Improving health literacy is one of the principal ways we can tackle inequality but it is far from a passive individual exercise, and must be a priority for policymakers in areas beyond health, write Marilyn Wise and Don Nutbeam.
In the early 21st century, Australians, at birth, can expect to be among the longest-lived people in the world. For a century or more, our health and life expectancy has been improving.
We have learned that our health is protected and sustained by safe physical environments and supportive social networks. We also need opportunities to acquire the knowledge and skills that make healthy choices easier.
Education, employment, income, housing, transport, and access to healthcare are widely known to be essential to health. We are also healthier and more likely to thrive in communities in which we feel that we are the equal of others, secure and respected; in which we can both give and receive material and social support, and in which we participate in making collective decisions – through government, business, and community organisations.
However, we have not, yet, been able to put these conditions in place for everyone and some people’s health is at risk (or already compromised) by both their environments and their lifestyles. To change this requires both social and personal actions – a combination of public policy, public education, collective action, modiﬁcation of health services, and environmental changes.
We know that using theory to guide the design and implementation of each of these strategies, that engaging communities, and that reinforcing positive changes in behaviours, environments and social norms over time are all important in determining long-term and sustainable improvements in health. It follows that successes have often been incremental, and hard won over time.
Disappointingly, our success in improving health overall has not been matched by progress in reducing unfair and avoidable inequalities in health within and between communities. Generally speaking, social groups with the most limited material resources are routinely and systematically under-represented in the groups making decisions about the future distribution of resources. And in this way inequity becomes entrenched.
Sadly, in Australia in 2015, inequalities in the distribution of income and wealth are increasing. Improving the average life expectancy of populations at the same time as reducing inequalities in health requires policies and interventions that improve the health of the poorest, fastest. This simple challenge has eluded public policy makers and the health system over successive decades in Australia. One part of the challenge has been to enable social groups to be present in policy-making, both to argue directly for the resources necessary to resolve problems they have identiﬁed, and to confer social recognition and respect – replacing negative stereotypes with positive cultural representation.
In short, although we can describe and predict the economic, social, and environmental conditions in which populations have the greatest opportunities to become and stay healthy, and although we can reduce risks to health and reduce inequities in health, we have not, yet, been able to apply that knowledge and skill as effectively as possible.
Improving health literacy
Health literacy is generally deﬁned as a set of skills that enable people to obtain, understand and use information to improve their health. Improving health literacy is central to many of the educational and communication initiatives that make critical contributions to improved health – by increasing positive health behaviours, and by inﬂuencing underlying public opinion about changes in policy and practice necessary to address major health problems. Current initiatives to reduce domestic violence or to reduce stigma associated with mental illness are examples of this in Australia.
However, improving health literacy can mean more than this – encouraging more interactive forms of learning to support people and communities to participate actively in decisions being made by the health sector; to improve people’s understanding and conﬁdence to critically analyse information about health and its determinants; and through that to enable people to take individual and collective action to increase their control over the social determinants of health. This “critical” health literacy is not only a means to improve control over personal decisions, but is also a set of skills that enables people to participate more actively in political and social decisions affecting their health – exactly what is required to enable the most disadvantaged to participate actively in health-related decision-making.
This “critical” health literacy is not only a means to improve control over personal decisions, but is also a set of skills that enables people to participate more actively in political and social decisions affecting their health – exactly what is required to enable the most disadvantaged to participate actively in health-related decision-making.
As well, critical health literacy – the capacity to predict the health impact of decisions made by sectors other than health – is required by policy makers and practitioners in the key sectors of government relating to the economy, education, housing, employment; or by those responsible more locally for urban design and land use.
The role of critical health literacy in improving the health of communities is challenging even within the health sector, which has yet to ﬁnd the best way to engage and empower the most disadvantaged communities in actions to promote health, and is only recently ﬁnding ways to work effectively with other sectors so that the impact of their decisions on health is positive.
A recent study found that academics, practitioners and policy makers from within the health sector (Sykes et al, 2013) had varied understandings of the key attributes of health literacy – with most of them still describing it as functional cognitive skills held by individuals who were seeking to ‘look after their health’, navigate the health system, or to participate in healthcare.
Few understood the concept as including the cognitive and social skills required to work through the political system or through social movements to change social, economic, or environmental conditions for health.
Improving health and reducing the prevalence of chronic disease requires multiple actions across societies by individuals, groups, organisations, and governments – in the community sector, the private sector and government. As impressive as the successes of the 20th and early 21st centuries in improving health are, lack of progress in reducing inequities in health reﬂects a collective failure in our society. Moreover, given that it is now possible to predict the conditions (social, economic, environmental) that give people the greatest opportunities to become and stay healthy, it is vital that this evidence be used by policy makers and practitioners in all key economic sectors to guide their decisions – including decisions about land use and urban design.
Though convenient to focus attention on individual behaviour and individual choice, and to limit health interventions to those designed for speciﬁc functional outcomes, it will not be enough to sustain progress overall, and is completely inadequate as a response to the persistent inequalities in health in Australia. Progress will be dependent upon interventions that improve the “critical” health literacy of populations and of policy makers and practitioners – so that all members of society to participate in decisions that affect our health.
This will require systems of governance that include and are open to the full range of voices, that are transparent about the decisions being made, and that consider the impact of decisions on health and equity in the population.
Important sources and recommended further reading
Chinn D. (2011). Critical health literacy: a review and critical analysis. Social Science and Medicine, 73: 60-67.
McCartney, G., et al. (2013). What (or who) causes health inequalities: Theories, evidence and implications? Health Policy 113: 221-227.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science and Medicine. 67 (12): 2072-8.
PolicyLink. Center for Health Equity and Place (2015). The Built Environment. Accessed at policylink. org on 6 October, 2015.
Sykes, S., et al. (2013). Understanding critical health literacy: a concept analysis. BMC Public Health 13(150).
Marilyn Wise is Associate Professor at the Centre for Primary Health Care & Equity, University of New South Wales.
Don Nutbeam is Visiting Professor at the Sydney School of Public Health, University of Sydney.