About us
The National Social Marketing Centre is developing a programme of research on health literacy in partnership with the Department of Health in England. This page sets out the rationale for the research programme, outlines the programe’s aims, and describes the approaches that will be taken.
Health literacy – a matter of definition
The term ‘health literacy’ has been in currency in the health field for more than 30 years. Over that period its meaning has evolved to reflect emerging debates about what health is, how it is produced and how it may be improved.
The NSM Centre’s vision of health literacy is that it is part of a set of ideas that considers the interests of the citizen to be paramount, that empowers consumers and that enables ordinary people to take greater control over the factors that influence their health and well being. Good health literacy is, in our view, essential for both individuals and society.
The development of the idea
Throughout the 1980s and 1990s - especially in the US and developing countries - health literacy was thought of as part of biomedical understanding of health. According to this logic, health was viewed narrowly as the absence of illness, and responsibility for health was considered to lie with the individual. Whether people chose to behave healthily or not was largely a matter of personal choice. The role of governments, and of health professionals, was to provide people with the information on which to make behavioural choices, such as whether they smoked or ate healthily or took physical activity, and to encourage them to behave healthily.
Functional health literacy, involving the basic skills of reading, writing and numeracy, was linked to this view of health. A certain level of health literacy was required in order for patients to comprehend information about how to take medication and to act on information to adopt healthy behaviours.
Functional health literacy and health campaigns
For health educators and health promotors, the functional skills of health literacy were important in guiding the development of health campaigns that sought to encourage people to behave healthily.
From anti-smoking to HIV prevention and healthy eating, information campaigns – or ‘social advertising’ - have been an important feature of public health policy for more than half a century.
These campaigns were premised on the belief that if people are provided with information about the risks of behaving in an unhealthy way - and of the benefits of behaving healthily - they would adopt the recommended healthy behaviours.
Health education campaigns can be bad for your health inequalities
However, the evidence of decades of evaluation research of this type of social advertising is that information alone is insufficient to achieve behaviour change or to improve health for many people – especially those who are least advantaged materially.
Where such information based campaigns have been effective, they have tended to benefit those who are most able to make the desired change. These people tend to be the better off and the better educated. As a result, a powerful criticism of social advertising in health education, is that it has contributed to an increase in inequalities in health and well being.
It would be wrong however, to dismiss all forms of social advertising as ineffective. Campaigns that are carefully conceived and developed can influence social norms – taking them beyond individual health education messaging, and providing a cultural context for other forms of health improvement.
A new orientation for health literacy – active citizens at the centre of health policy
With improved knowledge of how health is produced both among individuals and societies, has come a re-consideration of the role of health literacy as both a goal and an outcome of health promotion.
Increasingly, good health is considered to be both a right of citizenship for individuals and a resource for societies. As such it is appreciated that responsibility for the production of health depends on the actions of a range of agents including individuals, governments and others including the private sector.
Factors that influence health
(Source: Dahlgren and Whitehead)
The WHO defines health as:
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‘a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.’ |
In this context health literacy has acquired a much broader definition – building on the functional skills to include both social and analytical skills that enable people to exert control over all aspects of their life.
The WHO defines health literacy as:
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‘the cognitive and social skills which determine the motivation and ability of an individual to gain access to, understand, and use information in ways which promote and maintain good health.’ |
With the growing interest in health literacy for public health has come a reconsideration of the concept and of the goals of public health. In 2000 Nutbeam sought to distinguish ‘levels’ of health literacy as follows:
Functional
Sufficient basic skills to function in everyday life. The most recent research evidence of functional literacy indicates that around 16% of adults have literacy levels lower than those attained by the average 11 year old, and 46% have similarly low levels of numeracy.
Interactive
More advanced skills in interpreting information from different sources and balancing these in decision making.
Critical
Application of skills and analysis of information to exert control and participate in managing own health and contributing to wider decision making.
Other commentators have sought to identify the key dimensions of health literacy. These have been described as:
- Basic health knowledge
- Competencies to navigate the health systems and act as an adequate partner to professionals
- Consumer competencies to make health decisions in the selection and use of goods and services and to act upon consumer rights if necessary
- Informed voting behaviour in the political arena, knowledge of health rights, advocacy for health issues and membership of patients and health organisations.
Social marketing and health literacy in the health society
The public health white paper Choosing Health affirmed the Government’s commitment to a consumer centred approach to health improvement. It identified the importance of consumers both as users of health information and services – and as agents who can work together to effect improvements.
The rapid technological and social changes of the past decade have brought both benefits and new challenges for all of us both as consumers and citizens. In many respects health has become a dominant feature of modern societies. Commentators have identified the following as key features of the so called ‘health society’.
- An attention to increasing life expectancy
- Expansive health and medical care systems
- Rapidly growing private health markets
- The prevalence of health as a dominant theme in social and political discourse
- Health as a major personal goal in life and as a right of citizenship
These developments place new demands on us all to know about and to act in ways that influence our health. These may be through adopting and maintaining healthier lifestyles, navigating a way through social and medical care systems, or understanding and behaving as empowered consumers of health products and services.
Enabling and supporting citizens to take control of factors that effect their health is central to the idea of active citizenship. It is also this idea – the customer orientation to the achievement of social goals – that is at the heart of social marketing.
Social marketing starts from the premise that a consumer orientation is essential for the achievement of policy goals. A key challenge for social marketing is to enable consumers to critically interpret mass media messages in order to make informed decisions.
As part of the developing role of social marketing, we hope to understand better the health literacy needs of the public in order to develop social marketing interventions that assist people to gain greater control over the factors that influence their health. In this way health literacy has an important role to play as a social determinant of health – and one which may be important to address as a means of reducing inequalities in health.
References
Department of Health (2004). Choosing health: Making healthy choices easier. TSO London
Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259–267.
Zarcadoolas, C., Pleasant, A., & Greer, D. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20, 195–203.
The NSM Centre’s health literacy research programme is currently looking at three main areas:
Understanding Health Literacy
A review of literature on health literacy, exploring the potential of health literacy to reduce health inequalities and its links with social marketing.
Measuring levels of health literacy
The NSM Centre is the main partner for England on a European Union supported research study to assess levels of health literacy in a number of European states. The survey will seek to define and measure for the first time, levels of health literacy across nation states in Europe.
Assessing the costs of poor health literacy
The NSM Centre will fund a study to investigate the costs to society and to individuals of poor health literacy.
Click here to download a copy of the NSM Centre's recently produced health literacy review paper. (319KB) 
