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Health Literacy As A Public Health Goal
Health Literacy As A Public Health Goal
3
© Oxford University Press 2000 Printed in Great Britain
SUMMARY
Health literacy is a relatively new concept in health pro- distinctions between functional health literacy, interactive
motion. It is a composite term to describe a range of out- health literacy and critical health literacy. Through this
comes to health education and communication activities. analysis, improving health literacy meant more than trans-
From this perspective, health education is directed towards mitting information, and developing skills to be able to
improving health literacy. This paper identifies the failings read pamphlets and successfully make appointments. By
of past educational programs to address social and eco- improving people’s access to health information and their
nomic determinants of health, and traces the subsequent capacity to use it effectively, it is argued that improved
reduction in the role of health education in contemporary health literacy is critical to empowerment. The implications
health promotion. These perceived failings may have led to for the content and method of contemporary health edu-
significant underestimation of the potential role of health cation and communication are then considered. Emphasis
education in addressing the social determinants of health. A is given to more personal forms of communication, and
‘health outcome model’ is presented. This model highlights community-based educational outreach, as well as the
health literacy as a key outcome from health education. political content of health education, focussed on better
Examination of the concept of health literacy identifies equipping people to overcome structural barriers to health.
259
260 D. Nutbeam
and other preventive health services have a long and behaviours in populations (Andreasen,
history. In developing countries, health education 1995). Social marketing has encouraged creative
directed towards these goals remains a funda- approaches to the analysis of issues and the de-
mental tool in the promotion of health and velopment of programs, especially in relation to
prevention of disease. the communication of information. As a conse-
In developed countries, during the 1960s and quence, health education programs have evolved
1970s this early experience in health campaigning in their sophistication, reach and relevance to a
was directed towards the prevention of non- wider range of groups in populations.
communicable disease by promoting healthy Despite this progress, interventions which
lifestyles. Many of these early campaigns were have relied primarily on communication and edu-
characterized by their emphasis on the trans- cation have mostly failed to achieve substantial
mission of information, and were based upon a and sustainable results in terms of behaviour
relatively simplistic understanding of the relation- change, and have made little impact in terms of
ship between communication and behaviour closing the gap in health status between different
change. Over time, it became apparent that cam- social and economic groups in society.
paigns which focussed only on the transmission
of information and failed to take account of the
social and economic circumstances of individuals ADDRESSING SOCIAL
were not achieving the results which had been DETERMINANTS OF HEALTH
expected in terms of their impact on health be-
haviour. Many health education programs emerg- In the 19th century public health action resulted
ing during the 1970s were found to be effective from a need to address the devastating effects
only among the most educated and economically of the living and working conditions imposed
advantaged in the community. It was assumed on populations during the industrial revolution.
that these groups had higher levels of education The initial focus of public health action was,
and literacy, personal skills and economic means therefore, on the social and environmental deter-
to receive and respond to health messages com- minants of the health of the population. By the
municated through traditional media. late 20th century, however, there had been a shift
As a tool for disease prevention, health in the emphasis of public health action toward
education was considerably strengthened by modifying individual risk behaviours.
the development of a new generation of more However, recent epidemiological analysis of
sophisticated, theory-informed interventions health, disease and disability in the populations
during the 1980s. These programs focussed on of most developed countries confirms the role
the social context of behavioural decisions, and of social, economic and environmental factors in
focussed on helping people to develop personal determining increased risk of disease and adverse
and social skills required to make positive health outcomes from disease (Townsend et al., 1988;
behaviour choices. This type of program was Harris et al., 1999). Health status is influenced by
pioneered through school-based health education individual characteristics and behavioural pat-
programs directed towards preventing teenage terns (lifestyles) but continues to be significantly
substance misuse, and subsequently has been determined by the different social, economic and
applied in other settings (Glanz et al., 1997). environmental circumstances of individuals and
Several theories of behaviour change were populations. The relationships between these
developed during this period to guide educational social factors and health, although easy to observe,
programs. Examples include Azjen and Fishbein’s are less well understood and much more difficult
theory of planned behaviour, and Bandura’s social to act upon. Consequently they have been given
learning theory (Ajzen and Fishbein, 1980; much less attention as a basis for public health
Bandura, 1986). These theories have helped to intervention than have individual behaviours in
identify and explain the complex relationships the recent past.
between knowledge, beliefs and perceived social As the effects on population health of eco-
norms, and provide practical guidance on the nomic, social and environmental policies adopted
content of educational programs to promote be- in developed nations in the late 20th century
havioural change in a given set of circumstances. begin to emerge and are better understood,
During the same period, social marketing there has been renewed interest among public
evolved as a technique for influencing social norms health practitioners in acting to influence these
Health literacy as a public goal 261
determinants of health. This renewed interest relation to those risk factors. This may have had
was reflected through the Ottawa Charter for the unintended consequence of underestimating
Health Promotion (World Health Organization, the role of health education, and fails to properly
1986) and more recently confirmed in the Jakarta capture the potential of health education as a tool
Declaration (World Health Organization, 1997). to support a full range of contemporary public
Through the Charter, health promotion has come health interventions. The failings identified
to be understood as public health action which above reflect both an oversimplistic analysis of
is directed towards improving people’s control the determinants of health, and of the use of
over all modifiable determinants of health. This inappropriate measures of outcome.
includes not only personal behaviours, but also
the public policy, and living and working con-
ditions which influence behaviour indirectly, and HEALTH LITERACY AS AN OUTCOME
have an independent influence on health. OF HEALTH PROMOTION
This more sophisticated approach to public
health action is reinforced by accumulated evi- In the recent past, considerable attention has been
dence concerning the inadequacy of overly given to analysing the determinants of health,
simplistic interventions of the past. To take a con- and to the definition of outcomes associated
crete example, efforts to communicate to people with health promotion activity. This has led to the
the benefits of not smoking, in the absence of a development hierarchies of ‘outcomes’ from
wider set of measures to reinforce and sustain health interventions, which illustrate and explain
this healthy lifestyle choice, are doomed to fail- the linkages between health promotion actions,
ure. A more comprehensive approach is required the determinants of health, and subsequent
which explicitly acknowledges social and environ- health outcomes. Figure 1 provides a summary
mental influences on lifestyle choices and outcome model for health promotion (Nutbeam,
addresses such influences alongside efforts to 1996).
communicate with people. Thus, more compre- These models generally distinguish between
hensive approaches to tobacco control are now different levels of outcome. At the end-stage of
adopted around the world. Alongside efforts to interventions are ‘health and social outcomes’,
communicate the risks to health of tobacco use, usually expressed in terms of mortality, mor-
these also include strategies to reduce demand bidity, disability, dysfunction, quality of life and
through restrictions on promotion and increases functional independence.
in price, to reduce supply by restrictions on ac- Intermediate outcomes represent the deter-
cess (especially to minors), and to reflect social minants of these health and social outcomes.
unacceptability through environmental bans. Personal behaviours, e.g. smoking or physical
This more comprehensive approach is not only activity may increase or decrease the risk of ill
addressing the individual behaviour, but also health, and are summarized as ‘healthy life-
some of the underlying social and environmental styles’. ‘Healthy environments’ consist of the
determinants of that behaviour. environmental, economic and social conditions
It is now well understood from experiences that can both impact directly on health, as well
in addressing specific public health problems of as support healthy lifestyles, e.g. by making it
tobacco control, injury prevention and pre- more or less easy for an individual to smoke
vention of illicit drug use, and the more general (as described above), or adopt a healthy diet.
challenge of achieving greater equity in health, Access to, appropriate provision and appropriate
that education alone is generally insufficient to use of health services are acknowledged as
achieve major public health goals. important determinants of health status, and are
As a result of the failings of educational pro- represented as ‘effective health services’ in this
grams in the past, the role of health education as model.
a tool in the ‘new public health’ promoted by the Health promotion outcomes represent those
Ottawa Charter has been somewhat downplayed. personal, social and structural factors that can be
Health education has often been considered in a modified in order to change the determinants of
rather limited way as contributing only to im- health (i.e. intermediate health outcomes). These
provements in individual knowledge and beliefs outcomes also represent the most immediate
about risk factors for disease, and as having only target of planned health promotion activities.
a limited role in promoting behaviour change in Within this level of the model, ‘health literacy’
262 D. Nutbeam
Social outcomes
measures include: quality of
life, functional independence,
equity
Health and social
outcomes
Health outcomes
measures include: reduced
morbidity, disability, avoidable
mortality
Intermediate health
outcomes (modifiable Healthy lifestyles Effective health Healthy
determinants of measures include: services environments
health) tobacco use, food measures include: measures include:
choices, physical provision of safe physical
activity, alcohol and preventive services, environment,
illicit drug use access to and supportive economic
appropriateness of and social conditions,
health services good food supply,
restricted access to
tobacco, alcohol
Health promotion
outcomes (intervention Health literacy Social action and Healthy public
impact measures) measures include: influence policy and
health-related, measures include: organizational
knowledge attitudes, community practice
motivation, participation, measures include:
behavioural community policy statements,
intentions, personal empowerment, social legislation, regulation,
skills, self-efficacy norms, public opinion resource allocation,
organizational
practices
Health promotion
actions Education Social mobilization Advocacy
examples include: examples include: examples include:
patient education, community lobbying, political
school education, development, group organization and
broadcast media and facilitation, targeted activism, overcoming
print media mass communication bureaucratic inertia
communication
refers to the personal, cognitive and social skills between what we do and what we are trying to
which determine the ability of individuals to gain achieve in health promotion interventions.
access to, understand, and use information to Use of this model places health education and
promote and maintain good health. These in- communication into the wider context of health
clude such outcomes as improved knowledge and promotion, and highlights health literacy as a key
understanding of health determinants, and outcome from health education. In this context,
changed attitudes and motivations in relation how we define and measure health literacy is
to health behaviour, as well as improved self- both dictated by and influential on the content
efficacy in relation to defined tasks. Typically and methods of health education.
these are outcomes related to health education
activities.
The model also distinguishes two other types WHAT IS HEALTH LITERACY?
of health promotion outcome. ‘Social action and
influence’ describes the results of efforts to The term health literacy has been used in the
enhance the actions and control of social groups health literature for at least 30 years (Ad Hoc
over the determinants of health—illustrated by Committee on Health Literacy, 1999). In the
efforts to work effectively with to promote the United States in particular the term is used to
health of marginalized groups. ‘Healthy public describe and explain the relationship between
policy and organizational practices’ are the result patient literacy levels and their ability to comply
of efforts to overcome structural barriers to health with prescribed therapeutic regimens (Ad Hoc
—typically the outcome of political advocacy and Committee on Health Literacy, 1999). This
lobbying which may lead to legislative change. approach infers that ‘adequate functional health
Success in the introduction of tobacco control literacy means being able to apply literacy skills
legislation in many countries represents a con- to health related materials such as prescriptions,
temporary example of an outcome from effective appointment cards, medicine labels, and direc-
public health advocacy. tions for home health care’ (Parker et al., 1995).
The health promotion actions in the model Research based on this definition has shown, e.g.
include education for health, efforts to mobilize that poor functional health literacy poses a major
people’s collective energy, resources, skills to- barrier to educating patients with chronic diseases
wards the improvement of health, and advocacy (Williams et al., 1998), and may represent a major
for health. A typical health promotion program cost to the health care industry through inadequate
might consist of interventions targeted at all or inappropriate use of medicines (National
three of the factors identified as health pro- Academy on an Aging Society/Center for Health
motion outcomes above. For example, a program Care Strategies, 1998).
to promote healthy eating might consist of efforts However, this fundamental but somewhat
to educate people about basic food groups, to narrow definition of health literacy misses much
develop practical skills in food preparation and of the deeper meaning and purpose of literacy
selection, and different actions to improve access for people. The field of literacy studies is alive
to healthier food choices through supply-side with debate about different ‘types’ of literacy and
intervention. These could include, e.g. efforts to their practical application in everyday life. One
improve the food choices available in school and approach to classification simply identifies types
worksite canteens, and interventions with food of literacy not as measures of achievement in
retailers to improve the supply and promotion of reading and writing, but more in terms of what
healthier food choices. it is that literacy enables us to do (Freebody and
The different intervention strategies also mean Luke, 1990).
that a wide range of potential measures of health
promotion outcomes can be considered as evi- Basic/functional literacy—sufficient basic skills in
dence of success in the short term. Some of these reading and writing to be able to function effect-
are listed in the model in Figure 1. ively in everyday situations, broadly compatible
Figure 1 also provides the bridge between an with the narrow definition of ‘health literacy’
intervention (described as health promotion referred to above.
actions) and the goal of an intervention (modi- Communicative/interactive literacy—more ad-
fication of the determinants of health). These vanced cognitive and literacy skills which,
health promotion outcomes are the bridge together with social skills, can be used to actively
264 D. Nutbeam
communication programs which are inherent in Relating this interpretation of the term ‘health
the definition above. Table 1 summarizes some of literacy’ to the outcome model in Figure 1 illus-
the implications for health promotion action. It trates both lateral and vertical relationships
describes four different dimensions, i.e.: the between education, health literacy and the other
educational goal; the content of a particular form health promotion outcomes. For example, on a
of activity; the outcome expected; and the actions vertical plane, improved health literacy may
which could be taken by health workers. enable healthy lifestyle choices, and support
Level 1, ‘functional health literacy’ reflects the effective use of health services, including com-
outcome of traditional health education based pliance with treatment regimes. Laterally, edu-
on the communication of factual information on cational programs directed at achieving critical
health risks, and on how to use the health system. health literacy will improve capacity for social
Such action has limited goals directed towards action which may in turn be directed towards
improved knowledge of health risks and health changing public policy and organizational prac-
services, and compliance with prescribed actions. tices related to health. Examples of this form of
Generally such activities will result in individual action can be found in many community develop-
benefit, but may be directed towards population ment programs. Through this route health edu-
benefit (e.g. by promoting participation in im- cation can be directed towards achieving change
munization and screening programs). Typically in the social, economic and environmental deter-
such approaches do not invite interactive com- minants of health which may benefit the health
munication, nor do they foster skills development of whole populations, alongside more typical pro-
and autonomy. Examples of this form of action grams directed at individual lifestyles and health
include the production of information leaflets, system use.
and traditional patient education.
Level 2, ‘interactive health literacy’ reflects the
outcomes to the approach to health education CONCLUDING REMARKS—NEW OIL
which have evolved during the past 20 years. This INTO OLD LANTERNS
is focussed on the development of personal skills
in a supportive environment. This approach to Health literacy is a concept that is both new and
education is directed towards improving personal old. In essence it involves some repackaging of
capacity to act independently on knowledge, established ideas concerning the relationship
specifically to improving motivation and self- between education and empowerment. Edu-
confidence to act on advice received. Again, much cation for health directed towards interactive and
of this activity will result in individual benefit, critical health literacy is not new, and has formed
rather than population benefit. Examples of this part of social mobilization programs for many
form of action can be found in many contem- years. There are many contemporary examples
porary school health education programs of education being used as a powerful tool for
directed towards personal and social skill social mobilization with disadvantaged groups
development and behavioural outcomes. in both developed and developing countries.
Level 3, ‘critical health literacy’ reflects the Indeed those in developed countries may do
cognitive and skills development outcomes which well to retrace the roots of contemporary
are oriented towards supporting effective social health education in community development
and political action, as well as individual action. programs, and learn from their current
Within this paradigm, health education may application in health development projects in
involve the communication of information, and developing countries.
development of skills which investigate the Disappointingly, the potential of education as
political feasibility and organizational possibil- a tool for social change, and for political action
ities of various forms of action to address social, has been somewhat lost in contemporary health
economic and environmental determinants of promotion. Close attention to the impact of
health. This type of health literacy can be more public policy decisions on health, and the need to
obviously linked to population benefit, alongside create supportive environments for health may
benefits to the individual. Health education in have had the unintended consequence of leading
this case would be directed towards improving to structural interventions ‘on behalf’ of people
individual and community capacity to act on —health promotion which is done ‘on’ or ‘to’
these social and economic determinants of health. people, rather than ‘by’ or ‘with’ people. In turn,
266
D. Nutbeam
Outcome
Health literacy level Content Individual benefit Community/social Examples of educational activity
and educational goal benefit
Functional health literacy: Transmission of factual Improved knowledge Increased participation Transmit information through
communication of information on health of risks and health in population health existing channels, opportunistic
information risks and health services services, compliance programs (screening inter-personal contact, and
utilization with prescribed immunization) available media
actions
Interactive health literacy: As above and Improved capacity to Improved capacity to Tailor health communication to
development of personal opportunities to develop act independently on influence social norms, specific need; facilitation of
skills skills in a supportive knowledge, improved interact with social community self-help and social
environment motivation and groups support groups; combine
self-confidence different channels for
communication
Critical health literacy: As above and provision Improved individual Improved capacity to Provision of technical advice to
personal and community of information on social resilience to social act on social and support community action,
empowerment and economic and economic economic determinants advocacy communication to
determinants of health, adversity of health, improved community leaders and
and opportunities to community politicians; facilitate community
achieve policy and/or empowerment development
organizational change
Health literacy as a public goal 267