life expectancy at birth of 76 years and is classified as an upper middle-income economy. In spite of this, the country has struggled with low growth, high public debt and vulnerability to external shocks from global economic forces and natural disasters such as floods and hurricanes [12]. Across the Caribbean, governments are paying increased attention to the impact of NCDs on sustainable development. In the case of Jamaica, GDP output loss due to the four leading NCDs (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) and mental health conditions is projected at US\$ 18.45 billion over the 2015–2030 period. As a singular factor, cardiovascular disease is expected to account for 20% of this loss [13]. Furthermore, NCDs and mental health conditions are projected to reduce annual GDP by 3.9% between 2015 and 2030. Regional government commitment to policy and programs to address the NCD epidemic is relatively strong but challenged by economic realities.

#### **3. Hospital mortality data systems: measuring quality of care**

As the world faces a multiplicity of health challenges, the World Health Organization is following its 2019 watch list of 10 threats to global health: air pollution and climate change, non-communicable diseases, global influenza pandemic, fragile and vulnerable settings, antimicrobial resistance, Ebola and other high-threat pathogens, weak primary health care, vaccine hesitancy, dengue, and HIV [14].

Many of the deaths from these conditions and exposures occur in hospitals. Hospital mortality data is an important source of information to support health system strengthening globally by enabling monitoring and improvements in quality of care [15]. Robust public health planning requires the availability of timely and accurate data on the leading causes of death and disability.

The World Health Organization reports that cause-of-death statistics from hospital sources and other sources form the basis of statistics on the health of a population. This information is used for development planning by governments, researchers, and donor agencies and is often used to track progress on national and international development goals. However, the issue of accuracy has remained a concern in many jurisdictions. Addressing this issue requires an expanded awareness of the public health value of correct certification and coding of hospital deaths and the proper maintenance of hospital records to facilitate improved diagnoses and treatment. Continuous monitoring and evaluation of cause-of-death certification and coding and medical record practices is also necessary to support useful and effective national mortality data systems [16, 17].

Given the challenges in data quality and utilization for hospital performance metrics, experts recommend the following to improve the quality and use of hospital mortality data:


#### **4. Strategies, guidelines and lessons for LMICs**

Persons requiring hospital admission are those whose illnesses require professional supervision. The book outlines strategies to enable the best possible outcome

**7**

*Introductory Chapter: Mortality and Quality of Care Systems in LMICs*

with interventions focused on improving the health literacy of the patients and ensuring that their nutrition is optimal, ranging from the very preterm infant to

An informed consumer improves the likelihood of developing a cooperative relationship between the general public and the health team. Lynch and Franklin discuss health literacy, or the capacity of the patient to obtain, process and understand basic health information and services needed to make the basic health decisions for themselves and their loved ones. They outline what the concept of health literacy means, especially its limited prevalence, and explore possible strategies to

Global evidence suggest that efforts to standardize care for all patients help to improve outcomes, and as such there is a growing support for the development of clinical guidelines, which are adapted to local conditions, clear protocols for care and the use of checklists to ensure that the care process is consistent. With increasing life expectancy, few patients present with a single health problem nor is addressing even a specific problem the singular responsibility of one professional, so the building of multidisciplinary teams and improving the facility with which members of the health team work together for the good of the patient are discussed

Supportive care while in hospital requires attention to optimize the contribution of adequate nutrition to the patient's recovery and health maintenance going forward. Wright argues that this requires attention to the professional, skill, knowledge and experience of the health team as these are important correlates that may modify patient outcomes. Even in well-resourced settings, this aspect of care does not receive the attention it deserves; however the authors argue that in under-resourced developed states, it is important to capitalize on this valuable asset which can assist health teams to realize positive gains in patient survival through the establishment

Life-threatening complications require tertiary care, including access to intensive care services. Once these units are established, we need to understand the factors associated with adverse outcomes and ensure that strategies are put in place to address those preventable complications. Martin and colleagues explore the Burkina

Developing evidence-based models which are contextually relevant for LMICs is critical to reducing associated burden and mortality in these resource-limited

Addressing hospital mortality is a complex task and the span of issues covered in this book shows that there is a bigger frame within which all strategies should be considered. As much as the hospital is an entity strongly focused on clinical care, it remains a part of the wider health system. The book chapters cut across issues of personal risk and resource considerations to environmental exposures and policies affecting education and health literacy. Placing the strategies collectively within a broad field frame begs the question of the role of the hospital as a socially account-

While the strategies could be seen as acting upon a situation occurring within the institution, the institution as a whole must be seen as having collective responsibility and scope for action. Overall, social accountability is an effective strategy for improving the quality and performance of health-care service providers and institutions and it has been shown to have better status in private hospitals compared to public and teaching ones [20]. In low- and middle-income countries, such as Jamaica, the majority of hospital care of the population is delivered through public hospitals. As such, efforts to improve the overall social accountability must

Faso experience and lessons to reduce mortality among the elderly.

be a priority overarching strategy for reducing mortality.

improve its contribution to reducing hospital mortality and morbidity.

*DOI: http://dx.doi.org/10.5772/intechopen.86804*

end-of-life care for the elderly.

by Plummer and colleagues.

environments.

able institution.

of good policies and standards for care.

#### *Introductory Chapter: Mortality and Quality of Care Systems in LMICs DOI: http://dx.doi.org/10.5772/intechopen.86804*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

are projected to reduce annual GDP by 3.9% between 2015 and 2030. Regional government commitment to policy and programs to address the NCD epidemic is

As the world faces a multiplicity of health challenges, the World Health Organization is following its 2019 watch list of 10 threats to global health: air pollution and climate change, non-communicable diseases, global influenza pandemic, fragile and vulnerable settings, antimicrobial resistance, Ebola and other high-threat pathogens, weak primary health care, vaccine hesitancy, den-

Many of the deaths from these conditions and exposures occur in hospitals. Hospital mortality data is an important source of information to support health system strengthening globally by enabling monitoring and improvements in quality of care [15]. Robust public health planning requires the availability of timely and

The World Health Organization reports that cause-of-death statistics from hospital sources and other sources form the basis of statistics on the health of a population. This information is used for development planning by governments, researchers, and donor agencies and is often used to track progress on national and international development goals. However, the issue of accuracy has remained a concern in many jurisdictions. Addressing this issue requires an expanded awareness of the public health value of correct certification and coding of hospital deaths and the proper maintenance of hospital records to facilitate improved diagnoses and treatment. Continuous monitoring and evaluation of cause-of-death certification and coding and medical record practices is also necessary to support useful and

Given the challenges in data quality and utilization for hospital performance metrics, experts recommend the following to improve the quality and use of

• Regular national audits of mortality with feedback to hospitals to address gaps

• Training programs for doctors and medical students on cause-of-death certifi-

• Alignment of hospital cause-specific mortality reporting with disease surveil-

• Strengthening of maternal and perinatal death surveillance and response,

• Capacity building for clinical and population health epidemiology to enable

Persons requiring hospital admission are those whose illnesses require professional supervision. The book outlines strategies to enable the best possible outcome

focusing on lessons learned to improve quality and safety

improved sophistication in analyses [18, 19].

**4. Strategies, guidelines and lessons for LMICs**

**3. Hospital mortality data systems: measuring quality of care**

relatively strong but challenged by economic realities.

accurate data on the leading causes of death and disability.

effective national mortality data systems [16, 17].

gue, and HIV [14].

hospital mortality data:

in reporting and analysis

lance and response programs

cation and coding

**6**

with interventions focused on improving the health literacy of the patients and ensuring that their nutrition is optimal, ranging from the very preterm infant to end-of-life care for the elderly.

An informed consumer improves the likelihood of developing a cooperative relationship between the general public and the health team. Lynch and Franklin discuss health literacy, or the capacity of the patient to obtain, process and understand basic health information and services needed to make the basic health decisions for themselves and their loved ones. They outline what the concept of health literacy means, especially its limited prevalence, and explore possible strategies to improve its contribution to reducing hospital mortality and morbidity.

Global evidence suggest that efforts to standardize care for all patients help to improve outcomes, and as such there is a growing support for the development of clinical guidelines, which are adapted to local conditions, clear protocols for care and the use of checklists to ensure that the care process is consistent. With increasing life expectancy, few patients present with a single health problem nor is addressing even a specific problem the singular responsibility of one professional, so the building of multidisciplinary teams and improving the facility with which members of the health team work together for the good of the patient are discussed by Plummer and colleagues.

Supportive care while in hospital requires attention to optimize the contribution of adequate nutrition to the patient's recovery and health maintenance going forward. Wright argues that this requires attention to the professional, skill, knowledge and experience of the health team as these are important correlates that may modify patient outcomes. Even in well-resourced settings, this aspect of care does not receive the attention it deserves; however the authors argue that in under-resourced developed states, it is important to capitalize on this valuable asset which can assist health teams to realize positive gains in patient survival through the establishment of good policies and standards for care.

Life-threatening complications require tertiary care, including access to intensive care services. Once these units are established, we need to understand the factors associated with adverse outcomes and ensure that strategies are put in place to address those preventable complications. Martin and colleagues explore the Burkina Faso experience and lessons to reduce mortality among the elderly.

Developing evidence-based models which are contextually relevant for LMICs is critical to reducing associated burden and mortality in these resource-limited environments.

Addressing hospital mortality is a complex task and the span of issues covered in this book shows that there is a bigger frame within which all strategies should be considered. As much as the hospital is an entity strongly focused on clinical care, it remains a part of the wider health system. The book chapters cut across issues of personal risk and resource considerations to environmental exposures and policies affecting education and health literacy. Placing the strategies collectively within a broad field frame begs the question of the role of the hospital as a socially accountable institution.

While the strategies could be seen as acting upon a situation occurring within the institution, the institution as a whole must be seen as having collective responsibility and scope for action. Overall, social accountability is an effective strategy for improving the quality and performance of health-care service providers and institutions and it has been shown to have better status in private hospitals compared to public and teaching ones [20]. In low- and middle-income countries, such as Jamaica, the majority of hospital care of the population is delivered through public hospitals. As such, efforts to improve the overall social accountability must be a priority overarching strategy for reducing mortality.

A big part of such strategic intervention on social accountability in hospitals will be tied to having adequate corporate governance and corporate strategy social responsibility [21]. Stakeholders' demands must be met and there must be a culture of performance, conformance, and responsibility. Hospitals, seeking to improve health outcomes in a cost-effective manner, should consider preventive measures in developing intervention strategies. This is an important consideration around the strategies discussed in this book. Placing the hospital in a role to also address social determinants [22] may seem a misfit with its core mission. However, if real gains are to be made in LMICs with limited resources and the threat of stagnation within the epidemiological transition, a socially accountable framework must be considered to bring synergies with the overall health system and much needed and added value to individual strategies.

The issues covered in the book create a framework from which policies may be developed to improve the prevention and management of disease, with the hope of reducing the associated hospital mortality.

#### **Author details**

Jasneth Mullings\*, Affette McCaw Binns, Camille-Ann Thoms-Rodriguez, Antoinette Barton-Gooden and Tomlin Paul The University of the West Indies, Mona, Jamaica

\*Address all correspondence to: jasneth.mullings@uwimona.edu.jm

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**9**

*Introductory Chapter: Mortality and Quality of Care Systems in LMICs*

Increasing Access to NCD Medicine in the Caribbean; February 22-23, 2017

[8] Bloom D, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom L, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva:

[9] Centers for Disease Control. CDC in Burkina Faso. Available from: https:// www.cdc.gov/globalhealth/countries/ burkinafaso/pdf/BurkinaFaso\_

[10] Omran AR. The epidemiologic transition. The Milbank Memorial Fund

[11] World Bank. The World Bank in Burkina Faso. Available from: http:// www.worldbank.org/en/country/

[12] World Bank. The World Bank in Jamaica. Available from: http://www. worldbank.org/en/country/jamaica/

[13] Bloom DE, Chen S, McGovern ME.

noncommunicable diseases and mental health conditions: Results for Costa Rica, Jamaica, and Peru. Revista Panamericana de Salud Pública. 2018;**42**:e18. DOI: 10.26633/

[14] World Health Organization. Ten Threats to Global Health in 2019. Available from: https:// www.who.int/emergencies/

ten-threats-to-global-health-in-2019

Carter A. What do hospital mortality rates tell us about quality of care? Emergency Medicine Journal.

Hernandez B, Riley I, Lopez A. Hospital

[15] Goodacre S, Campbell M,

[16] Rampatige R, Mikkelsen L,

Quarterly. 1971;**49**:509-538

burkinafaso/overview

The economic burden of

overview

RPSP.2018.18

2015;**32**:244-247

World Economic Forum; 2011

Factsheet.pdf

*DOI: http://dx.doi.org/10.5772/intechopen.86804*

[1] United Nations, Department of Economic and Social Affairs, Population Division. World Mortality

2017—Data Booklet (ST/ESA/ SER.A/412). 2017. Available from: https://www.un.org/en/development/ desa/population/publications/pdf/ mortality/World-Mortality-2017-Data-

[2] Institute of Health Metrics and Evaluation (IHME). Global Burden of Disease Study 2017. 2018. Available from: http://www.healthdata.org/sites/ default/files/files/policy\_report/2019/

[3] Baroukil R, Gluckman P, Grandjean P, Hanson M, Heindel J. Developmental origins of non-communicable disease: Implications for research and public health. Environmental Health.

[4] GBD 2015 LRI Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: A systematic analysis for the Global Burden of Disease Study 2015. The Lancet Infectious Diseases. 2017;**17**(11):1133-1161. DOI: 10.1016/

S1473-3099(17)30396-1

September 18, 2018]

[5] WHO Media Centre. Tuberculosis. The World Health Organization [Online]. 2018. Available from: https:// www.who.int/en/news-room/factsheets/detail/tuberculosis# [Accessed:

[6] World Health Organization. The Top 10 Causes of Death. https://www. who.int/news-room/fact-sheets/detail/

[7] Luciani S. Non-communicable diseases: Regional plan of action and commitments to strengthening NCD Management. In: PAHO Meeting:

the-top-10-causes-of-death

GBD\_2017\_Booklet.pdf

**References**

Booklet.pdf

2012;**11**:42

*Introductory Chapter: Mortality and Quality of Care Systems in LMICs DOI: http://dx.doi.org/10.5772/intechopen.86804*

### **References**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

A big part of such strategic intervention on social accountability in hospitals will be tied to having adequate corporate governance and corporate strategy social responsibility [21]. Stakeholders' demands must be met and there must be a culture of performance, conformance, and responsibility. Hospitals, seeking to improve health outcomes in a cost-effective manner, should consider preventive measures in developing intervention strategies. This is an important consideration around the strategies discussed in this book. Placing the hospital in a role to also address social determinants [22] may seem a misfit with its core mission. However, if real gains are to be made in LMICs with limited resources and the threat of stagnation within the epidemiological transition, a socially accountable framework must be considered to bring synergies with the overall health system and much needed and added value to

The issues covered in the book create a framework from which policies may be developed to improve the prevention and management of disease, with the hope of

Jasneth Mullings\*, Affette McCaw Binns, Camille-Ann Thoms-Rodriguez,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: jasneth.mullings@uwimona.edu.jm

**8**

**Author details**

Antoinette Barton-Gooden and Tomlin Paul The University of the West Indies, Mona, Jamaica

provided the original work is properly cited.

individual strategies.

reducing the associated hospital mortality.

[1] United Nations, Department of Economic and Social Affairs, Population Division. World Mortality 2017—Data Booklet (ST/ESA/ SER.A/412). 2017. Available from: https://www.un.org/en/development/ desa/population/publications/pdf/ mortality/World-Mortality-2017-Data-Booklet.pdf

[2] Institute of Health Metrics and Evaluation (IHME). Global Burden of Disease Study 2017. 2018. Available from: http://www.healthdata.org/sites/ default/files/files/policy\_report/2019/ GBD\_2017\_Booklet.pdf

[3] Baroukil R, Gluckman P, Grandjean P, Hanson M, Heindel J. Developmental origins of non-communicable disease: Implications for research and public health. Environmental Health. 2012;**11**:42

[4] GBD 2015 LRI Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: A systematic analysis for the Global Burden of Disease Study 2015. The Lancet Infectious Diseases. 2017;**17**(11):1133-1161. DOI: 10.1016/ S1473-3099(17)30396-1

[5] WHO Media Centre. Tuberculosis. The World Health Organization [Online]. 2018. Available from: https:// www.who.int/en/news-room/factsheets/detail/tuberculosis# [Accessed: September 18, 2018]

[6] World Health Organization. The Top 10 Causes of Death. https://www. who.int/news-room/fact-sheets/detail/ the-top-10-causes-of-death

[7] Luciani S. Non-communicable diseases: Regional plan of action and commitments to strengthening NCD Management. In: PAHO Meeting:

Increasing Access to NCD Medicine in the Caribbean; February 22-23, 2017

[8] Bloom D, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom L, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum; 2011

[9] Centers for Disease Control. CDC in Burkina Faso. Available from: https:// www.cdc.gov/globalhealth/countries/ burkinafaso/pdf/BurkinaFaso\_ Factsheet.pdf

[10] Omran AR. The epidemiologic transition. The Milbank Memorial Fund Quarterly. 1971;**49**:509-538

[11] World Bank. The World Bank in Burkina Faso. Available from: http:// www.worldbank.org/en/country/ burkinafaso/overview

[12] World Bank. The World Bank in Jamaica. Available from: http://www. worldbank.org/en/country/jamaica/ overview

[13] Bloom DE, Chen S, McGovern ME. The economic burden of noncommunicable diseases and mental health conditions: Results for Costa Rica, Jamaica, and Peru. Revista Panamericana de Salud Pública. 2018;**42**:e18. DOI: 10.26633/ RPSP.2018.18

[14] World Health Organization. Ten Threats to Global Health in 2019. Available from: https:// www.who.int/emergencies/ ten-threats-to-global-health-in-2019

[15] Goodacre S, Campbell M, Carter A. What do hospital mortality rates tell us about quality of care? Emergency Medicine Journal. 2015;**32**:244-247

[16] Rampatige R, Mikkelsen L, Hernandez B, Riley I, Lopez A. Hospital cause-of-death statistics: What should we make of them? Bulletin of the World Health Organization. 2014;**92**:3- 3A. DOI: 10.2471/BLT.13.134106

[17] McCaw-Binns A, Holder Y, Mullings J. Certification of coroners cases by pathologists would improve the completeness of death registration in Jamaica. Journal of Clinical Epidemiology. 2015;**68**(9):979-987. DOI: 10.1016/j.jclinepi.2014.11.026. Epub: February 7, 2015

[18] English M, Mwaniki P, Julius T, Chepkirui M, Gathara D, Ouma P, et al. Hospital mortality—A neglected but rich source of information supporting the transition to higher quality health systems in low- and middle-income countries. BMC Medicine. 2018;**16**:32. DOI: 10.1186/s12916-018-1024-8. PMCID: PMC5833062. Published Online: March 1, 2018

[19] McCaw-Binns AM, Mullings JA, Holder Y. Vital registration and underreporting of maternal mortality in Jamaica. International Journal of Gynecology & Obstetrics. 2015;**128**:62- 67. DOI: 10.1016/j.ijgo.2014.07.023

[20] Mahmoudi G, Jahani MA, Rostami FH, Mahmoudjanloo S, Nikbakht H. Comparing the levels of hospital's social accountability: Based on ownership. International Journal of Healthcare Management. 2018;**11**(4):319-324. DOI: 10.1080/20479700.2017.1417074

[21] Brandão C, Rego G, Duarte I, Nunes R. Social responsibility: A new paradigm of hospital governance? Health Care Analysis. 2012;**21**(4):390- 402. DOI: 10.1007/s10728-012-0206-3

[22] Sullivan HR. Hospitals' obligations to address social determinants of health. AMA Journal of Ethics. 2019;**21**(3):E248-E258. DOI: 10.1001/ amajethics.2019.248

**11**

**Chapter 2**

**Abstract**

health outcomes

**1. Background**

services.

general supportive interventions.

due to its prevalent impact on health and well-being.

Health Literacy: An Intervention

*Monique Ann-Marie Lynch and Geovanni Vinceroy Franklin*

WHO has defined health literacy as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make basic health decisions for themselves and their loved ones. The purpose of this article is to outline the scope of low health literacy as a concept and explore some appropriate interventions that researchers and healthcare professionals may use to reduce its negative impact on health outcomes such as mortality. The authors conclude by identifying areas of research that are needed to advance the conceptualization of health literacy in reducing hospital mortality and morbidity.

**Keywords:** health literacy, health promotion, health behavior, health knowledge,

Over the last decade, there have been many studies on a variety of interventions to decrease mortality by improving the health of patients through literacy. Some researchers such as [1] have addressed direct literacy related barriers primarily by testing interventions to make health education materials easier to understand. While other researchers like [2] have focused on indirect barriers by providing more

According to the [3] individuals with low to moderate health care, literacy skills face implications that may include the incompetence to carry out positive self-management, it also means higher medical costs due to more medication and treatment errors, more frequent hospitalizations, longer hospital stays, more visits to their health care provider, and a lack of necessary skills to obtain needed

Notwithstanding the colossal implications of low health literacy, there remains a significant amount of misunderstanding surrounding the concept and its implications for healthcare professionals and facilities in Jamaica [4]. Health literacy is not a new concept to the Jamaican healthcare community, however, it has not been a concept that is practiced on a daily basis in our facilities [4]. In other countries, it has caught the attention of researchers, policy makers, and healthcare professionals

The purpose of this chapter is to outline health literacy as a concept and explore some appropriate interventions that can assist researchers and healthcare professionals to reduce its negative impact on health outcomes such as mortality. The chapter will also address issues concerning low health literacy in developed and developing countries. Firstly, the major definitions of health literacy are

to Improve Health Outcomes

#### **Chapter 2**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

cause-of-death statistics: What should we make of them? Bulletin of the World Health Organization. 2014;**92**:3- 3A. DOI: 10.2471/BLT.13.134106

[17] McCaw-Binns A, Holder Y, Mullings J. Certification of coroners cases by pathologists would improve the completeness of death registration

in Jamaica. Journal of Clinical

February 7, 2015

Online: March 1, 2018

Epidemiology. 2015;**68**(9):979-987. DOI: 10.1016/j.jclinepi.2014.11.026. Epub:

[18] English M, Mwaniki P, Julius T, Chepkirui M, Gathara D, Ouma P, et al. Hospital mortality—A neglected but rich source of information supporting the transition to higher quality health systems in low- and middle-income countries. BMC Medicine. 2018;**16**:32. DOI: 10.1186/s12916-018-1024-8. PMCID: PMC5833062. Published

[19] McCaw-Binns AM, Mullings JA, Holder Y. Vital registration and underreporting of maternal mortality in Jamaica. International Journal of Gynecology & Obstetrics. 2015;**128**:62- 67. DOI: 10.1016/j.ijgo.2014.07.023

[20] Mahmoudi G, Jahani MA, Rostami FH, Mahmoudjanloo S, Nikbakht H. Comparing the levels of hospital's social accountability: Based on ownership. International Journal of Healthcare Management.

2018;**11**(4):319-324. DOI: 10.1080/20479700.2017.1417074

amajethics.2019.248

[21] Brandão C, Rego G, Duarte I, Nunes R. Social responsibility: A new paradigm of hospital governance? Health Care Analysis. 2012;**21**(4):390- 402. DOI: 10.1007/s10728-012-0206-3

[22] Sullivan HR. Hospitals' obligations to address social determinants of health. AMA Journal of Ethics. 2019;**21**(3):E248-E258. DOI: 10.1001/

**10**

## Health Literacy: An Intervention to Improve Health Outcomes

*Monique Ann-Marie Lynch and Geovanni Vinceroy Franklin*

#### **Abstract**

WHO has defined health literacy as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make basic health decisions for themselves and their loved ones. The purpose of this article is to outline the scope of low health literacy as a concept and explore some appropriate interventions that researchers and healthcare professionals may use to reduce its negative impact on health outcomes such as mortality. The authors conclude by identifying areas of research that are needed to advance the conceptualization of health literacy in reducing hospital mortality and morbidity.

**Keywords:** health literacy, health promotion, health behavior, health knowledge, health outcomes

#### **1. Background**

Over the last decade, there have been many studies on a variety of interventions to decrease mortality by improving the health of patients through literacy. Some researchers such as [1] have addressed direct literacy related barriers primarily by testing interventions to make health education materials easier to understand. While other researchers like [2] have focused on indirect barriers by providing more general supportive interventions.

According to the [3] individuals with low to moderate health care, literacy skills face implications that may include the incompetence to carry out positive self-management, it also means higher medical costs due to more medication and treatment errors, more frequent hospitalizations, longer hospital stays, more visits to their health care provider, and a lack of necessary skills to obtain needed services.

Notwithstanding the colossal implications of low health literacy, there remains a significant amount of misunderstanding surrounding the concept and its implications for healthcare professionals and facilities in Jamaica [4]. Health literacy is not a new concept to the Jamaican healthcare community, however, it has not been a concept that is practiced on a daily basis in our facilities [4]. In other countries, it has caught the attention of researchers, policy makers, and healthcare professionals due to its prevalent impact on health and well-being.

The purpose of this chapter is to outline health literacy as a concept and explore some appropriate interventions that can assist researchers and healthcare professionals to reduce its negative impact on health outcomes such as mortality. The chapter will also address issues concerning low health literacy in developed and developing countries. Firstly, the major definitions of health literacy are

presented in the introduction. Then, the description of interventions, how they have been applied, the challenges and outcomes, the discussion of resources required for implementation, the authors' unique perspective on the issue and proposed a framework for the implementation and evaluation of health literacy interventions, including culturally appropriate programming and the multidisciplinary team approach.

### **2. Introduction**

The term health literacy was introduced in 1974 in a paper calling for minimum health education standards for all grade-school levels in the United States (US) [5]. The World Health Organization (WHO) later defined health literacy as "the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health" [6].

Kirsch et al. [7] explained that the inability to read, write, and use numbers effectively, is common and is associated with a wide range of adverse health outcomes in the Caribbean and the Americas. There are five health outcomes of low health literacy, which are health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. However, this chapter will only focus on health knowledge and health behaviors because research indicates that knowledge affects behavioral outcomes [7]. Additionally, in order to reduce hospital mortality rates, individuals must have the knowledge base to obtain, process, and understand basic health information and services needed to make appropriate health decisions [8].

Health knowledge, or health education, refers to the knowledge and understanding people have about health-related issues [9]. It is important that people understand the causes of ill-health and recognize the extent to which they are vulnerable to, or at risk from, a health threat. The World Health Organization's (WHO) definition of health was expanded in 1996 as a state of complete physical, mental and social well-being and now includes a social dimension. Additionally, some social scientist of that era, believed that WHO expansion of the health, must include a spiritual dimension [10].

According to the aforementioned [11] definition of health, it summarized complete health as the development of the social, physical, mental and spiritual dimension of a person. These four aspects of health were highlighted in the Bible, by Jesus Christ, when he said in Luke 2 verse 52 "he (Jesus) increased in wisdom (mental health) and stature (physical health) in favor with God (spiritual health) and man (social health)," [12]. Therefore, in order for a person to experience complete health, there must be growth in these four dimensions. Individuals in this twenty-first century must know that impairment in any one of these dimensions will affect the proper function of the other dimensions. These four components of health knowledge, spiritual, mental, social and physical will be defined and discussed below.

#### **2.1 Spiritual health**

The term "spiritual intelligence" was coined by Danah Zohar in 1997. Additionally, Ken O'Donnell in 1997 who is an Australian author and consultant living in Brazil, also introduced the term "spiritual intelligence" and Michal Levin in 2000 use this "spiritual intelligence" in his book to draw attention to the concept

**13**

*Health Literacy: An Intervention to Improve Health Outcomes*

of linking the spiritual and the material reality of life that is eventually concerned

It appears challenging to outwardly define spiritual health or spiritual intelligence without comprehending that the perception of spirituality is divergent from religiosity [16]. Fogel [17] opines that, for a very long time "spiritual" was, considered to be separate from "religious" and our secular societies prefers to steer as far as possible away from discussions on religion, for fear of kindling dormant conflicts

However, some researchers have tried to coin some functional definitions. For instance, [18] "spiritual intelligence is concerned with the inner life of mind and spirit and its relationship to being in the world." On the other hand, [19] defines spiritual intelligence as "the ability to act with wisdom and compassion, while

Research conducted by medical ethicists has reminded us that religion and spirituality form the basis of meaning and purpose for many people [20]. It is important to note that patients in health care institution, not only have the pain of physical ailment to confront with but the mental and spiritual pain that is associated with

According to [21], mental health literacy (knowledge) is defined as "knowledge and beliefs about mental disorders which aid their recognition, management or prevention." According to [22], there are key areas that help to equip persons with mental health knowledge. This will assist them with overcoming cultural and societal obstacles by challenging the fear of stigmatization. These areas include, but are not limited to; (a) the ability to recognize specific mental health problems, (b) knowledge and beliefs about risk factors, self-management approaches and the professional help available, (c) knowledge and beliefs about self-help interventions, (d) attitudes which facilitate recognition and appropriate help-seeking behaviors

The economic impacts of mental illness include its effects on personal income. These effects can only be quantified based on the ability of the persons with mental disorders or their caregivers to gauge the measurable economic burden of mental illness [23]. Bloom et al. [24] on the World Economic Forum (WEF) described three different approaches used to quantify economic disease burden, which do not only acknowledge the "hidden costs" of diseases, but also their impact on economic

Mental health is now getting a great deal of scrutiny around the world, it is an area of health that developing countries are seeking to end stigmatization and discrimination through literacy [26]. In a study conducted by [27] opines that the most commonly expressed emotional response to the mentally ill and mental illness was fear, often specifically a fear of "dangerousness." While the study reported some positive and empathetic responses, the most prominent emotional response was fear. Mental health literacy is the one of the most effective ways that fear towards

The possible recommendation could be that, to be effective and relevant, mental

health educators must seek to improve individual literacy and numeracy skills. Furthermore, mental health information needs to be written clearly and the information must be accessible to those who need it. This type of information must be useful in improving practical social skills and the communicative elements should

with the well-being of the universe and those who coexist in it [13–15].

maintaining inner and outer peace, regardless of the circumstances."

and (e) knowledge of how to seek and access mental health information.

growth at a macroeconomic level (**Figure 1**).

the mentally challenged can be mitigated [28].

aid these persons to access and maintain health [29].

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

or intruding on a taboo subject.

their sickness.

**2.2 Mental health**

#### *Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

of linking the spiritual and the material reality of life that is eventually concerned with the well-being of the universe and those who coexist in it [13–15].

It appears challenging to outwardly define spiritual health or spiritual intelligence without comprehending that the perception of spirituality is divergent from religiosity [16]. Fogel [17] opines that, for a very long time "spiritual" was, considered to be separate from "religious" and our secular societies prefers to steer as far as possible away from discussions on religion, for fear of kindling dormant conflicts or intruding on a taboo subject.

However, some researchers have tried to coin some functional definitions. For instance, [18] "spiritual intelligence is concerned with the inner life of mind and spirit and its relationship to being in the world." On the other hand, [19] defines spiritual intelligence as "the ability to act with wisdom and compassion, while maintaining inner and outer peace, regardless of the circumstances."

Research conducted by medical ethicists has reminded us that religion and spirituality form the basis of meaning and purpose for many people [20]. It is important to note that patients in health care institution, not only have the pain of physical ailment to confront with but the mental and spiritual pain that is associated with their sickness.

#### **2.2 Mental health**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

disciplinary team approach.

**2. Introduction**

good health" [6].

presented in the introduction. Then, the description of interventions, how they have been applied, the challenges and outcomes, the discussion of resources required for implementation, the authors' unique perspective on the issue and proposed a framework for the implementation and evaluation of health literacy interventions, including culturally appropriate programming and the multi-

The term health literacy was introduced in 1974 in a paper calling for minimum health education standards for all grade-school levels in the United States (US) [5]. The World Health Organization (WHO) later defined health literacy as "the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain

Kirsch et al. [7] explained that the inability to read, write, and use numbers effectively, is common and is associated with a wide range of adverse health outcomes in the Caribbean and the Americas. There are five health outcomes of low health literacy, which are health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. However, this chapter will only focus on health knowledge and health behaviors because research indicates that knowledge affects behavioral outcomes [7]. Additionally, in order to reduce hospital mortality rates, individuals must have the knowledge base to obtain, process, and understand basic health information

Health knowledge, or health education, refers to the knowledge and understanding people have about health-related issues [9]. It is important that people understand the causes of ill-health and recognize the extent to which they are vulnerable to, or at risk from, a health threat. The World Health Organization's (WHO) definition of health was expanded in 1996 as a state of complete physical, mental and social well-being and now includes a social dimension. Additionally, some social scientist of that era, believed that WHO expansion of the health, must

According to the aforementioned [11] definition of health, it summarized complete health as the development of the social, physical, mental and spiritual dimension of a person. These four aspects of health were highlighted in the Bible, by Jesus Christ, when he said in Luke 2 verse 52 "he (Jesus) increased in wisdom (mental health) and stature (physical health) in favor with God (spiritual health) and man (social health)," [12]. Therefore, in order for a person to experience complete health, there must be growth in these four dimensions. Individuals in this twenty-first century must know that impairment in any one of these dimensions will affect the proper function of the other dimensions. These four components of health knowledge, spiritual, mental, social and physical will be defined and

The term "spiritual intelligence" was coined by Danah Zohar in 1997. Additionally, Ken O'Donnell in 1997 who is an Australian author and consultant living in Brazil, also introduced the term "spiritual intelligence" and Michal Levin in 2000 use this "spiritual intelligence" in his book to draw attention to the concept

and services needed to make appropriate health decisions [8].

include a spiritual dimension [10].

**12**

discussed below.

**2.1 Spiritual health**

According to [21], mental health literacy (knowledge) is defined as "knowledge and beliefs about mental disorders which aid their recognition, management or prevention." According to [22], there are key areas that help to equip persons with mental health knowledge. This will assist them with overcoming cultural and societal obstacles by challenging the fear of stigmatization. These areas include, but are not limited to; (a) the ability to recognize specific mental health problems, (b) knowledge and beliefs about risk factors, self-management approaches and the professional help available, (c) knowledge and beliefs about self-help interventions, (d) attitudes which facilitate recognition and appropriate help-seeking behaviors and (e) knowledge of how to seek and access mental health information.

The economic impacts of mental illness include its effects on personal income. These effects can only be quantified based on the ability of the persons with mental disorders or their caregivers to gauge the measurable economic burden of mental illness [23]. Bloom et al. [24] on the World Economic Forum (WEF) described three different approaches used to quantify economic disease burden, which do not only acknowledge the "hidden costs" of diseases, but also their impact on economic growth at a macroeconomic level (**Figure 1**).

Mental health is now getting a great deal of scrutiny around the world, it is an area of health that developing countries are seeking to end stigmatization and discrimination through literacy [26]. In a study conducted by [27] opines that the most commonly expressed emotional response to the mentally ill and mental illness was fear, often specifically a fear of "dangerousness." While the study reported some positive and empathetic responses, the most prominent emotional response was fear. Mental health literacy is the one of the most effective ways that fear towards the mentally challenged can be mitigated [28].

The possible recommendation could be that, to be effective and relevant, mental health educators must seek to improve individual literacy and numeracy skills. Furthermore, mental health information needs to be written clearly and the information must be accessible to those who need it. This type of information must be useful in improving practical social skills and the communicative elements should aid these persons to access and maintain health [29].

**Figure 1.** *Different approaches used to estimate economic costs of mental disorders [25].*

#### **2.3 Social health**

The idea of social health is less recognizable to that of physical or mental health, but nonetheless, it's one of the four pillars (spiritual, mental and physical) that forms the WHO definitions of health. According to [30] accentuates that "a society is healthy when there is equal opportunity for all and access by all to the goods and services essential to full functioning as a citizen." Therefore, the success of a healthy society is influenced by the rule of law, equality in wealth distribution, public involvement in the decision-making process and a level of social capital.

In developing countries like Jamaica, there are many determinants of social health that affects the livelihood of many such as inequality, poverty, exploitation, violence and injustice, these are at the root of ill-health and the deaths of poor and marginalized people [31]. According to [32] mentioned that a determinant is any factor that contributes to person current state of health. Based on researchers, it is believed that social determinants of health are the situations in which people are born, grow, live, work and age. These conditions are molded base on the supply of money, power and resources at the global, national and local levels [33].

Julianne et al. [34] postulated that the quality of life and social relationship are closely related to mental health and the mortality rate. Furthermore, their opinion is that this modern way of life limits individual's social interactions, which results in people living insolation from extended families in developing countries. It is clear, that people of all different ages around the world are living alone, and loneliness on this crowded planet is becoming common [35].

#### **2.4 Physical health**

According to [36], physical health literacy is the ability to move with competence and confidence in a wide variety of physical activities in multiple environments that benefit the healthy development of the whole person. Moreover, it is supported by

**15**

**3. Methodology**

*Health Literacy: An Intervention to Improve Health Outcomes*

researchers that physical literacy is an essential and valuable human competency that can be described as a disposition learnt by human individuals surrounding that enthusiasm, confidence, physical competence, knowledge and understanding that

In her research, [38] gave a summary of the key features of physical literacy:

• Everyone can be physically literate as it is appropriate to each individual's

• Everyone's physical literacy journey is unique, physical literacy is relevant and

• At the heart of the concept is the motivation and commitment to be active, the disposition is evidenced by a love of being active, born out of the pleasure and

• A physically literate individual values and takes responsibility for maintaining purposeful physical pursuits throughout the life course and charting of progress of an individual's personal journey must be judged against previous

There are several definitions for health behavior, one such researcher, [39] defined health behavior as the activity undertaken by people for the purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image. Conner and Norman [40] added that any activity that is undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing is defined as a health behavior. In the Handbook of Health Behavior Research, [41] defines health behavior as behavior patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement' (Vol. 1, p. 3). Behaviors within this definition include medical service usage (e.g., physician visits, vaccination, screening), compliance with medical regimens (e.g., dietary, diabetic, antihypertensive regimens), and self-directed health behaviors (e.g., diet, exercise, smoking, alcohol consumption and illegal drug use). It is common to differentiate health enhancing from health impairing behaviors. Institute of Medicine (US) Committee on Health and Behavior Research, Practice, and Policy [42] explained that health impairing behaviors have harmful effects on health or otherwise predispose individuals to diseases and even mortality. Such behaviors include smoking, excessive alcohol consumption, illegal drug misuse and high dietary fat and sugar consumption [42]. In contrast, [43] stated that engagement in health enhancing behaviors conveys health benefits or otherwise protect individuals from disease. Such behaviors include exercise, fruit and vegetable consumption, consumption of water instead of juice, limited alcohol consumption, no usage of illegal drugs and condom use in response to the threat of sexually transmitted diseases [43].

This chapter utilized a multiple method approach to understand health literacy as an intervention to improve health outcomes. A meta-analysis, design was

achievements and not against any form of national benchmarks.

establishes physical quests as an important part of their lifestyle [37].

• The concept embraces much more than physical competence,

satisfaction individuals experience in participation,

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

valuable at all stages and ages of life,

endowment,

**2.5 Health behaviors**

researchers that physical literacy is an essential and valuable human competency that can be described as a disposition learnt by human individuals surrounding that enthusiasm, confidence, physical competence, knowledge and understanding that establishes physical quests as an important part of their lifestyle [37].

In her research, [38] gave a summary of the key features of physical literacy:


#### **2.5 Health behaviors**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

The idea of social health is less recognizable to that of physical or mental health,

but nonetheless, it's one of the four pillars (spiritual, mental and physical) that forms the WHO definitions of health. According to [30] accentuates that "a society is healthy when there is equal opportunity for all and access by all to the goods and services essential to full functioning as a citizen." Therefore, the success of a healthy society is influenced by the rule of law, equality in wealth distribution, public involvement in the decision-making process and a level of social capital.

*Different approaches used to estimate economic costs of mental disorders [25].*

In developing countries like Jamaica, there are many determinants of social health that affects the livelihood of many such as inequality, poverty, exploitation, violence and injustice, these are at the root of ill-health and the deaths of poor and marginalized people [31]. According to [32] mentioned that a determinant is any factor that contributes to person current state of health. Based on researchers, it is believed that social determinants of health are the situations in which people are born, grow, live, work and age. These conditions are molded base on the supply of

Julianne et al. [34] postulated that the quality of life and social relationship are closely related to mental health and the mortality rate. Furthermore, their opinion is that this modern way of life limits individual's social interactions, which results in people living insolation from extended families in developing countries. It is clear, that people of all different ages around the world are living alone, and loneliness on

According to [36], physical health literacy is the ability to move with competence and confidence in a wide variety of physical activities in multiple environments that benefit the healthy development of the whole person. Moreover, it is supported by

money, power and resources at the global, national and local levels [33].

this crowded planet is becoming common [35].

**14**

**2.4 Physical health**

**2.3 Social health**

**Figure 1.**

There are several definitions for health behavior, one such researcher, [39] defined health behavior as the activity undertaken by people for the purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image. Conner and Norman [40] added that any activity that is undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing is defined as a health behavior. In the Handbook of Health Behavior Research, [41] defines health behavior as behavior patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement' (Vol. 1, p. 3). Behaviors within this definition include medical service usage (e.g., physician visits, vaccination, screening), compliance with medical regimens (e.g., dietary, diabetic, antihypertensive regimens), and self-directed health behaviors (e.g., diet, exercise, smoking, alcohol consumption and illegal drug use).

It is common to differentiate health enhancing from health impairing behaviors. Institute of Medicine (US) Committee on Health and Behavior Research, Practice, and Policy [42] explained that health impairing behaviors have harmful effects on health or otherwise predispose individuals to diseases and even mortality. Such behaviors include smoking, excessive alcohol consumption, illegal drug misuse and high dietary fat and sugar consumption [42]. In contrast, [43] stated that engagement in health enhancing behaviors conveys health benefits or otherwise protect individuals from disease. Such behaviors include exercise, fruit and vegetable consumption, consumption of water instead of juice, limited alcohol consumption, no usage of illegal drugs and condom use in response to the threat of sexually transmitted diseases [43].

### **3. Methodology**

This chapter utilized a multiple method approach to understand health literacy as an intervention to improve health outcomes. A meta-analysis, design was employed using three key phrase search and six keywords search resulting from the analysis of 43 articles. A breakdown of the methodologies using the two of the three key phrases is tabulated below (**Tables 1** and **2**).


#### **Table 1.**

*Showing key phrase: the relationship between health literacy and health outcomes.*


**17**

*Health Literacy: An Intervention to Improve Health Outcomes*

**4. The relationship between health literacy and health outcomes**

U.S. Department of Health and Human Services [8] explained in their research that low health literacy has been correlated with negative health outcomes, including reduced use of preventive health services, poor disease-specific outcomes for certain chronic conditions, and increased risk of hospitalization and mortality. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association [48] agreed in their publication that health literacy is assumed to be a stronger predictor of health outcomes than social and economic status, education, gender, and age. With that being said, [49] stated that individuals with low health literacy have poorer health outcomes regardless of the illness they are diagnosed with. They went on to explain that low health literacy is more prevalent among vulnerable populations, such as the elderly, minorities, persons with lower

Several researches have shown that low literacy can have a direct and negative effect on health. Berkman et al. [50] explained that they expect this effect to be predominantly important for conditions that require substantial and complex self-care on the part of the patient because of the barriers to accessing and using health information, particularly written and calculated information. DeWalt et al. [2] agreed with [51, 48] by adding that low literacy can also be a marker for other conditions, such as poverty and lack of access to health care, that lead to poor health

The National Assessment of Adult Literacy report [44] explained that only 14% of adults have attained proficient health literacy, so in other words, nearly nine out of 10 adults may lack the skills needed to manage their health and prevent diseases. Additionally, it was reported that 16% of adults (50 million people) in having below basic health literacy and these adults were more likely to report their health as poorer (42%) than adults with proficient health literacy. Low literacy has been linked to poor health outcomes such as higher rates of hospitalization, less frequent

In a study conducted by [45], a health literacy intervention was carried out in the cities of Black River, Balaclava, and Parottee, Jamaica by creating prescription drug visual aids that will assist the elderly health illiterate population with their medica-

The results from the questionnaire used in the research showed that 80% of the overall sample were below the sixth-grade education literacy level, with 64% below the third-grade level and 16% between the fourth and sixth-grade levels. Additionally, 12% of respondents specifically from the city of Black River reported the ability to read but not to write. From the verbal questioning, 60% of the 64% of respondents who were below the third-grade education literacy level believed that visual aids would make medications easier to take. Furthermore, 8% of the 16% of respondents who were between the fourth and sixth grade education literacy levels believe that visual medication aides will benefit them. The results also displayed that a health literacy problem does exist in the areas in St. Elizabeth, Jamaica.

The findings indicated that the health literacy of the elderly population in rural Jamaica is a national health concern [45]. If these persons are incapable of understanding what type of medications they are taking and why, they are less likely to

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

education, and persons with chronic disease.

outcomes especially outcomes such as mortality.

use of preventive services and even hospital mortality [44].

**4.1 Health literacy interventions to reduce mortality**

tion adherence and to promote health literacy.

*4.1.1 The Jamaican context*

#### **Table 2.**

*Showing key phrase: health literacy interventions to reduce mortality.*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

key phrases is tabulated below (**Tables 1** and **2**).

[44] One-

**Table 1.**

third (77 million)

**Author Population Participants Methods**

**Author Population Participants Methods**

the NAAL.

*Showing key phrase: the relationship between health literacy and health outcomes.*

Over 19,000 adults from 38 states and the district of Columbia participated in the national and state-level assessments to create data for

sample was 25 elderly and health illiterate persons using a mixed method and a convenience sampling approach.

dating from 1997 to 2006, a review confined to complex intervention study design was used and a sample range of 40-2046 participants.

dating from 1992 to 2002, a controlled or uncontrolled experimental design was used and a sample range from 28 to 1744 participants.

The instrumentations used were verbal questioning (perception of drug visual aide assistance) and a written questionnaire on how prescription medication instructions should be written currently and in the future; since the sample was compiled of both literate and illiterate people, questions were asked verbally and the questionnaire was administered. The methods used were paper & pencil recording of the types of prescriptions each individual tool, what they should have taken and if they felt comfortable taking their current

The 2003 National Assessment of Adult Literacy (NAAL) which is a nationally representative assessment of English health literacy was distributed to American adults age 16 and older.

A systematic review of randomized and quasirandomized controlled trials with a narrative synthesis. The search strategy included searching eight databases from start date to 2007, reference checking and contacting expert informants. After the initial screen, two reviewers independently assessed eligibility, extracted data and evaluated

The 20 studies were of three types: randomized controlled trials (n = 9), nonrandomized controlled trials (in which subjects were assigned to intervention or control groups by the day or the week or some other nonrandom fashion; n = 8), and uncontrolled, single-group trials (n = 3). The number of participants enrolled ranged from 28 to 1744; most studies had between 100 and 500 participants. All but 2 studies were conducted in the United States. Most interventions and outcome assessments were administered in single sessions. Interventions to improve dietary behavior and one other study delivered multisession interventions and/or followed participants longitudinally to assess changes in

prescriptions.

study quality.

outcomes.

[45] Not stated The demographic

[46] Not stated There were 15 studies

[47] Not stated There were 20 studies

*Showing key phrase: health literacy interventions to reduce mortality.*

employed using three key phrase search and six keywords search resulting from the analysis of 43 articles. A breakdown of the methodologies using the two of the three

**16**

**Table 2.**

### **4. The relationship between health literacy and health outcomes**

U.S. Department of Health and Human Services [8] explained in their research that low health literacy has been correlated with negative health outcomes, including reduced use of preventive health services, poor disease-specific outcomes for certain chronic conditions, and increased risk of hospitalization and mortality. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association [48] agreed in their publication that health literacy is assumed to be a stronger predictor of health outcomes than social and economic status, education, gender, and age. With that being said, [49] stated that individuals with low health literacy have poorer health outcomes regardless of the illness they are diagnosed with. They went on to explain that low health literacy is more prevalent among vulnerable populations, such as the elderly, minorities, persons with lower education, and persons with chronic disease.

Several researches have shown that low literacy can have a direct and negative effect on health. Berkman et al. [50] explained that they expect this effect to be predominantly important for conditions that require substantial and complex self-care on the part of the patient because of the barriers to accessing and using health information, particularly written and calculated information. DeWalt et al. [2] agreed with [51, 48] by adding that low literacy can also be a marker for other conditions, such as poverty and lack of access to health care, that lead to poor health outcomes especially outcomes such as mortality.

The National Assessment of Adult Literacy report [44] explained that only 14% of adults have attained proficient health literacy, so in other words, nearly nine out of 10 adults may lack the skills needed to manage their health and prevent diseases. Additionally, it was reported that 16% of adults (50 million people) in having below basic health literacy and these adults were more likely to report their health as poorer (42%) than adults with proficient health literacy. Low literacy has been linked to poor health outcomes such as higher rates of hospitalization, less frequent use of preventive services and even hospital mortality [44].

#### **4.1 Health literacy interventions to reduce mortality**

#### *4.1.1 The Jamaican context*

In a study conducted by [45], a health literacy intervention was carried out in the cities of Black River, Balaclava, and Parottee, Jamaica by creating prescription drug visual aids that will assist the elderly health illiterate population with their medication adherence and to promote health literacy.

The results from the questionnaire used in the research showed that 80% of the overall sample were below the sixth-grade education literacy level, with 64% below the third-grade level and 16% between the fourth and sixth-grade levels. Additionally, 12% of respondents specifically from the city of Black River reported the ability to read but not to write. From the verbal questioning, 60% of the 64% of respondents who were below the third-grade education literacy level believed that visual aids would make medications easier to take. Furthermore, 8% of the 16% of respondents who were between the fourth and sixth grade education literacy levels believe that visual medication aides will benefit them. The results also displayed that a health literacy problem does exist in the areas in St. Elizabeth, Jamaica.

The findings indicated that the health literacy of the elderly population in rural Jamaica is a national health concern [45]. If these persons are incapable of understanding what type of medications they are taking and why, they are less likely to

take them regularly and as scheduled/prescribed. However, many of these same persons understand and acknowledge that they also need help in terms of understanding and taking their medications and illnesses. The outcome of this study stated that rural elderly Jamaicans believe visual medication aides will benefit them and the results indicated that a health literacy problem does exist in the area, and visual aides are needed due to the literacy level and health literacy level of the region.

The main limitation stated for this intervention was that the sample size used was relatively small (25) and it might have played a role in respondents indicating their receptiveness to visual aids. Future implications of this research suggested that there is a need to conduct further research on the public health disparity between individuals in urban versus rural areas and that research might reveal disparities in the health outcomes.

#### *4.1.2 The international context*

Another study conducted by [46] in the United States of America, to evaluate the published literature of the effects of complex interventions intended to improve the health-related outcomes of individuals with limited literacy or numeracy. The focus of the 15 studies aforementioned in the methodology was on: health professionals (n = 2), literacy education (n = 1), and health education/management interventions (n = 12). In most of these studies (9 out 15), outcomes were measured in the intervention session or immediately afterwards. One study did not specify its follow-up period. The other five studies reported follow-up periods ranging from 1 week to 10.5 months with a median 5.5 months.

The primary results showed that there were statistically significant in 13/15 trials, though 8/13 had mixed results across primary outcomes. Two trials showed no significant positive finding in primary outcomes: one failed to show a significant improvement in health knowledge and the other failed to show significant changes in cholesterol and blood pressure changes. It was recommended that health related improvements were reported across all four intervention types, however, all interventions were complex interventions and it is not known which components of each initiative were effective. This, combined with the fact that some of the interventions were resource intensive, demands that future initiatives are carefully designed and based on sound theoretical and pragmatic reinforcements. The wider empowerment and community participation aspect of some of the interventions represent a welcome, broader approach to health literacy.

It was concluded that a variety of interventions for adults with limited literacy can be beneficial in improving some health outcomes especially mortality. The classes of outcome most likely to improve based on the study such as knowledge and self-efficacy. The implications suggested that more research was needed on the mechanisms of interventions that are most effective for improved health outcomes (specifically mortality). Additionally, there was limited evidence on interventions that targeted health professionals and their aptitude to deliver care optimally to patients with limited health literacy and to improve mortality rates especially in a hospital setting.

Pignone et al. [47] reported on a systematic review of interventions designed to improve health outcomes for persons with low health literacy in developed countries defined as United States, Canada, Western Europe, Japan, Australia and New Zealand. The focus of the studies were easy-to-read printed materials (n = 4), video/audio tapes (n = 4), computer-based programs (n = 3) and individual or group instructions (n = 9). The primary results displayed that the diversity of outcomes limits conclusions about the effectiveness, though effectiveness "appeared mixed". There were limitations in research quality that also hindered the drawing of conclusions. The five articles which dealt with the interaction between literacy level and

**19**

*Health Literacy: An Intervention to Improve Health Outcomes*

the effect of the intervention stated mixed results. It is therefore recommended that research is needed to establish whether the correlation between low literacy and poor health outcomes is direct or indirect so as to most efficiently direct interventions. The results of the interventions should be stratified by literacy level and future studies should focus on intermediate to longer term outcomes rather than shortterm knowledge outcomes or health behaviors. There is no research which has considered how interventions may impact on health disparities or care costs based on race, ethnicity, culture or age. Multi-component interventions should be ana-

It was concluded that several interventions based on the study have been developed to improve health for individual with low health literacy. There were limitations in the interventions tested and outcomes assessed make drawing deductions about effectiveness very difficult. Finally, advanced research is required to have a better understanding of the types of interventions that are most effective and efficient for overcoming health literacy-related barriers to good health and to improve

World Health Organization Regional Office for South-East Asia [51] stated in their Health Literacy Toolkit for Low- and Middle-Income Countries that the Optimizing Health Literacy and Access to health information and services (Ophelia) approach is an effective system that supports the documentation of community health literacy needs, and the advancement and testing of possible solutions to reduce mortality. Each Ophelia project seeks to improve health and equity by increasing the availability and accessibility of health information and services

Projects have been carried out in Lavender Hill, an informal settlement, Cape Town: Ophelia South Africa under the title, "Identifying health literacy needs and developing local responses to health emergencies"; in Thailand under the title, "Optimizing health literacy needs of people" in Thailand and in New Zealand under the title, "Health literacy and Whanau Ora Outcomes: Ophelia New Zealand." The outcomes generated new data and tools that were used to inform practice and policy and aid practitioners at both the patient and organization levels to comprehend and meet the needs of the community, targeting those with low health literacy [52]. Batterham et al. [52] stated that the Ophelia approach is innovative as it recognizes that health literacy is multidimensional and different people may have different health literacy needs and that it took a systematic and grounded approach to

**4.2 Health literacy issues affecting developed and developing countries**

tion has challenges in understanding health information which affect how they traverse the health care system. Decades of investigation show that there is a strong correlation between limited literacy in dealing with challenges in the health care and lower health knowledge intertwine with misinterpretation of prescriptions and

In both developed and developing countries, a significant portion of the popula-

In both developed and developing countries for the population to benefit from better health care, they must be knowledgeable about the various aspects of health care. Mayagah and Wayne [54] identified six general themes that help determine why health literacy is important for population health, firstly, large numbers of people affected because some developed countries have high adult literacy rates, while in developing countries approximately half have rates below the global developing country average of 79%. Research indicated that in developing countries literacy rates are lower among women than men, which is affecting how these

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

lyzed to establish efficacy and effectiveness.

health outcomes such as mortality.

in locally appropriate ways [51].

intervention development.

lower receipt of preventive care [53].

#### *Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

take them regularly and as scheduled/prescribed. However, many of these same persons understand and acknowledge that they also need help in terms of understanding and taking their medications and illnesses. The outcome of this study stated that rural elderly Jamaicans believe visual medication aides will benefit them and the results indicated that a health literacy problem does exist in the area, and visual aides are needed due to the literacy level and health literacy level of the region. The main limitation stated for this intervention was that the sample size used was relatively small (25) and it might have played a role in respondents indicating their receptiveness to visual aids. Future implications of this research suggested that there is a need to conduct further research on the public health disparity between individuals in urban versus rural areas and that research might reveal disparities in

Another study conducted by [46] in the United States of America, to evaluate the published literature of the effects of complex interventions intended to improve the health-related outcomes of individuals with limited literacy or numeracy. The focus of the 15 studies aforementioned in the methodology was on: health professionals (n = 2), literacy education (n = 1), and health education/management interventions (n = 12). In most of these studies (9 out 15), outcomes were measured in the intervention session or immediately afterwards. One study did not specify its follow-up period. The other five studies reported follow-up periods ranging from

The primary results showed that there were statistically significant in 13/15 trials, though 8/13 had mixed results across primary outcomes. Two trials showed no significant positive finding in primary outcomes: one failed to show a significant improvement in health knowledge and the other failed to show significant changes in cholesterol and blood pressure changes. It was recommended that health related improvements were reported across all four intervention types, however, all interventions were complex interventions and it is not known which components of each initiative were effective. This, combined with the fact that some of the interventions were resource intensive, demands that future initiatives are carefully designed and based on sound theoretical and pragmatic reinforcements. The wider empowerment and community participation aspect of some of the interventions

It was concluded that a variety of interventions for adults with limited literacy can be beneficial in improving some health outcomes especially mortality. The classes of outcome most likely to improve based on the study such as knowledge and self-efficacy. The implications suggested that more research was needed on the mechanisms of interventions that are most effective for improved health outcomes (specifically mortality). Additionally, there was limited evidence on interventions that targeted health professionals and their aptitude to deliver care optimally to patients with limited health literacy and to improve mortality rates especially in a hospital setting. Pignone et al. [47] reported on a systematic review of interventions designed to improve health outcomes for persons with low health literacy in developed countries defined as United States, Canada, Western Europe, Japan, Australia and New Zealand. The focus of the studies were easy-to-read printed materials (n = 4), video/audio tapes (n = 4), computer-based programs (n = 3) and individual or group instructions (n = 9). The primary results displayed that the diversity of outcomes limits conclusions about the effectiveness, though effectiveness "appeared mixed". There were limitations in research quality that also hindered the drawing of conclusions. The five articles which dealt with the interaction between literacy level and

**18**

the health outcomes.

*4.1.2 The international context*

1 week to 10.5 months with a median 5.5 months.

represent a welcome, broader approach to health literacy.

the effect of the intervention stated mixed results. It is therefore recommended that research is needed to establish whether the correlation between low literacy and poor health outcomes is direct or indirect so as to most efficiently direct interventions.

The results of the interventions should be stratified by literacy level and future studies should focus on intermediate to longer term outcomes rather than shortterm knowledge outcomes or health behaviors. There is no research which has considered how interventions may impact on health disparities or care costs based on race, ethnicity, culture or age. Multi-component interventions should be analyzed to establish efficacy and effectiveness.

It was concluded that several interventions based on the study have been developed to improve health for individual with low health literacy. There were limitations in the interventions tested and outcomes assessed make drawing deductions about effectiveness very difficult. Finally, advanced research is required to have a better understanding of the types of interventions that are most effective and efficient for overcoming health literacy-related barriers to good health and to improve health outcomes such as mortality.

World Health Organization Regional Office for South-East Asia [51] stated in their Health Literacy Toolkit for Low- and Middle-Income Countries that the Optimizing Health Literacy and Access to health information and services (Ophelia) approach is an effective system that supports the documentation of community health literacy needs, and the advancement and testing of possible solutions to reduce mortality. Each Ophelia project seeks to improve health and equity by increasing the availability and accessibility of health information and services in locally appropriate ways [51].

Projects have been carried out in Lavender Hill, an informal settlement, Cape Town: Ophelia South Africa under the title, "Identifying health literacy needs and developing local responses to health emergencies"; in Thailand under the title, "Optimizing health literacy needs of people" in Thailand and in New Zealand under the title, "Health literacy and Whanau Ora Outcomes: Ophelia New Zealand." The outcomes generated new data and tools that were used to inform practice and policy and aid practitioners at both the patient and organization levels to comprehend and meet the needs of the community, targeting those with low health literacy [52]. Batterham et al. [52] stated that the Ophelia approach is innovative as it recognizes that health literacy is multidimensional and different people may have different health literacy needs and that it took a systematic and grounded approach to intervention development.

#### **4.2 Health literacy issues affecting developed and developing countries**

In both developed and developing countries, a significant portion of the population has challenges in understanding health information which affect how they traverse the health care system. Decades of investigation show that there is a strong correlation between limited literacy in dealing with challenges in the health care and lower health knowledge intertwine with misinterpretation of prescriptions and lower receipt of preventive care [53].

In both developed and developing countries for the population to benefit from better health care, they must be knowledgeable about the various aspects of health care. Mayagah and Wayne [54] identified six general themes that help determine why health literacy is important for population health, firstly, large numbers of people affected because some developed countries have high adult literacy rates, while in developing countries approximately half have rates below the global developing country average of 79%. Research indicated that in developing countries literacy rates are lower among women than men, which is affecting how these

persons respond to health information [55]. Additionally, difficulties with health literacy affect all people, but the elderly and chronically ill are most at-risk, and also have the greatest health care needs and expenses [56]. People with low health literacy are overwhelmed by health care because their skills and abilities are challenged by the demands and complexity required [57].

Secondly, poor health outcomes, findings indicated that there is a clear correlation between inadequate health literacy as measured by reading fluency and increased mortality rates. Report on the Council of Scientific Affairs [58] suggested that poor health literacy is "a stronger predictor of a person's health than age, income, employment status, education level, and race." Moreover, UNICEF, reported that hundreds of millions of people around the globe are living in extreme poverty. Both poverty and poor health are linked and can be the result of social, political, and economic injustices. The linkage is a vicious, self-perpetuating cycle where poverty causes poor health and poor health keeps communities in poverty. Research cited that people who are economically deprived and living in poor environments are faced with many health risk factors in their everyday life [59].

Thirdly, increasing rates of chronic disease are estimated to account for almost half (47%) of the total burden of disease. Likewise, chronic diseases often occur with co-morbidities (concomitant but unrelated diseases) and co-morbidity further increases the demand for health care. For example, individuals with diabetes and very high co-morbidity are expected to use 10 times the healthcare resources of the population average [60]. Research done on the Canadian Health Care System that indicated help is provided to people with chronic conditions such as diabetes, asthma, congestive heart failure, renal failure and chronic obstructive pulmonary disease. A large proportion of the available healthcare resources are devoted to treating chronic conditions and, in Canada, 67% of all health care costs are incurred as a result of caring for those with chronic conditions. More than half of Canadians aged 12 or older report at least one chronic condition and at age 65, 77% of men and 85% of women have at least one chronic condition [61]. Health literacy plays a crucial role in chronic disease self-management. In order to systematically manage chronic conditions on a daily basis, individuals must be able to assess, understand, evaluate, and use health information [62]. According to the Adult Literacy and Life Skills Survey, more than half (55%) of working-age Canadians do not have adequate levels of health literacy and only one in eight adults (12%) over age 65 has adequate health-literacy skills [63]. Also, [1] specified that populations most likely to experience low-literacy levels are among those being asked to manage their condition such as older adults, ethnic minorities, people with low levels of educational attainment, people with low income levels, nonnative speakers of English, and people with compromised health [64].

Also, those with low literacy skills are not likely to attend voluntary peer-led self-management programs even if they are aware, they exist. In 2003, the Institute of Medicine in its priority areas for national action, identified self-management/ health literacy as an area that cut across many health problems [64]. Schloman [65] opines that "improved health literacy was put forward as a condition necessary to enable active self-management of patients for most conditions."

Fourthly, health care costs; the additional costs of limited health literacy range from 3 to 5% of the total health care cost per year. Research has indicated that, insufficient health literacy has been associated with an increased need for disease management, higher medical service utilization among older, racial, ethnic minorities, and with low educational attainment [1]. Research conducted by the [66] in managing care, suggested that individuals with low health literacy have higher medical costs and are less efficient when using services than those individuals with adequate health literacy. Their findings estimated the costs associated with inadequate health literacy among adults at the national level to be \$73 billion annually.

**21**

*Health Literacy: An Intervention to Improve Health Outcomes*

Fifthly, health information demand has created discrepancies between the reading levels of health-related materials and the reading skills of the intended audience. Often, the use of jargon and technical language made many health-related resources unnecessarily difficult to use [54]. The populations in both developing and developed countries are challenged with the increasing demands to understand and utilize health information, which are some of the complexities that are facing modern health care systems [67]. Additionally, the increasing proportion of people living with chronic conditions, competencies for proactive self-management of health and participation in collaborative care have become key public health agendas. The ability to take active part in shared decision making with healthcare providers is important for adherence to treatment, self-management of chronic diseases [68]. Lastly, equity is a factor that suggests that low levels of health literacy often means that a person is unable to manage their own health effectively, access health services effectively, and understand the information available to them and thus make informed healthy decisions [54]. Researchers over the past two decades, have been investigating the importance of health literacy and have examined over 1600 related research articles such as the field of "health care disparities" [69]. Improving the health literacy of those with the worst health outcomes is an important tool in

It's evident that the challenges with [70] equity may still exist today. Many countries have failed to document data about the population that will make inferences about the disparities that have contributed to the lower quality of care. Due to the limited data about these disparities, situations that affects individuals with low literary skills are often times overlooked and efforts to address inequities in health care are rendered as ineffective. Furthermore, health care researchers are of the view that data to properly assess these disparities can be collected. However, health care organizations are lacking in the measurement tools to assess patient literacy in populations served by operating health care systems [70]. Isham [70] further lamented that quality measures for improving health literacy are lacking. Therefore, the current problems of low health literacy should perhaps be viewed less as a patient problem and more as a challenge to health care providers and health systems to reach out and more effectively communicate with patients. The United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute of Statistics (UIS) projected that over 776 million adults, which is about 16% of the world's adult population lacking basic literacy skills [71]. These figures appear to be alarmed by the strides that the human race has made in development of education. Additionally, a recent survey of health literacy among 2000 adults in the United Kingdom found that one in five people had difficulty with the basic skills required

for understanding simple information that could lead to better health [72].

higher among certain groups. These findings raise questions of equity [54].

It seems that quality health care is advancing in the developed countries due to the developments in technology [73], while on the other hand, the population in developing countries is affected by low literacy levels due to the limited advancement of technology [74]. However, research has indicated that 60% of adult Canadians (ages 16 and older) lack the capacity to obtain, understand and act on health information and services, and also the ability to make appropriate health decisions on their own. In addition, the proportion of adults with low levels of health literacy is significantly

Findings from comparable studies done in Europe, Australia, Latin America and other countries have correlated literacy levels with access to education, ethnicity and age as determinants to better health care [75]. Other studies have indicated that having limited literacy or numeracy skills also acts as an independent risk factor for poor health, which lead to medication errors and insufficient understanding of diseases and treatments [76]. Additionally, [49] from their review determined

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

reducing health inequalities [54].

#### *Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

lenged by the demands and complexity required [57].

persons respond to health information [55]. Additionally, difficulties with health literacy affect all people, but the elderly and chronically ill are most at-risk, and also have the greatest health care needs and expenses [56]. People with low health literacy are overwhelmed by health care because their skills and abilities are chal-

Secondly, poor health outcomes, findings indicated that there is a clear correlation between inadequate health literacy as measured by reading fluency and increased mortality rates. Report on the Council of Scientific Affairs [58] suggested that poor health literacy is "a stronger predictor of a person's health than age, income, employment status, education level, and race." Moreover, UNICEF, reported that hundreds of millions of people around the globe are living in extreme poverty. Both poverty and poor health are linked and can be the result of social, political, and economic injustices. The linkage is a vicious, self-perpetuating cycle where poverty causes poor health and poor health keeps communities in poverty. Research cited that people who are economically deprived and living in poor environments are faced with many health risk factors in their everyday life [59].

Thirdly, increasing rates of chronic disease are estimated to account for almost half (47%) of the total burden of disease. Likewise, chronic diseases often occur with co-morbidities (concomitant but unrelated diseases) and co-morbidity further increases the demand for health care. For example, individuals with diabetes and very high co-morbidity are expected to use 10 times the healthcare resources of the population average [60]. Research done on the Canadian Health Care System that indicated help is provided to people with chronic conditions such as diabetes, asthma, congestive heart failure, renal failure and chronic obstructive pulmonary disease. A large proportion of the available healthcare resources are devoted to treating chronic conditions and, in Canada, 67% of all health care costs are incurred as a result of caring for those with chronic conditions. More than half of Canadians aged 12 or older report at least one chronic condition and at age 65, 77% of men and 85% of women have at least one chronic condition [61]. Health literacy plays a crucial role in chronic disease self-management. In order to systematically manage chronic conditions on a daily basis, individuals must be able to assess, understand, evaluate, and use health information [62]. According to the Adult Literacy and Life Skills Survey, more than half (55%) of working-age Canadians do not have adequate levels of health literacy and only one in eight adults (12%) over age 65 has adequate health-literacy skills [63]. Also, [1] specified that populations most likely to experience low-literacy levels are among those being asked to manage their condition such as older adults, ethnic minorities, people with low levels of educational attainment, people with low income levels, nonnative speakers of English, and people with compromised health [64]. Also, those with low literacy skills are not likely to attend voluntary peer-led self-management programs even if they are aware, they exist. In 2003, the Institute of Medicine in its priority areas for national action, identified self-management/ health literacy as an area that cut across many health problems [64]. Schloman [65] opines that "improved health literacy was put forward as a condition necessary to

enable active self-management of patients for most conditions."

literacy among adults at the national level to be \$73 billion annually.

Fourthly, health care costs; the additional costs of limited health literacy range from 3 to 5% of the total health care cost per year. Research has indicated that, insufficient health literacy has been associated with an increased need for disease management, higher medical service utilization among older, racial, ethnic minorities, and with low educational attainment [1]. Research conducted by the [66] in managing care, suggested that individuals with low health literacy have higher medical costs and are less efficient when using services than those individuals with adequate health literacy. Their findings estimated the costs associated with inadequate health

**20**

Fifthly, health information demand has created discrepancies between the reading levels of health-related materials and the reading skills of the intended audience. Often, the use of jargon and technical language made many health-related resources unnecessarily difficult to use [54]. The populations in both developing and developed countries are challenged with the increasing demands to understand and utilize health information, which are some of the complexities that are facing modern health care systems [67]. Additionally, the increasing proportion of people living with chronic conditions, competencies for proactive self-management of health and participation in collaborative care have become key public health agendas. The ability to take active part in shared decision making with healthcare providers is important for adherence to treatment, self-management of chronic diseases [68].

Lastly, equity is a factor that suggests that low levels of health literacy often means that a person is unable to manage their own health effectively, access health services effectively, and understand the information available to them and thus make informed healthy decisions [54]. Researchers over the past two decades, have been investigating the importance of health literacy and have examined over 1600 related research articles such as the field of "health care disparities" [69]. Improving the health literacy of those with the worst health outcomes is an important tool in reducing health inequalities [54].

It's evident that the challenges with [70] equity may still exist today. Many countries have failed to document data about the population that will make inferences about the disparities that have contributed to the lower quality of care. Due to the limited data about these disparities, situations that affects individuals with low literary skills are often times overlooked and efforts to address inequities in health care are rendered as ineffective. Furthermore, health care researchers are of the view that data to properly assess these disparities can be collected. However, health care organizations are lacking in the measurement tools to assess patient literacy in populations served by operating health care systems [70]. Isham [70] further lamented that quality measures for improving health literacy are lacking. Therefore, the current problems of low health literacy should perhaps be viewed less as a patient problem and more as a challenge to health care providers and health systems to reach out and more effectively communicate with patients. The United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute of Statistics (UIS) projected that over 776 million adults, which is about 16% of the world's adult population lacking basic literacy skills [71]. These figures appear to be alarmed by the strides that the human race has made in development of education. Additionally, a recent survey of health literacy among 2000 adults in the United Kingdom found that one in five people had difficulty with the basic skills required for understanding simple information that could lead to better health [72].

It seems that quality health care is advancing in the developed countries due to the developments in technology [73], while on the other hand, the population in developing countries is affected by low literacy levels due to the limited advancement of technology [74]. However, research has indicated that 60% of adult Canadians (ages 16 and older) lack the capacity to obtain, understand and act on health information and services, and also the ability to make appropriate health decisions on their own. In addition, the proportion of adults with low levels of health literacy is significantly higher among certain groups. These findings raise questions of equity [54].

Findings from comparable studies done in Europe, Australia, Latin America and other countries have correlated literacy levels with access to education, ethnicity and age as determinants to better health care [75]. Other studies have indicated that having limited literacy or numeracy skills also acts as an independent risk factor for poor health, which lead to medication errors and insufficient understanding of diseases and treatments [76]. Additionally, [49] from their review determined

that there is a relationship between literacy and health outcomes that was directly corresponding to several adverse health-related factors, such as, knowledge about health and health care, hospitalization, global measures of health, and some chronic diseases.

In exploring the link between literacy and mortality, Baker and colleagues suggest that there is a strong correlation between inadequate health literacy—as measured by reading fluency—and increased mortality rates [77]. Neuroscience and Behavioral Health specialists opine that health literacy is essential to overall patient care. It's very important for every citizen in both developed and developing countries to understand basic health information. This understanding will empower people to make better decision as it relates to self-care and medical decisions. Educating the population of any country about health is crucial in mitigating inequalities that exist in health care systems. It is evident that individuals with low health literacy have poorer health status and higher rates of hospital admission, are less likely to adhere to prescribed treatments and care plans, experience more drug and treatment errors, and make less use of preventive services [78].

Poor health literacy with limited access to education may result in a deficiency in patient self-management. According to [79] believes that lack of understanding of procedures of basic health information, will interfere with their ability to take better care of themselves and make health related informed decisions. Therefore, it's evident that patients who are involved self-management will mostly experience positive health outcomes and place fewer demands on the healthcare system.

The role of healthcare facilities and health care professionals is to assist patients in becoming better in self-management and limit the patients' dependency on the health care system. It's important to understand that health literacy is pivotal in the management of chronic medical conditions. Patients need to learn and understand self-management by having access to health information which will enable them to better cope with daily challenges (includes a complex medical regimen, plan and make lifestyle adjustment) that comes with chronic illness [80].

Another major issue that affects both developed and developing countries is the cost that is attached to health care. Research has concluded that is difficult to correctly evaluate the real economic cost that is associated with low health literacy. Factors such as what constitutes health literacy and insufficient data collection on the frequency of low literacy help to compound the challenge of economic cost. Researchers believe that despite these challenges in evaluating the impact of limited health literacy studies that are available underscore the importance of addressing limited health literacy from a financial perspective [81].

Vernon et al. [82] revealed that the findings of a health literacy cost study that was based on an analysis of US National data revealed that the cost of low health literacy to the U.S. economy is in the range of \$106–\$238 billion annually. Additionally, he stated, "when one accounts for the future costs of low health literacy that result from current actions (or lack of action), the real present-day cost of low health literacy is closer in range to \$1.6–\$3.6 trillion" [82].

It is clear that tracking the economic cost associated with low health literacy will strongly depend on the strength of the economic status of the developed and developing countries. Rootman and Ronson [83] stated that inequality is another major factor that affects the citizens of all countries. They postulate that "a person's literacy level is influenced by many factors and conditions; these determinants of literacy are similar to the determinants of health commonly referred to in the health promotion literature." Studies have indicated that factors like education, personal ability, early childhood development, aging, living and working conditions, gender and culture and language help to influence literacy rates in countries around the world [83].

**23**

*Health Literacy: An Intervention to Improve Health Outcomes*

Research in the United Kingdom indicated [84] that low health literacy is emphatically connected with more unfortunate health outcomes, and every dynamic increment towards higher health literacy is related to a more prominent probability of participating in a solid and healthier way of life, explicitly eating at least five servings of fruits and vegetables and being a non-smoker. Likewise, [83] expressed that low levels of health literacy frequently imply that an individual cannot deal with their own wellbeing adequately, access health services viably, or comprehend the data accessible to them and therefore settle on educated and sound health choices. Enhancing the health literacy of those with the poor, negative health

It's important for developing countries to comprehend that health literacy entails development of individual level of knowledge, personal skills and the confidence to take action to improve self-management and community health by encouraging changes in the personal lifestyle and living conditions. Therefore, health literacy is more than people reading pamphlets and making appointments but is the overall improvement in the individual's ability to access health data and their capacity to

In both developed and developing countries but mostly in developing nations,

health care systems need to address the needs of communities and breaking down the barriers that exist through health literacy, such as, lack of compliance medication regime. Lack of health educators working with vulnerable citizens in communities like women, those living rural areas and immigrants. Other barriers like language, socio-political, economic and cultural barriers and time constraints pose challenges to health care providers and health literacy advancement. Research has shown that these vulnerable people have significantly worse outcomes which is associated with high mortality and morbidity rates due to the lack health literacy levels. Therefore, developing countries like the Caribbean in tackling the economic cost of low literacy must apply a comprehensive, and integrated health approach to

the services that are important in transforming in the model of care [79].

Pan American Health Organization [79] reported that regardless of the improvements has been achieved in health literacy, poverty and inequities remain a challenge in the Region. Recent data suggest that Latin America and the Caribbean (LAC) remains the most inequitable region in the world, with 29% of the population below the poverty line and the poorest 40% of the population receiving less than 15% of total income. Such inequities are reflected in health outcomes: for example, the Region of the Americas did not achieve the Millennium Development Goal (MDG) target for the reduction of maternal mortality by 2015, and despite significant reductions in infant mortality, very sharp differences exist between countries. Without specific interventions to transform health systems, economic

As a developing country, Jamaica is confronted with many health issues. Specifically, there are concerns with an ever-aging population, which continues to grow in size at an astounding rate of 11.3% each year [86]. Coverson [45] asked these impertinent questions, "who will take care of this aging population, what services will be available, and how the elderly will maintain a reasonable quality of life are all questions that are facing Jamaica in the near future. People are living longer and with this increase in life-years come other concerns such as the cost of care, who will administer the care, and access to care as travel becomes more

Paul and Bourne [87] suggested that this vulnerable group in the population that are affected by reading difficulties have greater challenges in understanding the high level of grammar associated with health care instruments, diagnostic tests, directions and medications. This lack of comprehension can result in patients

outcomes is a critical device in diminishing health inequalities [83].

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

effectively use that information [85].

growth is not sufficient to reduce inequities.

difficult with increased age."

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

chronic diseases.

that there is a relationship between literacy and health outcomes that was directly corresponding to several adverse health-related factors, such as, knowledge about health and health care, hospitalization, global measures of health, and some

In exploring the link between literacy and mortality, Baker and colleagues suggest that there is a strong correlation between inadequate health literacy—as measured by reading fluency—and increased mortality rates [77]. Neuroscience and Behavioral Health specialists opine that health literacy is essential to overall patient care. It's very important for every citizen in both developed and developing countries to understand basic health information. This understanding will empower people to make better decision as it relates to self-care and medical decisions. Educating the population of any country about health is crucial in mitigating inequalities that exist in health care systems. It is evident that individuals with low health literacy have poorer health status and higher rates of hospital admission, are less likely to adhere to prescribed treatments and care plans, experience more drug

Poor health literacy with limited access to education may result in a deficiency in patient self-management. According to [79] believes that lack of understanding of procedures of basic health information, will interfere with their ability to take better care of themselves and make health related informed decisions. Therefore, it's evident that patients who are involved self-management will mostly experience positive health outcomes and place fewer demands on the healthcare system.

The role of healthcare facilities and health care professionals is to assist patients in becoming better in self-management and limit the patients' dependency on the health care system. It's important to understand that health literacy is pivotal in the management of chronic medical conditions. Patients need to learn and understand self-management by having access to health information which will enable them to better cope with daily challenges (includes a complex medical regimen, plan and

Another major issue that affects both developed and developing countries is the cost that is attached to health care. Research has concluded that is difficult to correctly evaluate the real economic cost that is associated with low health literacy. Factors such as what constitutes health literacy and insufficient data collection on the frequency of low literacy help to compound the challenge of economic cost. Researchers believe that despite these challenges in evaluating the impact of limited health literacy studies that are available underscore the importance of addressing

Vernon et al. [82] revealed that the findings of a health literacy cost study that was based on an analysis of US National data revealed that the cost of low health literacy to the U.S. economy is in the range of \$106–\$238 billion annually. Additionally, he stated, "when one accounts for the future costs of low health literacy that result from current actions (or lack of action), the real present-day cost

It is clear that tracking the economic cost associated with low health literacy will strongly depend on the strength of the economic status of the developed and developing countries. Rootman and Ronson [83] stated that inequality is another major factor that affects the citizens of all countries. They postulate that "a person's literacy level is influenced by many factors and conditions; these determinants of literacy are similar to the determinants of health commonly referred to in the health promotion literature." Studies have indicated that factors like education, personal ability, early childhood development, aging, living and working conditions, gender and culture and language help to influence literacy rates in countries

and treatment errors, and make less use of preventive services [78].

make lifestyle adjustment) that comes with chronic illness [80].

limited health literacy from a financial perspective [81].

of low health literacy is closer in range to \$1.6–\$3.6 trillion" [82].

**22**

around the world [83].

Research in the United Kingdom indicated [84] that low health literacy is emphatically connected with more unfortunate health outcomes, and every dynamic increment towards higher health literacy is related to a more prominent probability of participating in a solid and healthier way of life, explicitly eating at least five servings of fruits and vegetables and being a non-smoker. Likewise, [83] expressed that low levels of health literacy frequently imply that an individual cannot deal with their own wellbeing adequately, access health services viably, or comprehend the data accessible to them and therefore settle on educated and sound health choices. Enhancing the health literacy of those with the poor, negative health outcomes is a critical device in diminishing health inequalities [83].

It's important for developing countries to comprehend that health literacy entails development of individual level of knowledge, personal skills and the confidence to take action to improve self-management and community health by encouraging changes in the personal lifestyle and living conditions. Therefore, health literacy is more than people reading pamphlets and making appointments but is the overall improvement in the individual's ability to access health data and their capacity to effectively use that information [85].

In both developed and developing countries but mostly in developing nations, health care systems need to address the needs of communities and breaking down the barriers that exist through health literacy, such as, lack of compliance medication regime. Lack of health educators working with vulnerable citizens in communities like women, those living rural areas and immigrants. Other barriers like language, socio-political, economic and cultural barriers and time constraints pose challenges to health care providers and health literacy advancement. Research has shown that these vulnerable people have significantly worse outcomes which is associated with high mortality and morbidity rates due to the lack health literacy levels. Therefore, developing countries like the Caribbean in tackling the economic cost of low literacy must apply a comprehensive, and integrated health approach to the services that are important in transforming in the model of care [79].

Pan American Health Organization [79] reported that regardless of the improvements has been achieved in health literacy, poverty and inequities remain a challenge in the Region. Recent data suggest that Latin America and the Caribbean (LAC) remains the most inequitable region in the world, with 29% of the population below the poverty line and the poorest 40% of the population receiving less than 15% of total income. Such inequities are reflected in health outcomes: for example, the Region of the Americas did not achieve the Millennium Development Goal (MDG) target for the reduction of maternal mortality by 2015, and despite significant reductions in infant mortality, very sharp differences exist between countries. Without specific interventions to transform health systems, economic growth is not sufficient to reduce inequities.

As a developing country, Jamaica is confronted with many health issues. Specifically, there are concerns with an ever-aging population, which continues to grow in size at an astounding rate of 11.3% each year [86]. Coverson [45] asked these impertinent questions, "who will take care of this aging population, what services will be available, and how the elderly will maintain a reasonable quality of life are all questions that are facing Jamaica in the near future. People are living longer and with this increase in life-years come other concerns such as the cost of care, who will administer the care, and access to care as travel becomes more difficult with increased age."

Paul and Bourne [87] suggested that this vulnerable group in the population that are affected by reading difficulties have greater challenges in understanding the high level of grammar associated with health care instruments, diagnostic tests, directions and medications. This lack of comprehension can result in patients experiencing confusion in navigating the healthcare system, and are significantly handicapped in the task of self-management or caring for their family members.

#### **4.3 Cultural issues affecting health literacy in developed and developing countries**

Baker [88] concurring with other researchers agree that culturally, health care is multifaceted idea. National Center for Cultural Competence [89], culture has been defined as the "integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group."

State of illness is viewed through a cultural lens in countries around the world. With these cultural lens people summarize health and sickness and based on their perception will respond to the health message. It's important to note that culture will help people determine what treatment options are best (by going to the medical doctor or the herbalist), and it helps people interpret symptoms [90]. It is important to recognize that based on these cultural health beliefs that an individual has, will greatly impact how they think and feel about their health and health challenges. It also affects the kind of people that they seek care from and how they respond to recommendations to make changes to their lifestyle and how they accept health intervention messages [91].

Due the complex nature of health literacy and cultural practices, health literacy cannot have one "sprang" approach in reaching the populace. Health literacy is not determined solely by an individual's capacity to read, understand, process, and act on health information. However, it's dependent on the request that individuals make for health information and their ability to decode, interpret, and understand the information presented. Furthermore, health literacy is not constant, but is a dynamic state that may change with the situation [88]. Researchers have agreed that in order to effectively deal with low health literacy in the health care system, there needs to be an aggressive research agenda that will in cooperate evidence base tools that will provide relevant data in order to address these challenges [92].

Cultures also vary in their styles of communication, in the meaning of words and gestures, and even in what can be discussed regarding the body, health, and illness. Health literacy requires communication and mutual understanding between patients and their families and healthcare providers and staff. Culture and health literacy, both influences the content and outcomes of health care encounters [29]. Cooper and Roter [93] review the relationship that exists between the relationship between culture, patient-provider interaction, and quality of care and have concluded that culture gives significance to health information and messages. The awareness that people have about the definitions of health and illness, preferences, language and cultural barriers, and stereotypes are strongly influenced by the individual's culture which can greatly sway health literacy and health outcomes. Furthermore, others challenges are developed due to the different educational backgrounds among patients and providers and those responsible to create health information can lead to cultural challenges based on the wording used to share the information [93].

Research done on the importance of culture and health literacy in European-American cultural groups indicated that the use of language differs in discussing symptoms such as pain [94–95]. Base on the cultural, linguistic differences were linked with changes in diagnoses, regardless of symptomology. African-American patients frequently experience shorter physician-patient interactions and less patient-centered visits than Caucasian patients [93, 96].

With the ever increasing melting pot of ethnicity in countries around the world, health care systems are forced to recognize these different ethnic groups with

**25**

**Figure 2.**

*Health Literacy: An Intervention to Improve Health Outcomes*

systems and the holistic health for their citizens [73].

*The intersection of health literacy with health care improvement [98].*

cultural diversity in order to be inclusive [93]. Therefore, cultural, social, and family norms have transformed the attitudes and beliefs which will significantly impact the levels of health literacy (native language, socioeconomic status, gender, race, and ethnicity are considered as influencers that limits person's control which affects his or her ability to participate fully in a health-literate society [97]. It behooves the health care providers to properly utilize the various modes of communication such as news publishing, advertising, marketing, and the plethora of health information sources available through electronic channels are also integral to the social-cultural landscape of health literacy when communicating with cultural masses [29].

By incorporating a greater focus on health literacy, health care professionals will

Governments around the world must understand that need to develop a health

Since health literacy is not constant, but dynamic, governments must observe health literacy as fundamental to health, and essential for improving quality of patient care. Low levels of health literacy present a formidable challenge to the widespread and effective use of patient self-management [99]. However, these challenges can be met. Although, health literacy continues to get more attention at the national level and economic cost becomes visible, improving health literacy will be crucial in reducing adverse outcomes that are connected with low health literacy [73]. Within the twenty-first century there is no universal solution, but by gathering relevant data and implementing best practices can be strategies that can be steadily used to improve health literacy for populations around the world. By simplifying health literacy information which will increase the usability of this information must be the priority focus.

move closer toward a patient-centered health care system (**Figures 1** and **2**).

care system that works is not the burden of health care consumer. The need to improve health literacy must be seen as a partnership between public and private organizations whose primary focus is to help citizens become health literate. This cohesive partnership will help both developed and developing nation's realized improvements in health literacy will play a major role in improving health care

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

#### *Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

**4.3 Cultural issues affecting health literacy in developed and developing** 

**countries**

religious or social group."

intervention messages [91].

experiencing confusion in navigating the healthcare system, and are significantly handicapped in the task of self-management or caring for their family members.

Baker [88] concurring with other researchers agree that culturally, health care is multifaceted idea. National Center for Cultural Competence [89], culture has been defined as the "integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic,

State of illness is viewed through a cultural lens in countries around the world. With these cultural lens people summarize health and sickness and based on their perception will respond to the health message. It's important to note that culture will help people determine what treatment options are best (by going to the medical doctor or the herbalist), and it helps people interpret symptoms [90]. It is important to recognize that based on these cultural health beliefs that an individual has, will greatly impact how they think and feel about their health and health challenges. It also affects the kind of people that they seek care from and how they respond to recommendations to make changes to their lifestyle and how they accept health

Due the complex nature of health literacy and cultural practices, health literacy cannot have one "sprang" approach in reaching the populace. Health literacy is not determined solely by an individual's capacity to read, understand, process, and act on health information. However, it's dependent on the request that individuals make for health information and their ability to decode, interpret, and understand the information presented. Furthermore, health literacy is not constant, but is a dynamic state that may change with the situation [88]. Researchers have agreed that in order to effectively deal with low health literacy in the health care system, there needs to be an aggressive research agenda that will in cooperate evidence base tools

Cultures also vary in their styles of communication, in the meaning of words and gestures, and even in what can be discussed regarding the body, health, and illness. Health literacy requires communication and mutual understanding between patients and their families and healthcare providers and staff. Culture and health literacy, both influences the content and outcomes of health care encounters [29]. Cooper and Roter [93] review the relationship that exists between the relationship between culture, patient-provider interaction, and quality of care and have concluded that culture gives significance to health information and messages. The awareness that people have about the definitions of health and illness, preferences, language and cultural barriers, and stereotypes are strongly influenced by the individual's culture which can greatly sway health literacy and health outcomes. Furthermore, others challenges are developed due to the different educational backgrounds among patients and providers and those responsible to create health information can lead to

that will provide relevant data in order to address these challenges [92].

cultural challenges based on the wording used to share the information [93].

patient-centered visits than Caucasian patients [93, 96].

Research done on the importance of culture and health literacy in European-American cultural groups indicated that the use of language differs in discussing symptoms such as pain [94–95]. Base on the cultural, linguistic differences were linked with changes in diagnoses, regardless of symptomology. African-American patients frequently experience shorter physician-patient interactions and less

With the ever increasing melting pot of ethnicity in countries around the world,

health care systems are forced to recognize these different ethnic groups with

**24**

cultural diversity in order to be inclusive [93]. Therefore, cultural, social, and family norms have transformed the attitudes and beliefs which will significantly impact the levels of health literacy (native language, socioeconomic status, gender, race, and ethnicity are considered as influencers that limits person's control which affects his or her ability to participate fully in a health-literate society [97]. It behooves the health care providers to properly utilize the various modes of communication such as news publishing, advertising, marketing, and the plethora of health information sources available through electronic channels are also integral to the social-cultural landscape of health literacy when communicating with cultural masses [29].

By incorporating a greater focus on health literacy, health care professionals will move closer toward a patient-centered health care system (**Figures 1** and **2**).

Governments around the world must understand that need to develop a health care system that works is not the burden of health care consumer. The need to improve health literacy must be seen as a partnership between public and private organizations whose primary focus is to help citizens become health literate. This cohesive partnership will help both developed and developing nation's realized improvements in health literacy will play a major role in improving health care systems and the holistic health for their citizens [73].

Since health literacy is not constant, but dynamic, governments must observe health literacy as fundamental to health, and essential for improving quality of patient care. Low levels of health literacy present a formidable challenge to the widespread and effective use of patient self-management [99]. However, these challenges can be met. Although, health literacy continues to get more attention at the national level and economic cost becomes visible, improving health literacy will be crucial in reducing adverse outcomes that are connected with low health literacy [73]. Within the twenty-first century there is no universal solution, but by gathering relevant data and implementing best practices can be strategies that can be steadily used to improve health literacy for populations around the world. By simplifying health literacy information which will increase the usability of this information must be the priority focus.

**Figure 2.**

*The intersection of health literacy with health care improvement [98].*

When patients can relate health information in plain language in both the written and spoken formats will help in improving the decision-making capacity of the client [92]. The method of assessing and responding to health literacy at the governmental level has been a progression in the focus of health literacy as a responsibility of the patient. However, organizations and systems are accountable for designing service delivery that challenges the health literacy needs of the clients of health care providers [99].

### **5. Recommendations**

Governments, policy makers, organizations, health practitioners and community members must work in partnership to address health literacy issues contributing to poor health outcomes such as mortality and morbidity. We are therefore recommending the following:


### **6. Conclusions**

This visualization for health literacy as an intervention to reduce hospital mortality and morbidity rates can be effective as the data presented shows the importance of meeting the needs of patients with low health literacy in Jamaica. Healthcare professionals have an important role to play, but the responsibility for achieving real progress for patients facing challenges related to health literacy must extend to greater government involvement by creating health literacy policies and programs in both rural and urban areas.

Greater emphasis needs to be placed where the hard-to-reach or disadvantaged or vulnerable groups which include the elderly, children and patients with disability (mental/physical/intellectual). In Jamaica, we are still stuck at the developmental stage of understanding the scope of health literacy and the challenges patients face and developing cultural relevant interventions to address them. The relationship between health literacy and health outcomes such as mortality and morbidity needs to be explored through further research. The interventions identified in this chapter are stepping stones which need significantly greater support, resources for research and implementation of interventions.

**27**

**Author details**

Monique Ann-Marie Lynch1

provided the original work is properly cited.

2 University of the West Indies, Mona

*Health Literacy: An Intervention to Improve Health Outcomes*

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 World Federation for Mental Health, University of the West Indies, Mona

\*Address all correspondence to: monique.a.lynch@gmail.com

\* and Geovanni Vinceroy Franklin2

*Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

**5. Recommendations**

recommending the following:

community.

**6. Conclusions**

When patients can relate health information in plain language in both the written and spoken formats will help in improving the decision-making capacity of the client [92]. The method of assessing and responding to health literacy at the governmental level has been a progression in the focus of health literacy as a responsibility of the patient. However, organizations and systems are accountable for designing service delivery that challenges the health literacy needs of the clients of health care providers [99].

Governments, policy makers, organizations, health practitioners and community members must work in partnership to address health literacy issues contributing to poor health outcomes such as mortality and morbidity. We are therefore

• Implementing the Ophelia (Optimizing Health Literacy and Access to health information and services) Australian approach in our health care system and in extent in all developing countries. This approach involves the collaboration of a wide range of healthcare professionals, government leaders or representatives, community health center or hospital patients and leaders to develop health literacy interventions that are based on needs identified within a hospital or

• Develop and implement policies that promote documentation of health literacy

• Develop and implement policies that promote equitable access to health

This visualization for health literacy as an intervention to reduce hospital mortality and morbidity rates can be effective as the data presented shows the importance of meeting the needs of patients with low health literacy in Jamaica. Healthcare professionals have an important role to play, but the responsibility for achieving real progress for patients facing challenges related to health literacy must extend to greater government involvement by creating health literacy policies and

Greater emphasis needs to be placed where the hard-to-reach or disadvantaged or vulnerable groups which include the elderly, children and patients with disability (mental/physical/intellectual). In Jamaica, we are still stuck at the developmental stage of understanding the scope of health literacy and the challenges patients face and developing cultural relevant interventions to address them. The relationship between health literacy and health outcomes such as mortality and morbidity needs to be explored through further research. The interventions identified in this chapter are stepping stones which need significantly greater support, resources for research

issues and the implementation of targeted responses.

information and services for all citizens.

programs in both rural and urban areas.

and implementation of interventions.

**26**

### **Author details**

Monique Ann-Marie Lynch1 \* and Geovanni Vinceroy Franklin2


\*Address all correspondence to: monique.a.lynch@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A Prescription to End Confusion. The National Academies Press; 2004. Available from: http://www.nap.edu/ books/ 0309091179/html/

[2] DeWalt DA, Broucksou KA, Hawk V, Brach C, Hink A, Rudd R, et al. Developing and testing the health literacy universal precautions toolkit. Nursing Outlook. 2011;**59**(2):85-94. DOI: 10.1016/j.outlook.2010.12.002

[3] Office of Disease Prevention and Health Promotion. Health Literacy and Health Outcomes. 2004. Available from: https://health.gov/communication/ literacy/quickguide/factsliteracy.htm

[4] Campbell W. Health Literacy Key for All Jamaicans. 2017. Available from: http://jamaica-gleaner. com/article/letters/20170218/ health-literacy-key-all-jamaicans

[5] U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC: U.S. Government Printing Office; 2000. Originally developed for Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, editors. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000

[6] World Health Organization (WHO). Health Promotion Glossary. Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit. Geneva: World Health Organization; 1998. p. 10. Available from: www.who.int/hpr/NPH/ docs/hp\_glossary\_en.pdf

[7] Kirsch I, Jungeblut A, Jenkins L, Kolstat A. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. 2000. pp. 1-201

[8] U.S. Department of Health and Human Services. Quick Guide to Health Literacy Services. 2011. Available from: http://www.health.gov/communication/ literacy/quickguide/factsbasic.html

[9] Donatelle R. Promoting healthy behavior change. In: Health: The Basics. 8th ed. San Francisco, CA: Pearson Education, Inc.; 2009. p. 4

[10] World Health Organization. Constitution of the World Health Organization—Basic Documents. 45th ed. Switzerland: WHO Press; 2006. Available from: https:// www.who.int/governance/eb/ who\_constitution\_en.pdf

[11] World Health Organization, Geneva. Equity in Health and Health Care. 1996. Available from: www.WHO/ ARA/96.1

[12] Vaughan, F. What is Spiritual Intelligence? Journal of Humanistic Psychology. Sage Publications. 2003;**42**(2):16-33

[13] Zohar D. Rewiring the Corporate Brain: Using the New Science to Rethink How We Structure and Lead Organizations. Berrett-Koehler Publishers; 1997. ISBN: 9971-5-1214-9

[14] O'Donnell K. Endoquality—As dimensões emotionais e espirituais do ser humano nas organanizões. Brazil: Casa da Qualidade; 1997. ISBN 858565127X

[15] Levin M. Spiritual Intelligence. Australia: Hodder Headline Publishers; 2000. ISBN 0-340-73394-2

[16] Koenig HG, McCullough M, Larson DB. The Handbook of Religion and

**29**

*Health Literacy: An Intervention to Improve Health Outcomes*

Health Ministers. 2001. Available from: https://www.who.int/mental\_health/

Robertson-Hickling H, Haynes-Robinson T, Abel W, Whitley R. Mad, sick, head nuh good: Mental illness stigma in Jamaican communities. Transcultural

[28] Academies of Sciences, Engineering, and Medicine. Approaches to Reducing Stigma. In: Ending Discrimination against People with Mental and

Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: National Academies Press (US); 2016. Available from: https://www.ncbi.nlm.

media/en/249.pdf

[27] Hickling FW, Arthur CM,

Psychiatry. 2010;**47**:252-275

nih.gov/books/NBK384914/

[29] Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and health communication strategies into the 21st century. Health Promotion International. 2000;**15**(3):259-267

[30] Russell RD. Social health: An attempt to clarify this dimension of well-being. International Journal of Health Education. 1973;**16**:74-82

[31] People's Health Movement. People's Charter for Health. 2018. Available from: https://phmovement.org/wp-content/ uploads/2018/06/phm-pch-english.pdf

[32] U.S. Department of Health and Human Services. Healthy People 2020 Draft. U.S. Government Printing Office.

[33] World Health Organization. "Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health" The Final Report of the WHO Commission on Social Determinants of Health. Switzerland: WHO Press; 2008. Available from: https://www.who.int/ social\_determinants/final\_report/ csdh\_finalreport\_2008.pdf

2009

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

Health. New York: Oxford University

Egalitarianism. Chicago: The University

[17] Fogel RW. The Fourth Great Awakening and the Future of

[18] Vaughan F. What is spiritual intelligence? Journal of Humanistic Psychology. 2003;**42**(2):16-33

[19] Wigglesworth C. Why spiritual intelligence is essential to mature leadership. Integral Leadership Review.

[20] Foglio JP, Brody H. Holy religion, faith and family medicine. The Journal of Family Practice. 1988;**27**(5):473-474

[21] Jorm AF, Korten AE, Jacomb PA. 'Mental health literacy': A survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia. 1997;**166**:182-186

[22] Public Health England. Local Action on Health Inequalities; Promoting Health Literacy to Reduce Health Inequalities. London: Public Health

[23] World Health Organization, Geneva. Investing in Mental Health. 2003. Available from: https://www.who.int/ mental\_health/media/investing\_mnh.pdf

[24] Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum; 2011

[25] Traurmann S, Rehm J, Wittchen H-U. The Economic Costs of Mental Disorders. 2016. Available from: embor. embopress.org/content/early/2016/08/04/

[26] World Health Organization. Mental Health: A Call for Action by World

embr.201642951.figures/only

of Chicago Press; 2000

2006;**VI**(3):224-227

England; 2015

Press; 2000

*Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

Health. New York: Oxford University Press; 2000

[17] Fogel RW. The Fourth Great Awakening and the Future of Egalitarianism. Chicago: The University of Chicago Press; 2000

[18] Vaughan F. What is spiritual intelligence? Journal of Humanistic Psychology. 2003;**42**(2):16-33

[19] Wigglesworth C. Why spiritual intelligence is essential to mature leadership. Integral Leadership Review. 2006;**VI**(3):224-227

[20] Foglio JP, Brody H. Holy religion, faith and family medicine. The Journal of Family Practice. 1988;**27**(5):473-474

[21] Jorm AF, Korten AE, Jacomb PA. 'Mental health literacy': A survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia. 1997;**166**:182-186

[22] Public Health England. Local Action on Health Inequalities; Promoting Health Literacy to Reduce Health Inequalities. London: Public Health England; 2015

[23] World Health Organization, Geneva. Investing in Mental Health. 2003. Available from: https://www.who.int/ mental\_health/media/investing\_mnh.pdf

[24] Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum; 2011

[25] Traurmann S, Rehm J, Wittchen H-U. The Economic Costs of Mental Disorders. 2016. Available from: embor. embopress.org/content/early/2016/08/04/ embr.201642951.figures/only

[26] World Health Organization. Mental Health: A Call for Action by World

Health Ministers. 2001. Available from: https://www.who.int/mental\_health/ media/en/249.pdf

[27] Hickling FW, Arthur CM, Robertson-Hickling H, Haynes-Robinson T, Abel W, Whitley R. Mad, sick, head nuh good: Mental illness stigma in Jamaican communities. Transcultural Psychiatry. 2010;**47**:252-275

[28] Academies of Sciences, Engineering, and Medicine. Approaches to Reducing Stigma. In: Ending Discrimination against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: National Academies Press (US); 2016. Available from: https://www.ncbi.nlm. nih.gov/books/NBK384914/

[29] Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and health communication strategies into the 21st century. Health Promotion International. 2000;**15**(3):259-267

[30] Russell RD. Social health: An attempt to clarify this dimension of well-being. International Journal of Health Education. 1973;**16**:74-82

[31] People's Health Movement. People's Charter for Health. 2018. Available from: https://phmovement.org/wp-content/ uploads/2018/06/phm-pch-english.pdf

[32] U.S. Department of Health and Human Services. Healthy People 2020 Draft. U.S. Government Printing Office. 2009

[33] World Health Organization. "Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health" The Final Report of the WHO Commission on Social Determinants of Health. Switzerland: WHO Press; 2008. Available from: https://www.who.int/ social\_determinants/final\_report/ csdh\_finalreport\_2008.pdf

**28**

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

A First Look at the Findings of the National Adult Literacy Survey. 2000.

[8] U.S. Department of Health and Human Services. Quick Guide to Health Literacy Services. 2011. Available from: http://www.health.gov/communication/ literacy/quickguide/factsbasic.html

[9] Donatelle R. Promoting healthy behavior change. In: Health: The Basics. 8th ed. San Francisco, CA: Pearson

[10] World Health Organization. Constitution of the World Health Organization—Basic Documents. 45th ed. Switzerland: WHO Press; 2006. Available from: https:// www.who.int/governance/eb/ who\_constitution\_en.pdf

[11] World Health Organization, Geneva. Equity in Health and Health Care. 1996. Available from: www.WHO/

[12] Vaughan, F. What is Spiritual Intelligence? Journal of Humanistic Psychology. Sage Publications.

[13] Zohar D. Rewiring the Corporate Brain: Using the New Science to Rethink How We Structure and Lead Organizations. Berrett-Koehler Publishers; 1997. ISBN: 9971-5-1214-9

[14] O'Donnell K. Endoquality—As dimensões emotionais e espirituais do ser humano nas organanizões. Brazil: Casa da Qualidade; 1997. ISBN

[15] Levin M. Spiritual Intelligence. Australia: Hodder Headline Publishers;

[16] Koenig HG, McCullough M, Larson DB. The Handbook of Religion and

2000. ISBN 0-340-73394-2

ARA/96.1

2003;**42**(2):16-33

858565127X

Education, Inc.; 2009. p. 4

pp. 1-201

[1] Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A Prescription to End Confusion. The National Academies Press; 2004. Available from: http://www.nap.edu/

[2] DeWalt DA, Broucksou KA, Hawk V,

books/ 0309091179/html/

**References**

Brach C, Hink A, Rudd R, et al. Developing and testing the health literacy universal precautions toolkit. Nursing Outlook. 2011;**59**(2):85-94. DOI: 10.1016/j.outlook.2010.12.002

[3] Office of Disease Prevention and Health Promotion. Health Literacy and Health Outcomes. 2004. Available from: https://health.gov/communication/ literacy/quickguide/factsliteracy.htm

[4] Campbell W. Health Literacy Key for All Jamaicans. 2017. Available from: http://jamaica-gleaner. com/article/letters/20170218/ health-literacy-key-all-jamaicans

[5] U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC: U.S. Government Printing Office; 2000. Originally developed for Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, editors. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and

Human Services; 2000

docs/hp\_glossary\_en.pdf

[7] Kirsch I, Jungeblut A, Jenkins L, Kolstat A. Adult Literacy in America:

[6] World Health Organization (WHO). Health Promotion Glossary. Division of Health Promotion, Education and Communications Health Education and Health Promotion Unit. Geneva: World Health Organization; 1998. p. 10. Available from: www.who.int/hpr/NPH/ [34] Julianne H, Smith T, Bradley Layton J. Social relationships and mortality risk: A meta-analytic review. PLoS Medicine. 2010;**7**(7):1-2

[35] Klinenberg E. Social isolation loneliness, and living alone: Identifying the risks for public health. American Journal of Public Health. 2016;**106**(5):786-787. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4985072/

[36] Mandigo J, Francis N, Lodewyk K, Lopez R. Physical literacy for educators. Physical Education and Health Journal. 2012;**75**(3):27-30

[37] Almond L, Whitehead M. Physical literacy: Clarifying the nature of the concept. Physical Education Matters. 2012;**7**(1):255-257. ISSN: 1751-0988

[38] Whitehead M. Physical Literacy: Throughout the Lifecourse. London: Routledge; 2010

[39] Cockerham WC. Medical Sociology. 12th ed. Boston: Pearson Education; 2012. p. 120

[40] Conner M, Norman P, editors. Predicting Health Behaviour. Buckingham, UK: Open University Press; 1996

[41] Gochman DS, editor. Handbook of Health Behavior Research. Vol. 1-4. New York, NY: Plenum; 1997

[42] Institute of Medicine (US) Committee on Health and Behavior Research, Practice, and Policy. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences, Behavioral Risk Factors. Vol. 3. Washington, DC: National Academies Press; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK43744/

[43] Conner MT. Health Behaviors. 2002. Available from: https://www.researchgate.net/ publication/266862660\_Health\_Behaviors

[44] National Center for Education Statistics. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education; 2006

[45] Coverson D. Health literacy in rural Jamaica: Visual aides to assist and increase medication adherence. MOJ Public Health. 2015;**2**(5):149-152. DOI: 10.15406/mojph.2015.02.00038

[46] Clement S, Ibrahim S, Crichton N, Wolf M, Rowlands G. Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education and Counseling. 2009;**75**(3):340-351

[47] Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN. Interventions to improve health outcomes for patients with low literacy. Journal of General Internal Medicine. 2005;**20**:185-192

[48] Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health Literacy: Report of the Council on Scientific Affairs. JAMA. 1999;**281**(6):552-557. DOI:10.1001/ jama.281.6.552

[49] DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, Pignone M. Literacy and health outcomes: A systematic review of the literature. Journal of General Internal Medicine. 2004;**19**:1228-1239

[50] Berkman ND, Dewalt DA, Pignone MP. (RTI International-University of North Carolina Evidence-based Practice Center): Literacy and Health Outcomes: Evidence Report/Technology Assessment Number. 2004. Available from: http:// www.ahrq.gov/clinic/litinv.htm

[51] World Health Organization Regional Office for South-East Asia. Health

**31**

*Health Literacy: An Intervention to Improve Health Outcomes*

National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006

[58] Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association.

[59] Amini S. Poor Health Outcomes Associated with Low SES Status; How Poverty Can Be a Determinant of Health. University of Florida(UF) Health; 2016

[60] Broemeling A-M, Watson D, Black C. Chronic Conditions and Co-Morbidity Among Residents of British Columbia. Vancouver, BC: Centre for Health Services and Policy Research; 2005. Available from: https://www.researchgate.net/ publication/255585868\_Chronic\_ conditions\_and\_co-morbidity\_among\_

residents\_of\_British\_Columbia

chronic conditions and pain in seniors. Health Reports.

2018;**2**:134-138

Compacency-2007.pdf

[61] Gilmour H, Park J. Dependency,

2006;**16**(supplement):21-32. Statistics Canada catalogue no. 82-003-SIE

[62] van der Heide I, Poureslami I, Mitic W, Shum J, Rootman I, Mark Fitz Gerald J. Health literacy in chronic disease management: A matter of Interaction. Journal of Clinical Epidemiology.

[63] Canadian Council on Learning. State of Learning in Canada: No Time for Complacency. Canadian Council on Learning; 2007. Available from: https://www.dartmouthlearning.net/ wp-content/uploads/2013/02/Stateof-Learning-in-Canada-No-Time-for-

[64] Current Clinical Issues. The crucial link between literacy and health. Annals

Health Literacy: Report of the Council on Scientific Affairs. JAMA. 1999;**281**(6):562-564. DOI:10.1001/

jama.281.6.562

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

Literacy Toolkit for Low- and Middle-Income Countries that the Optimizing Health Literacy and Access to Health Information and Services. 2014. Available from: http://www.searo.who. int/entity/healthpromotion/documents/

[52] Batterham R, Buchbinder R, Beauchamp A, Dodson S, Elsworth GR, Osborne RH. The Optimising HEalth LIterAcy (Ophelia) process: Study protocol for using health literacy profiling and community engagement to create and implement health reform. 2014. Available from: https:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-14-694

[53] Adult Basic and Literacy Education Inter-agency Coordinating Council. A Report on Health Literacy. Pennsylvania State University. 2002. Available from: http://www. csg.org/knowledgecenter/docs/ ToolKit03HealthLiteracy.pdf

[54] Mayagah K, Wayne M. Promoting Health and Development: Closing the Implementation Gap. World Health Organization Report, Nairobi, Kenya;

[55] Lam Y, Broaddus ET, Surkan PJ. Literacy and healthcareseeking among women with low educational attainment: Analysis of cross-sectional data from the 2011 Nepal demographic and health survey. International Journal for Equity in Health. 2013;**12**:95. DOI:

10.1186/1475-9276-12-95

[56] Chesser AK, Keene Woods N, Smothers K, Rogers N. Health literacy and older adults: A systematic review. Gerontology & Geriatric Medicine. 2016;**2**:1-13. DOI: 10.1177/2333721416630492

[57] Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results From the 2003

2009. pp. 26-30

hl\_tookit/en/

*Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

Literacy Toolkit for Low- and Middle-Income Countries that the Optimizing Health Literacy and Access to Health Information and Services. 2014. Available from: http://www.searo.who. int/entity/healthpromotion/documents/ hl\_tookit/en/

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

https://www.researchgate.net/

Education; 2006

publication/266862660\_Health\_Behaviors

America's Adults: Results From the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of

[44] National Center for Education Statistics. The Health Literacy of

[45] Coverson D. Health literacy in rural Jamaica: Visual aides to assist and increase medication adherence. MOJ Public Health. 2015;**2**(5):149-152. DOI:

10.15406/mojph.2015.02.00038

[46] Clement S, Ibrahim S, Crichton N, Wolf M, Rowlands G. Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education and Counseling. 2009;**75**(3):340-351

[47] Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN. Interventions to improve health outcomes for patients with low literacy. Journal of General Internal Medicine. 2005;**20**:185-192

[48] Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association.

Health Literacy: Report of the Council on Scientific Affairs. JAMA. 1999;**281**(6):552-557. DOI:10.1001/

[49] DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, Pignone M. Literacy and health outcomes: A systematic review of the literature. Journal of General Internal Medicine.

[50] Berkman ND, Dewalt DA, Pignone MP. (RTI International-University of North Carolina Evidence-based Practice Center): Literacy and Health Outcomes: Evidence Report/Technology Assessment Number. 2004. Available from: http:// www.ahrq.gov/clinic/litinv.htm

[51] World Health Organization Regional Office for South-East Asia. Health

jama.281.6.552

2004;**19**:1228-1239

[34] Julianne H, Smith T, Bradley Layton J. Social relationships and mortality risk: A meta-analytic review. PLoS Medicine.

[35] Klinenberg E. Social isolation loneliness, and living alone:

Identifying the risks for public health. American Journal of Public Health. 2016;**106**(5):786-787. Available from: https://www.ncbi.nlm.nih.gov/pmc/

[36] Mandigo J, Francis N, Lodewyk K, Lopez R. Physical literacy for educators. Physical Education and Health Journal.

[37] Almond L, Whitehead M. Physical literacy: Clarifying the nature of the concept. Physical Education Matters. 2012;**7**(1):255-257. ISSN: 1751-0988

[38] Whitehead M. Physical Literacy: Throughout the Lifecourse. London:

[39] Cockerham WC. Medical Sociology. 12th ed. Boston: Pearson Education;

[40] Conner M, Norman P, editors. Predicting Health Behaviour. Buckingham, UK: Open University

[41] Gochman DS, editor. Handbook of Health Behavior Research. Vol. 1-4.

New York, NY: Plenum; 1997

[42] Institute of Medicine (US) Committee on Health and Behavior Research, Practice, and Policy. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences, Behavioral Risk Factors. Vol. 3. Washington, DC: National Academies Press; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/

2010;**7**(7):1-2

articles/PMC4985072/

2012;**75**(3):27-30

Routledge; 2010

2012. p. 120

Press; 1996

**30**

NBK43744/

[43] Conner MT. Health

Behaviors. 2002. Available from:

[52] Batterham R, Buchbinder R, Beauchamp A, Dodson S, Elsworth GR, Osborne RH. The Optimising HEalth LIterAcy (Ophelia) process: Study protocol for using health literacy profiling and community engagement to create and implement health reform. 2014. Available from: https:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-14-694

[53] Adult Basic and Literacy Education Inter-agency Coordinating Council. A Report on Health Literacy. Pennsylvania State University. 2002. Available from: http://www. csg.org/knowledgecenter/docs/ ToolKit03HealthLiteracy.pdf

[54] Mayagah K, Wayne M. Promoting Health and Development: Closing the Implementation Gap. World Health Organization Report, Nairobi, Kenya; 2009. pp. 26-30

[55] Lam Y, Broaddus ET, Surkan PJ. Literacy and healthcareseeking among women with low educational attainment: Analysis of cross-sectional data from the 2011 Nepal demographic and health survey. International Journal for Equity in Health. 2013;**12**:95. DOI: 10.1186/1475-9276-12-95

[56] Chesser AK, Keene Woods N, Smothers K, Rogers N. Health literacy and older adults: A systematic review. Gerontology & Geriatric Medicine. 2016;**2**:1-13. DOI: 10.1177/2333721416630492

[57] Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006

[58] Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Health Literacy: Report of the Council on Scientific Affairs. JAMA. 1999;**281**(6):562-564. DOI:10.1001/ jama.281.6.562

[59] Amini S. Poor Health Outcomes Associated with Low SES Status; How Poverty Can Be a Determinant of Health. University of Florida(UF) Health; 2016

[60] Broemeling A-M, Watson D, Black C. Chronic Conditions and Co-Morbidity Among Residents of British Columbia. Vancouver, BC: Centre for Health Services and Policy Research; 2005. Available from: https://www.researchgate.net/ publication/255585868\_Chronic\_ conditions\_and\_co-morbidity\_among\_ residents\_of\_British\_Columbia

[61] Gilmour H, Park J. Dependency, chronic conditions and pain in seniors. Health Reports. 2006;**16**(supplement):21-32. Statistics Canada catalogue no. 82-003-SIE

[62] van der Heide I, Poureslami I, Mitic W, Shum J, Rootman I, Mark Fitz Gerald J. Health literacy in chronic disease management: A matter of Interaction. Journal of Clinical Epidemiology. 2018;**2**:134-138

[63] Canadian Council on Learning. State of Learning in Canada: No Time for Complacency. Canadian Council on Learning; 2007. Available from: https://www.dartmouthlearning.net/ wp-content/uploads/2013/02/Stateof-Learning-in-Canada-No-Time-for-Compacency-2007.pdf

[64] Current Clinical Issues. The crucial link between literacy and health. Annals of Internal Medicine. 2003;**139**(10):875- 878. DOI: 10.7326/0003-4819-139-10- 200311180-00038

[65] Schloman B. Health literacy: A key ingredient for managing personal health. Online Journal of Issues in Nursing. 2004;**9**(2):6

[66] Center on an Aging Society at Georgetown University. Low Health Literacy Skills Increase Annual Health Care Expenditures by \$73 Billion. Center on an Aging Society at Georgetown University. 1999. Available from: https://hpi.georgetown.edu/ healthlit/

[67] Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. Journal of the American Medical Association. 2002;**288**(19):2469-2475

[68] Appelbaum PS. Review clinical practice. Assessment of patients' competence to consent to treatment. The New England Journal of Medicine. 2007;**357**(18):1834-1840

[69] Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2003

[70] Isham G. Opportunity at the Intersection of Quality Improvement, Disparities Reduction, and Health Literacy, Toward Health Care Equity and Patient-Centeredness. Institute of Medicine Workshop Summary. 2009

[71] UNESCO. 2009. Available from: http://www.unesco.org/en/ efa-international-coordination/ the-efa-movement/efagoals/ adult-literacy/27

[72] Sihota S, Lennard L. Health lLiteracy: Being able to make the most of health. In: National Consumer Council. 2004

[73] Koh HK, Berwick DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly 'crisis care'. Health Aff (Millwood). 2012;**31**(2):434-443. DOI:10.1377/ hlthaff.2011.1169

[74] Mia M, Omar A. Technology Advancement in Developing Countries During Digital Age. 2012. Available from: https://pdfs.semanticscholar.org/22b7/522 50e726faefd35c64d8836328533bc4c42.pdf

[75] Health literacy Australia. Australian Bureau of Statistics. 2006. Available from: http://www.ausstats.abs.gov.au/ ausstats/subscriber.nsf/0/73ED158C6 B14BB5ECA2574720011AB83/\$File/42 330\_2006.pdf

[76] Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: A study of patients with hypertension and diabetes. Archives of Internal Medicine. 1998;**158**:166-172

[77] Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. Journal of General Internal Medicine. 1998;**13**:791-800

[78] Board on Neuroscience and Behavioral Health, Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004

[79] Pan American Health Organization. Regional declaration on the new orientation for primary health care (Declaration of Montevideo), 46th Directing Council, 57th Session of the Regional Committee, Washington, D.C., Sept. 26-30 (CD46/13). 2005

[80] Johnston Lloyd L, Ammary N, Epstein L, Johnson R, Rhee K. A trans disciplinary approach to improve health

**33**

*Health Literacy: An Intervention to Improve Health Outcomes*

[89] National Center for Cultural Competence. Cultural Competence. Center for Child and Human

1989. Available from: https:// nccc.georgetown.edu/curricula/ culturalcompetence.html

Development: Georgetown University;

[90] Heurtin-Roberts S, Reisin E. The relation of culturally influenced lay models of hypertension to compliance with treatment. American Journal of Hypertension. 1992;**5**(11):787-792

[91] Morse A. Language access: Helping non-english speakers navigate health and human services. In: National Conference of State Legislature's Children's Policy Initiative; 2003

[92] DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, et al. Health Literacy Universal Precautions Toolkit. (AHRQ Publication No. 10-0046-EF). Rockville, MD: Agency for Healthcare Research and Quality;

[93] Cooper LA, Roter DL. Patientprovider communication: The effect of race and ethnicity on process and outcomes in health care. In: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Baltimore, Maryland: Johns Hopkins

[94] Zborowski M. Cultural components in response to pain. Journal of Social

[95] Zola IK. Culture and symptoms: An analysis of patients' presenting complaints. American Sociological Review. 1966;**31**(5):615-630

[96] Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, et al. Race, gender, and partnership in the patient-physician relationship. Journal of the American Medical Association.

2010

University; 2003

Issues. 1952;**8**(4):16-30

1999;**282**(6):583-589

*DOI: http://dx.doi.org/10.5772/intechopen.86269*

literacy and reduce disparities. Health Promotion Practice. 2006;**3**:331-335

Confusion. 2004. Available from: http://

[82] Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy. Washington, DC: Department of Health Policy, School of Public Health and Health Services, The George Washington University; 2007

[83] Rootman I, Ronson B. Literacy and Health in Canada: What We Have Learned and What Can Help in the Future? 2003. Available from: http:// www.cpha.ca/uploads/portals/h-l/

[84] Schwartzberg JG, Cowett A, Vangeest J, Wolf MS. Communication techniques for patients with low health literacy: A survey of physicians, nurses and pharmacists. American Journal of Health Behavior. 2007;**31**(Suppl

[85] UN Chronicle. Health Literacy and Sustainable Development. The Magazine of the United Nation.

[86] World Health Organization. Definition of an Older or Elderly Person. Geneva: 2014. Available from: https://www.who.int/healthinfo/survey/

[87] Paul A, Bourne CM. Health literacy and health seeking behavior among older men in a middle income nation. Patient Related Outcome Measures.

[88] Baker DW. The meaning and the measure of health literacy. Journal of General Internal Medicine.

literacy\_e.pdf

1):S96-S104

2009;**XLXI**(1&2).p. 1

ageingdefnolder/en/

2010;**2010**:39-49

2006;**21**(8):878-883

[81] Institute of Medicine. Health Literacy: A Prescription to End

www.iom.edu/?id=19750

#### *Health Literacy: An Intervention to Improve Health Outcomes DOI: http://dx.doi.org/10.5772/intechopen.86269*

literacy and reduce disparities. Health Promotion Practice. 2006;**3**:331-335

*Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs)...*

[73] Koh HK, Berwick DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly 'crisis care'. Health Aff (Millwood). 2012;**31**(2):434-443. DOI:10.1377/

[74] Mia M, Omar A. Technology Advancement in Developing Countries During Digital Age. 2012. Available from: https://pdfs.semanticscholar.org/22b7/522 50e726faefd35c64d8836328533bc4c42.pdf

[75] Health literacy Australia. Australian Bureau of Statistics. 2006. Available from: http://www.ausstats.abs.gov.au/ ausstats/subscriber.nsf/0/73ED158C6 B14BB5ECA2574720011AB83/\$File/42

[76] Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients' knowledge of their chronic disease: A study of patients with hypertension and diabetes. Archives of Internal Medicine.

[77] Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. Journal of General Internal Medicine.

[78] Board on Neuroscience and

Regional declaration on the new orientation for primary health care (Declaration of Montevideo), 46th Directing Council, 57th Session of the Regional Committee, Washington, D.C.,

Sept. 26-30 (CD46/13). 2005

[80] Johnston Lloyd L, Ammary N, Epstein L, Johnson R, Rhee K. A trans disciplinary approach to improve health

Behavioral Health, Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National

[79] Pan American Health Organization.

hlthaff.2011.1169

330\_2006.pdf

1998;**158**:166-172

1998;**13**:791-800

Academies Press; 2004

of Internal Medicine. 2003;**139**(10):875- 878. DOI: 10.7326/0003-4819-139-10-

[65] Schloman B. Health literacy: A key ingredient for managing personal health. Online Journal of Issues in

[66] Center on an Aging Society at Georgetown University. Low Health Literacy Skills Increase Annual Health Care Expenditures by \$73 Billion. Center on an Aging Society at Georgetown University. 1999. Available from: https://hpi.georgetown.edu/

[67] Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. Journal of the American Medical Association. 2002;**288**(19):2469-2475

[68] Appelbaum PS. Review clinical practice. Assessment of patients' competence to consent to treatment. The New England Journal of Medicine.

[69] Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National

[70] Isham G. Opportunity at the Intersection of Quality Improvement, Disparities Reduction, and Health Literacy, Toward Health Care Equity and Patient-Centeredness. Institute of Medicine Workshop Summary. 2009

[71] UNESCO. 2009. Available from: http://www.unesco.org/en/ efa-international-coordination/ the-efa-movement/efagoals/

[72] Sihota S, Lennard L. Health lLiteracy: Being able to make the most of health. In: National Consumer Council. 2004

adult-literacy/27

2007;**357**(18):1834-1840

Academies Press; 2003

200311180-00038

Nursing. 2004;**9**(2):6

healthlit/

**32**

[81] Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. Available from: http:// www.iom.edu/?id=19750

[82] Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy. Washington, DC: Department of Health Policy, School of Public Health and Health Services, The George Washington University; 2007

[83] Rootman I, Ronson B. Literacy and Health in Canada: What We Have Learned and What Can Help in the Future? 2003. Available from: http:// www.cpha.ca/uploads/portals/h-l/ literacy\_e.pdf

[84] Schwartzberg JG, Cowett A, Vangeest J, Wolf MS. Communication techniques for patients with low health literacy: A survey of physicians, nurses and pharmacists. American Journal of Health Behavior. 2007;**31**(Suppl 1):S96-S104

[85] UN Chronicle. Health Literacy and Sustainable Development. The Magazine of the United Nation. 2009;**XLXI**(1&2).p. 1

[86] World Health Organization. Definition of an Older or Elderly Person. Geneva: 2014. Available from: https://www.who.int/healthinfo/survey/ ageingdefnolder/en/

[87] Paul A, Bourne CM. Health literacy and health seeking behavior among older men in a middle income nation. Patient Related Outcome Measures. 2010;**2010**:39-49

[88] Baker DW. The meaning and the measure of health literacy. Journal of General Internal Medicine. 2006;**21**(8):878-883

[89] National Center for Cultural Competence. Cultural Competence. Center for Child and Human Development: Georgetown University; 1989. Available from: https:// nccc.georgetown.edu/curricula/ culturalcompetence.html

[90] Heurtin-Roberts S, Reisin E. The relation of culturally influenced lay models of hypertension to compliance with treatment. American Journal of Hypertension. 1992;**5**(11):787-792

[91] Morse A. Language access: Helping non-english speakers navigate health and human services. In: National Conference of State Legislature's Children's Policy Initiative; 2003

[92] DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, et al. Health Literacy Universal Precautions Toolkit. (AHRQ Publication No. 10-0046-EF). Rockville, MD: Agency for Healthcare Research and Quality; 2010

[93] Cooper LA, Roter DL. Patientprovider communication: The effect of race and ethnicity on process and outcomes in health care. In: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Baltimore, Maryland: Johns Hopkins University; 2003

[94] Zborowski M. Cultural components in response to pain. Journal of Social Issues. 1952;**8**(4):16-30

[95] Zola IK. Culture and symptoms: An analysis of patients' presenting complaints. American Sociological Review. 1966;**31**(5):615-630

[96] Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, et al. Race, gender, and partnership in the patient-physician relationship. Journal of the American Medical Association. 1999;**282**(6):583-589

**35**

Section 2

Managing Patients in the

Hospital Setting

[97] Center for Substance Abuse Treatment (US). Improving Cultural Competence. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2014 (Treatment Improvement Protocol (TIP) Series, No. 59) 1, Introduction to Cultural Competence. Available from: https:// www.ncbi.nlm.nih.gov/books/ NBK248431/

[98] DeWalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL. A heart failure self-management program for patients of all literacy levels: A randomised, control trial. BMC Health Services Research. 2006;**6**(30):1-10

[99] Rothman R, De Walt D, Malone R, Bryant B, Shintqani A, Crigler B, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes management program. Journal of the American Medical Association. 2004;**292**(14):1711-1716

Section 2
