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Prof. Diane Levin-Zamir PhD, MCHES, MPH
National Director, Department of Health Education and Promotion
Clalit Health Services, Israel
Associate Professor, University of Haifa School of Public Health, Israel
IUHPE Global Working Group on Health Literacy
Health Literacy Interventions at the
Policy Level
WHO Global Coordination Mechanism (GCM/NCD)
Working Group on Health Literacy for NCDs –
Stakeholder Hearing
June 12, 2017
IUHPE Global Working Group on Health Literacy
Position Paper on Health Literacy
• A systems approach to health literacy at the global, international, national
and local levels.
• Recognize that health literacy is content and context specific across the
life span.
• Ensure the inclusion of health literacy as a social determinant of health
in global and regional discussions on health promotion.
• Emphasize health literacy as a community-based consumer education
and empowerment process.
• Funding, producing and promoting research to build an evidence base that
demonstrates how health literacy can reduce health inequalities.
• Building capacity and sharing knowledge
• Identifying and engaging relevant stakeholders
• Highlighting the role of health literacy as a cross-cutting issue for the
advancement of global health.
• Universal healthcare coverage for all citizens of Israel
primary, secondary and tertiary care, since 1995
• Life expectancy – Overall 82 yrs, ranks 4th in the world
• Risk Factors- 22 % smokers, over 60% overweight or
obese, 20-30% regularly engage in physical activity
• Average number of visits to physician – 6 per capita/yr.
• Growing rates of adult population with chronic disease
• Growing rate of out-of-pocket expenses for health
• Recognized disparities regarding health behavior and
service utilization
Health in Israel - Profile
Case Study – Country experience: Health Literacy, Policy and NCDs
• 4.4 million members; 54% of Israel’s population
• 40,000 workers
• 1,400 primary and specialized care community clinics
• 14 major teaching hospitals: 8 general, 2 psychiatric, 1
pediatric, 2 geriatric, 1 rehabilitation
• 416 pharmacies
• 40 diagnostic imaging centers
• 67 laboratory centers
• 83 physiotherapy units
• 30 occupational therapy units
• 87 diet & nutrition consultation units
• 22 mental health clinics, 70 dental clinics
• 20 alternative medicine clinics
• Over 4 million entries in the Clalit website/month
Health Literacy Action in Health Care System Clalit Health Services
2nd largest non-government health care organization in the
world (non-profit)
Measuring Health Literacy – The National Health Literacy Study in Israel
HLS (ISR) by average income in Israel
P < 0.0001
Distribution of HLS (ISR)
scores Methodology: Face-to-face home
interviews
Include a representative sample of 600
Languages: Hebrew, Arabic, Russian
HLS (ISR) and physical activity
(reported)
• Community Primary Care
• Hospitals
• Media/Online
Promoting Health Literacy:
Focus on settings
Preparation for new landmark policy
Professional guidelines were developed
Group cessation counsellors were trained
A computer record was developed: data base
A health education kit was developed for
participants in the workshops
Evaluation protocol developed and implemented to
examine scope and effectiveness of the new policy
Smoking cessation added to the National Health Insurance Basket of Services - 2010
Annual smoking cessation participation: comparison of rates before and after policy
implementation
600
13910
0
2000
4000
6000
8000
10000
12000
14000
16000
before nat policy 5 yr after policy
X20
• 45% maintenance of cessation rate 3-5 years after intervention
• Smoking cessation services in 148 cities through Israel; 20% in
Arab cities/towns
Cultural Competence in Health Systems
“The capacity to function effectively as an
individual and as an organization within the
context of cultural beliefs, behaviors, and
needs presented by consumers and their
communities.” (HHS)
Addressing Health Literacy in Policy
Initiatives for Reducing Disparities:
Partnerships for HP of New Immigrants
• Cross-cultural liasons in primary care clinics -
“Refuah Shlema”
• Partnering with NGOs:
• Telephone translation
• Community diabetes programs
• Training and coaching health staff
on cultural competence skills
Levin-Zamir D, Keret S, Yaakovson O, Lev B, Kay C, Verber G, Lieberman N. (2011) A cross-
cultural programme for promoting communication and health among Ethiopian immigrants in the
primary health care setting in Israel Special Edition on Health Promotion Effectiveness, Global
Health Promotion;18;1:51-54
Addressing Health Literacy in Policy
Diabetes, Innovation and Health Literacy: focus
on empowerment and self-management
• Multi-disciplinary workshops offered nationwide
• Text messages (SMS) for people with diabetes - tailored
Transtheoretical Stages of Change Model
• Health Coach - culturally appropriate
• “Information Prescriptions” : Automatically sent by e-
mail from the electronic health record – over 130
diagnoses, using patient portal
• Partner in Diabetes Literacy Project - EU
Addressing Health Literacy in Policy
Effectiveness and outcomes in diabetes: HbA1C measures
intervention
Following
intervention
Before
intervention
P=<0.001
1 2 3
Estimated Marginal Means of measure_1
7.8
8.8
Media and Digital Health Literacy
The extent to which
one recognizes content
related to health
The extent to which one is
aware of the potential
influence of the content
on the behavior on others
The extent to which critical
analysis expressed by the
individual regarding the
content to which
he is exposed
The extent to which
an intention is expressed
towards personal and/or social
action (advocacy) as a result of
the content in the media.
Levin D, Gofin R, Lemish D. Health Education Research, 2011.
Conclusions and policy recommendations
• Universal health care (SDG) requires meeting demand for
health literate appropriate services: primary care, hospital
and media/digital arenas
• Measuring and monitoring health literacy on ongoing
basis is critical for identifying progress and groups at
risk
• Health literacy sensitive interventions facilitate achieving
health outcomes, including capacity building
• Cultural appropriateness is essential for best practice in
health education and promotion
• A systems approach to health literacy interventions is
necessary in order to receive results
Including health literacy in
public health and healthcare
policy is essential for
overcoming challenges and to
ensure a sustainable benefit in
the area of NCDs.
Health Literacy and Policy
Health Literacy
Improve
Urban Health
Good
Governance
for Health
Health
Promotion
