Health literacy: Concept and definition
Health literacy was first introduced in the 1970s in the United States and Canada and has since evolved globally as a concept and a field of research. The concept has also made its way onto the political agenda in many countries, as can be seen, for example, from the many national health literacy policies (Nutbeam, 2017). In the Nordic region, so far only Norway has a national strategy on health literacy.
Throughout the years, several definitions and conceptual models have been used to explain the concept of health literacy, partly because it has been employed in many different contexts (Sørensen et al., 2012). In the beginning, the focus was mainly on the ability to understand health information related to healthcare. Later the focus has broadened, and a paradigm shift has taken place. Today, health literacy generally focuses on several skills and competencies needed to access, understand, appraise, and apply health information that has to do with healthcare, disease prevention and health promotion.
In the 1998* health promotion glossary, the WHO 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 implies the achievement of a level of knowledge, personal skills, and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment (WHO, 1998)."
In 2000, Nutbeam operationalised the WHO definition of health literacy and created a conceptual model operating on three levels of health literacy known as basic/functional, communicative/interactive, and critical health literacy. What started out as being a qualification of sufficient reading and writing skills, and with a basic knowledge of health (basic/functional health literacy), health literacy has evolved into a competence in the ability to perform knowledge-based literacy tasks to exert greater control over life events and situations (critical health literacy). A higher level of health literacy also leads to greater autonomy and personal empowerment (Nutbeam, 2000; Nutbeam, 2017).
Furthermore, different approaches and efforts are needed to meet the needs and skills of people at each level of health literacy. This applies, for example, to adapted information and media use, as there is no one-size model that fits all (Nutbeam, 2017). For many years, Nutbeam’s conceptual model was the most used in explaining the concept of health literacy.
*By the final review of this report, it became known that WHO had updated the health promotion glossary from 1998 and modified the definition of health literacy. In the new health promotion glossary of terms, WHO defines health literacy as representing
"the personal knowledge and competencies that accumulate through daily activities, social interactions and across generations. Personal knowledge and competencies are mediated by the organizational structures and availability of resources that enable people to access, understand, appraise, and use information and services in ways that promote and maintain good health and well-being for themselves and those around them (WHO, 2021)."
An integrated model of health literacy
In 2012, Sørensen and colleagues published a systematic literature review of existing definitions and concepts of health literacy as reported in international literature. The systematic review resulted in several definitions and conceptual models of health literacy, which guided the content analysis and led to an integrated model of health literacy (Figure 1). This model outlines the main dimensions of health literacy (represented in the concentric oval shape in the middle of the figure) together with a logical model showing the proximal and distal factors that impact on health literacy, and the pathway linking health literacy to health outcomes.
Figure 1: An integrated model of health literacy (Sørensen et al., 2012)
Health literacy is closely linked to literacy and includes people’s knowledge, competence, and motivation to access (to seek, find, and obtain health information), understand (to comprehend the health information that is accessed), appraise (to interpret, filter, judge, and evaluate the health information that has been accessed), and apply (to communicate and use) the health information. Each step of the process represents a crucial dimension of health literacy which is related to specific cognitive and psychosocial qualities, but also to the quality of the information provided. The process also incorporates the levels of functional, interactive, and critical health literacy as defined by Nutbeam (2000).
The process of accessing, understanding, appraising, and applying health information generates competencies and skills, which enables a person to navigate, make judgements and decisions in everyday life within the three domains of healthcare, disease prevention, and health promotion. However, as contextual demands change over time, and the capacity to navigate the health system depends on cognitive and psychosocial development as well as previous and current experiences, the competencies and skills of health literacy develop during the life course and are linked to life-long learning. Health literacy is also impacted by other factors such as societal and environmental determinants (for example, demographic situation, culture, language, political forces, societal systems), personal determinants (such as age, gender, race, socioeconomic status, education, employment, income, literacy), and situational determinants (such as social support, family and peer influences, media use, and physical environment).
Health literacy can influence health behaviour and the use of health services, which can affect health outcomes and the health costs in society. Advancing health literacy will progressively allow greater autonomy and personal empowerment, and the process of health literacy can be seen as a part of individual development towards improved quality of life. In the population it may also lead to more equity and sustainability of changes in public health. Limited health literacy can be addressed by educating persons to become more resourceful (for example, increasing their personal health literacy) and by making the task or situation less demanding (for example, improving readability of the system and the information provided) (Sørensen et al., 2012). Today, the integrated model by Sørensen and colleagues (2012) is widely used in international literature and research to explain the concept of health literacy.
Organisational health literacy
Although health literacy has often been defined and portrayed as a personal trait, there is a growing appreciation that health literacy does not depend on the skills of individuals alone. It is the product of individuals’ capacities and the health literacy-related demands and complexities of the healthcare system. To align healthcare demands better with the public’s skills and abilities calls for systemic and organisational changes (Brach et al., 2012).
"A health-literate organisation can be described as enabling people to navigate, understand, and apply information and services to take care of their health (Farmanova et al., 2018)."
There are different options to choose from in becoming a health-literate organisation, and different healthcare organisations can choose different strategies. What is important is how well the chosen strategies work in relation to the different people in the population that the health organisations serve (Kickbusch et al., 2013).
Brach and colleagues (2012) introduced a list of ten attributes (see below) to exemplify a health-literate healthcare organisation. The list is not exhaustive nor is it adapted to societies globally, but it represents an attempt to synthesise a body of knowledge and practice, supported by the science in health literacy. Therefore, healthcare organisations that embody these attributes create an environment that enables people to access and benefit optimally from the range of healthcare services.
The ten attributes of a health-literate healthcare organisation:
- Has leadership that makes health literacy integral to its mission, structure, and operations.
- Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement.
- Prepares the workforce to be health-literate and monitors progress.
- Includes populations served in the design, implementation, and evaluation of health information and services.
- Meets the needs of populations with a range of health literacy skills while avoiding stigmatisation.
- Uses health literacy strategies in interpersonal communication and confirms understanding at all points of contact.
- Provides easy access to health information and services and navigation assistance.
- Designs and distributes print, audio-visual, and social media content that is easy to understand and act on.
- Addresses health literacy in high-risk situations, including care transitions and communications about medicines.
- Communicates clearly what health plans cover and what individuals will have to pay for services.
The ten attributes thus relate to the structure and work within the organisation, the design and implementation of information, communication and services, and what knowledge the staff in the organisation have. The attributes also demonstrate that healthcare organisations can immediately take concrete, practical action to close the gap between individuals’ health literacy skills and the demands of complex healthcare systems. Healthcare organisations that adopt and invest in these attributes, even in a modest way, will create an environment that enables people to access and benefit optimally from the range of healthcare services, which will contribute to improved population health (Brach et al., 2012).