Health literacy as a means of empowering people

This article is part of a larger work carried out within the framework of a UNESCO Latin America financed Project, conducing to a publication supported by the National Institute of Statistics, Geography and Informatics of Mexico (INEGI) and Virtual Educa. The book is currently being edited for publication.

Within the last decades, we have witnessed an international change of paradigm in terms of health policies, which have transitioned from focusing on the treatment of pathologies to a focus on prevention and health promotion.

Aaron Antonovsky, one of the first and main promoters of the health assets concept, has insisted on the need to focus on what he has defined as the generalized resources of resistance (GRR). These allow citizens to create a sense of coherence in their lives; in other words, we must consider what the subject resources to face external and internal aggressions to their health. Additionally, Paulo Freire insists on the need to awaken the consciences of citizens so that they are active actors in their own destiny. We consider social awareness as a primary element in the search for better living conditions.

In this context, the Ottawa Charter for Health Promotion is created at the first International Conference for Health Promotion held in 1986 in Canada. Its main objective was to move forward in the consolidation of health access for all people.

Health literacy: The history of a concept

The origin of “Health Literacy” as a concept, dates to the ‘70s when Simonds (1974) uses it to refer to health education as a social policy of health education. Subsequently, Pleasant, et al. [1] have developed two variants of the concept: one focused on public health policies (according to a European and Latin American approach), and the other dealing with clinical activity linked to health literacy (from the North American point of view).

From the clinical standpoint, health literacy is used as an instrument for delivering knowledge to patients so that they can clearly understand the indications of the healthcare professionals. On the other hand, a public health perspective faces the problem considering three different aspects: treatment, prevention, and health promotion. In recent years, these approaches have captured the interest of researchers from all over the world due to the fact that health literacy (hereinafter HL) Works as a far better predictor of an individual’s health status tan, for example, their income, educational level, or ethnic group [1-3].

From the Clinical (individual) and Public Health (Holistic) perspectives, HL is a key factor in determining the burden of any healthcare system [4]. Insufficient or inadequate HL levels in the population are associated with unhealthy lifestyles, less adherence or poor compliance with medical treatments, poor management of chronic diseases, little use of preventive health services, and higher rates of hospitalization. What is even more serious, health literacy is a critical component of serious social inequities between groups of various social, economic and ethnic backgrounds [5].

Multiple definitions have been formulated for the concept of HL. In this study, we lean towards the proposal by the European Union: Health literacy is linked to literacy and entails people’s knowledge, motivation, and competencies 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 [6].

There is no consensus on an HL definition or a measurement instrument, so studies worldwide measure different aspects of this factor with different instruments [7]. Nevertheless, according to the criteria of these researchers, the definition presented above suits our social context, for it provides a measurement instrument consistent with a conceptual framework within.

The conceptual framework addresses HL as a complex, dynamic and social phenomenon, and recognizes determinant aspects of health, namely individual aspects such as prior knowledge and educational level, among others; and environmental ones, like the family nucleus and social context, among others, which are important in the HL process. This framework also identifies the main competencies needed to navigate the health system in the three stages of the health-disease continuum: prevention, promotion, and care or rehabilitation. In addition, the model includes the progression from the individual to the public health perspective, which makes it one of the most complete ones [8].

For example, in a previous study carried on by these researchers [9]. Health literacy was evaluated in first-year students of the health and education programs, for they are projected as fundamental agents for social change. Within the universe of subjects analyzed, 60.7% of them presented inadequate and problematic levels of HL, similar to what was reported by Zhang [4] in students from the health area in Chongqing, China, where most of the students obtained insufficient levels. In our study, students in the teaching programs presented the greatest deficit, while those in the health area ― not including medicine ― presented a somewhat lower percentage. However, despite the fact that medical students obtained the best results, an important fraction of them showed problematic and inadequate HL levels (40.7%). The high percentage of this group is striking, considering that they are students with excellent academic performance and most of them come from a higher socioeconomic level [10].

To face the challenge of measuring HL in its territory, the European Consortium of Health Literacy was created with the participation of 8 countries and coordinated by the University of Maastricht. The HL measurement instrument consists of a matrix that combines the elements of the conceptual framework (www.health-literacy.eu). The instrument assigns questions for the three dimensions (treatment, prevention, and promotion) regarding the ability of the subjects to access existing information, understand this information, critically evaluate it and apply it correctly. This way, 12 sub-dimensions of HL are identified, and 47 questions derive from them. The latter measures the perception of the user according to their performance in the face of the demands imposed by the health system in its three stages mentioned above. The survey uses a semantic differential scale with the poles “very easy” and “very difficult”.

The European conceptual framework for HL adopts a comprehensive approach to the analysis of HL, which makes the instrument quite versatile, meaning that it can be used to obtain information on a wide range of aspects related to the abilities of the population to navigate the health. In addition, it allows long-term monitoring to measure the impact of specific health policies and also the advances of HL in the population according to a country´s public health legislation.

By including all three stages of the health-disease continuum, the European conceptual framework allows for determining the population’s perception of their management of different health activities, which are necessary to maintain and improve their own health status and that of their community. Regarding the users, the model aims to empower them within their community so that they can recognize the solutions to their health inquiries, throughout their lifetime. It is decisive that they are able to access information on health issues (that is, knowing where to look for the information needed), understand this information (through cognitive processes), evaluate it (critically judge whether the information is reliable or if it applies to their particular case) and apply it (perform actions based on the information obtained).

There is still a long way to go regarding the subject of HL in our country. To date, the published studies are case studies and target specific sectors of the population [9] and use instruments that measure literacy in a general sense (reading and arithmetic competence), plus they do not consider all the factors involved in HL.

In June 2021, The Economist’s “The Intelligence Unit” published a study in 7 countries on the progress of HL worldwide [10]. The results speak of an urgent need to generate health policies focused on the health education of citizens to achieve their empowerment in health challenges immersed in increasingly complex health systems. Thus, as The Economist mentions, “health literacy achieves herd immunity against fake news” [10-12].

1. Pleasant A, Kuruvilla S. A tale of two health literacies: public health and clinical approaches to health literacy. Health Promot Int. 2008 Jun;23(2):152-9. doi: 10.1093/heapro/dan001. Epub 2008 Jan 25. PMID: 18223203.
2. Weiss BD. Health Literacy: A Manual for Clinicians. American Medical Association/American Medical Association Foundation, 2003: 7.
3. World Health Organization. Health literacy and health behaviour. 2011. www.who.int/healthpromotion/conferences/7gchp/track2/en/
4. Zhang Y, Zhang F, Hu P, Huang W, Lu L, Bai R, Sharma M, Zhao Y. Exploring Health Literacy in Medical University Students of Chongqing, China: A Cross-Sectional Study. PLoS One. 2016 Apr 6;11(4):e0152547. doi: 10.1371/journal.pone.0152547. PMID: 27050169; PMCID: PMC4822854.
5. Osborne RH, Batterham RW, Elsworth GR, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health. 2013 Jul 16;13:658. doi: 10.1186/1471-2458-13-658. PMID: 23855504; PMCID: PMC3718659.
6. Comparative report on health literacy in eight EU member states. The European Health Literacy Project 2009.2012. Maastricht, HLS-EU Consortium, 2012.
7. Ibid.
8. Squiers L, Peinado S, Berkman N, Boudewyns V, McCormack L. The health literacy skills framework. J Health Commun. 2012;17 Suppl 3:30-54. doi: 10.1080/10810730.2012.713442. PMID: 23030560.
9. Zilic M, Vera A, Herrera ME, Casanova MP, Salazar O, de Orué P. Measurement of Health Literacy in First Year Students of Health Careers and Education at the University of Concepción: Application of the Hls-Eu Q47, Version Adapted to the Chilean Context. March-May 2015. National Autonomous University of Mexico, National School of Social Work. 2019.
10. World Health Organization. Regional Office for Europe. Health Literacy: The Solid Facts. 2013.
11. Escoda J, Terrazas F, y Manzur F. Health Literacy in the Public Health System in Chile. Thesis to opt for the title of Commercial Engineer. University of Chile. 2008.
12. The economist, intelligence Unit: Health literacy around the world. June 2021.