The multifaceted relationship between health promotion and health literacy

The late 20th century must have been an exciting era. While some were developing the Ottawa Charter version of health promotion, others thought about something called ‘health literacy’. They developed a concept meant to analyse and explain the relationship between literacy of a population (in terms of the ability to access, understand and appraise complex information) and health outcomes (Parker, 2000; Kickbusch, 2001; Nutbeam, 2008). The idea ‘health literacy’ originally stems from the medical field—the field of patient care, more precisely—where it was welcomed as a concept and tool to enhance patient adherence, to educate patients to better take care of their health and to make informed (and shared) decisions. This first stage of health literacy is what Nutbeam (Nutbeam, 2008) describes as the ‘risk factor’ perspective: interventionist solutions to improve the take up of medical information. De Leeuw (De Leeuw, 2012) calls it the ‘first generation health literacy development’. This manifestation of health literacy focused primarily on the individual, seeing it as the individual’s responsibility to become health literate, to understand the information that is given to them. It was seen as a ‘personal disposition’ that can be improved through learning (Pelikan and Dietscher, 2015), as a ‘set of individual capacities’ to acquire and use new information (Baker, 2006). Once the concept became established, some governments (primarily the USA) have realized the potential of health literacy and have integrated the approach into their health system (U.S. Department of Health & Human Services, 2008). Health literacy thus also became a political tool and a buzzword (which could be a reason why many scholars in health promotion eye health literacy critically). The ‘second generation of health literacy development’ (De Leeuw, 2012), which Nutbeam labelled the ‘asset-based perspective on health literacy’ (Nutbeam, 2008), started when broader issues of equity, equality and empowerment were included. Thus, besides the medical context, health literacy established roots in public health, health promotion and health education. This is when the field of health promotion (and this journal) adopted health literacy as a concept. Especially health education as a means to educate a population, not just patients, was always directed at improving the health literacy of individuals (Nutbeam, 2000). According to Nutbeam (Nutbeam, 2000), health education has been underestimated in its role and potential to support public health interventions. From this point of view, the concept of health literacy seems to be the missing link between health education and health behaviour change. The asset-based manifestation of health literacy comprises not only education but also the empowerment of individuals and communities. Adding the perspective of health promotion, health literacy can be seen as a means to enabling individuals to take greater control over their health, to make informed and engaged decisions that have an impact on the determinants of health (Nutbeam, 2008; Nutbeam et al., 2018). Now, increasingly, health literacy is defined in a wider perspective, reflecting a dual nature of communication: what information is disseminated and how do people understand the information (Parker, 2009). Health literacy becomes a responsibility of the system, rather than focusing on a deterministic view of what skills people are lacking. Baker (Baker, 2006) speaks of a ‘dynamic state’ of this perspective on health literacy: an individual’s health literacy depends on the medical problem being treated, the health care provider and the system providing the care. Similar to health promoting settings, health literate organizations (and other settings such as communities) are seen as important environments that can support health literacy by providing easy access to high-quality health information and by establishing trusting relationships between provider and user (doctor–patient, teacher–student, employee–consumer, etc.) (Brach et al., 2012; Farmanova et al., 2018). A health literate organization makes it easier for people to navigate, understand, and use information and services to take care of their health (Brach et al., 2012). Thus, next to health literacy as a personal asset, organizations and settings are ascribed a role in enhancing health literacy. There are several tools and guidelines for health literate health care organizations (e.g. from the ‘International Working Group Health Promoting Hospitals and Health Literate Health Care Organisations’). For other types of settings, such as schools and communities, there is still a need for more research and support. In the above narrative I have touched (too) briefly on the relationship between health literacy and health promotion. This has been the case because there is indeed a paucity of conceptual development on that relationship. For the different types and stages of health literacy outlined there would be a different research, development and practice approach in their relations to health promotion ambitions. For instance, health promotion and clinical settings may each require a different research approach to health literacy (Nutbeam, 2000, 2008; Abel et al., 2015). Stressing the differences is important to make full use of health literacy as a concept as well as a tool. To continue the focus on the context of health promotion I will distinguish the different ways health promotion and health literacy relate to each other. These different relationships are not exclusive and do not contradict each other, rather, they are different perspectives of looking at health literacy from a health promotion standpoint. They also show different ways health promotion can benefit from the concept of health literacy. Figure 1 shows a visualization of the relationships. The relationships between health promotion and health literacy. It can be assumed that (in most cases) health literate individuals, a health literate society and a health literate setting/organization are good foundations for health promotion activities—in other words that health literacy acts as a moderator for the effect of health promotion. In a recent document of the WHO—the Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development—it is stated that health literacy ‘empowers individual citizens and enables their engagement in collective health promotion action’ (WHO, 2016). Similarly, Nutbeam et al. (Nutbeam et al., 2018) see interactive and critical health literacy is a foundation of modern health promotion. Health literacy improves awareness of and for health-related issues, which is why any health-related activity will likely be taken up better by health literate individuals than by those with low health literacy (IUHPE Global Working Group on Health Literacy, 2018). Wångdahl and Mårtensson (Wångdahl and Mårtensson, 2015) share this observation by saying that a possible reason why health promotion sometimes has little effects is the level of health literacy among individuals that participate in the health‐promoting interventions. Furthermore, several studies have shown that health literate individuals adopt healthier lifestyles and healthier behaviours (Davis et al., 2013; Reisi et al., 2014; Chahardah-Cherik et al., 2018). Health promotion aims at influencing various determinants of health, at both individual and contextual level (such as the physical environment and support networks). One of these determinants is health literacy—in the sense of an individual’s capacity to access, understand, appraise and apply relevant health information to maintain or improve his or her health (Sørensen et al., 2012). These capacities are influenced by health promotion actions that aim at enhancing health-related knowledge attitude, motivation, behavioural intentions, personal skills and self-efficacy (Nutbeam, 2017). Health literacy can therefore be seen as one of the most immediate outcomes of health education, as a health promotion strategy. In this respect, health literacy can be seen as a mediator of the effects of health education on health behaviour change. With the development of health literacy as a science (Parker, 2009), health literacy and health promotion can be ‘partners in crime’. Both concepts as well as both settings (health promoting settings and health literate organizations) are completely compatible (Nutbeam et al., 2018) and can work side by side (if not together), complementing each other. By accepting health literacy as a competent partner, health promotion can focus on the promotion of health in its core: healthy relationships, healthy settings, healthy policies—i.e. the principles of the Ottawa charter (WHO, 1986). Health literacy can support this and make a contribution in areas where health promotion is not sufficient. For example, health literate organizations could be a step towards finally achieving a reorientation of health services—an Ottawa charter principle that is still not fully developed (De Leeuw, 2009). Furthermore, the two fields can benefit from each other if one follows the other. Settings that have adopted a health promotion approach can easily become health literate settings and vice versa, because structures and processes have already been reoriented and important changes (including awareness) have already been implemented. Health literacy has become a political tool and has gained much (political) attention in the past years. Policy-makers and politicians have become interested in making a change and improving the health literacy of their state. Health promotion can make use of this commitment by supporting health literacy and the movement with the necessary framework. Nutbeam et al. (Nutbeam et al., 2018) see this as the International Union for Health Promotion and Education’s role: to continue to act as a credible, independent source of information on effective action, to provide substance to current political interest, and to ensure that health literacy continues to be considered within the wider context of health promotion, as one of a number of complementary approaches to improving health in populations including social mobilisation and political advocacy. However, this role can be much wider as everyone working in health promotion can use health literacy as a driver to spread broader awareness for health issues. Health literacy measurement is very complex and a highly debated issue (Sørensen et al., 2013; Duell et al., 2015; Chan and Kisa, 2019). The data health literacy measurement generates has to be handled carefully and seen in the specific context it was created. However, it can provide some useful information for health promotion activities. Studies show that people with lower health literacy have less quality of life, a diminished life expectancy and worse life styles than people with higher health literacy (IUHPE Global Working Group on Health Literacy, 2018). These are all areas where health promotion (besides health literacy) can make a difference. Furthermore, health literacy measurement tools can be used to assess change in individuals and communities following health promotion interventions (IUHPE Global Working Group on Health Literacy, 2018). In conclusion, health promotion and health literacy have a multifaceted relationship. As both health promotion and health literacy are evolving and undergoing developments brought on by societal changes, this relationship will continue to change and grow. De Leeuw (De Leeuw, 2012) suggested a ‘third generation of health literacy development’—health system literacy, i.e. ‘the skills, capacities and knowledge required to access, understand and interact with social and political determinants of health and their social discourse’. Taking this even further, the US Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for Healthy People 2030 have only just proposed a new definition: ‘Health literacy occurs when a society provides accurate health information and services that people can easily find, understand, and use to inform their decisions and actions’ (Department of Health and Human Services, 2019). Digitalization of the health sector brings about changes for both health promotion (Kickbusch, 2019) and health literacy. Some authors speak of ‘digital health literacy’ (van der Vaart and Drossaert, 2017; Dunn and Conard, 2018) or ‘eHealth literacy’ (Neter and Brainin, 2012). Similarly, the climate crisis calls for different approaches in both health promotion and health literacy. Health promotion faces new challenges as it has to respond to new health issues and adopt ideas and frameworks from the sustainability field (Patrick et al., 2012). For health literacy, new issues have to be taken on board, leading to the emergence of a ‘climate-related health literacy’ (APCC, 2018) or an ‘environmental health literacy’ (Finn and O’Fallon, 2017). The multifaceted relationship of health promotion and health literacy will remain through all of these new challenges. We need to continue to analyse this relationship, and learn how health literacy can support health promotion. But we also need to ask ourselves the question, what health promotion can do to support the field of health literacy. Maybe it is time to formalize the relationship and take it to the next level. It seems that both sides are ready to do so. Health literacy has always been a part (and partner) of health promotion. Health literacy has gained increasing attention at the World Conferences on health promotion organized by the IUHPE. Similarly, when the Ottawa Charter called to advocate, enable and mediate, and to create support environments, when the Bangkok Charter called to build capacities and commit to partnerships, when the Nairobi conference identified health literacy as one of the main themes, and finally when the Shanghai Declaration identified health literacy as key for the future of health promotion–health literacy has always been there. Health promotion not only has the capacity, but also the responsibility to bridge the different functions and disciplines and to advocate for a good, adaptive way of further developing the (health) literacy field.

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