SEA-HE-212 Distribution: General
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era Nay Pyi Taw, Myanmar, 4-6 July 2017
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era SEA-HE-212 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons AttributionNonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for noncommercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. South-East Asia Regional Meeting on Health Literacy for health and wellbeing in the SDGs Era. [New Delhi]: World Health Organization, Regional Office for SouthEast Asia; 2007. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
Contents Page 1. 2. Background ................................................................................................. 1 Introduction ................................................................................................. 4 2.1 General Objectives ............................................................................. 7 2.2 Specific Objectives ............................................................................. 7 3. Opening Session: ........................................................................................ 7 3.1 Opening Statement from Regional Director WHO South-East Asia, delivered by WHO Representative to Myanmar, Dr Stephan Paul Jost ....................................................... 7 3.2 Opening Remarks by His Excellency Minister of Myanmar .......... 10 4. Business Session ...................................................................................... 13 4.1 Keynote address: “Health literacy in the Global Development 2030” presented by Professor Dr Richard Osborne ....................... 13 4.2 Global Commitments on Health Literacy from Health Promotion “Shanghai Declaration” and call to actions .................. 15 4.3 Health Literacy and Health Promotion Strategies in South-East Asia: Overview linkage to NCDs, School health programmes, health services, and mental health .................................................. 15 4.4 Role of Health Literacy in achieving health goals and reduce health inequities: .............................................................................. 18 4.5 Health literacy, community, and sustainable development: .......... 19 4.6 Health Literacy studies, research, and practices in South-East Asia ................................................................................................... 20 4.7 Implementation and Initiation of Health Literacy at country level (Myanmar & Thailand experiences) ........................................ 22 4.8 Group work 1: key areas for implementation in South-East Asia countries ................................................................................... 25
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4.9 Health literacy in policy development and health governance ....... 25 4.9 Media, education, and technologies for health literacy .................. 27 4.10 Group work 2: country roadmaps toward health literacy for health and well-being in SDGs era .................................................. 28 5. Draft Strategic pathways to strengthen health literacy in South-East Asia to achieve health and well-being in sustainable development ....... 30 5.1 Key message ..................................................................................... 30 5.2 Two pathways to strengthen health literacy in South-East Asian Countries: ............................................................................... 33 6. Ways forward and recommendations ...................................................... 34 Annexes 1. 2. Agenda ....................................................................................................... 36 List of participants .................................................................................... 42
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1.
Background In 2006 the concept of health literacy was used to within the health education and communication fields and focused on applying literacy skills to health materials such as prescriptions, appointment cards, medicine labels, etc. In Europe health literacy was positioned as a potential outcome of health promotion actions where measures of health literacy focused on health-related knowledge, attitudes, motivation, behavioural intention, personal skills, and self-efficacy. Thus, these approaches to health literacy mainly relate to fundamental education and/or literacy levels of individuals. The 7th Global Conference on Health Promotion (7GCHP) 2009 in Nairobi clearly outlined that health literacy goes beyond a narrow concept of health education and individual behaviour-oriented communication, and addresses the environmental, political, and social factors that determine health. The “Nairobi Call to Action” 2009 urged all governments and stakeholders to response to strategic actions including health literacy interventions that need to be designed based on health, social, and cultural needs. Health literacy is not a sole responsibility of individuals, but equally the roles of governments and health systems to present clear, accurate, appropriate, and accessible information for diverse audiences. Health literacy has benefits at both the personal and social levels. The United Nation ECOSOC Ministerial Declaration of 2009 also provided a clear mandate for action: “We stress that health literacy is an important factor in ensuring significant health outcomes and in this regard, call for development of appropriate action plans to promote health literacy.” 2013, WHO European Office published “Health literacy; the solid facts,”. This publication described health literacy as a means and outcome of actions promoting empowerment and participation of people in health care, which is a key dimension of Health 2020. WHOEURO introduced the European Health Literacy Survey showing prevalence and levels of health literacy across education, income, and 1
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
cultural background. A “General health literacy index” was categorized into very poor, poor, fair, good, and very good. National data and comparative study across European countries were generated. Health literacy was then promoted as a key determinant of health and plain language initiatives were launched along calls for a whole-of-government responses to health literacy. In 2014, the Outcome Document of the high-level Meeting of the UN General Assembly on the comprehensive review and assessment of the progress achieved in the prevention and control of NCDs government committed to continue to develop, strengthen and implement multisectoral public policies and action plans to promote health education and health literacy, with a particular focus on populations with low health awareness and/or literacy.” Health literacy has become an interface between people and professionals, and in different settings. Leaders who understand health and able to promote health literacy across sectors can use health literacy as means to achieve development goals. The Healthy City Movement is an example where health literacy contributes to decision makers, politicians, citizens, and professionals in many sectors to be conscious of health and continue to improve the physical appearance of cities, social environments, and to expand community resources to enable people to develop their maximum potential for health and well-being. December 2013, WHO-SEARO in collaboration with Deakin University organized a workshop on “Creating systemic processes for maximising equity and access to health care in Asia: the role of health literacy,” at the Health System in Asia Conference. The outcomes of the workshop identified needs for health literacy in the region, the importance of community participation in making health decision, innovative forms of communication with specific disadvantage groups such as slum dwellers, street vendors, or people in extreme social dislocation; multiple measurement tools, roles of families, volunteer health workers, and peers as health literacy facilitators; roles of health literacy in bringing multisectoral collaboration to address social determinants of health. To understand and improve the level of literacy among less develop countries, innovative approaches are required to enhance 2
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
population-based health literacy, focusing not only the individual, but also focusing at communities and the development of social capital. WHO SEARO developed a “Health Literacy Toolkit: for Low- and Middle-income Countries” in 2014 as a series of information sheets to empower communities and strengthen health systems. Measuring health literacy is part of the process to design appropriate health interventions that response to needs of individual and communities, using available health and social resources optimizes the sustainability and scalability of health literacy interventions. The toolkit was launched in the 4th World Congress of Public Health in Calcutta, 2014. Four countries in the region, namely Thailand, Indonesia, Nepal and Myanmar, have been adopting and adapting the whole and some parts of the toolkit to implement health literacy in their respected countries. Some institutions in India and Bhutan expressed interest in pursuing health literacy in their countries, however work has yet to start. Deakin University’s WHO Collaborating Center for Health Literacy has been working closely with several institutes in SEAR countries with WHO-SEARO guidance and supports. In 2015, health literacy workshops were organized as part of the 22nd International Conference on Health Promotion organized by IUHPE, in Thailand and a part of the 2nd International Health Promoting Hospital in Medan, Indonesia, partially supported by SEARO. Health literacy has subsequently became known in the region. The Health Systems Research Institute, MOPH, Thailand completed a series of studies, including comprehensive consultations across the country, to develop a unique set of questionnaires/tools for health literacy including special versions for people who were blind, deaf or with other. Academic institutes in Indonesia began to work with these health literacy tools for health literacy measurement in the country. The Regional Workshop on Health Promotion in Sustainable Development, 2016 placed health literacy as one of the key actions areas toward achieving the sustainable development goals and calls for health literacy capacity strengthening for SEAR countries. WHO 9th Global Conference on Health Promotion November 2016, resulted in the Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development recognized health 3
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
literacy as a critical determinant of health and calls for investment in its development. Member States have committed to develop, implement, and monitor intersectoral national and local strategies for strengthening health literacy in all populations and in all educational settings, in order to increase citizens’ control of their own health and its determinants, and to ensure that consumer environments support healthy choices through pricing, policies, transparent information, and clear labelling. The Global Coordinating Mechanism on NCD (GCM/NCD) has set up the first meeting with technical working group on health literacy and health promotion in Geneva in February 2017. With two members from each of the six WHO regions, Member States are actively developing recommendations for global health literacy actions to improve NCD control and management.
2.
Introduction Since 2009 the World Health Organization has 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 which promote and maintain good health. Health Literacy means more than being able to read pamphlets, successfully make appointments, understand food labels, or comply with prescribed actions from doctors. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment. http://www.who.int/healthpromotion/conferences/7gchp/track2/en/ World Health Day 2017 focused on “Depression: Let’s talk” resonates with the need for mental health literacy which is absent in most of countries and inadequately understood by public health professions. Health literacy is important to physical and mental health and general well-being of the population. Accelerating prevention of NCD and chronic illness management Health literacy is an important means to support actions to control and prevent NCDs. Pictorial health warnings, especially on tobacco
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product package, have emerged as a specific and cost-effective application of the basic function of health literacy. As compare with text-based warnings, large pictorial health warnings have been shown to have greater impacts in alerting consumers to harms of tobacco products, while overcoming literacy challenges, especially among low literacy populations, children and young people. Similarly traffic light labelling for foods in school cafeteria, restaurants, and on food packages, shows almost universal understanding by consumers, bypassing language barriers and other issues inherent in written nutrition labelling or text warnings. Health literacy is also a mean to enhance chronic illness management and accelerate quality of care within health system because it involves abilities to seeking, understanding, and use health information within health care setting. A critical ability of patients and families to seek health information determines whether they required immediate medical attention or could be self-managed, within the context of health care system they encounter or experience. Health literacy encompasses patient health literacy, patient-health profession interaction, and broader determinants such as the health care system, economic factors, education, social support, cultural influences, attitudes and past experiences. Studies have shown that people who have a high degree of health literacy (regardless their formal educational level), can navigate health system and manage health care better than those with low health literacy. Mental health literacy and stigma reduction WHO-mhGAP 2014 reveals that mental disorders constitute 14% of the global burden of disease, and yet large numbers of people across populations have mental illness but go undiagnosed and untreated due to lack of knowledge and negative attitudes toward mental illness. Mental health literacy is an important part of mental health promotion which can enhance people’s ability to obtain, access and use mental health information. Persons with better understanding of mental illness are more likely to access mental health care, are less likely to hold stigmatising attitudes and as a result they are more likely to treat a person with mental illness with dignity. Mental health literacy includes not only knowledge of basic mental health care, but also an understanding of social environments that are conducive to
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recovery, respect for self-determination, the importance of safety and security, personal liberty and legal capacity, freedom from inhuman or degrading treatment and from exploitation, violence and abuse as well as the right to live independently and be included in the community. Studies show that mental health education for general population in the region has been lacking and absent from health promotion and education for the most part. There is inadequate knowledge of mental health literacy within communities, and how socio-cultural factors such as stigma affect the realization of mental health care and support. For policy makers and the enhancement of multisectoral actions The role of health literacy and its potential for achieving development goals first came to high level attention in the UN Economic and Social Council (ECOSOC) in 2009 show in the Report of Annual Ministerial Review Regional Preparatory Meeting on Promoting Health Literacy. Health literacy was recognized as effective interventions in countries outside the Asia and Pacific region, except Thailand that utilize health literacy approachs to increase prevention and control of HIV/AIDS, education on breastfeeding, and pictorial warning for tobacco control. The report showed that mass media campaigns and classroom-based health education are insufficient to increase health literacy and bring behavioural changes. Health literacy that enhances multi-sectoral collaboration across sectors are one of the key factors, especially when health literacy of policy makers in other sectors increase. For example city mayors and governors who have a high level of health literacy can make positive impacts on the health of populations in cities and foster multisectoral supports to achieve development goals. Health literacy strengthening in community-based organizations and education sectors plays important roles in advancing health literacy, especially in combination with promotion of better access to and use of information and technology to empower stakeholders. Promotion of health literacy means to empower individuals, families, and communities, with increased skills and resources that they can apply in collective efforts to address health priorities and make government and relevant sectors accountable for the health consequences of their policy and practices.
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2.1
General Objectives To develop regional actions to implement health literacy in SouthEast Asia
2.2
Specific Objectives (1) (2) To share country experiences and best practices on health literacy and health promotion actions To update and exchange global progress, international approaches, tools and methods to support implementation of health literacy and health promotion in SDGs era. To facilitate the development of draft country plans for actions to implement health literacy in SDGs
(3)
3. 3.1
Opening Session: Opening Statement from Regional Director WHO SouthEast Asia, delivered by WHO Representative to Myanmar, Dr Stephan Paul Jost Your Excellency, Union Minister of Health and Sports, delegates, distinguish guests, and colleagues, It is with great pleasure that I welcome you to this Regional Meeting on Health Literacy for Health and Wellbeing in the Sustainable Development Era. Although our Regional Director would have very much liked to attend this important event, she is unable to do so due to a prior commitment. I take great pleasure in delivering the following message to you on her behalf. The Regional Director says media and health literacy are intertwined and influence the way people access, understand and use information. She emphasizes that good health literacy is critical for lifelong health and wellbeing.
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
Since 2009, she says, the World Health Organization has 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 which promote and maintain good health.” The Regional Director says health literacy is key to health promotion and empowering individuals to achieve their health goals, develop their knowledge and potential, and participate fully in the community and wider society. She says citizens who are health literate can effectively engage in health promotion and prevention of diseases; can understand their rights as patients and better navigate health systems; can stay informed of the health risks of products or services and about options in health services; and can act individually or collectively to improve health through participation in civil society. Dr Khetrapal Singh says that since the Seventh WHO Global Conference on Health Promotion in 2009 health literacy has been a core component of health promotion. She says the 7th Global Conference on Health Promotion resulted in the ‘Nairobi Call to Action’, which states clearly that health literacy goes beyond narrow concepts of health education and individual behavior-oriented communication, and instead addresses the environmental, political, and social factors that determine health. The Regional Director says that health literacy is a complex phenomenon involving individuals, families, communities and systems, and that within these systems are consumers, patients, caregivers and other laypersons whose situation may vary with respect to access, skills, knowledge, ability, life stage, culture, language or education. She says many patients will have a limited understanding of health and medical vocabulary, concepts such as risk or knowing how the health care system functions. These individuals and their families may not have the skills to gather or comprehend health information, or to speak and share personal health history or symptoms. She says they may also lack the skills to act on information to comply with medical procedures, or to make health-positive decisions such as healthy eating and exercising or managing chronic disease.
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
The Regional Director says the principles of health literacy can help control and prevent NCDs. Pictorial health warnings on tobacco product packages, for example, are more effective than text-based warnings, especially among low literacy populations, children and young people. Similarly, the Regional Director says, traffic light labelling for foods in school cafeterias, restaurants and on food packages is nearly always understood by consumers. Dr Khetrapal Singh says mental health literacy is another important part of mental health promotion, as it enhances an individual’s ability to obtain, access, and use mental health information effectively to seek appropriate health care. She says mental health literacy can reduce the stigma of mental and neurological disorders and can also include understanding the social and environmental conditions conducive to recovery among other key factors. The Regional Director says the impact of health literacy in achieving development goals first came to high level attention in the UN Economic and Social Council (ECOSOC) in 2009, which emphasized that health literacy enhances multi-sectoral collaboration across sectors through increasing health literacy among policy makers in other sectors. Dr Khetrapal Singh says that in 2016 WHO’s 9th Global Conference on Health Promotion in Shanghai demonstrated that city mayors and governors who have high levels of health literacy have a positive impact on public health and foster multisectoral support to achieve development goals. The Regional Director believes that health literacy among policy makers, community-based organizations and the education sector plays an important role in advancing health literacy while promoting health and wellbeing, as well as access to and use of information and technology that empowers people. Dr Khetrapal Singh says the WHO South-East Asia Regional Office is committed to advancing health literacy in the Region. The Regional Director is pleased that Myanmar’s Ministry of Health requested WHO SEARO to organize this first regional meeting on
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
health literacy in the SDG era, realizing the importance of health literacy in working across sectors and strengthening health systems. The Regional Director appreciates the presence of colleagues from the Global Coordination Mechanism for NCDs Technical Working Group on Health literacy, technical advisors and academic institutes, particularly Deakin University, who have been working with WHO SEARO to develop a health literacy toolkit for low- and middle-income countries. She also appreciates the presence of WHO Colleagues from headquarters and country offices who have joined Member States to build health literacy and enhance sustainable development. Finally, the Regional Director expresses her wish to host more activities of the GCM and its working groups, noting the positive national and regional impact hosting such events can have. She wishes you successful deliberations and a productive meeting. Excellency, distinguished participants, I echo that sentiment and wish you all the best. Thank you.
3.2
Opening Remarks by His Excellency Minister of Myanmar His Excellency Minister of Myanmar, Dr Mytn Htwe, gave his opening remarks by thanking WHO-SEARO for bringing international meeting on health literacy to Myanmar. He values the opportunity for member states to shared experiences, success and challenges in promoting health literacy. He recognized that different countries are in different stages of developing health literacy. He echoed the background documents of this workshop that a lot more to be done especially in areas where people were neglected, under-served, hard-to-reach. Dr Mytn Htwe considered health literacy as important actions from health promotion that all public health officers need to translate knowledge into actions ensuring people that the information we have given are made into practice. Health sector need better equipped themselves to understand health literacy and promote it accordingly.
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
H.E. Minister recognized numbers of factors underlying people health behaviours that could not be tackled without health literacy. These factors include education, social and economic conditions, cultural belief systems. He emphasized that health sector needed to understand these underlying factors while promoting health literacy in appropriate manners so that people can translate what they learnt from health education and information into practices. He stated that the subject is also important to all ministries and all states. Minister of Health and Sports, Myanmar recognized this importance of health literacy, thus create a new division to promote health literacy in the country. Dr Mytn Htwe urged participants to consider the why and how to translate health knowledge into actions and influences the publics for healthier nation, healthier states. He suggested that health sector need to increase people understanding of health and become empowered peer pressure groups to promote health. His vision includes that of where all states in Myanmar will promote health literacy, health officers, health promotors, health literacy officers become key man power to promote health, be peer groups to impart their knowledge to society. Under his leadership, Myanmar Health Ministry is committed for the next 10 years for health literacy in Myanmar as he had put this issue as one of his top three priorities. He also would like to focus more on the hard-to-reach population and underserved areas rather than main city like Yangon. H.E. Minister emphasized the need to promote health literacy among medical and public health staffs. They play important roles in operationalize health literacy, where more communication skills are also needed. He announced to all Director Generals, and all of health officers, to develop health literacy in all programme areas. Within one year he would like to see health literacy is streamlined for the whole ministry. His vision is also to have customized digital tool/divice and software to guide medical and public health officers to become more skillful and use health literacy in their practices in every day operations. Dr Mytn Htwe noted the objectives of the workshop and applauded the well focus objectives with clear vision to develop strategy for the region, and facilitate the countries to develop plan of actions on health literacy in the view of SDG. He highly appreciated 11
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
and considered this workshop a good strategic work for SEARO to bring health and development agendas into practices. He urged all participants to read background papers of this workshop, including the Shanghai Declaration on Health Promotion, the Ottawa Charter for Health Promotion. He echoed that we had come a long way from trying to provide health for all and now all for health. He encouraged participants to read the WHA and RC resolutions relevant to health promotions and link them with actions to promote healthy life-styles while trying to reach universal health coverage. Students and workers in different industries should be primary target population to promote health literacy. Students from primary, secondary schools to university should have health literacy. Involving these groups of population generate long-term gains for the whole society. He finally commenced WHO-SEARO and the operation officer, Dr Suvajee Good, for putting also research in the agendas. He considered having operational research contributed a great deal not only knowing the situation but also strengthen capacity to improve the situation and promote further skills on health literacy. He appreciated WHO-SEARO and urged SEARO to integrate health literacy in all programme areas where all technical officers made to understand how to operate health literacy in their programmes, not only NCD, but also HIV, MCH, malaria, TB and other programmes. Dr Myth Htwe would like to see the progress in two-three year time and way forward to achieving SDG. He stated that “I seriously urge WHO-SEARO to promote health literacy in all of our Member States with sufficient budget for implementation.” He would like to propose this topic as an agenda for the next Regional Committee. He conveyed his message of appreciation for Regional Director and declare the official opening of the workshop.
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4. 4.1
Business Session Keynote address: “Health literacy in the Global Development 2030” presented by Professor Dr Richard Osborne Professor Osborne emphasized importance of health literacy as one of the global instruments to achieve the 2030 Sustainable Development Goals, particularly SDG 3 “Good health and Well-being”. The WHO 9th Global Conference on Health Promotion in Shanghai reaffirms that health and well-being are essential to achieving sustainable development and health is a shared social goal and political priority for all countries. Key areas of actions to promote health in the 2030 SDG include good governance, healthy cities and communities, and health literacy. Dr Osborne described the evolution of health literacy since 1980s to the SDG era and several definitions of health literacy emerging over the years. Dr Osborne explained how health literacy can be utilized to support countries to achieve SDGs. First countries need to recognize that health literacy is a critical determinant of health and governments need to invest in its development. Secondly, governments need to develop, implement, and monitor intersectoral strategies to strengthen health literacy in all populations and in all education settings. Third, health literacy can increase people’s capacities to take control over their own health and its determinants which are the ultimate goals of health promotion. With the help of digital technology, health literacy implementation could take advantage of reaching out to larger populations. Lastly, health literacy can ensure that consumer environments support healthy choices through pricing policies, transparent information and clear labeling. Health literacy can be applied in different ways, with different target groups and different tools. In order to achieve health outcomes and equity, we must strengthen the health literacy of individuals and communities as this will enable a broad range of populations to change their health behaviours, adopting healthier lifestyle, increasing ability to participate in screening for early prevention, facilitate people to seek appropriate treatment, and will enable
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communities to collectively raise concerns about conditions that affecting their lives and the lives of their families. While a key aim of heath literacy is to empower individuals and their families, a critical application of health literacy is the generation of ‘health literacy-responsive’ organizations and services. Ultimately, we need health and social care services enabled to be responsive to all members of society such that irrespective of their health literacy challenges, they are supported to get all the information, services and care that need in an equitable and timely manner. A major activity of the health delivery system is to deliver effective services. While every programme may wish to reach 100 per cent coverage and effectiveness, in reality almost all fall well short of this. The common scenario when interventions or services are initially created and delivered is that the programme starts with largescale efforts, relatively rapid and substantial wins which are achieved through the delivery of a few tasks that fit the ‘average’ person. As the intervention programme mature, the margin of return from investment on the programme becomes narrower, and consequently reaches a plateau followed by stagnation of the program and little no increase in reach and impact even with further investment. What is of important here is that the programmes designed and delivered to the ‘average’ consumer fail those not suited to the average program. Such ‘one size-fits-all’ approaches are likely to be improve outcomes and equity for a reasonable proportion of the population, but what is missing is a thorough understanding of what is not working for those for whom the current systems do not reach or neglect. Health literacy is a critical tool to understand why people are falling through the gaps and how to build new programmes that can reach a larger proportion of the population, and, ultimately, leave no one behind. Professor Osborne analyzed the reasons why health education and specific interventions were not effective for all people and how health literacy can provide solutions meeting the needs of people who were left out from major programmes and campaigns. Professor Osborne described the mechanism and system to implement health literacy which fosters coordination multisectoral co-design and actions among various sectors while tailoring the fit-for-purpose interventions for health literacy which can be extended to improving
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health literacy among policy makers, leaders, and managers to improve health and equity.
4.2
Global Commitments on Health Literacy from Health Promotion “Shanghai Declaration” and call to actions Dr Faten Ben Abdelaziz, Coordinator for Health Promotion, WHO-HQ could not attend the meeting but sent her presentation for Dr Suvajee Good to present on her behalf. From WHO-HQ perspectives, the Shanghai Declaration from the 9th Global Conference on Health Promotion put health literacy as a key action area that can be implemented in all levels. Dr Abdelaziz’s presentation emphasis the transformative approaches for health promotion that will lead to sustainable action and impacts. Health literacy needs to go beyond health communication and raising awareness through campaigns. She described basic requirements to achieve health literacy and key indicators for successful implementation. Dr Abdelaziz shared that WHO is working towards a global health literacy plan of action where steering advisory committee and technical advisory group are being set up. The goal is to effectively implement health literacy to support SDG agendas by 2030.
4.3
Health Literacy and Health Promotion Strategies in South-East Asia: Overview linkage to NCDs, School health programmes, health services, and mental health Dr Suvajee Good, Programme Coordinator for Health Promotion and Social Determinants of Health, WHO-SEARO introduced the Health Promotion Strategies in South-East Asia and how health literacy is placed in the regional strategies. Similar how people’s literacy contribute to social development, health literacy of policy-makers, high-level decision making officers across sectors will be key to ensure that every sectors consider health impacts/outcomes in their respected responsibilities. Dr Good analyzed the myths and gaps of understanding of health literacy and challenges in implementation. Dr Good also provided distinctions between traditional health education and health promotion and
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underlying theoretical perspectives. Dr Good shared key concepts and research on health literacy exists in South-East Asia. Health literacy in low resource settings with complex problems needs to be implemented with understanding of people health belief systems, linkage between education and literacy, how people access to information, services, resources, livelihood and how people manage their health, what kind of social capital exists for an individual, family, and communities. Practitioners of health literacy in the sustainable development goals will have to consider the social, economic and political context of health in decision-making, and policy development as well as understanding of development priorities across sectors. Current situation in South-East Asia is favoring implementation of health literacy, especially in countries where there is political commitments, a National Health Promotion Strategic Plan, and drive for capacity building on health literacy. Myanmar and Thailand represented the highest political commitments for health literacy where national government established institutional mechanism to implement health literacy, and the Minister of Health put health literacy in a high priority agenda. Countries such as Bhutan and Timor Leste that have national health promotion strategic plans that integrate health literacy and health in all policies, will be a suitable to start implementing health literacy. Countries that need health literacy at policy levels are Indonesia, Nepal, and India where health in all policies are being advocated. Numbers of countries can use health literacy to enhance or accelerate NCD interventions through tobacco control, food labeling, counter media advertisement. Dr Good introduced the WHO-SEARO health literacy toolkits for low- and middle-income countries. At the end, Dr Good concluded that “health literacy is beyond a measurement tool, it involves empowering processes for individual, community, and society to take control of their health and well-being with support from health systems and services, health policy, and other public policies for more sustainable society.” In absence of Dr Nazneen Anwar, regional advisor for mental health and Dr Angela De Silva, regional advisor for nutrition, Dr Good presented the two agendas based on the presentation prepared by 16
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
both regional advisors. For mental health, Dr Nazneen described the importance of mental health and neurological disorders in context of SDGs, issues on stigmatization, health literacy and utilization of mental health services and the role of health literacy in reaching the hard to reach or left-out populations. Dr Nazneen’s presentation showed that despite of availability of mental health services, 67% of adults and 80% of adolescent with mental illnesses are not receiving services. Mental health literacy composed of an ability to recognize symptoms, having knowledge of causes, and understanding or believing that mental illness require medical attention and ones need to seek help. From medical services promotion of mental health literacy to population will elevate presumptions that prevent people from utilizing the services, including the stigma surrounding mental health care and services. To advance mental health literacy to achieve SDGs, government and society need to address mental health literacy in a broader context to engage with multistakeholders to understand the needs and barriers, to integrate and implement mental health literacy through support from policy level. Mental health literacy should be integrated in existing health literacy implementation along with strengthening community responsiveness. In humanitarian situation, mental health literacy and psycho-social support for response and preparedness need to be considered and implemented along with health and emergency response. For health literacy and nutrition, Dr Good presented on behalf of regional advisor for nutrition and health development, highlighting double burden of malnutrition (obesity and under-nutrition) and nutrition transition changing diet patterns in low- and middle-income countries. More than ever, health sector needs to understand the determinants of malnutrition, ranging from behavior and biological factors; to social, economic, and environmental conditions; to political, economic and social system that influences available resources, etc. Global Nutrition targets are explained in the NCD targets to reduce salt and halt the rise in obesity and diabetes, while in the SDG targets, nutrition is linked between SDG2 linking food systems, nutrition and sustainable agriculture in the same goal, and SDG3 targets for NCD and preventable death of newborns and children under five from malnutrition. Health literacy will be an importance intervention to support nutrition and development issues, 17
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
by way of scale up evidence informed policy interventions reaching out vulnerable groups, by promoting an enabling environment for healthy and safe diets, and support community for effective implementation of nutrition policies.
4.4
Role of Health Literacy in achieving health goals and reduce health inequities: Participants from Indonesia, Myanmar and expert, Mr Roy Batterham presented how health literacy played roles in achieving health goals. From Indonesia, research found health literacy to be useful tool to provide care for TB patients and controlling diseases from health service delivery itself. Health literacy improve quality of care and strengthen health promoting hospitals in many cases. Dr Phone Myint Win, Burnet Institute for Medical Research and Practical Action, Myanmar, presented the role of health literacy in achieving health outcomes as joint actions of government partnership with academic and civil society. Key areas of experiences in Myanmar include integrated services between community- and clinic-based interventions to improve health and rights of Myanmar men who have sex with men. Increase health literacy of MSM, family, communities and health service delivery increased uptake of HIV counselling and testing as well as sexual health services in general. Other experiences included support for MDR-TB prevention and management, on maternal and child health, and adolescent reproductive health. Most of the projects and programmes have a substantial health literacy component and integrated approach to address socio-biological determinants of these diseases. Community awareness and knowledge of TB reduced stigma with peer support activities. The programmes will need to increase health literacy among stakeholders to close the gaps of service delivery and increase health literacy among partners. Mr Roy Batterham, expert on health literacy from WHOCC Health Literacy, Deakin University, demonstrated what need to be done and considered when implement health literacy in the key health goal in SDG, particularly goal 3.8 where achieving universal health coverage including financial risk protection, access to quality essential health-care services and essential medicines and vaccines.
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To ensure that health system leave no-one behind, new approaches to consider health literacy and social determinants of health are the keys. He presented the four intervention blocks toward achieving health goals are (a) health in al policies, (b) social determinants of health, (c) universal health coverage, and (d) health literacy (formation of health knowledge, beliefs, and decisions about health at all levels). Mr Batterham endorsed WHO-SEARO’s regional framework on health in all policies that rightly focus on the structure determinants of health (governance, policy development, human rights, transparencies, decentralization, and accountability) affecting population health; as well as the focus on the intersectoral and multisectoral actions and relevant policies that improve health system performance through UHC, primary health care and other disease control programmes. Health system can benefit from implementing health literacy in health care to improve quality of care and efficiency in service delivery process as well as reaching out to people in communities with better understanding. Health literacy in communities through health workers will also support people to manage their chronic illnesses, prevent NCDs through proactive care, and support people in all age groups who otherwise will be left out from the system. The expert emphasize that health literacy is best thought of as a problem solving tool, to assess and meet the needs of those who do not access or benefit from existing services. It has embedded approach to tackle inequities recognizing needs of different group of people in different contexts, including problems from service delivery itself or the treatment procedure. Health literacy strategy is to improve health of population and to improve service delivery while closing the gaps for people with low health literacy or difficult to be reached by services.
4.5
Health literacy, community, and sustainable development: Professor Osborne emphasize important of the goal of health literacy in closing the gaps and contextualize the practices for community needs. Dr Good and Professor Osborne jointly presented the
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importance of health literacy in the sustainable development goals. The panel concluded that In order to tackle health inequities, multisectoral interventions are needed from different players. Health literacy responsiveness and interventions that focus on vulnerable groups will be the key. Health literacy for nutrition, for example, will need to consider traditional knowledge and relationship between people and the land or water resources they used for their livelihood. Health literacy response through qualitative research will be more appropriate than measuring level of health literacy based on written language and one dimensional-knowledge based survey. It is critical for health research to engage with and use behavioral and social science knowledge to investigate health literacy needs before designing the interventions. Co-creation of interventions between technical professional persons and communities will be one of the ways to use health literacy in reducing health inequities and achieving other health goals. Community-based interventions as shown in the SEARO health literacy toolkit will be a significance contribution to the sustainable development goals. Example from Afghanistan on the “Golden Village Project” and positive deviance project were shared to the participants on how to turn around the professional driven projects to communitybased intervention and health literacy responsiveness to address health inequalities and equities in a more sustainable manner where people’s experiences and perspectives are considered at the centre of solutions.
4.6
Health Literacy studies, research, and practices in South-East Asia The session presented by Professor Chomar Kaung Myint, Head of Behaviour and Communication Department, University of Public Health, Myanmar and Dr Shyam Sundar Budhathoki, School of Public Health and Community Medicine, Nepal. Health literacy research in Myanmar began with assessment of health literacy status among rural population in Phapon township, Ayeyawady region of Myanmar. Professor Choma described that Myanmar’s health literacy was translated directly from the HLS-Asia questionnaire which emphasize three domains of health literacy:
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health care literacy, health literacy on disease prevention, and health promotion literacy. The finding shows 75% inadequate, 20% problematic, 4% sufficient, and none was excellent. From the study, most people do not know how to find information or understand health information and unable to judge health information nor knowing how to apply health information for their usage. The research provided situation for responsible agencies to develop intervention strategies to improve health literacy status. Another study that was done in Myanmar is on health literacy for prevention of behavioural risk factors of the NCD using the HL-Asia questionnaire to assess ability to obtain information provided by media and health personals, ability to process and understand information, ability to apply health information, and self-identified risk factors. Research on health education among teacher and students in monastic education reveals students had better understand of healthy behavior and applied in their daily life through school health programmes. Integrated health literacy in school to build capacity of teachers on health literacy long with creating healthy environment are key to response to health literacy needs for students in Myanmar. Dr Budhathoki, use health literacy toolkit developed by WHOSEARO, applying the principle of Optimize Health Literacy (OphiLia), the Health Literacy Questionnaires (HLQ), and ISHA-Q developed in Thailand. Since there was no baseline information on health literacy in Nepal, Dr Budhathoki started with literature review and found limited research related to health literacy yet not resonated with health literacy. It is common that people used disease awareness, knowledge or health education interchangeably with health literacy. He identifies key opportunities to utilize health literacy to address health and its determinants lie in the SDGs for Nepal, particularly SDG1, 2, 3, 4, 8, 9, 10, and16. Nepal has just completed the HLQ in Nepali version and ongoing research continues for chronic kidney illness patients in East Nepal. Measuring of outcomes of health literacy interventions is needed at all levels including for the people and communities. Researchers found key important impacts on health literacy interventions particularly impacts on how people access and utilize health services, how they have meaningful interactions with health service providers, how people care for their own health and of
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other in their families, and how they participate in decision making for important medical procedure. Dr Budhathoki found that the health literacy HLQ and ISHA-Q tools proposed in WHO-SEARO toolkit is valuable in identifying vulnerable population who potentially be left behind, and keeping track of people who are vulnerable, and those who should not be left behind. They are the people who have low health literacy. Dr Budhathoki strongly supports having health literacy implementation in Nepal as the time and commitment from the government particularly the Ministry of Health and Population.
4.7
Implementation and Initiation of Health Literacy at country level (Myanmar & Thailand experiences) Myanmar: Dr Pyu Phyu Aye, Director of Health Literacy Promotion Unit, Department of Public Health, Ministry of Health and Sports and Dr Ye Win, Myanmar Partnership and Lieison Manager, Deakin University and programme manager of Burnet Institute of Myanmar presented the implementation of initiation of health literacy in Myanmar. Dr Pyu Phyu Aye presented the health literacy initiative and leadership from the Minister of Health and Sport. The Health Literacy Promotion Unit was created to strengthen state and regional health department capacity to implement health literacy in coordinate between the Department of Public Health and Department of Medial Services. The Ministry has strong commitment on this initiative with secure fund to support health literacy, particularly at the community health centers for quality service delivery. Ministry of Health has an MOU with Burnet Institute of Myanmar (BIMM) to conduct numbers of public health research and provide technical support for health literacy. Deakin University and Burnette Institute of Myanmar signed another MOU on Deakin-Burnet Myanmar Public Health Partnership (MPHP) to enhance and improve the planning and delivery health services in Myanmar through the provision and participation in high quality research and trainings. Myanmar National Health Plan 2017-2021 has prioritized health
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literacy in joint research between departments where academic will be trained and provided training to students and others in a long term. Since beginning of 2017 the health literacy promotion unit conducted a series of advocacy and coordination activities with numbers of partners including WHO at all levels particularly in providing support for technical capacity and future development of national operational plan. Dr Ye Win Aung described research and collaboration between Deakin University and Burnet Institute Myanmar (BIMM) where capacity building workshop on health literacy to promote health for sustainable development are being pursuit right after the regional meeting of WHO. MOU between Ministry of Health and Sport and Burnet Institute Myanmar showed commitment from the government to develop continuing operational work plans. Two of the key important plans is to develop National Health Literacy Demonstration Project on NCD and the National Health Literacy Strategic Plan. He explained health literacy is important for Myanmar to tackle risk factors for NCDs, and improve childhood nutrition condition. Through research they have jointly create structure and system to implement health literacy and defined roles of the Central Health Literacy Promotion Unit to promote health literacy from disease specific to institution-based and community-based interventions with reporting systems from academic institutes and departments of the Ministry. Thailand: Dr Vijj Kasemsup, Lecturer from Department of Community Medicine, Faculty of Medicine, Ramathibodhi Hospital, Mahidol University, and Mr Saichon Kloyiam, Office of the Department of Health 4.0 and Health Literacy, Department of Health, Ministry of Public Health (MOPH), Thailand jointly presented the development of health literacy in Thailand. The Three key institutional processes that led to establishment of the Department of Health 4.0 and Health Literacy in November 2016 are the National Reform Steering Assembly, the Legislative Assembly, and the Cabinet. Technical groups in the Ministry of Public Health did research and came up with conceptual model of health literacy for Thailand using “Life-course approach” adapted from systematic review of integrated models published in the British Medical Journal. The model considered a range of situation people live in both social and environmental factors and life events that people have to go 23
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
through as individual and as a whole group of population. The outcome of interactions in all situations influence how people understand, appraise, apply and access to health care, or participate in health system for sustainable health and equity. Thailand has developed model that fit for Thailand called “Health literacy system: Thai HL Matrix-3 dimension” The model described different aspects of health literacy skills for self-care and disease prevention, promotion, screening, and utilize available health services of population in different setting and different stages of life. Dr Vijj Sasomsub explained that the government of Thailand has a policy to increase percentage of Thai citizens with good health literacy by 25% by the year 2021. This policy is under the 12th National Health Development Plan. To implement the policy, the MOPH organized the Promotion and Prevention Excellent Strategic Plan to discuss the road map. The most relevant policy/plan to implement health literacy in Thailand is the National Noncommunicable Disease Prevention and Control Strategic Plan. The Health Literacy Initiatives in Thailand began with having partnership with all sectors at different level with appropriate investment. Advocacy for regulation and institutionalized health literacy has been initiated. National Survey on Health Literacy staring in July 2017 (after the SEARO meeting) will provide a set of basic health information (knowledge, lifestyle, and health literacy skills). In 2018, the government planned to have target for “Health Literate Organization” for all units in the MOPH by the end of the year. By 2027, Thailand aims to have built-in health literacy capacity in at least 2,000 primary care clusters (PCC) for all family doctors using holistic approach to deliver care. Beside the institutional health literate organization, Thailand’s health literacy initiatives also aims to reac h hard to reach populations through hotlines for AIDS and unplanned pregnancies, quit line for smoking, emergency medical services, depression screening, as well as malaria control in Tak province border areas. With these aims, Thailand plans to increase health volunteer to promote health and increase access health care services from 3% to 30%. Under the universal health care (UHC), numbers of new services to provide care for chronically ill patients such as renal dialysis, hypertension, and others are increasing health care cost. Health 24
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
literacy for chronic illness management will be critical for Thailand to keep the UHC function at reasonable cost. MOPH gave emphasis on health literacy and community actions which still needs to be developed further. Dr Sasomsub and Mr Kolyiam reflected that the regional meeting on health literacy is timely for Thailand and they gained numbers of ideas and inputs from experts.
4.8
Group work 1: key areas for implementation in SouthEast Asia countries Participants were divided into groups of countries to consider which SDG targets are primary targets for public health and for the country at their best understanding of national policies for health and development agenda. The group also identified what health literacy issues or other issues that need to be addressed to bridge the gaps in achieving the SDG targets being discussed. After identified SDG targets and health literacy issues, the participants were provided with templates to rate the relevant importance of each of the ten health literacy focus areas provided for the group work. Subsequently, participants describe and give examples of what need to be done for the most three important foci. As a result almost all of the countries present in the meeting choose to implement health literacy in NCD programmes and ranking the most important areas of health literacy to be focus on. Out of the ten areas, three to four major foci are a) health literacy and behavior change as part of competencies of health care staff; b) health literacy for policy makers including of those across sectors; c) health literacy for school children and adolescent; d) health literacy and the formation of community beliefs and attitude about health. These areas are identified as the first and important steps to take as strategies to implement health literacy in respected countries. Other areas of focus are given as important or as a long-term strategy.
4.9
Health literacy in policy development and health governance Professor Osborne presented the importance of having health literacy in structural governance system for countries, realizing 25
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
interconnected of health, well-being, and development agendas. Following the WHO 9GCHP, Shanghai Declaration. Good governance with in health systems will required the government particularly Ministry of Health to be more open up for quality assurance, accountability, and transparencies. In the case of quality of care and accountability, WHO initiatives on integrated people-centered health services will demand significance in health system that considering people’s perspectives towards the manners of service deliveries. Improving people health literacy will one of important ways to assist the individuals, families, communities to have meaningful dialogues with service providers and improve the quality of care. However, in order to strengthen health literacy, public health professions need to identify which mechanisms work for them within their national context. Some countries start doing health literacy by building sufficient evidences, researches, survey, pilot study that can be used for policy dialogues. While many countries where there is strong political commitment from the government, having national health literacy policy may be the way to ensure there are both human and financial resources to conduct research, create road maps, develop operational plan, or implementation of the plan. Health literacy can be started where it most suitable for countries using different approaches or dimension of the health literacy. Dr Suvajee Good, HPE, presented matrix of dimensions of health literacy and applications of health literacy in different domains and relevant process that can be used in prevention, promotion, and health care services. However, Dr Good emphasizes where health literacy is placed in the health promotion framework. The generic frameworks from Ottawa Chatter to Shanghai Declaration, Dr Good pointed out that the end products of health promotion is to generate “health for all” and encourage “all for health” where people, citizen groups, civil society groups and other sectors can contribute to health of society. Health promotion does not limited to people’s behavioral change, but also promotion of health in all settings and at the policies level. Thus health promotion need to works across sector to promote health in all policies, addressing health inequities, and advocating for healthy public policies. Dr Good proposed to participants to consider implementing health literacy at policy level which mean promoting health through 26
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
influencing decision making of policy makers in respected to system design to ensure service deliveries, expenditure and resources for health and its determinants of health. Health promotion and public health profession need to understand key factors that trigger policy makers outside health sector to be aware of how their decisions are affecting health. Leaders and policy makers must be aware of the critical elements such as that contribute to their health literacy. Increase health literacy of policy makers of other sectors and public will improve policy development resulting in healthier public policies and sustainable development.
4.9
Media, education, and technologies for health literacy Dr Suvajee Good provided participants with new paradigm in thinking of role of health promotion in using medias and technologies to empower masses and increase health literacy. In the new paradigm, consumerisms society, commercialization of health and medicine became part of daily lives for large numbers of population, which ones can witness increasing “commercial determinants of health,” Dr Good analyzes current influences of media in creating medicalization of society where people increasingly use bio-medical paradigm to advertise health and commercialized products for health. For instance obesity is one of the most medicalized and commercialized in society today that resulted in numbers of medical/health products for people to wants to lose weight (without having medical diagnosis). At the same time, commercialization of health products such as running shoes, fashionable exercise clothes, gadgets, home gym products create a new illusion that if people have the products they will exercise more and reduce weight. The “commercial determinants of health” are largely influenced by the media and need to be engaged with. Media is powerful tool to create new social norms and is very useful for health promotion to use media affectively. New technologies can increase people access to health information at their own will. Investment in medial capacity training to increase their health literacy can create new allies for health and critical mass to promote health. Investment for public health to understand health literacy and have media literacy will support public health profession to become more effective in delivering health messages and empower
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the society. In order to achieve health in all goals, Dr Good provide guidance that media and technology must be developed with understanding that (a) health is societal goals, (b) health is everyone business and good for all business, (c) healthy life-styles is a new norm, (d) health is a result of good governance, and (e) health is a human rights. Media can play critical roles in supporting these arguments for health. Dr Good emphasizes that integrating media, education, technologies for health literacy (MET_HL) using marketing communication in health promotion for health literacy. The approach can provide basis for informed decision-making among population. Presenting and framing health literacy as a salient element of everyone’s life is a key challenge that health promotion. It requires new capacities of health promotion and public health, to understand types of media people in different age groups and the styles of communications needed for each types of media. To optimize health literacy of population through media, Dr Good suggests the following: Sensitize media through media health literacy training, Use social marketing for health literacy of population, create channel for policy or programme dialogues raising concerns and awareness on health impacts of policies or programme, or projects in countries, and encourage ethical use of media to monitor and measure accountability for health governance.
4.10 Group work 2: country roadmaps toward health literacy for health and well-being in SDGs era The participants are divided into country groups to discuss the country road maps for implementation of literacy. In summary, countries are planned to achieved the following tasks by the end of next year. Bhutan: Building on existing health promotion national strategic plan, Bhutan will increase capacity of public health to understand health literacy and do a survey to find out health literacy level in the
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country. Integrated health literacy in school will be the feasible path for implementation in Bhutan. Indonesia: Using the country coordination mechanism for healthy Indonesia (NCD), multisector engagement for health literacy implementation will be achievable. Indonesia identified the need for health literacy capacity building for health care staffs, strengthen health literacy across programme areas, and health literacy at school and community level. Maldives: Three major gaps in implementing multisectoral actions for NCD were identified namely risk behavior, lack of intersectoral collaboration, lack of monitoring mechanisms. The group intended to use the WHO-SEARO health literacy toolkit, particularly the ISHA-Q to assess the health literacy needs and build capacity of health care staffs. The participants also would like to create health literacy across programmatic areas, having policy briefs, and engage with academia in strengthening M&E systems. Myanmar: Participants from Myanmar set priority areas for actions based on available resources and capacities which is being the high priority of the Ministry of Health and Sport. These priority areas are health literacy capacity building for health service providers, community health literacy survey and community empowerment, and works with target school children and adolescent. The country aims to have national training on health literacy, working with local media and community-based organization. Nepal: participants observed national opportunities to implement health literacy right now in the national health policy, health sector strategy and the new constitution. The country need to do assessment to understand the gaps building on the resent research presented in this meeting. The participants suggest to developing demonstration (pilot) sites to test appropriate tools to be use for community in Nepal context. The group also suggests to developing health literacy package and tailor-made interventions. Sri Lanka: the participants see opportunities to engage with media and works on health literacy for media while the new health promotion bureau that has recently been revitalized from health
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education bureau. The group emphasizes making policy briefs and strengthening communication for health. Thailand: the Health Literacy Bureau has already developed health literacy in the promotion and prevention strategies in the next 20 years. Health literacy is important for Thailand to reduce risingcost in universal health care. Health literacy will be used to improve quality of care at the primary health care clusters, using smart phones for one million health volunteers. Thailand is targeting to strengthen health literacy competencies of policy makers, communities and schools. Timor Leste: health literacy is integrated in the new National Health Promotion Strategy and will be prioritized to implement health literacy in schools, work places, municipalities, and media, especially trying to reach the hard to reach population.
5.
Draft Strategic pathways to strengthen health literacy in South-East Asia to achieve health and well-being in sustainable development The session involved group discussion after countries’ outlined their needs for improvement of health literacy and road maps to implement health literacy. The following is summary of draft regional strategic pathways for health literacy.
5.1
Key message The World Health Organization defines “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 which promote and maintain good health. Health Literacy means more than being able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment.” www.who.int/healthpromotion/conferences/7gchp/track2/en/
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It is important to note that Health Literacy goes beyond a narrow concept of health education and individual behaviour-oriented communication, and addresses the environmental, political and social factors that determine health. Health literacy, in this more comprehensive understanding, aims to influence not only individual lifestyle decisions, but also raises awareness of the determinants of health, and encourages individual and collective actions which may lead to a modification of these determinants. The 9th Global Conference on Health Promotion resulted in the Shanghai Declaration highlighting the three action points for countries to be strengthened to achieve sustainable development. These actions include good governance, healthy cities, and health literacy. Emphasis for health literacy is to increase knowledge and social skills to help people make healthy choices and decisions for their families and themselves. Figure 1: Shanghai Declaration defining three pillars of health promotion for the sustainable development
Thus health literacy is a determinant of health for individual, families, communities which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health. By improving
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people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment. Health literacy can also be a structural determinant of health when applies to health literacy of policy makers who make decisions that contributed to availability of healthy choices and healthy environment for the population. Strengthen health literacy among policy makers mean to engage policy makers to understand health and recognize potential impacts of their decisions on health and wellbeing of the people and on the public health. Health literacy is an instrument to enhance healthy public policies. Health literacy for policy makers will be crucial to improve health for all population through public policies that will improve quality of life, such as education, social protection, land ownership, housing, employment, loan, small grants for investment, etc. While a key aim of heath literacy is to empower individuals and their families, a critical application of health literacy is the generation of ‘health literacy responsive’ organizations and services. Ultimately, we need health and social care services enabled to be responsive to all members of society such that irrespective of a person’s health literacy challenges, they are supported to get all the information, services and care that need in an equitable and timely manner. It will be important for Member States to build health literacy responsive systems and policies. Strategic actions to strengthen health literacy have to go beyond measurement and utilize existing tools. Health literacy strengthening should be taken as an empowering process for individual, community, and society, to take control of their health and well-being with support from health systems, policy and services. The integration of health literacy into public policies will address crucial structural determinants of health and achieve further sustainable development.
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5.2
Two pathways to strengthen health literacy in SouthEast Asian Countries: A. Strategic pathway for SDG3 (within the health sector) Mainstreaming health promotion in all health programmes, particularly sensitize new tools and approaches for effective health promotion Build health literacy capacity among health workforce to improve health care services and responses using a peoplecantered approach within universal health coverage. Build capacity within health workforce to be able to take proactive actions to promote health and take preventive measures within health system and working across sectors Build capacity for multidisciplinary expertise to create effective tools, interventions, and research for evidencebased health promotion Create conducive and inclusive environments for health promotion enabling healthy behavior within health sector Create champions and role models for health among public health profession Build strategic partnership for engagement, and social mobilization health, community
Scale-up health information systems to collect and build evidence relevant to health promotion Set up mechanisms to support implementation of health literacy including improving social skills to empower the most vulnerable population groups to ensure no one left behind across health programmes or services Systematically develop new, and improve existing, health services to be responsive to the health literacy strengths and weaknesses of all population groups such that all persons can get equitable access to services and timely care.
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B. Strategic pathway for other SDGs (beyond health sector) Develop sets of targets and indicators for joint-actions to promote health literacy for all Strengthen health literacy, community empowerment, health literacy responsiveness, and innovative health promotion Positioning health and well-being at the core of the development process and putting people’s health at the centre of sustainable development Advocate for health literacy and partnership with other sectors to create win-win situations Engage multisectoral partners to secure high political commitments and leverage national development agendas as entry points to achieve buy-in for partnership Select high leverage areas/settings such as school/workplaces/ communities that have high return of investment in partnership Utilize legislative frameworks and legal measures (such as FCTC, social protection act, etc.) Develop strategic actions for health in all policies and health impact assessment to build momentum for coordination and collaboration Promote social mobilization and partnership across multisectors with effective and meaningful communications
6.
Ways forward and recommendations Participants discussed and recommended to WHO and member states to take following actions Provide technical assistance to develop country-specific health literacy programmes and operational plans for implementation
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Establish a pool of experts from across countries to support health literacy needs within countries Develop a policy brief on health literacy for South-east Asia particularly for the non-communicable disease prevention and promotion of healthy life-styles, as well as for primary care services Provide support for implementation of appropriate tools and measurements Conduct regional and/or national health literacy profiling to document health literacy strengths and weaknesses Consider placing health literacy in public/political domain to gain political commitment Document and share experiences from countries and monitoring progress made Engage strategic partners particularly from non-health sectors Build an ongoing network of health literacy researchers and academia in the region
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Annex 1
Agenda 4 July 2017 Day1: Health Literacy in Global Health Agendas Time Session 1.1 9.00-9.30 AM Programme Inauguration session: Opening Speech H.E. Dr Myint Htwe, Union Minister of Health and Sports, Myanmar 9.30-9.45 AM Welcome Remark and RD’s speech Dr. Stephan Paul Jost 9.45-10.15 AM WHO Representative to Myanmar Photo Session Refreshment Session 1.2 10.15-10.30 AM Session 1.3 10.30-11.00 AM Keynote address: “Health literacy in Global Development 2030” Introduction Self-introduction of Participants Professor Dr Richard Osborne, Deakin University and WHO CC for Health Literacy Video file will be sent from WHO HQ Dr. Suvajee Good
11.00-11.30 AM
Global Commitments on Health Literacy from Health Promotion “Shanghai Declaration” and call to actions Health Literacy and Health Promotion Strategies in South-East Asia: Overview linkage to NCDs, School health programmes, health services, and mental health Lunch and active break
11.30-12 noon
12.00-13.00
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Time Session 1.5 13.00-14.00
Programme Role of Health Literacy in achieving health goals and reduce health inequities: Supporting health workforce in achieving maternal and child health, example from Myanmar by Director of Maternal and Reproductive Health Division Healthy diets and reducing double burden of malnutrition, by Dr Suvajee Good, Programme Coordinator, HPE, WHO-SEARO on behalf of Dr Angela De Silva, regional advisor on nutrition and Dr Roy Batterham Addressing mental health and neurological disorder, by Dr Suvajee Good, Programme Coordinator, HPE, WHO-SEARO, on behalf of Dr Nazneen Anwar, Regional advisor on mental health
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Presentation followed by Questions & Answer session Session 1.6 14.00-15.00 Role of Health Literacy in achieving health goals and reduce health inequities: Health literacy and support to prevent and control neglected tropical diseases (TB, Dengue, Leprosy), example from countries (online – skype) Health literacy roles in schools and prevention of diseases and health promotion (Director of School Health Division, Myanmar) Health literacy roles in strengthen health system and universal health coverage (Roy Batterham, WHOCC- Health literacy, Deakin University)
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Presentation followed by Questions &
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
Time 15.00-15.30 Session 1.7 15.30-16.30
Programme Answer session Healthy break How to assess health literacy of individuals and population, and analyze the health literacy needs for country: tools and measurements, facilitated by Mr Roy Batterham, WHOCC for Health literacy, Deakin University and Dr Shyam Budhathoki, B P Koirala Institute of Health Sciences
16.30 -17.00
Conclusion for the day one
Facilitate by Dr Suvajee Good
5 July 2017 Day 2: Health Literacy from Country Experiences Time Programme Facilitator/speaker/ moderator
Session 2.1 8.30 – 9.15
Health literacy, community, and sustainable development: Perspectives from countries Panel: Professor Dr Osborne and high level delegates from SEAR countries
Reflection from participant’s perspective Moderated by: Dr Suvajee Good Experiences from research and practices
Session 2.2 9.15-10.45
Health Literacy studies, research, and practices in South-East Asia Panel: Representatives from Thailand (Mr Saichon Kloyaiam and Mr Roy Batterham, WHOCCHealth Literacy, Deakin Unviersity) Nepal, (Dr Shyam Budhatoki) Myanmar (Dr Chomar, University of Public Health, Myanmar and Dr Phone Myint Win, Burnet Institute)
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
Time Follow by Q&A 10.45-11.00 Session 2.3 11.00-12:00
Programme
Facilitator/speaker/ moderator
Healthy break Implementation and Initiation of Health Literacy at country level (Myanmar & Thailand experiences) Country situation and sustainable development Key areas of interventions Structure and systems Capacity Experiences and plan for implementation and planning
Myanmar: Dr Phyu Phyu Ae and Burnet Institute (Dr Ye Win Aung, Programme Manager) Thailand: Dr Vijj Kasemsup and Mr Saichon Kloyiam with Mr Roy Batterham 12.00-12.45 Session 2.4 12:45-13:00 13.00-15.00 Instruction for Group Work Group work 1: key areas for implementation in South-East Asia countries Health literacy within health sector Health literacy among health partners Health literacy and impacts on health interventions, outcomes, programme and policies Healthy break Group presentations Lunch
15.00-15.30 Session 2.5 15.30-17.00
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
6 July 2017 Day3: Strategic pathways for health literacy in South-East Asia Time 8.30-9.00 Programme Recap Day2 Facilitator/speaker/moderator Participants/focal point
Session 3.1 9.00 - 9.45
Health literacy in policy development and health governance: important instruments to promote health in all goals Followed by reflection from participants on the need of health literacy at policy level
Professor Richard Osborne, and Dr Suvajee Good
Session 3.2 9.45-10.00
Media, education, and technologies for health literacy: public participation and empowerment Healthy break Group work 2: country roadmaps toward health literacy for health and well-being in SDGs era Lunch
Dr Suvajee Good
10.00-10.30 Session 3.3 10.30-12.00
Drawing experiences from team work preparation prior to the regional meeting.
12.00-13.00
Facilitator team meeting
Session 3.4 13.00-14.30 14.30-15.00
Country presentations (include Q&A) Healthy break Myanmar Side Meeting 14:30-15:45 pm
Session 3.5 15.00-15.45
Strategic pathways for health literacy to achieve health and well-being in South-East Asia Followed by Q&A
Interactive and visual aids
Session 3.6
Ways forward and Recommendations
Representative from countries
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
Time 15.45-16.30 16.30
Programme
Facilitator/speaker/moderator
Conclusion and vote of thanks
High level Official from Myanmar Representative of local NGOs
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
Annex 2
List of participants Bangladesh Mr Dorji Phub Chief Program Officer Health Promotion Division Department of Public Health Ministry of Health, Thimphu Ms Pemba Yangchen Dy. Chief Nutritionist Non-Communicable Disease Division Department of Public Health Ministry of Health, Thimphu Dr Chencho Dorjee Dean Faculty of Nursing and Public Health Khesar Gyalpo University of Medical Sciences Thimphu Indonesia Dr Grace Lovita Tewu Head of Potential Resources of Health Promotion Sub Directorate Directorate of Health Promotion and Public Empowerment, Ministry of Health Jakarta Mr Welly Vitriawan Head of Sub Division of Education Development Center of Education of Human Resources for Health Ministry of Health Jakarta Dr Dyah Erti Mustikawati Head of Sub Directorate of Diabetes and Metabolic Disorders Control Ministry of Health Jakarta Maldives 42 Ms Aishath Shaheen Ismail Dean Faculty of Health Sciences Maldives National University Male Mr Ibrahim Nizam Public Health Programme Manager Health Protection Agency Ministry of Health Male Mr Zuhudha Shakir Public Health Programme Officer Health Protection Agency Ministry of Health Male Myanmar Dr Myint Shwe Director Non Communicable Diseases Control Department of Public Health Ministry of Health and Sports Nay Pyi Taw Dr Phyu Phyu Aye Director Health Literacy Promotion Unit Department of Public Health Ministry of Health and Sports Nay Pyi Taw Dr Chomar Kaung Myint Professor University of Public Health Nepal
South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
Mr Shree Krishna Bhatta Director National Health Training Centre Teku, Kathmandu, Nepal Mr Biswo Ram Shrestha Senior Public Health Administrator PHC Revitalization Division Teku, Kathmandu, Nepal Mr Binay Manandhar Senior Health Education Administrator Regional Health Training Centre Pathlaiya, Bara Sri Lanka Dr P D S P Dissanayake Director Health Education Bureau Ministry of Health Nutrition & Indigenous Medicine, Colombo, Sri Lanka Dr B K K R Batuwanthudawa CCP Health Education Bureau Ministry of Health Nutrition & Indigenous Medicine, Colombo, Sri Lanka Dr L Nilaweera NCD Unit Ministry of Health Nutrition & Indigenous Medicine Colombo, Sri Lanka Thailand Dr Vijj Kasemsup Lecturer Department of Community Medicine Faculty of Medicine Ramathibodhi Hospital Mahidol University Ministry of Education Thailand Mr Saichon Kloyiam Public Health Technical Officer Practitioner Level Office of the Department of Health 4.0 and
Health Literacy Department of Health, Ministry of Public Health, Nonthaburi, Thailand Ms Thidarat Apinya Public Health Technical Officer Bureau of Non Communicable Diseases Department of Disease Control, Ministry of Public Health Nonthaburi Timor Leste Dr Helder Juvinal Neto da Silva Head of NCD Department Ministry of Health, Dili Ms Agusta Amaral Lopes Health Promotion Officer for CDC &NCD Ministry of Health, Dili Dr Valente da Silva, SKM, MPH Officer for Health and Research Institute of Health Science, Dili Resource Persons Dr Richard H Osborne Professor and Chair in Public Health NHMRC Senior Research Fellow Head, Health Systems Improvement Unit School of Health and Social Development Centre For Population Health Research Faculty of Health, Deakin University Australia Dr Roy Batterham Senior Research Fellow Health Systems Improvement Unit School of Health and Social Development Centre For Population Health Research,Faculty of Health Deakin University, Australia Dr Shyam Sundar Budhathoki Assistant Professor School of Public Health & Community Medicine
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South-East Asia Regional Meeting on Health Literacy for health and well-being in the SDGs Era
B P Koirala Institute of Health Sciences Dharan, Nepal Secretariat WHO/SEARO, New Delhi, India Dr Suvajee Good Programme Coordinator - Health Promotion Department of Noncommunicable Diseases Ms Shalini Khattar Executive Assistant Health Promotion Unit Department of Noncommunicable Diseases WHO Country Office Dr Sadhana Bhagwat National Professional Officer/NCD WCO India
Dr Myo Paing National Professional Officer Focal point for Health Literacy Promotion WCO Myanmar Dr Nilmini Hemachandra National Professional Officer RMNCAH & Nutrition WCO Sri Lanka Ms Rinzi Om Dorji Executive Associate Administrative and Programme Associate WCO Bhutan Ms Stellar Myint Executive Assistant WCO, Myanmar
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