"Skills-based views of health literacy have encouraged information developers to design resources that reflect the comprehension skills of the service users"

Interest in health literacy has developed alongside policies which position patients and their family members as active players who can make important contributions to their health care and whose values should shape that healthcare.

Health literacy is increasingly recognised as somehow relevant to efforts to ensure people can keep themselves healthy, manage their minor illnesses and long term conditions, share in decision-making about any professionally regulated treatments they might have, and help ensure their safety as they use health services. But it is often unclearhowhealth literacy is related to health promotion, self-management, shared decision-making, and patient involvement in patient safety. This is partly because the concepts can all be understood in different ways. The different ways of understanding these concepts have important practical implications (Entwistle, Cribb and Watt, 2012; Entwistle and Cribb, 2013). We focus here on health literacy, shared decision-making and self-management.

Health literacy is often understood as a combination of information-related skills that are somehow useful for health (Sorenson et al, 2012). The table shows three widely used definitions that reflect this skills-based view of health literacy. The ‘skills’ components are presented separately from the ‘purpose’ components.

Source of definition / ‘Skills’ component of definition of health literacy / ‘Purpose’ component of definition of health literacy
World Health Organization, 1998 / 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.
American Medical Association, 1999 / A constellation of skills, including the ability to perform basic reading and numerical tasks... / required to function in the health care environment.
Institute of Medicine, 2004 / The individuals' capacity to obtain, process and understand basic health information and services... / needed to make appropriate health decisions.

Efforts to support shared decision-making and effective self-management of health conditions often focus strongly on information provision – to inform choice in the case of shared decision-making and to inform behaviour in the case of self-management. Adoption of skills-based views of health literacy has usefully encouraged information developers to design resources that reflect the reading and comprehension skills of the people who are supposed to use them. A number of examples of more widely accessible and usable information decision-aids and self-management support materials have been developed as a result.

Information and information-related skills are not the only things that matter, however, and it is important to consider other important values that could be associated with health literacy, shared decision-making and service support for self-management.

Informational interventions that are supposed to support shared decision making or self-management sometimes reflect quite particular beliefs about what is good for people. They implicitly steer people towards particular treatments, behaviours or health-related goals without recognising that those treatments, behaviours or goals are not consistent with everyone’s priorities. The ‘purpose’ components of several skills-based definitions of health literacy can be interpreted in ways that support narrowly biomedical judgements, for example about which health decisions are appropriate and what counts as good health. These can support the application of skills-based understandings of health literacy in ways that discourage the kinds of responsiveness to individuals that are valued in the ideals of person-centred approaches to shared decision-making and support for self-management.

Careful attention to the purpose components of definitions and understandings of health literacy could clearly help address some concerns about the values that are in play in discussions and activities relating to health literacy, shared decision-making and support for self-management. To some extent, considerations of purpose are evident in ideas about the different levels of health literacy that might be aspired to. Don Nutbeam, for example, encouraged us to look beyond basic information-related skills such as reading and writing (functional health literacy), to include more interpersonal communication skills (interactive health literacy) and more critical evaluative and advocacy skills (critical health literacy for personal and community empowerment) (Nutbeam, 2000).

Other ways of thinking about health literacy consider the literacydemandsthat health services place on the people who use them, and the literacypracticesthat people adopt as they negotiate and seek to make best use of services (Papen, 2009). These ways of thinking about health literacy, which are less individualistically oriented, can provide a valuable contrast and complementary insights to skills-based views of the concept.

Ways of thinking about health literacy that take seriously its situationally specific, socially constituted and dynamic nature can better encourage us to think not just about how health literacy (skills) can help people participate in shared decision making and self-management, but also about how health services and staff can approach the sharing of treatment decision-making and the provision of support for self-management in ways that avoid placing unnecessary demands on people and enhance their health literacy (skills and practices) in ways that enable them to contribute to healthcare and goals that are good on their own terms.

Vikki Entwistle

Vikki conducts research into the ethical and social aspects of healthcare provision to support improvements to healthcare policy and practice. She is currently Professor of Health Services Research and Ethics at the University of Aberdeen.

References

American Medical Association (1999)Health literacy: report of the council on scientific affairs.Journal of the American Medical Association,281(6):552-557.

Entwistle VA, Cribb A, Watt IS (2012). Shared decision making: enhancing clinical relevance. Journal of the Royal Society of Medicine 2012, 105: 416-421.

Entwistle VA, Cribb A (2013). Enabling people to live well: fresh thinking about collaborative approaches to care for people with long term conditions. London: The Health Foundation.

Institute of Medicine (2004)Health literacy: a prescription to end confusion.Washington DC: The National Academies.

Nutbeam D (2000) Health literacy as a public goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion Internatonal, 15(3): 259-267.

Papen U (2009) Literacy, learning and health – a social practices view of health literacy. Literacy and Numeracy Studies, 16 (2): 17-34.

Sorensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H, (HLS-EU) Consortium Health Literacy Project European (2012). Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health, 12:80.

World Health Organization (1998) Health Promotion Glossary. Geneva: World Health Organization