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Extending the definition of health literacy

In document Health Literacy: (Page 74-83)

Chapter 3 Health Literacy

3.3 Definitions of health literacy

3.3.2 Extending the definition of health literacy

The notion of health literacy has expanded as has the complexity of health systems. The Institute of Medicine (Institute of Medicine, 2004, p. 2) acknowledges that health literacy is more than just obtaining information and

“…emerges when expectations, preferences, and skills of individuals seeking health information meet the expectations, preferences, and skills of those providing information and services. Health literacy arises from a convergence of education, health services, and social and cultural factors” (emphasis added).

Although this definition includes other than literacy skills and implies contextual and interaction factors, there is an emphasis on information and on health literacy as an outcome only not a process.

The perspective widely followed in Europe and Australia connects health literacy with education, empowerment, and social marketing of public health interventions, from the perspective of health literacy as an asset (not a risk to be managed). This group of definitions underscores the importance of developing a range of skills and relational attributes that enable effective interaction between all parties involved in the communications and decisions about health (Peerson & Saunders, 2009; Zarcadoolas, Pleasant, & Greer, 2003). This perspective parallels the interactive and critical health literacy in Nutbeam’s typology and signals an emphasis on health literacy as a process not just an outcome. In this way, health literacy is considered both a resource and a skill that facilitates valuable interactions within an individual’s health contexts and encounters (Dubbin, Chang,

& Shim, 2013).

These broadened definitions move health literacy from a strictly functional focus on reading, writing and numeracy to referring to decisions, not only in health-related settings but also about health. Including interactive aspects, these definitions view health literacy as a set of interconnected abilities that include reading literacy but extend to: communicating one’s needs and acting upon information; and a cluster of “individual skills to obtain, process and understand health information and services necessary to make appropriate health decisions”

(Sørensen et al., 2012, p. 3). In doing so, such definitions acknowledge the


responsibility of each individual but also that health literacy changes over time, contexts, and according to varying levels of information and resources (not just individual skills).

The individual is therefore an active participant engaged in health decisions in a range of settings and at a range of levels - individual, community and policy. In these definitions, health literacy is accepted as encompassing knowledge acquisition, knowledge application, motivation, communication, and decision making processes. Another major shift apparent in this perspective is the acknowledgement that these competencies and skills need to be considered in a variety of contexts, and therefore that they also apply to the other ‘actors’ (co-creators of health literacy) in those contexts – including, healthcare providers, the healthcare system, public health message disseminators. In line with the expanded notion of health literacy there has been increasing interest on developing measures that encompass the patient perspective and functional, interactive and critical dimensions of health literacy. Researchers in the UK (Chinn & McCarthy, 2013) have recently developed the All Aspects of Health Literacy Scale (AAHLS) and Australian researchers (Jordan et al., 2013) have constructed the Health Literacy Management Scale (HeLMS) and the Health Literacy Questionnaire (HLQ) (Osborne et al., 2013).

Health literacy definitions continue to evolve with some researchers suggesting that there may never be international consensus on a single definition (Begoray, Gillis, & Rowlands, 2012; Pleasant, 2013). There are diverse and nuanced definitions of the term; Tones (2002) suggests that this supports his contention that health literacy is little more than re-packaged health promotion.

Notwithstanding the diversity of definitions and seeking to avoid the broadening of scope of the term until it encompasses everything (e.g., simply health), a recent systematic review of definitions identified 17 explicit definitions and 12 conceptual frameworks (Sørensen et al., 2012). Table 3.1 summarises the health literacy definitions from that review adding unique definitions published since 2009, the date of the data collection by Sørensen et al. (2012). The updating process (refer Appendix 5) followed the Sørensen et al. approach, searching the


Web of Science and PubMed (including Medline) databases and, in addition, searching the Scopus and PsycINFO databases, for additional unique definitions.

The far right-hand column of Table 3.1 identifies the key perspective of each definition. All these definitions have been important in the researcher’s pre-understandings, however the orange-shaded cells are those definitions that have been particularly instrumental in guiding the research process and in the hermeneutic processes of data interpretation.


Table 3.1 Definitions of health literacy (chronological order)

Definition Comments / Emphasis

1998 WHO (cited in Nutbeam, 1998) Most cited

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.

Individual skills, including motivation and social skills.

Health promoting behaviours.

1999 American Medical Association.

Most cited

The constellation of skills, including the ability to perform basic reading and numeral tasks required to function in the healthcare environment.

Individual skills.

2000, 2008

Nutbeam The personal, cognitive, and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information to promote and maintain good health.

Motivation, interaction, engagement, & application of information.

Not simply a derivative of literacy & numeracy skills.

2001 Selden, Zorn, Ratzan, et al.

The currency patients need to negotiate a complex healthcare system. Includes healthcare context.


2004 Sihota & Lennard The capacity of an individual to obtain, interpret and understand basic health information and services in ways that are health-enhancing.

Individual skills.

2004 Institute of Medicine (also refer Healthy People, 2010; Ratzan

& Parker, 2000) Most cited

The individuals’ capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Individual capabilities.

Cognitive skills.

Health literacy as a risk factor to be managed.

2006 Baker The ability to function in the healthcare environment and depends on characteristics of both the individual and the healthcare system. An individual’s health literacy is context specific (dynamic) and may vary depending upon the medical problem being treated, the healthcare provider, and the system providing care.


Includes health knowledge.

2006 Kwan, Frankish, &


People’s ability to find, understand, appraise and communicate information to engage with the demands of different health contexts to promote health across the life course.

Cognitive & social skills.

Health promoting behaviours.

2006 Paasche-Orlow &


An individual’s possession of requisite skills for making health-related decisions, which means that health literacy must always be examined in the context of the specific tasks that need to be accomplished.

Individual skills according to context.

2006 Zarcadoolas, Pleasant,

& Greer

The wide range of skills, and competencies that people develop to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life.

A health literate person is able to use health concepts and information generatively - applying information to novel situations.

Individual & social skills.

Media literacy skills.

Health promoting behaviours.


2007 Abel Health literacy means to understand the conditions that determine health and to know how to change them.

Includes ability to access information, critical thinking skills, and acting on


2007 European Commission The ability to read, filter, and understand health information in order to form sound judgments.

Includes judgment skills.

2008 Australian Bureau of Statistics

The knowledge and skills required to understand and use information relating to health issues such as drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid, emergencies, and staying healthy.

Health promoting behaviours.

2008 Ishikawa & Yano The knowledge, skills, and abilities that pertain to interactions with the healthcare system

Individual skills.

Healthcare system.

2008 Kickbusch & Maag Health literacy is the capacity to make sound health decisions in the context of

everyday life – at home, in the community, at the workplace, in the health-care system, in the market place, and in the political arena. It is a critical empowerment strategy to increase people’s control over their health, their ability to seek out information, and their ability to take responsibility

Emphasis on cognitive skills &

decision making. Not restricted to healthcare environment.

Essential part of social capital.

2008 Mancuso A process that evolves over one’s lifetime and encompasses the attributes of capacity, comprehension, and communication. The attributes of health literacy are integrated within and preceded by the skills, strategies, and abilities embedded within the competencies needed to attain health literacy.

Personal, social, critical thinking, & problem solving skills


2008 Pavlekovic

(cited in Sørensen et al.)

The capacity to obtain, interpret and understand basic health information and services and the competence to use such information to enhance health.

Personal & social skills.

Health promoting behaviours.

2008 Rootman & Gordon-El-Bihbety

The ability to access, understand, evaluate, and communicate information as a way to promote, maintain and improve health in a variety of settings across the life course.

Personal & social skills.

Health promoting behaviours.

2009 Adams et al. The ability to understand and interpret the meaning of health information in written, spoken or digital form, and how this motivates people to embrace or disregard actions relating to health.

Cognitive & social skills including motivation for health promoting behaviours.

2009 Adkins & Corus The ability to derive meaning from different forms of communication by using a variety of skills to accomplish health-related objectives. Health literacy is socially constructed between the consumers and the healthcare providers.

Socio-cultural skills.

2009 Freedman et al. The degree to which individuals and groups can obtain process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community.

Health promoting behaviours.

Community level.

2009 Peerson & Saunders Information and decision-making skills occurring in the workplace, in the supermarket, in social and recreational settings, within families and neighbourhoods, and in relation to the various information opportunities and decisions that impact upon health every day.

Broad context and settings for health literacy.

2009 Yost et al. The degree to which individuals have the capacity to read and comprehend health-related print material, identify and interpret information presented in graphical format

Functional literacy in a health context.


(charts, graphs and tables), and perform arithmetic operations in order to make appropriate health and care decisions.

2010 Berkman et al. The degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions.

Cognitive skills.

2010 Parker & Ratzan Health literacy occurs when the skills and ability of those requiring health information and services are aligned with the demand and complexity of information and

services…how patients access, understand, and use health information provided to them to promote, protect, and manage their health.

Cognitive & social skills for health promoting behaviours.

Interaction with healthcare system.

2012 Begoray & Kwan The degree to which people are able to [1] access, [2] understand, [3] appraise and [4]

communicate information to engage with the demands of different health contexts to promote and maintain health across the life-course.

Added dimensions of context and life course.

2012 de Leeuw The skills, capacities and knowledge required to access, understand, and interact with social and political determinants of health and their social discourse.

Includes social & political dimensions.

2012 Martensson & Hensing Complex approach to health literacy described in three themes – acknowledging the complexity, the significance of the context, and shared responsibility.

More than an individual skill or responsibility.

2012 Paakkari & Paakkari Health literacy is a broad range of knowledge and competencies that people seek to encompass, evaluate, construct and use. Health literacy enables people to understand themselves, others and the world in a way that will enable them to make sound health decisions, and to work on and change the factors that constitute their own and others' health chances.

Theoretical knowledge, practical knowledge, critical thinking, self-awareness, & citizenship.


2012a Schulz & Nakamoto Health literacy entails patients capitalizing on their domain of unique expertise - the experience of their health condition as a basis for judgments related to health decisions…Health literacy as phronesis becomes the capacity of making health

information relevant for action by recognizing personal needs or limitations which may stand in the way of good health decisions.

Literacy distinguished from empowerment.

Individual internalised construct.

Critical self-examination.

2012 Sørensen et al.

and adopted by HLS-EU

Health literacy is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course.

Comprehensive definition.

2013 Jordan et al. An interaction between individual abilities and factors at a personal, healthcare system, and broader community level…an individual’s health literacy is not fixed, and is dependent on a combination of circumstances, several of which may be outside the control of the individual.

Multiple dimensions of abilities and contextual influences.

2013 Sykes et al. Critical health literacy as a distinct concept with…a unique set of characteristics of advanced personal skills, health knowledge, information skills, effective interaction between service providers and users, informed decision making and empowerment including political action.

Based on colloquial and theoretical concept analysis.

In document Health Literacy: (Page 74-83)