World No Tobacco Day 2018

The focus of this year’s World No Tobacco Day on May 31st is the impact of tobacco on cardiovascular health. In 1967 the Surgeon General’s report definitively linked smoking to lung cancer and presented evidence that it causes cardiovascular problems. Despite all the evidence and outcry from health professionals, it was not until the 1990s when many countries around the world banned smoking in public places. There have been several policies including those deterring tobacco companies from advertising to younger age groups and forcing them to add warning labels on tobacco products. Despite all these efforts, tobacco still kills 7 million people each year and tobacco use (and secondhand smoke) is responsible for nearly 12% of all deaths globally due to cardiovascular diseases (CVDs).


Tobacco smoke contains more than 7000 chemicals and is divided into a) a particulate phase which contains nicotine and total aerosol residue or tar and b) gas phase which contains carbon monoxide and other gases. The image below depicts how chemicals in tobacco cause CVDs.


While the effects of tobacco on heart health are well known, knowledge among the public that tobacco is one of the leading causes of CVD is very low. The figure below from WHO’s brochure shows the percentage of adults who do not believe or do not know that smoking causes stroke and heart attacks.


The goals of World No Tobacco Day 2018 are to:

  • Emphasize the links between use of tobacco products and CVDs
  • Increase awareness among the broader public about the impact of tobacco and exposure to secondhand smoke on heart health
  • Provide opportunities to make commitments to promote heart health
  • Encourage countries to strengthen implementation of MPOWER

WHO and the US Centers for Disease Control and Prevention launched the Global Hearts initiative in September 2016. The initiative aims to support governments in bolstering prevention and control of CVD. Global Hearts comprises of three technical packages: a) MPOWER for tobacco control b) SHAKE for salt reduction and c) HEARTS to strengthen management of CVD in primary health care settings.

Hopefully, on this World No Tobacco Day, the governments will commit to protect their citizens from tobacco use. The truth of the matter remains: prevention and control are not sole responsibilities of governments. Health care professionals, public health agencies/staff, national/state/local governments, educational institutions, business leaders/businesses, community based organizations and community leaders all have a role in making everyday a “No Tobacco Day”.


Happy #InternationalWomensDay!

A message from our section chair, Laura Altobelli

In 1909 and 1917, women organized to demand better wages, equal working conditions, and the right to vote.

In 1975, the United Nations established March 8 for the annual recognition of these struggles.

On this International Women’s Day, the tendency is to think that today celebrates women just for BEING WOMEN — instead of its true meaning….THE GLOBAL STRUGGLE FOR EQUAL RIGHTS OF WOMEN.

Today is to commemorate the hard work that has not yet ended, and to celebrate those women (and some men), past, present, and future, who push the boundaries toward empowerment of women and girls and gender equality in all aspects of life.

Today is an annual call to continue the struggle.

In international health and global development work, this is arguably the most important of our callings — to reach the 5th Sustainable Development Goal: to ‘achieve gender equality and empower all women and girls,’ after which all other SDGs will be easier to reach.

Have a good day and keep up the struggle!

New paper released on the global burden of severe neonatal jaundice

While severe neonatal jaundice (SNJ) that is not successfully treated is rare in the U.S. and Western Europe, and thus often ignored as a global health problem, there is  evidence that SNJ is still a problem globally. In a paper co-authored by IH Section Councilor Dr. Mark Strand on the global burden of severe neonatal jaundice in newborns, the incidence of SNJ was found to be at 667.8 per 10 000 live births in the African region, where it is the highest, followed by Southeast Asia (251.3), Eastern Mediterranean (165.7), and the Western Pacific (9.4). This condition is easily diagnosed and inexpensive to treat and can save lives of children.

Read the rest of the research article here:

The Evaluation and Measurement of Health Literacy

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the third blog in a three-part series the IH Blog will feature this summer, Global health literacy: Conceptual basis, measurement and implications.

Part III. The Evaluation and Measurement of Health Literacy

While the IOM’s (now National Academy of Medicine) definition of health literacy (HL) is recognized and accepted, there is a lack of standardization in its conceptualization and operationalization within and between countries. Initially HL was perceived as a derivation of literacy with it’s primary purpose serving to as important tools to maximize comprehension during clinical encounters. In recent years the meaning and purpose of HL have broadened in scope to incorporate a health promotion perspective. This expanded and dynamic definition has resulted in increased utility in both clinical medicine and public health but has left this construct susceptible to conceptual drift.  A recent systematic review of the construct of HL found 17 varying definitions and 12 conceptual models that were employed in the literature.  

According to IOM’s report Health Literacy: Improving Health, Health Systems, and Health Policy Around the World: Workshop Summary, countries around the world have used a wide range of designs and approaches as well as purposes for examining HL.  These approaches have involved the usage of proxies such as education, income, or literacy to approximate HL. Other countries have relied on single items, often as a part of other measures (e.g. school attendance/enrollment, reading score), to evaluate HL. Thus, currently there is lack of comparability between estimates of HL within and between countries. Furthermore, the validity of many measures in assessing IOM’s definition of HL remains unclear. It is important to note that nearly all of the studies in this review were conducted in high income countries. Very little research has constructed a measure for use in LICs and LMICs. A robust measure of HL provides the foundation for comparison of HL across countries as well as its evaluation in relation to health outcomes.

My colleagues and I (see acknowledgements below) sought to develop a robust measure of HL using data from Demographic Health Surveys (DHS) conducted between 2006-2015 in 14 developing countries: Cameroon, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Ivory Coast, Lesotho, Rwanda, Niger, Namibia, Sierra Leone, Swaziland, Toto, and Zambia. The same survey was administered in all countries, after translation into versions appropriate by language.  The DHS Program is administered by the United States Agency for International Development (USAID). Beginning in 1984, surveys have been administered in over 90 countries. The DHS survey includes items that represent domains of the IOM definition of HL. We identified eight survey questions that corresponded to elements of the four domains of health literacy as defined by the IOM: capacity to interpret, capacity to obtain, capacity to understand, and ability to make appropriate health decisions. We then applied factor analysis methods to extract a single factor – a measure of health literacy – and evaluate the results for reliability and validity.

In our work, a total of 259,684 individuals between the ages of 15 and 49 years were included.  The derived dichotomous measure of health literacy demonstrated internal consistency (Cronbach’s α = 0.72), good content validity, and importantly, was comprised of the elements described by the IOM.  The prevalence of high health literacy overall was 35.2%.  Health literacy varied by sex (females, 34.1% vs males, 39.2%) and education level (primary education or less, 8.9%, some secondary education, 69.4%, secondary education or higher, 84.4%). Health literacy varied considerably across nations, from 8.5% in Niger to 63.9% in Namibia.  

This was the first study to derive a robust indicator of health literacy following the IOM definition in a large number of national samples. In future work we plan to use this indicator with DHS datasets to measure health literacy in other countries, and ultimately test how health literacy relates to health behavior and outcomes, including for HIV/AIDS and domestic violence. An abstract of these findings was published in the Lancet Global Health, Volume 5, Special Issue, S18, April 2017.


The following individuals contributed to the investigation of HL as discussed in this blog series:

Douglas J. Wiebe, Phd, Associate Professor, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania

Julia M. Alber, Phd, Postdoctoral Fellow, Center for Health Behavior Research, University of Pennsylvania

Sara M. Schrauben, MD, Renal Research Epidemiology Fellow, University of Pennsylvania

Carmella M. Mazzola, College of Health Sciences, Arcadia University

Ashley Andrews, MPH, Perelman School of Medicine, University of Pennsylvania


Dr. Heather F. de Vries McClintockis currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.



Health Literacy: Is Educational Attainment Enough?

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the second blog  in a three-part series the IH Blog will feature this summer, Global Health Literacy: Conceptual Basis, Measurement and Implications.

Part II: Health Literacy: Is Educational Attainment Enough?

For over a decade I worked in primary care practices providing health education to patients with a broad range of educational and professional backgrounds, from persons who had dropped out of high school to those with dual doctoral degrees. I recall that when I first started I assumed that persons with higher levels of educational attainment would more readily understand and incorporate health education into their daily lives. I soon realized that I was entirely wrong. While persons who had higher levels of education were somewhat more likely to comprehend health information, a large proportion of these persons were unable to adequately understand and act on the health information presented to them. I remember sitting with a patient who had a doctoral degree who explained to me how his depression medication worked best when taken only on Sundays. Conversely, one patient who had not completed high school explained to me the intricacies of high blood pressure management with such clarity that it would have rivaled any veteran educator’s attempts at explaining it. All of these experiences fostered my interest in this concept of health literacy. What was health literacy? How could we adequately measure and improve it? What caused poor health literacy? Was it poor communication, a lack of numeracy skills, cultural barriers or other factors? The complexity of these questions fascinated me and I have pondered them over the last several years in my research.

In recapping my exploration let’s start by discussing how health literacy was initially distinguished from educational attainment. Much evidence has demonstrated that social factors occurring outside of the clinical encounter, namely education and income, profoundly influence health outcomes. Health disparities based on population (e.g. age, race, class, disability) or geographic residence (e.g. neighborhood, urban, country) are significant and have been the subject of much investigation. While a myriad of indicators have been explored in relation to such disparities, many investigations report that educational attainment is the most influential predictor of health. This relationship has been substantiated in a wide range of settings and time periods as well as by the application of varying methodological approaches and indicators of health. Educational attainment improves health through mechanisms on the individual level (e.g., health literacy and skill development); community level (e.g., location of residence characteristics); and macro level (e.g., policies, legislation, infrastructure).

The term health literacy (HL) was introduced and differentiated from educational attainment or literacy beginning in the 1970’s. During this time it was found that while one’s HL level was related to educational attainment (years of schooling) or reading ability/literacy, there was not a perfect linear correlation between educational attainment/literacy and HL. Research showed that individuals who functioned successfully at home or work often lacked adequate literacy to function within the context of a health care system. While varying opinions on the definition of HL have existed over time and are the subject of ongoing debate, generally speaking, being health literate meant that one could read, understand, and act on health information that was provided to them. HL encompassed proficiency in more than just reading ability but also writing, speaking, and listening as well as computational abilities (numeracy). A health literate individual was able to understand health information and use that health information appropriately. For example, a health literate elderly adult who received instructions from a primary physician on how to take medication for blood pressure would both understand the instructions and then take the medication as instructed by the physician. Thus, those with low HL were unable to adequately function within the healthcare environment increasing their risk for poor outcomes.

Some recent initiatives have sought to document stories related to health literacy. To this end, the U.S. federal government hosted an initiative called ‘Stories from the field’ as a part of a program to reduce the burden of low HL. In one story a doctor in Wisconsin struggled with his patients’ lack of comprehension of his instructions during medical encounters. He pondered whether it was poor communication on his part or whether there were other causes. After research and reflection he identified low HL as a prominent underlying cause and founded a small statewide literacy organization aimed at improving low HL called Wisconsin Literacy.

In order to address what has been called a “Health Literacy Epidemic,” both governmental and non-governmental initiatives have been developed to improve HL and in turn, reduce it’s public health burden. A transdisciplinary approach has been encouraged and specific guidelines have been established to foster improved communication. The U.S. Department of Health and Human Services (HHS) developed a National Action Plan to Improve Health Literacy. Broad goals and strategies of this plan are to improve HL in every sector and organization that provides health information and services. With the aim of fostering effective communication the federal government created The Plain which is an internet clearinghouse of information pertaining to the use of clear and understandable language. This initiative defines plain language as “… communication your audience can understand the first time they read or hear it. Language that is plain to one set of readers may not be plain to others.” The Plain Language Action and Information Network (PLAIN), a group of federal employees from many different agencies and specialties who support the use of clear communication in government writing, work to manage the initiative’s website. The Partnership for Clear Communication was established to spread awareness and address the issue of low HL. It established the “Ask me 3” program which informs healthcare consumers of 3 questions that should be asked during a medical encounter: (1)“What is my main problem?” (2) “What do I need to do?” (3) “Why is it important for me to do this?”  The Health Literacy Tool Shed, is a database created and administered by Boston University and the National Library of Medicine to foster collaboration and resource-sharing related to health literacy. The online search engine includes 129 tools related to the assessment of health literacy which range in terms of their purpose and design. They are either general in scope or focus on a certain domain(s) within the construct of health literacy (e.g. numeracy). Many of these tools aim to assess HL related to a specific medical condition (e.g. arthritis or cancer), categorization of health (e.g. oral health) or population (e.g. Dutch, Japanese).  Some tools were developed for rapid assessment.

For the global examination of HL the Institute of Medicine Roundtable on Health Literacy was convened to bring together leaders in the global health field to discuss activities and progress around the world related to HL. The United Nations as well as over a dozen countries were present at this meeting. The roundtable discussed different country’s unique approach to addressing low HL. For example, in Australia HL initiatives are part of the national Commission on Safety and Quality in Health Care. Canada connects HL with health promotion activities and the public health sector governs HL initiatives. A consensus from the meeting was that educational systems do not provide their students with the skills to adequately use health information and access health services. Furthermore, participants agreed that there was a lack of capacity for health care services to meet the needs of persons with low HL. This was accompanied by a lack of data on the nature and scope of the problem of low HL as well as the effectiveness of interventions targeting HL. This issue was particularly pronounced in LICs and LMICs, in which very little research had examined HL in any form.

Given the lack of evaluation of HL in LICs and LMICs there is an urgent need to develop a measure HL that can be feasibly employed. Establishing a measure that can assess the burden of low HL as well assess it’s relation to health outcomes is important so that effective interventions can be developed and deployed. Please stay tuned for Part III: The Evaluation and Measurement of Health Literacy in which I discuss my research group’s work in creating and establishing a measure of HL for use in LICs and LMICs.


Dr. Heather F. de Vries McClintockis currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.