Points of View Current status of health literacy in Japan, policies and efforts to improve it

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Akiko Yoshida, Senior Researcher, Pharmaceutical Industry Policy Institute

SUMMARY

1. Introduction

The author believes that one of the issues to be addressed toward the ideal drug price and drug pricing system that is highly convincing to the public is public awareness and understanding. In terms of public awareness, understanding, and behavior, as shown in Table 1, the issues include "improving interest in and recognition of basic information on drug prices and systems," "promoting understanding of the various values of drugs," "improving awareness and behavior to save medical costs," and "improving behavior regarding drug use with the intention of saving medical costs ^awareness1). Since these issues are likely to be encompassed by health literacy, this paper reviews and discusses the current status of health literacy in Japan, as well as policies and examples of efforts to improve it, based on literature and other sources.

2. about health literacy

2.1 What is Health Literacy?

Health literacy is a term coined by combining the English words "health" and "literacy. Since the 1990s, many researchers and organizations, such as Nutbeam and Sorensen, have defined health literacy, and the debate continues. Even within Japan, there are a variety of slightly different and varying expressions. As if condensed in the shortest description, "refers to the ability to utilize health information. " ²⁾ Almost all of the descriptions shown included the four words synonymous with "health," "information," "utilization," and "ability. In this paper, the definition of "health", which is considered to be an organized summary of many definitions, is "the knowledge, willingness, and ability to obtain, understand, evaluate, and utilize health information, which enables people to make judgments and decisions about health care, disease prevention, and health promotion in their daily lives, and to maintain and improve their quality of life throughout their lives. ³⁾ "to maintain and improve quality of life throughout life by making decisions and making judgments about health care, disease prevention, and health promotion in their daily lives.

2.2. number of articles

Next, in order to understand the number of articles related to health literacy and their trends, a search was conducted using the Web of Science (Clarivate) for the last 10 years, limited to original papers, with the topic set to "health literacy". The number of hits was 7. The number of original papers found was 7,959, and the annual trends and growth rates by country/region are shown in Fig. 1. Japan had the eighth highest number with 197 reports. There has been a rapid increase in the number of papers on health literacy topics in recent years, especially in the last five years. Although Japan lags behind the rest of the world in the number of papers, the growth rate is high, and it can be said that Japan is in the process of making progress in research. By Web of Science field, Public Environmental Occupational Health, i.e., public environmental and occupational health, had the largest number of papers in both Japan and the world.

2.3. cases of low/high health literacy

Next, in order to understand health literacy, we organized examples of behaviors that are associated with low or high health literacy based on information provided in various literatures (Table 3). (Table 3)

Low: not using preventive services (e.g., flu shots) ⁴⁾, having little knowledge of diseases, treatments, and ^{medications4)}, not being able to read labels and ^messages4), not easily recognizing the first signs of a medical problem (making it worse) ⁴⁾, having difficulty managing long-term or chronic illness4 ⁾, having difficulty managing chronic hospitalization for ^illness4), less likely to express their concerns to health professionals4 ⁾, more likely to use emergency ^services4), more likely to be injured at ^work4), higher mortality ^rates4), and higher health care ^costs5).

Many of the high cases describe the flip side of the low cases. They can use health checkups and vaccines to prevent and treat diseases at an early ^stage6), they can find out correct information about diseases and medicines and understand the advantages and disadvantages of treatment6 ⁾, they can take medicines properly without making mistakes6 ⁾, they can visit medical facilities as needed without missing the symptoms of ^diseases6), they can continue to lead healthy lives and avoid chronic ⁶⁾ can prevent chronic illness from ^worsening6), establish healthy behavioral ^habits7), have a high self-evaluation of their ^health8), can consult doctors and nurses well and receive necessary medical examinations and other ^assistance6), and proactively solve problems and seek support from others in dealing with work ^stress7), higher job ^{performance9)}.

Being able to prevent and treat diseases at an early stage through the use of health checkups and vaccines, being able to look up correct information about diseases and medicines, understanding the advantages and disadvantages of treatment, and being able to take medicines properly without making mistakes are important points that contribute to extending the nation's health and healthy life expectancy by maximizing the benefits of medicines. This is an important point. In addition, the proper use of ambulances to meet the ever-increasing demand for emergency medical services, as well as the increasing mortality rate and medical costs, are important issues that affect not only individuals, but also contribute to our nation's social issues.

Inferring from the high level of health literacy shown in Table 3, it can be inferred that improving health literacy includes "increasing interest in and awareness of basic information such as drug prices and systems," "promoting understanding of the various values of drugs," "improving awareness and behavior to save medical costs," and "improving behavior regarding drug use with the intention of saving medical costs. Improvements" were suggested to include.

2.4 Evaluation Scale and Current Status in Japan 2.5.

What tools are available to measure health literacy? The U.S. National Library of Medicine and Boston University School of Medicine have made the Health Literacy ^ToolShed10) available to the public as an online database, and as of September 2023, 275 rating scales had been listed. The following table lists some examples by category based on the information provided in the Health Literacy ToolShed (Table 4). （As shown in Table 4, there were a variety of measurement tools by purpose, ranging from those that are easy to use, to those that can be used for a wide range of purposes, to those that can be used for different diseases and conditions, and those that have been translated for use in different countries. In addition, assessment scales related to medication use were also found, indicating that they are being developed.

Here, we describe the European Health Literacy Survey Questionnaire (HLS-EU-Q47), which is one of the comprehensive scales and is also available in Japanese for comparison with other countries. ¹¹⁾ The HLS-EU-Q47 is a questionnaire that was developed by the European Health Literacy Commission (EHLS) and is used to assess the health literacy of people who take medicines. The HLS-EU-Q47 is described as a comprehensive instrument capable of assessing domains and competencies in more detail. It measures the four abilities of "obtaining," "understanding," "evaluating," and "using" health information in the three domains of "health care (e.g., when ill or experiencing symptoms, when using health care)," "disease prevention (e.g., immunizations, screening, disease prevention behaviors)," and "health promotion (e.g., evaluating living environment and participating in health-related activities). The survey measures these in three domains: disease prevention (e.g., immunization, health checkups, and disease prevention behaviors), and health promotion (e.g., evaluating the living environment and participating in health activities). The questionnaire has 47 questions. For example, "understand the doctor's or pharmacist's instructions on how to take prescribed medication" is answered with the options "very easy," "somewhat easy," "somewhat difficult," and "very difficult. The idea is that it reflects not only the individual's ability, but also the situation or environment in which it is difficult to perform it, and how strongly it is required of them.

What is the current state of health literacy in Japan? Unfortunately, according to Nakayama et al. Although it should be noted that this is not a direct comparative study conducted simultaneously and that there are differences in national characteristics when answering the questionnaire, Japanese respondents answered "more difficult" than Europeans on all items for judging health literacy, suggesting that health literacy in Japan is low. The Japanese were reported to have particularly high levels of difficulty with items related to judgment and decision-making.

The reasons for this are considered to include opportunities to receive primary care and health education from family physicians, health education from preschool age and the development of problem-solving and decision-making skills, easy-to-understand and reliable health information resources and websites provided by the National Library of Medicine and other sources, and difficulties in accessing health science and medical articles (see Section 12). ¹²⁾.

In light of these points, the author speculates that Japan has issues related to health education itself, the creation of an environment in which correct information can be obtained, recognized, and understood, and the development of the ability to make judgments and decisions.

2.5. Policies in Japan

How has health literacy been presented and promoted in Japanese policy?

In 2000, the Ministry of Health, Labour, and Welfare (MHLW) launched "Healthy Japan 21 (National Health Promotion Campaign in the 21st Century), " ¹³⁾ a national campaign to promote health from the perspective of primary prevention. This campaign aims to extend the healthy life expectancy of the nation by setting numerical targets for various health issues for the entire population and systematically working to improve lifestyle habits. In addition, eight years ago, in 2015, the Ministry of Health, Labour and Welfare (MHLW) published the "Health and Medical Care 2035 Proposal " ¹⁴⁾. This is a vision created with a view to 2035, 20 years from now, in order to resolve the issues surrounding Japan's healthcare environment and realize a healthcare system in which all people can continue to play an active role with peace of mind. One of the goals of the vision is to have "improved knowledge and awareness of health, with each patient proactively participating and collaborating in their own healthcare choices" by 2035. Specifically, "Until now, users of medical services have tended to have excessive expectations of and reactions to medical care due to a lack of basic knowledge and passive involvement in health care. In order to remedy this, support is provided for the development of health literacy through school education, outreach from health care professionals, government, NPOs, and insurers." The statement is as follows. In addition, "society as a whole needs to support prevention and health promotion throughout life, from children to the elderly," in order to "realize healthy lifestyles throughout life. To this end, we must provide opportunities for intergenerational health education in all settings, from childcare and early childhood education to the workplace and community, and promote efforts to develop health literacy. This is stated as follows. And in the Basic Policies for Economic and Fiscal Management and Reform 2022 (Kotta-no-Kakaku 2022) ¹⁵⁾, in the section "Strengthening and Promoting Integrated Economic and Fiscal Reform in the Social Security Sector," it is stated that "efforts will be made to improve health literacy.

Since around 2000, policies in Japan have been designed to improve the health literacy of the public, and this statement is included in the "Health and Medical Care 2035 Proposal" and the "Kotto Policy 2022". They indicated the importance of developing health literacy from the perspective of improving the people's own health or extending healthy life expectancy.

These policies have led to educational reforms surrounding health literacy, such as the inclusion of a section on "mental illness" in high school "health" textbooks starting in April 2022 for the first time in 40 years, and the beginning of new mental health (mental health literacy) ^education16). The entire nation will be working to create health education itself and an environment that enables access to correct information, recognition, and improved understanding, as well as the development of the ability to make judgments and decisions.

2.6. Examples of Efforts to Improve

Finally, we will look at what kinds of efforts are being made to improve health literacy in Japan. The initiatives can be divided into three categories: those aimed at the general public, those aimed at employees of companies, and those aimed at patients. Table 5 summarizes some of these initiatives and provides some examples. Note that the conditions for certification as a "health management brand" or "excellent health management corporation " ¹⁷⁾ initiated in 2015 by the Ministry of Economy, Trade and Industry (METI) and the Tokyo Stock Exchange include efforts to improve employee health literacy, and how a company can raise the level of employee health literacy is one of the issues. Therefore, many companies are considering the health management of their employees from a managerial perspective and strategically implementing it, which is expected to lead to the revitalization of the organization by improving the vitality and productivity of employees, which in turn leads to improved business performance and stock price, and various efforts are being made.

For the general public, in addition to books, the St. Luke's International University Academic Information Center's "Health Literacy Course " ¹⁸⁾ provides e-learning materials on a You-Tube channel that anyone can access at any time to acquire and enhance basic health literacy. In addition, the "Health Literacy Test " ¹⁹⁾ is posted on the Tokyo Metropolitan Medical Association's website, where users can access the site from their smartphones or PCs and answer 15 questions to find out their own level of health literacy. The site also includes a "Tell us about your health literacy test" (20)! Health Literacy" ⁽²⁰⁾, in addition to explaining health literacy, includes videos of doctors explaining in simple language about frailty, which seniors should be aware of, why doctors recommend exercise, and the importance of vaccinations and health checkups for children. The general public has the opportunity to learn about health and disease prevention in an easy-to-understand manner, to obtain correct information, to increase awareness and understanding, and to acquire the ability to make judgments and decisions when health concerns arise.

Among the general public, those targeted at corporate employees mainly included on-site classes, e-learning materials, chat consultations, and the dissemination of health information through a portal site. Otsuka Pharmaceutical's "Women's Health Promotion Project " ²¹⁾ offers delivery classes that provide seminars aimed at improving women's own health literacy and contributing to men's understanding; SOMPO Health Support's "Health Care e-learning " ²²⁾ provides medical and nutritional studies in accordance with the body clock TRULY " ²³⁾, an e-learning program to improve health care literacy that can be learned on line, which provides easy-to-understand explanations via video and text on everything from specialized knowledge about the physical and mental changes and disorders caused by hormones in men and women to general care methods and the law, and "health care e-learning" in which doctors and specialists provide health consultations directly to employees via chat. The company also offers "LINE Chat Consultation," in which doctors and specialists provide direct consultation via chat to employees on their health issues. The Japan Health Insurance Corporation ⁽ JHIC ⁾²⁴ provides health information on its website, including how-to information that can be easily implemented, with a particular focus on improving lifestyle habits, so that employees can correctly recognize their physical and mental health status and work on their own to maintain and promote their health. Employees have the opportunity to learn about health and prevention during their work time, to obtain correct information, to improve their recognition and understanding, and to acquire the ability to make judgments and decisions when they have concerns about their physical or mental health.

Among those targeting patients, there were some that were undertaken by pharmaceutical companies and the pharmaceutical industry as a group, and others by hospitals. For example, ^Smile-One25) provided by Chugai operates a disease awareness and information website to bring smiles to hemophilia patients and their families, and provides disease information through videos and cartoons to help patients and their families. EFPIA Japan, a pharmaceutical industry (organization), provides content such as interviews with experts (e.g., on the significance of ^vaccines26) to encourage patients and their families to choose medical and health information wisely and to improve their health literacy. In addition, a collection of medical and health information websites for the general public provided by EFPIA Japan member companies are posted and guided, offering a wide range of prevention and disease information. In some cases, hospitals are working to support the transition from childhood to adulthood, i.e., to help patients develop their own health literacy toward ^adulthood27). One example is the Chiba Children's Hospital, which, based on its Adult Transition Support Program, is working to support patients to increase what they can understand and self-manage by emphasizing discussions with them to help them understand diseases and treatments that are appropriate for their development. Specifically, the program conducts questionnaires using the Adult Transition Assessment Sheet to confirm understanding of the disease and medications, which is then utilized in subsequent support, and creates "My Passport" to record the progress of treatment and lifestyle precautions by themselves for use in health management. By disease, there was also an ^{application28)} that helps cancer patients understand the details of treatment proposed by their doctor and deepen their knowledge about the disease, treatment, etc. Patients and their families, according to disease and age, have the opportunity to learn about diseases, prevention, and prevention of serious illnesses, to obtain correct information, to improve recognition and understanding, and to acquire the ability to make judgments and decisions.

Efforts to improve health literacy in our country have included some aimed at the general public, some at employees of companies, and some at patients. These efforts were aimed at health education itself, support for obtaining correct information, awareness, and understanding, and development of the ability to make appropriate judgments and decisions in the event of health concerns. Each of the programs was designed from the viewpoint of the target audience, with careful explanations using plain language, devices to increase interest, ideas to help busy people understand in a short period of time, and ideas for patients tailored to their diseases and age groups.

3. summary and discussion

In this paper, we have reviewed the current status of health literacy in Japan, as well as policies and examples of efforts to improve it, based on literature and other sources.

Health literacy has been defined and debated by many researchers and organizations since the 1990s, and even in Japan, the term has been expressed in a variety of slightly different ways. In the author's research, as if condensed into "the ability to utilize health information," which was the shortest definition given, many definitions include words synonymous with "health," "information," "utilization," and "ability," which may indicate a meaning that can be summarized in four words in a nutshell.

In order to understand health literacy, we have organized case studies based on information provided in various literature on what behaviors are associated with low or high health literacy. The ability to use health checkups and vaccines to prevent and treat diseases at an early stage, to look up correct information on diseases and medicines, to understand the advantages and disadvantages of treatment, and to take medicines properly without making mistakes are examples of behaviors that contribute to the health of the population and the This is an important point that can contribute to extending the healthy life expectancy of the population. In addition, inferring from the high level of health literacy, it is suggested that improving health literacy includes "improving interest in and awareness of basic information such as drug prices and systems," "promoting understanding of the various values of drugs," "improving awareness and behavior to save medical costs," and "improving behavior regarding drug use with the intention of saving medical costs. were suggested to be included in the study. At present, it is argued that health literacy in Japan is low compared to other countries, and no literature was found to indicate the opposite, that it is high. In response to this current situation, our country's policies have focused on increasing the health literacy of the population from the perspective of promoting the health of the people themselves. In fact, examples of Japanese efforts to improve health literacy are found in health education itself, support for obtaining correct information, awareness, and understanding, and development of the ability to make judgments and decisions when health concerns arise, all of which are consistent with the direction of national policy. In Japan, the relationship between health literacy and health-related outcomes such as quality of life is also being ^{demonstrated29)}, and we hope that the results of these efforts will lead to improved health literacy.

4. conclusion

In conclusion, I would like to share the author's personal views on the following issues that are considered to be encompassed in the area of health literacy: "improving interest in and awareness of basic information such as drug prices and systems," "promoting understanding of the various values of drugs," "improving awareness and behavior to save medical costs," and "improving behavior regarding drug use with the intention of saving medical costs. Personal opinions on the recognition of the issues will be presented.

With reference to the current status of health literacy, policies, and examples of efforts to improve health literacy, it is necessary to provide basic education on the price, system, and value of medicines, as well as activities and environments that support the acquisition of correct information, awareness, and understanding of medical costs, including drug prices, and to develop the ability to make correct judgments and decisions regarding medical care and medicines. It is also necessary to develop the ability to make correct judgments and decisions regarding medical care and pharmaceuticals. The target audience should be not only patients but also the public at large.

The "Survey on Awareness of Prices, Systems, and Values of Pharmaceuticals" conducted by the National Institute for Policy Studies (NIPR) suggests expectations for various changes, such as increased awareness and interest in the prices, systems, and values of pharmaceuticals, and expectations for changes in behavior when faced with medical ^treatment30). As for the pharmaceutical industry, through the provision of knowledge on health issues such as diseases, their treatment, and prevention of serious illness through the creation of pharmaceuticals and other products, and information on the value that innovative pharmaceuticals bring to the public, patients, and their families, we can raise awareness and understanding of value-centered pharmaceuticals and further contribute to improving health literacy in our country. This may be possible.

On the other hand, while the participation of the public as the main actors is essential to improve public awareness and understanding, the participation of patients (citizens) is generally not well recognized nor is there a high level of awareness of the ^issues31). New ideas that involve not only patients but also the public at large are needed. The public has changed its attitude toward health, medicine, and medicine after the Corona ^vortex31) and has become more health-conscious, etc. Now is the time to involve the public and further increase health literacy in our country.

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