Understanding health and healthcare 2017/18: New Zealand Health Survey

Understanding health and healthcare refers to how people find, understand and use health information and healthcare services. A good understanding of health and healthcare is linked to better health outcomes.

People's understanding of health and healthcare can be improved through the provision of more appropriate health information and health services. To do this, we need to know about current levels of understanding and identify particular strengths and weaknesses across different population subgroups.

A module called 'Understanding health and healthcare' was included in the 2017/18 New Zealand Health Survey. The module included the Health Literacy Questionnaire (HLQ), which is a multi-dimensional tool that collects information on how people find, understand and use health information, and how people manage their health and interact with healthcare providers. The HLQ was developed in Australia (Osborne et al 2013) and has been extensively tested internationally (Osborne nd).

The HLQ has nine domains, with six of these domains (in bold) included in the 2017/18 New Zealand Health Survey:

1. Feeling understood and supported by healthcare providers
2. Having sufficient information to manage my health
3. Actively managing my health
4. Social support for health
5. Appraisal of health information
6. Ability to actively engage with healthcare providers
7. Navigating the healthcare system
8. Ability to find good health information
9. Understand health information well enough to know what to do.

The first five domains ask respondents to indicate their level of agreement with a list of statements, with four response options (strongly disagree; disagree; agree; strongly agree). The remaining four domains ask respondents to report their capability at doing a list of tasks, with five response options (cannot do/always difficult; usually difficult; sometimes difficult; usually easy; always easy).

For each domain, a mean score is calculated by averaging responses across all items in that domain. There is no overall score because this could mask strengths or weaknesses in particular domains. For more information about how the HLQ is scored see Methodology.

Approximately 13,500 people aged 15 years or older completed the module from July 2017 to June 2018. Results for the six domains that were included in the survey are presented in the subsequent sections.

Things to consider when interpreting results

The Health Literacy Questionnaire (HLQ) is a self-report instrument, which means that it asks people to report what they experience in relation to finding, understanding and using health information and services. The HLQ does not directly measure functional skills, such as reading and comprehension of health information.

The HLQ was tested on a small number of people during preparation for the survey, but it has not been validated in New Zealand. While this testing did not identify any particular issues, it is possible that some parts of the HLQ are not meaningful to everyone. For example, population groups that have a more collective view of health may not relate to domains that imply personal responsibility, such as 'Actively managing my health'.

The HLQ produces a score for each domain by averaging results across all questions in that domain. This approach could mask strengths and weaknesses in particular areas within a domain, which could be useful for informing interventions.

The New Zealand Health Survey is a population-based survey. This means that it includes a sample of people from the across the population, including some that have not sought health information or interacted with health services recently. For this reason, results for some domains (eg, ability to actively engage with healthcare providers) might reflect people's confidence rather than their actual experience.

The 'Understanding health and healthcare' module was self-complete, which is generally the best method for collecting data on sensitive topics. However, this approach meant that a small number of survey respondents could not complete the module because they needed language assistance (the HLQ was in English). While only 2% of survey respondents overall required language assistance, the percentage was higher for Asian (13.9%) and Pacific (7.1%) respondents. It is also possible that some people who did complete the module had trouble understanding some aspects of the HLQ and were reluctant to ask for help from the interviewer.

Data were collected from July 2017 to June 2018 so results may not reflect the current situation. While most things covered in the New Zealand Health Survey do not change much in the space of a few years, COVID-19 is likely to have impacted on people's understanding of health and healthcare.

Results are not comparable with previous surveys in New Zealand due to differences in survey questions and methods. The last national survey of health literacy was the 2006 Adult Literacy and Lifeskills Survey, which New Zealand participated in along with other OECD countries. Respondents in this international survey were interviewed face-to-face and directly tested for functional aspects of health literacy, such as understanding text, finding information in documents and problem solving skills. In contrast, the HLQ is a multi-dimensional tool that moves beyond the functional approach used in the 2006 survey and was self-complete. A key benefit of the HLQ data is that it covers a broader range of personal and social health literacy characteristics and shifts the focus from perceived deficits at an individual level to opportunities to improve access to health services and information.

Results are not directly comparable with other countries that have used the HLQ due to differences in survey design, the mode of data collection and the context of healthcare provision.

Key findings

• The majority of New Zealand adults have a good understanding of health and healthcare, but there are opportunities for improvement.
• About one in seven adults (14.3%) indicated that they were not actively managing their health and about one in eight adults found it difficult to actively engage with healthcare providers (11.9%) or difficult to navigate the healthcare system (12.5%).
• Women were more likely than men to find it difficult to engage with health care providers or difficult to navigate the healthcare system. In contrast, men were less likely to be actively managing their health and had more difficulty understanding health information well enough to know what to do.
• Young adults (15–24 years) were most likely to strongly agree that they have social support for health.
• Adults aged 25–44 years scored lower across several domains, especially when it comes to actively managing their health, actively engaging with healthcare providers, and navigating the healthcare system.
• Older adults (75+ years) scored higher across most domains, with the exception of understanding health information well enough to know what to do.
• Māori adults indicated greater challenges across most domains, with the exception of social support for health. Māori adults were much less likely to be actively managing their health than other adults.
• Pacific adults indicated challenges across several domains, particularly the domain of understanding health information well enough to know what to do.
• Asian adults had more difficulty understanding health information well enough to know what to do and navigating the healthcare system.
• Adults living in the most socioeconomically deprived areas scored lower across all domains, especially the two domains related to information: sufficient information to manage their health, and understanding health information well enough to know what to do.

Domain 2: Having sufficient information to manage my health

This domain looks at whether people believe they have the information they need to live with and manage their health concerns.

The following items¹ were used to assess this domain:

• I feel I have good information about health
• I have enough information to help me deal with …
• I am sure I have all the information I need to …
• I have all the information I need to look after my health

Overall, 28.6% of adults strongly agreed that they have sufficient information to manage their health, 65.5% agreed, and 6.0% disagreed or strongly disagreed.

Selected findings for this domain:

• 30.6% of women strongly agreed that they have sufficient information to manage their health compared with 26.4% of men.
• Adults aged 25–34 years were more likely to disagree or strongly disagree they have sufficient information to manage their health than adults in other age groups.
• 9.4% of Māori and Pacific adults disagreed or strongly disagreed that they have sufficient information to manage their health compared with 5.2% of European/Other adults.
• Adults living in the most socioeconomically deprived neighbourhoods were more likely to disagree or strongly disagree that they have sufficient information to manage their health than adults living in the least deprived neighbourhoods (8.2% vs 4.1%).

¹Due to copyright some items are truncated. The full items are available from the author of the Health Literacy Questionnaire (HLQ).

Domain 3: Ability to actively manage health

This domain looks at how people engage in their own healthcare and make decisions about their health.

The following items were used to assess this domain:

• I spend quite a lot of time actively managing my health
• I make plans for what I need to do to be …
• Despite other things in my life / I make time to be healthy
• I set my own goals about health and fitness
• There are things that I do regularly to make myself …

Overall, 21.3% of adults strongly agreed that they are actively managing their health, 64.4% agreed, and 14.3% disagreed or strongly disagreed.

Selected findings for this domain:

• 16.4% of men disagreed or strongly disagreed that they were actively managing their health compared with 12.4% of women.
• Younger adults were more likely to disagree or strongly disagree they were actively managing their health than older adults. For example, about 17% of those aged 15 to 44 years strongly disagree or disagree that they were actively managing their health compared with 7–8% of those aged 65 years or older.
• 20.1% of Māori adults disagreed or strongly disagreed that they were actively managing their health, compared with 13–14% of Pacific, Asian and European/Other adults.
• Adults living in the most socioeconomically deprived neighbourhoods were more likely to disagree or strongly disagree that they were actively managing their health than adults living in the least deprived neighbourhoods (16.8% vs 12.9%).

Domain 4: Social support for health

This domain looks at whether people have all the support for health that they want or need.

The following items were used to assess this domain:

• I can get access to several people who understand and support me
• When I feel ill / the people around me really understand what I am going through
• If I need help / I have plenty of people I …
• I have at least one person who can come to medical appointments with me
• I have strong support from …

Overall, 30.9% of adults strongly agreed that they have social support for health, 63.1% agreed, and 6.0% disagreed or strongly disagreed.

Selected findings for this domain:

• Young adults (15–24 years) were most likely to strongly agree that they have social support for health (42.5%).
• 26.8% of Asian adults strongly agreed that they get social support for health, compared with about 30% of Māori, Pacific and European/Other adults.

Domain 6: Ability to actively engage with healthcare providers

This domain looks at whether people are active or passive in their approach to healthcare and if they actively seek or clarify information, advice and/or service options to ensure it meets their needs.

The following items were used to assess this domain:

• Make sure that healthcare providers understand your problems properly
• Feel able to discuss your health concerns with a healthcare provider
• Have good discussions about your health …
• Discuss things with healthcare providers …
• Ask healthcare providers questions to get …

Overall, 31.4% of adults reported it always easy to engage with healthcare providers, 56.8% reported it was usually easy, and 11.9% found it difficult².

Selected findings for this domain:

• 13.4% of women found it difficult to engage with healthcare providers compared with 10.3% of men.
• Young adults found it more difficult to actively engage with healthcare providers than older adults. For example, about 15% of adults aged 25 to 44 years found it difficult compared with 7–8% of those aged 65 years or older.
• About one in four Pacific (26.8%) and Asian (24.1%) adults found it always easy to actively engage with healthcare providers compared with one in three European/Other (32.7%) adults.
• Adults living in the most socioeconomically deprived neighbourhoods were more likely to find it difficult to actively engage with healthcare providers than adults living in the least socioeconomically deprived neighbourhoods (14.8% vs 8.7%).

²Difficult includes ‘Cannot do or always difficult’, ‘Usually difficult’ and ‘Sometimes difficult’

Domain 7: Navigating the healthcare system

This domain looks at whether people are able to advocate on their own behalf and find someone who can help them. It examines if people look beyond obvious resources and if they have an understanding of what is available and what they are entitled to.

The following items were used to assess this domain:

• Find the right healthcare
• Get to see the healthcare providers you need to
• Decide which healthcare provider you need to see
• Make sure you find the right place to get …
• Find out which healthcare services you are …
• Work out what the best care is for you.

Overall, 28.2% of adults reported it always easy to navigate the healthcare system, 59.2% reported it was usually easy, and 12.5% found it difficult.

Selected findings for this domain:

• Younger adults were more likely to find it difficult to navigate the healthcare system than older adults. For example, about 16% of those aged 25 to 44 years found it difficult compared with about 8% of those aged 65 years and over.
• 19.9% of Asian adults found it always easy to navigate the healthcare system compared with 29.7% of European/Other adults.
• Adults living in the most socioeconomically deprived neighbourhoods were more likely to find it difficult to navigate the healthcare system than adults living in the least deprived neighbourhoods (15.1% vs 9.4%).

Domain 9: Understand health information well enough to know what to do

This domain looks at whether people have problems understanding any written health information or instructions about treatments or medication, or difficulty filling in medical forms.

The following items were used to assess this domain:

• Confidently fill medical forms in the correct way
• Accurately follow the instructions from healthcare providers
• Read and understand written health information
• Read and understand all the information on …
• Understand what healthcare providers are …

Overall, 34.8% of adults reported it always easy to understand health information well enough to know what to do, 57.0% reported it was usually easy, and 8.3% found it difficult.

Selected findings for this domain:

• 38.9% of women found it always easy to understand health information well enough to know what to do compared with 30.4% of men.
• About one in 10 adults in the oldest (10.9%) and youngest (9.5%) age groups found it difficult to understand health information well enough to know what to do.
• 36.7% of European/Other adults found it always easy to understand health information well enough to know what to do compared with 28–29% of Māori, Pacific and Asian adults.
• Adults living in the most socioeconomically deprived neighbourhoods were much more likely to find it difficult to understand health information well enough to know what to do than adults living in the least deprived neighbourhoods (12.0% vs 4.9%).

If you have any queries please email [email protected].

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References

Osborne, R. nd. Health Literacy Questionnaire (HLQ). URL: https://healthliteracy.bu.edu/hlq (accessed 25 August 2022).

Osborne RH, Batterham RW, Elsworth GR, et al. 2013. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health 13:658.

The Health Literacy Questionnaire (HLQ).© Copyright 2014 Swinburne University of Technology. Authors: Richard H Osborne, Rachelle Buchbinder, Roy Batterham, Gerald R Elsworth. No part of the HLQ can be reproduced, copied, altered or translated without the permission of the authors. Further information: [email protected].