Health Education Research, Vol. 17, No. 3, 287-290,
June 2002
© 2002 Oxford University Press
EDITORIAL |
Health literacy: new wine in old bottles?
UK Editor
Health promotion seems to have rediscovered health literacy. This is not merely a case of reviving a useful concept; rather it would seem to involve re-packaging a number of other important concepts central to the ideological commitments, and the theory and practice of health promotion. This trend is not just an unnecessary exercise in re-branding, but rather a development that risks creating confusion, and threatens the refinement and sophistication of existing health education and health promotion theory. This Editorial will explore the meaning of health literacy proper, and, in particular, will challenge the appropriateness of using the term to re-define the territory that has, so far, been more appropriately mapped by existing conceptualizations of individual and community empowerment.
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Literacy and health |
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Literacy has a clear and unequivocal dictionary definition: `the ability to read and write; the ability to use language proficiently'. The term `literate', on the other hand, can be used not only to refer to a person who is able to read and write, but may also be applied to one who is `educated; learned' (Collins English Dictionary, 1979
). It is quite clear that literacy is healthy and illiteracy, unhealthy. It is, of course, possible to assert that being literate is one component of general fulfilment and therefore part of `positive health', but more usually a lack of literacy has been associated with the prevalence of disease and failure to take measures to prevent it. Nutbeam and Kickbusch cited a World Development Report that identified access to education (Nutbeam and Kickbusch, 2000) `...as being one of the most fundamental actions, which could be taken to improve public health in the world's poorest countries' (World Bank, 1993). Kickbusch rightly draws our attention to the extent of the problem noting that some 25% of the world's adult population are illiterate—and the majority of them are women and girls [(Kickbusch, 2001), p. 290]. She also cites a report by Health Canada (Health Canada, 1999):
...literacy levels, which are usually, but not always, related to levels of education, are important predictors of employment, active participation in the community and health status. They are also important predictors of the success of a nation.
The above quotation makes, in passing, an important distinction between literacy and education. Education is indeed essential to achieving a wide range of health goals, but it is important to note at the outset that education is concerned with much more than literacy—just as health education has more extensive concerns than the achievement of health literacy.
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Health literacy defined |
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According to Ratzan (Ratzan, 2001
) `Health Literacy', was first employed by Scott Simonds (Simonds, 1974). While this is doubtless true, Simonds' use of the term was very different from current usage. Simonds was, in fact, arguing a case for school health education with the intention that pupils would not only be educated in the customary curriculum subjects, but might become as `literate' in health as they were, for example, in history and science. Subsequently `health literacy' acquired a more limited technical meaning. This meaning is clearly exemplified in the US National Institute of Health's Current Bibliography on Health Literacy (Selden et al., 2001) which defines health literacy as `...the currency patients need to negotiate a complex health care system'. Selden et al. cite an American Medical Association report (American Medical Association, 1999) that refers to health literate individuals being able to `...read and comprehend prescription bottles, appointment slips, and the other essential health-related materials'. The majority of the 3500 citations in the bibliography centers on this narrow definition of health literacy—a definition which, ironically in the light of later observations on the use of this term for empowerment, frequently considers the ability to understand health communications as the first step leading to the ultimate goal of patient compliance! |
Health literacy: expanded definitions |
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In addition to its extended application to general learning and scholarship, literacy has also been applied to the possession of skills not precisely related to reading and writing, e.g. `political literacy'. This contributes little to understanding the skills involved. The term `quantitative literacy' has also been used—which is even more nonsensical since a perfectly sound word `numeracy' already exists. The use of `visual literacy' is, however, perfectly acceptable since it is akin to the psychological processes involved in the perception of written and spoken words, and is often an essential part of the communication process (McBean, 1988
). The rarely used term `oracy' might be applied with equal logic to describe oral communication skills. However, the kind of territorial expansion involved in translating limited, but clearly defined concepts into much broader, semantically unrelated constructs is both unnecessary and counter productive.
Nutbeam, who has been influential in this process of re-definition, quite legitimately commented on the limitations of the narrow definition of health literacy to which reference was made above (Nutbeam, 2000). Indeed, the often substantial gap between `knowledge' and `practice' has formed part of psychological and education theory for many decades. However, Nutbeam prefers to extend the definition of health literacy to incorporate the many psychological, social and environmental factors that influence health choices and the adoption of health- and illness-related actions. He quotes from the WHO's glossary of health promotion terminology [(Nutbeam, 1998), p. 264] as follows:
Health literacy represents 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 means more than being able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment.
He proposes a tripartite typology for health literacy.
- Basic/functional literacy. This is considered to be equivalent to the narrow `traditional' definition. It is characterized by `sufficient basic skills in reading and writing to be able to function effectively in everyday situations'.
- Communicative/interactive literacy. `More advanced cognitive and literacy skills which, together with social skills, can be used to actively participate in everyday activities, to extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances.'
- Critical literacy. `More advanced cognitive skills which, together with social skills, can be applied to critically analyse information, and to use this information to exert greater control over life events and situations'.
It is doubtless true that the cognitive skills needed to interact effectively with other people both in the face-to-face situation and within a community setting are of a different order from the skills needed to be functionally literate—although it is not very clear what they might be. It is also self-evident that social skills are essential to engage in social interaction. What is debatable, however, is whether it is appropriate to use the term `literacy' to describe competent social interaction—even as a metaphor. It is certainly not necessary since there is a considerable, well-developed and theoretically sound literature already available to illuminate and guide practice [e.g. (Trower et al., 1978)]. In short, the term social interaction skills is to be preferred—and, equally appropriately, is often incorporated in broader systems of `lifeskills' or `action competences' (Tones, 1994).
Nutbeam locates the reinvented concept of health literacy within a broader `outcome model' for health promotion. Three categories of outcome (or `intervention impact measures') are identified. Health literacy is viewed as one of these three outcomes (the other two are social action and influence and healthy public policy and organizational practice) and is considered to include `health related knowledge, attitudes, motivation, behavioural intentions, personal skills, self efficacy'. In other words, it would seem that the new, omnibus edition of health literacy incorporates all of the major psychological, social and environmental constructs that influence individual health choices! It is by no means clear how this particular compendium of constructs improves on the many well-researched models that describe empowered health-related decision making.
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The empowerment dimension |
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The Health Literacy `movement' and those influenced by it [e.g. (Wang, 2000
; Levin-Zamir and Peterburg, 2001)] have moved so far away from the original conception of health literacy that the term has become almost synonymous with the concept of empowerment, i.e. the central principle underpinning all health promotion. For instance, Level 2 and 3 versions of health literacy have been explicitly associated with empowerment and, as noted above, critical literacy is deemed to be necessary to help people `exert greater control over life events and situations'. Certainly, it would not be unreasonable to apply the term `critical literacy' to the `critical analysis of information'—were it not for the fact that the kinds of capability and skill involved in this process of critical analysis have already been described in a more sophisticated and detailed fashion within the field of cognitive and social psychology [note for instance Gagne's (Gagne, 1985) description of `problem solving' and Janis and Mann's (Janis and Mann, 1977) analysis of the process of `decision making' at individual and group levels]. In short, following the precept of Occam's Razor, there seems little advantage in coining a new term when existing terms are more than adequate. There is even more reason to do so if the new terminology is lacking in precision.
Nutbeam's use of the word `critical' presumably derives from the concept of Critical Theory and is thus concerned with the imperative to create social and political change, e.g. to address problems of inequity and social justice. `Level 3' health literacy apparently includes `...the cognitive and skills development outcomes which are oriented towards supporting effective social and political action, as well as individual action' [(Nutbeam, 2000), p. 265]. Doubtless some of the social skills included in Communicative/interactive literacy (Level 2) might also contribute to those critical/emancipatory health education strategies needed to achieve political change. Once more, though, we must ask the question, why use neologisms when there is a well researched and developed literature encapsulated in coherent theories of individual and community empowerment? Indeed, the Freirean strategy of critical consciousness raising springs to mind and has frequently been specifically applied to health outcomes [e.g. (Minkler and Cox, 1980)]. Again Fien's discussion of `Education for Sustainable Consumption' is part of a long-standing tradition of Critical Environmental and Health Education (Fien, 2000).
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Re-packaging health literacy: a step too far? |
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TopLiteracy and healthHealth literacy definedHealth literacy: expanded...The empowerment dimensionRe-packaging health literacy: a...References |
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In conclusion, there seems little if any justification for extending the original formulation of health literacy and incorporating in it re-packaged versions of existing theoretical formulations. Regrettably, however, this process of territorial encroachment seems to be maintaining its impetus. As Kickbusch reported, a `Health Literacy Workshop' meeting in June 2000 [(Kickbush, 2001), p. 293]:
...resolved to widen the glossary definition to include the dimensions of community development and health-related skills beyond health promotion, and to understand health literacy not only as personal characteristic, but also as a key determinant of population health.
Nutbeam described health literacy as involving `some repackaging of established ideas concerning the relationship between education and empowerment' (Nutbeam, 2000). He likened this process to putting `new oil into old lanterns'. A different proverb would be more apposite. It cautions against `putting new wine into old bottles'. It is certainly not good for the wine and offers no benefit for the bottle!
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References |
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American Medical Association (1999) Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs: Health Literacy: Report of the Council on Scientific Affairs. Journal of the American Health Association, 281, 552–557.
Collins English Dictionary (1979) Collins, Glasgow.
Fien, J. (2000) Education for sustainable consumption: towards a framework for curriculum and pedagogy. In Jensen, B. B., Schnack, K. and Simovska, V. (eds), Critical Environmental and Health Education. Danish University of Education, Copenhagen, pp. 45–65.
Gagne, R. M. (1985) The Conditions of Learning and Theory of Instruction, 4th edn. Holt-Saunders, New York.
Health Canada (1999) Toward a Healthy Future: Second Report on the Health of Canadians. Health Canada, Ottawa, Canada.
Hopson, B. and Scally, M. (1981) Lifeskills Teaching. McGraw-Hill, London.
Janis, I. L. and Mann, L. (1977) Decision Making: A Psychological Analysis of Conflict, Choice, and Commitment. Free Press, New York.
Kickbusch, I. (2001) Health literacy: addressing the health and education divide. Health Promotion International, 16, 289–297.
Levin-Zamir, D. and Peterburg, Y. (2001) Health literacy in health systems: perspectives on patient self-management in Israel. Health Promotion International, 16, 87–94.
McBean, G. (1988) Rethinking visual literacy: research in progress. Health Education Research, 3, 393–398.
Minkler, M. and Cox, K. (1980) Creating critical consciousness in health: applications of Freire's philosophy and methods to the health care setting. International Journal of Health Services, 10, 311–322.
Nutbeam (1998) Health promotion glossary. Health Promotion International, 13, 349–364.
Nutbeam, D. (2000) Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st Century. Health Promotion International, 15, 259–267.
Nutbeam, D. and Kickbusch, I. (2000) Advancing health literacy: a global challenge for the 21st century [Editorial]. Health Promotion International, 15, 183–184.
Ratzan, S. C. (2001) Health literacy: communication for the public good. Health Promotion International, 16, 207–214.
Selden, C., Zorn, M., Ratzan, S. C., Parker, R. M. and Ruth, M. (compilers) (2002) Health literacy (bibliography online). National Library of Medicine, Bethesda, MD. Cited 13 October 2001. http://www.nlm.nih.gov/pubs/resources.html
Simonds, S. K. (1974) Health education as social policy. Health Education Monograph, 2, 1–25.
Tones, B. K. (1994) Health promotion, empowerment and action competence. In Jensen, B. B. and Schnack, K. (eds), Action and Action Competence as Key Concepts in Critical Pedagogy. Didaktiske studier, vol. 12, Royal Danish School of Educational Studies, Copenhagen, pp. 163–184.
Trower, P., Bryant, B. and Argyle, M. (1978) Social Skills and Mental Health. Methuen, London.
Wang, R. (2000) Critical health literacy: a case study from China in schistosomiasis control. Health Promotion International, 15, 269–274.
World Bank (1993) World Development Report: Investing in Health. World Bank, Washington, DC.
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