A recent editorial in The Lancet led with the provocative title: “Why is health literacy failing so many”.1 Although a useful provocation, the title represented a fundamentally flawed interpretation of health literacy. The editorial defined the “failure” of health literacy in terms of its perceived focus on the responsibility of the individual and because it “neglects the societal and structural forces that shape our choices” and “social and environmental factors outside the control of individuals”.1 This proposition fails to adequately reflect most contemporary interpretations of health literacy.
Health literacy is a concept that continues to evolve as we learn from research and practical experience how it can best be defined, measured, and improved. It is generally understood as an observable set of personal skills and capacities that enable people to find, understand, appraise and use health information. Importantly, contemporary definitions of health literacy also recognise that a person’s health literacy skills are substantially mediated by the environmental demands and complexities that are placed on them.2
It follows that if health literacy is understood as an observable set of personal skills, this necessarily focuses our attention on improving individuals’ skills and capacities through communication and education. Recognising the demands and complexities of different environments also focuses attention on reducing those demands, for example, by simplifying communication, reducing organisational complexity that limits access to health information and healthcare, and regulating the information environment. Both dimensions represent important methods for reducing the impact of poor health literacy in our health systems and the wider community.
It is those of us involved in health communication and the systems in which we operate that too often fail people, not “health literacy”.
Recognising the importance of improved health literacy, several countries have developed national health literacy improvement strategies. These include, for example, the US National Strategy for Health Literacy3 and, more recently, the German National Plan for Health Literacy.4 Australia has an existing national statement on health literacy and is currently in the later stages of developing a more comprehensive national strategy for health literacy.5
These national plans have some common features: improving the quality and targeting of health communication; reducing the complexities of access to healthcare; and improving the education and training of frontline staff in the health system (and beyond).
The coronavirus disease (COVID-19) pandemic also highlighted the serious challenges of misinformation and deliberate disinformation emerging in a form that the World Health Organization (WHO) describes as an “infodemic”.6,7 This has highlighted the lack of regulation of health information and health claims, especially those made through digital and social media when compared to regulation of traditional “terrestrial” media. It has required governments and health organisations (including and especially the WHO) to directly address the misinformation and myths that had the capacity to derail broader public health actions to control the pandemic. Responding to inaccurate and deliberately misleading information online also requires complementary strategies to both improve the accessibility of quality online information and to support people in effectively navigating the digital world to access trustworthy sources of information.
The poor conception of health literacy reflected in the title of The Lancet editorial1 seems predicated on the idea that health literacy is promoted as a solution to all contemporary social and economic challenges in public health. This is absurd. The editorial also laments the paucity of research exploring the position of health literacy in the context of wider social determinants of health, including the commercial determinants of health. This is ill-informed. A decade or more of research has helped us identify the position of health literacy as a mediating determinant of health but not a panacea for health inequities created by the maldistribution of opportunity and resources.8 This research also identifies that it is possible to optimise the contribution that improved health literacy can make in mediating the causes and effects of established social determinants of health.9
Health literacy can best be viewed as a personal and population asset offering greater autonomy and control over health decision-making. Developing transferable skills, supporting critical thinking about the determinants of health and empowering people to act requires a fundamental change in our approaches to health communication – in both methods and content. Developing these “critical health literacy” skills requires the use of more interactive and adaptable communication methods and a significant widening of health information content to include the social determinants of health and to support the development of skills in social mobilisation and consumer advocacy in response. This is in marked contrast to many established health communication models, which are focused on individuals and changing specific knowledge, attitudes and behaviours.
Health literacy isn’t “failing” people. It is government inaction, poor quality health communication, and complexity in our health services and information environments that make it very difficult for the majority of people to find, understand, appraise and use the health information they need to protect their health. What is needed now in most countries is a clearer recognition of health literacy as a personal and societal asset that needs to be improved. This must be matched by strategies, funding and practical actions designed both to work directly with people to develop their health literacy skills and to reduce the demands and complexities of different information environments – including unverifiable health claims made in the commercial environment and through social media. This will require better regulation where necessary.
Professor Nutbeam is the Editor-in-Chief of Public Health Research & Practice.
Internally peer reviewed, commissioned.
© 2023 Nutbeam D. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.