Integrating Health Literacy, Good Governance and

Urban Health - the Case for Health Promotion

A short policy response to WHO Shanghai Draft Document
Aug 25, 2016

Respectfully submitted by the IUHPE Global Working Group on Health Literacy*

Outline
Introduction: Rationale on Integrated Framework
Part One: Linking the 3 areas of the draft WHO Shanghai report
Part Two: Recommendations for policy makers

Introduction

The integrated Framework for Health Promotion Actions, employing three

interconnected, cross-cutting themes – urban and rural health, governance, health
literacy – provides a powerful framework to guide and support the achievement of the
Sustainable Development Goals (SDGs). Health literacy is associated with health and
wellbeing and is linked with health disparities and inequities; inadequate health
literacy contributes to poor health outcomes, with a negative economic effect on
countries well-being.
Health literacy is considered a modifiable influence on health inequity. All regions,
low, middle and even high income countries would benefit from promoting health
literacy, not only in an urban context but also in rural areas where people lack
immediate provisions. Supported by good governance, promoting health literacy
could mitigate some of the setbacks that intensive urban development is having on the
planet. Supporting health literacy of people where ever they live can help them feel
empowered to pursue their lives more integrated in their environments. While there is
no specific target on health literacy within the SDGs, efforts to strengthen health
literacy will be crucial in whether the social, economic and environmental ambitions
of 2030 Agenda for Sustainable Development are fully realized (World Health
Organisation [WHO] 2016, Policy brief 4). Health Literacy needs to be a part of the
strategies aimed at good governance and supporting urban and rural health if we are to
achieve the 2030 United Nations Sustainability Goals. The three areas are not only
interrelated; they influence one another and can serve to strengthen each other.

Part One - Linking the 3 areas of the draft WHO Shanghai report

The three themes reflect critical entry points to make a difference through whole-of-
government and whole-of-society approaches, people's living environment and the
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settings of everyday life and people’s capacity to increase control over their own
health and its determinants. Within each of these areas, we can develop innovative
approaches to coordination, greenness, equity and inclusiveness, transparency and
accountability, community participation and adapting to the potential of a global
digital society.
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* compiled for the IUHPE GWG-HL by: (in alphabetical order): Janine
Broeder, Diane Levin-Zamir, Evelyn McElhinney, Paola Ardiles, Kristine
Sorensen, with special contribution from Luis Saboga Nunes and Orkan Okan

Figure 1: Three integrated themes of in the context of health promotion

Health Literacy

Health literacy refers, broadly, to the ability of individuals to “gain access to,
understand and use information in ways which promote and maintain good health” for
themselves, their families and their communities (WHO 2016, Policy brief 4, p.1).
Moreover, health literacy is contextual: The ability to promote one's health and that of
his or her family are embedded in, and influenced by, culture and community.
Urban life is characterized by a sum of communities – whether geographic, cultural or
by any other commonality that bring people together. A wealth of opportunities exist
for promoting health through improved health literacy in communities using the

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settings approach, and other methods to reach people appropriately where they live,
learn, work, play and love.

The social gradient for health literacy is acknowledged as has been shown in
numerous studies. As such, people and communities at risk for low health literacy can
be identified. Systems, including health systems are placing information burdens on
populations. As such, people with higher levels of health literacy are more likely to
adopt healthier behaviours and be able to make health promoting decisions for their
health and access and use the relevant resources including information, services and
universal health coverage (WHO 2016, Policy brief 4, p.2). Health literacy
development starts early in life and continues throughout the life course. While
investments in health literacy can take place in multiple ways, different skills are
needed for different situations and contexts. Health literacy is a toolbox that enables
people to protect and promote their individual health and that of their family and
community and provide them with the abilities to become advocates for their human
right to health. Hence, health literacy is both a personal resource for health, as much
as it is a societal health resource. Investing in citizens’ and communities' health
literacy provides them with the skills and capabilities necessary for actively
participating in decisions about their health. Creating opportunities for citizens to take
control over their health at all levels of society will ensure their voices are heard.

Urban Health

Promoting Urban Health requires an upstream approach that recognizes the social and
ecological determinants that influence the design of healthy cities and healthy
communities. Urban settings play an important role in addressing the determinants
including the planning and management of services, and activities which aim to
improve health or reduce health inequities (WHO, 2016). Recognizing and making
visible the assets within a community that can contribute to improving health literacy
through the use of social resources such as, peer support, intergenerational knowledge
and skills, and social marketing are important to ensuring that individuals and
communities can continue to improve health literacy without ongoing professional
support. Health Literacy interventions are increasingly considering their impact on
determinants of health and health equity.

Municipalities and other governing bodies should invest in empowering and

strengthening people's capacity to promote their health through initiatives that
develop and support skills comprising functional, interactive and critical health
literacy. In accordance with health promotion tenets, civil society must be engaged to
participate in this process at all levels. Communities' needs for accessing useful
culturally appropriate health information that addresses challenges and practical
needs, such as navigation of the health and social services, must be represented in the
decision making process in every community.

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Peri-urban and Rural Health (We suggest adding this perspective although it is
not one of the 3 themes of the conference)

Since the industrial revolution, rapid urbanization brought new challenges to public
health. The poor conditions in which people lived and worked left a mark on the price
to be paid for the so called “development”. Currently, certain perspectives are
pointing at the price of this “development” as a the turning point with huge numbers
of (forced) unemployed city citizens. Also, certain societal frameworks closely linked
with the cities' way of life, have had a negative consequence on those forced to retire
from the vibrant city life. An increased number of seniors are led to sedentary life
styles with known consequences for their health condition. City dwellers that are not
integrated in social security systems face unprecedented challenges and are left
unaccounted for in most of the statistics produced around the myth of “development”.
In countries that were hit hard with the last financial and economic crisis, this has
surfaced with countless negative consequences and also, surprisingly, with some
innovative solutions, such as the migration movements marked by the return to rural
areas. This has been pointed out as a viable possibility to mitigate the negative
consequences of urbanization. Facilitating this movement based on empowering
strategy, may also be an ingredient for creating an answer to the environment issues,
posed by the mega-conglomerates of city dwellers.

Good Governance

Governments must take a strong leadership role in developing and implementing

health literacy promotion policies by providing sustained funding, establishing and
sustaining special programs, coordinating action across sectors, and conducting health
literacy surveillance regularly (Kickbusch et al., 2013).

Improving and measuring health literacy (both strengths and needs) is particularly
important in disadvantaged areas, such that disadvantaged populations are empowered
to engage in early and sustained health promoting actions, whether to prevent acute
and chronic conditions or to promote and adopt active and curative treatments.
Surveillance and monitoring can enable decision makers from different government
sectors to better understand the significance of health literacy, both to health and to
their sector’s core objectives

Strengthening participatory and representative decision-making about health literacy

development and equity at all levels will promote individual and community action
for health. This can scale up commitment to work across disciplines and sectors and
enable learning and transfer of knowledge and experience across settings and context
(at community, sectional, national as well as cross-country level), especially to
achieve the SDGs (WHO 2016, Policy brief 4, p.2).

In addition, by promoting health literacy, policy- and decision-makers can more

actively involve citizens and all people as partners in developing and implementing
health policy at the urban, community, regional and national levels.

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Practical Recommendations

Intersectoral approaches to promote health are critical when addressing the social
determinants of health. There is ample evidence that action is required by policy
makers, civil society and the private sector, in addition to practitioners. In order to
achieve the SDGs, the health promotion sector needs to adopt a whole of society
approach to health literacy. Therefore, strengthening health literacy will require
government ministries to strengthen partnerships and influence and guide businesses,
civil society and other organizations through:

● Policy: Integrating Health Literacy into All Policies, including creating and
implementing National Health literacy action plans and digital strategies
● Education: Using health literacy as a framework for improving school health
education and adult education in all countries, educating societies on health
issues throughout the lifespan with particular focus on children and youth.
● Health Communication, Health Information and Language: Adopting new
legislation and regulations for example; more understandable food additive
labelling to help the public to make nutritional health choices, embedding
health literacy skills and practices into school curricula, and creating
transparent, consumer friendly environments, and easy to understand social
media strategies.
● University Programmes and Training: Implementing academic health
literacy training and supporting the implementation of health literacy
professorships in all countries. Improving awareness of the outcomes of
inadequate health literacy through professionals' undergraduate and
postgraduate university programmes.
● Research and Funding: Sustained funding for health literacy research
● Capacity Building: Supporting professionals, networks, and all parties
interested in health literacy, developing easy access online resources and
databases, implement and supporting national contact points and working
groups, and investment in health literacy.
● Collaboration: Cross sector, country, and continental collaboration to
improve health literacy. Developing stronger links with health promoting
schools, hospitals, healthy cities movement, and NGO and private sector
organisations and with a wide range of stakeholders
● Whole Setting Approach: Develop strategies in various settings such as:
primary care, schools, communities, workplaces, media, social web, etc.
● Investment: Investing in health care including mental health and social care
to make these sectors more user friendly, person-centered and health literate.
● Empowerment and Inclusion: Positioning health literacy as an
empowerment tool for a health agenda which can be promoted through a
multi-strategic approach at individual, community and society level. A

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 sustainable approach leaves no one behind. Inclusion of all on individual and
population level regardless of their culture.
● Health Equity Agenda and Social Justice: Exploring associations at the
intersections of health equity, health inequalities, and health literacy to
improve health equity and health for all. Using proportionate universalism as
the practice approach to address hard to reach groups.

Figure 2: IUHPE GWG-HL Recommendations visualized

Conclusion

The health promotion strategies developed to achieve the SDGs can benefit from
considering the 3 Pillars of Sustainability: a) environmental protection of the planet,
b) social equity and wellbeing, and c) economic development (Goodland, 1995).
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Health literacy is an instrument for providing people at all levels – urban, peri-urban,
rural, community, national level with the capacities and knowledge to understand,
evaluate and advocate for the conditions and structures that influence their health.
Those with higher levels of health literacy are empowered to hold their governments
accountable, whether it is to access to essential medicines, universal health coverage,
removing environmental air pollutants or tearing down discriminatory laws and
practices that impact the most disadvantaged. The time to invest in health literacy is
now as the return of investments will benefit not only the health sector but also other
areas in society.

Selected Policy References

Goodland, Robert. “The concept of environmental sustainability.” Annual review of

ecology and systematics, 1995: 1-24.

Kickbusch I, Pelikan J, Apfel F, Agis T, editors. “Health Literacy: The Solid Facts,
1st edn.” Copenhagen: World Health Organisation Regional Office for Europe,
2013. Accessible at
http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf?ua=1

World Health Organisation. “Health In the SDGs. Policy brief 4: Health literacy.” 9th
Global Conference on Health Promotion (9GCHP). Geneva: World Health
Organisation, 2016. Accessible at
http://www.who.int/healthpromotion/conferences/9gchp/policy-brief4-health-
literacy.pdf

World Health Organisation. “Global report on urban health: equitable, healthier cities
for sustainable development.” Kobe, Japan: World Health Organization Centre for
Health Development, 2016. Accessible at
http://www.who.int/kobe_centre/measuring/urban-global-report/ugr_full_report.pdf

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