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Kickbusch I and Maag D Health Literacy. In: Kris Heggenhougen and Stella

Quah, editors International Encyclopedia of Public Health, Vol 3. San Diego:

Academic Press; 2008. pp. 204-211.

Conclusion

All countries can make some progress toward the health

MDGs and ensure that the poor do not lag behind. The

second half of the period 1990–2015 can go better than the

first half. The focus on the MDGs at the start of this decade

has contributed to a shift in the attention given by develop-

ment partners – donors and governments – to health out-

comes and to the contributions of multiple sectors to health.

However, the attention span is often of short duration and it

is always a challenge in global health to keep the momen-

tum going and sustain the commitment to any health goal,

be it disease-specific goals or broader development goals

such as the MDGs. What could make a significant differ-

ence would be for communities and civil society to take

greater ownership of the MDGs and use MDG monitoring

to keep local, national, and global leadership accountable

for the commitment they made to achieve the MDGs for all.

See also: Alma Ata and Primary Health Care: An Evolving

Story; Peoples Health Movement; Populations at Special

Health Risk: Unemploye d: Unemploy ment and Job

Insecurity; Health Inequalities; Health Finance, Equity

in; Universal Coverage in Developing Countries, Transi-

tion to; Social Gradients and Child Health; WHO

Definition of Health, Rethinking the; Patient Empower-

ment in Health Care; Social Dimensions of Infectious

Diseases; Social Determinants of Health, the United

Nations Commission of.

Citations

The Bellagio Study Group on Child Survival (2003) Knowledge into

Action for Child Survival. Lancet 326: 323–327.

Disease Control Priorities Project (2006) The Disease Control Priorities in

Developing Countries, 2nd edn. http://www.dcp2.org (accessed

October 2007).

Esrey SA, Potash JB, and Roberts L (1991) Effects of improved water

supply and sanitation on ascariasis, diarrhoea, dracunculiasis,

hookworm infection, schistosomiasis, and trachoma. Bulletin of the

World Health Organization 69: 609–621.

Haines A and Cassels A (2004) Can Millennium Development Goals be

attained? British Medical Journal 329: 394–397.

UNICEF (2001) Progress since the World Summit for Children.

A Statistical Review. New York: UNICEF.

UN Millennium Project (2005) Who’s Got the Power? Transforming

Health Systems for Women and Children. Task Force on Child Health

and Maternal Health. The Millennium Development Project. http://

www.unmillenniumproject.org/documents/ChildHealthEBook.pdf.

Wagstaff A and Claeson M (2004) The Millennium Development Goals

for Health: Rising to the Challenges. Washington, DC: The World

Bank.

World Bank (2001) Health, nutrition and population development goals:

Measuring progress using the poverty reduction strategy framework.

Report of a World Bank Consultation. Washington DC: The World

Bank.

World Bank (2003) World Development Report 2004: Making Servic es

Work for Poor People. Washington, DC: Oxford University Press.

World Bank (2003a) Global Economic Prospects and the Developing

Countries. Washington, DC: The World Bank.

World Health Organization (2001) Commission on Macroeconomics and

Health: Investing in Health for Economic Development. Geneva,

Switzerland: WHO.

World Health Organization (2005) Health and the Millennium

Development Goals. Geneva, Switzerland: WHO.

Further Reading

Achieving the Milennium Development Goals for Health: So far, progress

is mixed-can we reach our targets? http://www.dcp2.org/file/67/

DCCP%20 – %20MDGs.pdf

Relevant Websites

http://www.hlfhealthmdgs.org – High-Level Forum on the Health

MDGs.

http://www.undp.org/mdg – United Nations Development Programme,

Millennium Development Goals (MDGs).

http://www.un.org/millenniumgoals – The UN Millennium Development

Goals.

http://www.developmentgoals.org – The World Bank Group, Millennium

Development Goals.

http://www.who.int/mdg/en/ – WHO, Health and the Millennium

Development Goals.

Health Literacy

I Kickbusch, Kickbusch Health Consult, Brienz, Switzerland

D Maag, Health Promotion Switzerland, Bern, Switzerland

Introduction

In modern health societies, almost every aspect of our

lives is faced with questions and decisions about health, as

the sphere of health has expanded far beyond the confines

of the health-care system itself. Citizens are expected

to actively take a wide range of health decisions for

themselves and their families – this includes decisions

on health behaviors, nutrition, medication, choice of pro-

viders, and treatments. Health-care systems are becoming

more complex and encompass a broader range of provi-

der s from different sectors than ever before. They have

204 Health Issues of the UN Millennium Development Goals

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also become mor e dependent on high levels of patient

participation. Moreover, health policy discussions engage

in topics such as informed patients, active citizens, or

empowered communities. However, most of us lack access

to the necessary information and do not have the necessary

skills to make sound decisions for health (see Figure 1).

In particular, the health society subjects the individual to

an information deluge on health issues, promises, risks, and

warnings that are often more confusing than helpful. People

are confronted by a variety of health information from the

news media, the Internet, TV and radio, family and friends,

popular media, governmental health organizations, health-

care providers, health associations, books, peer-reviewed

journals, and health insurance organizations.

As the sphere of health expands far beyond the confines

of the health-care system itself and grows increasingly

complex, citizens need ever more capacities to navigate

this new health environment. Alongside these develop-

ments, the notion of health literacy introduces new dimen-

sions to capture and describe what we understand by the

ability to make sound health decisions in the context of

everyday life. Increasingly, the realization is growing that

health literacy will become one of the central life skills

needed in modern health societies (see Figure 2). Health

literacy serves as a map or a compass on what may be a

difficult and unpredictable journey.

Understanding Health Literacy

Literacy

Health literacy is closely related to the notion of literacy,

being defined as the ability to read and write as well as to

have numeric skills (UNECSO, 2003 ). This task-based

definition has been recently replaced by a skill-based

conceptualization of literacy, focusing on the knowledge

and abilities an adult must possess in order to perform

in various societal domains (home and community, health

care, work, politics, and market). These abilities range

from basic to higher-level skills such as drawing appro-

priate inferences from continuous text. Usually literacy is

classified into prose, document, and quantitative literacy.

The concept, typically associated with levels of education,

is an important predictor of community participation,

employment, and health status. Applying this understand-

ing of literacy to the health context, health literacy focuses

on the ability to apply reading comprehension as well as

numeric skills in the health-care setting. Skills include the

ability to read consent forms, medical labels and insertions,

and other written health-care information, as well as the

ability to understand written and oral information given by

health-care professionals (Figures 3 and 4).

Health Literacy Research

Since the 1980s, various researchers and public health

professionals have proposed different health literacy defi-

nitions. Most of them limited health literacy to basic

reading or numeric skills within the health-care context

(Maag, 2005). While basic literacy is surely helpful in

under standing health literacy, it does not fully capture

all its important components. Just as the understanding

of general literacy has been extended, so does health

literacy encompass more than the ability to read and

comprehend health information.

Health Literacy Skills

The World Health Organization (WHO, 1998) first pro-

posed a view of health literacy that expanded the notion

of pure literacy. Health literacy was understood as the

cognitive and social skills as well as the abilities of an

individual to gain access to, understand, and use health

information in ways that promote and maintain good

health. In this sense, health literacy offers the potential

to be a useful composite health promotion outcome mea-

sure, and it fills the term ‘empowerment for health’ with

• Health literacy is an essential life skill for individuals

• Health literacy is a public health imperative

• Health literacy is an essential part of social capital

• Health literacy is a critical economic issue

Figure 1 Why is health literacy so critical?

The modern health society is characterized by:

• An increasing life and health expectancy

• An expansive health and medical care system

• A rapidly growing private health market

• The prevalence of health as a dominant theme in social and political discourse

• The establishment of health as a major personal goal in life and as a right of citizenship

Figure 2 The modern health society.

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some concrete meaning and strategic direction. Health

literacy, in an extended view, has to be understood as

a critical life skill – as the ability to navigate health in a

broader sense.

For this purpose, people need a here, a there, a map,

a compass, and a friend. Being health literate means

placing one’s own health and that of one’s family and

community into context, for example, by understanding

one’s current health state as well as the socioeconomic

factors and cultural values that influence it. It is important

to recognize why one should be healthy and informed

about personal health issues. Additionally, to be health

literate, people need knowledge and understanding.

It follows that an individual with an adequate level of

health literacy has competencies and learned abilities to

take responsibility for her or his health.

Health literacy incorporates three different dimen-

sions: functional, interactive, and critical health literacy

(Nutbeam, 2000). Functional health literacy is defined

by basic reading and numeric skills related to health. Inter-

active health literacy refers to more elaborate literacy

and social skills that can be used to actively participate

in health. Finally, critical health literacy encompasses

advanced cognitive and social skills needed to analyze

health information and understand political and economic

dimensions of health.

Health Literacy and Health Information

Good health information and the understanding of this

information are essential for the development of health

literacy. One cannot be health literate if the path is

incomprehensible. Instead, in order to have the capacity

to exercise control over their health, people need com-

prehensible health messages that are accessible and

appropriate to individual needs and cultural and social

backgrounds. Sometimes it might be useful to have a

compass – health professionals or additional information

sources like publications or the Internet – to serve as

helpful guides.

Health Literacy as Social Capital

Health literacy – like social capital – also has an important

community dimension, which, as well as the predisposi-

tion and ability to assist community members in need,

includes understanding a broad range of information,

such as population-based health data and resources and

knowledge on health determinants necessary to improve

health. It is this dimension that leads to engaged citizens

and consumers who act not only as individuals but who

also act together for common rights, access, and saf ety.

Health Literacy and Empowerment

Empowerment is a key dimension of health literacy.

It includes not only health-promoting behavior but also

the ability to perform primary, self, and family care and in

some cases even first aid. It encompasses the knowledge

of when to enter the health-care system and how to navigate

through its complexity. It means understanding advice and

instructions by health professionals and actively participat-

ing with them in the process of deciding on treatment. And

indeed, health literacy is active. As society changes, so do

Health literacy is the capacity to make sound health decisions in the context of every day

life – at home, in the community, at the workplace, in the health-care system, in the

market place, and in the political arena. It is a critical empowerment strategy to increase

people’s control over their health, their ability to seek out information, and their ability to

take responsibility

Figure 3 Health literacy definition.

Literacies

Prose

Home/Community

Politics

Health care

Market

Work

Document Quantitative

Figure 4 Literacies in context. Adapted from White S and

McCloskey M (2005) Framework for the 2003 National

Assessment of Adult Literacy (NCES 2006–473). In: White S and

Dillow S (2005) Key Concepts and Features of the 2003 National

Assessment of Adult Literacy (NCES 2006–471). Washington,

DC: National Center for Education Statistics.

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the necessary literacy skills needed to function within it.

Health literacy is also dynamic, as health-literate indivi-

duals are involved in continuous exchange and dialogue

with the environments they are living in.

Health Literacy in Sickness and Health

Health literacy skills are needed in sickness and in health .

The Ottawa Charter for Health Promotion (WHO, 1986 )

states that health is created in the context of everyday

life, where people live, love, work, and play. It follows

that health literacy becomes relevant in various situations

of life as well as in peoples’ capacities as community

members, consumers, or patients.

Thus, health literacy skills have to be arranged around

five domains of everyday life: health care, home and

community, work, politics, and the market (Table 1

and Figure 5).

The Prevalence and Costs of Poor Health

Literacy

Underlying the expectation that individuals take respon-

sible roles in navigating health and make sound health

decisions for themselves as well as for others is the flawed

assumption that people actually have the necessary skills

to act as health-literate citizens. While health literacy

is undoubtedly reliant on cognitive development, the

assumption that the ability to make sound health deci-

sions is based on general literacy levels provides support

to use data from large-scale literacy surveys to retrieve

information about the prevalence of low literacy and

consequently low health literacy within whole popula-

tions. Such surveys were conducted in the United States

and in Canada as well as internationally under the super-

vision of the Organisation for Economic Co-operation and

Development (OECD). Individuals poorly performing in

these surveys lack the ability to read, compute, and solve

problems at levels of proficiency necessary to function on

the job and in society, to achieve goals, and to develop

knowledge and potential. Translated to the health setting,

these results show that, for example in the United States,

millions of Americans find themselves lost nearly every

time they visit a health-care professional, try to read medi-

cation instructions, or are presented with some type of

general health information. Additionally, U.S. researchers

have developed – based on the analysis of the health-

related items found in two large-scale literacy surveys – a

set of 191 health related indicators, the Health Activities

Literacy Scale (HALS) (Rudd et al., 2004). They arranged

these 191 indicators around five important health activity

areas: health promotion, health protection, disease preven-

tion, health-care maintenance, and system navigation

(Table 2). According to HALS, about 19% of American

adults totally lack the health literacy skills needed and

another 27% have serious problems in functioning effec-

tively in an extended health environment.

Home and

community

Politics

Critical

Interactive

Market

Work

Functional

Health-care

system

Figure 5 Health literacy domains.

Table 1 Health literacy domains and competencies

Domains of

competencies Focus

Health-care

system

Patient competencies to navigate the

health systems and act as an adequate

partner to professionals

Home and

community

General health competencies and the

application of health-promoting,

health-protecting, and disease-

preventing behaviors, as well as self and

family care and first aid

Workplace Operational/working competencies: health

protection through accident prevention

as well as through the avoidance of

industrial or occupational disease,

campaigning for job safety and

health-promoting work

environments, and aiming at an

adequate work–life balance

Political arena Community member competencies:

informed voting behavior in the political

arena, knowledge of health rights,

advocacy for health issues, and

membership of patients and health

organizations

Marketplace Consumer competencies to make health

decisions in the selection and use of

goods and services and to act upon

consumer rights if necessary

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Confusing Health-Related Materials, Confused

Health Professionals

But not just citizens are performing poorly on literacy

surveys. The health materials they are confronted with are

often written at literacy levels far exceeding general

reading abilities – and complex medical information

challenges audiences with even adequate literacy skills

(Ad Hoc Committee on Health Literacy, 1999). Patient

education material is often written and presented at

reading levels far above recommended standards. This

reflects a clear mismatch between people’s health literacy

and the demands that the health system – and in a broader

sense the whole health environment – imposes on them.

Inadequate, not-user-friendly, and incomprehensible con-

sumer information are both cause and effect of problems

associated with low health literacy. Confusing interactions

with health-care prof essionals due to their incapacity

to detect and handle low health literacy contribute to

misunderstandings in doctor–patient interactions.

Health Literacy and Poor Health

Poor health literacy not only influences peoples’ ability to

handle health-related information and limits their personal

development but has huge economic as well as social and

cultural consequences and significantly contributes to bad

health. Studies find, for example, that low health literacy is

the single biggest cause of poor health outcomes. It follows

that low health literacy may be a strong contributor to

health inequalities – and this relationship is reciprocal.

While empirical data on the effects of low health literacy

in Europe are limited, research from the United States

concluded that people with poor health literacy:

1. are more likely to use emergency services,

2. are more likely to be hospitali zed,

3. are less likely to be compliant with medicines,

4. are less likely to use preventive services, and

5. incur higher health-care costs.

Poor Health Literacy Can Affect All of Us

Low health literacy affects people regardless of race,

ethnicity, income level, or geographic location. According

to a survey estimating the prevalence of limited health

literacy (Rudd et al., 2004), only a small portion of the

90 million Americans estimated to have problems under-

standing health information were born outside the United

States. The majority of U.S. adults with poor health liter-

acy are white, native-born Americans. Consequently,

although health literacy is undoubtedly reliant on basic

literacy skills and cognitive development, literate people

are also at risk of low health literacy. It needs to be

recognized that people with a high level of education

and advanced literacy skills can experience difficulty in

obtaining, understanding, and using health information.

A person who functions well at home or in the work

environment can still have insuf ficient literacy in the

health-care realm.

Table 2 Health activities

Health activities Focus Examples of materials Examples of tasks

Health promotion Enhance and maintain

health

Media messages (newspaper articles) Purchase food

Booklets and brochures Cook food

Food labels Choose adequate exercise

Product descriptions

Health protection Safeguard health Media messages (newspaper articles) Decide among product options

Booklets and brochures Use of different products

Health safety warnings Food storing

Environmental quality reports Voting

Referendums

Disease prevention Take preventive

measures

Media messages (news alerts) Determine health risks and act

Booklets and brochures for screening Engage in screening or early detection

Test and retest result letters Go for follow-up diagnostics

Health care and

maintenance

Seek care, form

partnerships

Health history forms Describe and measure symptoms

Medicine labels Follow directions on medicine labels

Prescription forms Calculate timing for medicine intake

Systems navigation Access health services Application forms Locate facilities (doctors, hospitals)

Informed consent forms Choose health insurance package

Appointment slips Apply for social benefits

Health insurance

Rights and responsibilities statements

Agree/disagree with informed consent

ETS materials selected from Literacy and Health in America, 2004, Educational Testing Service, Reprinted Rudd R, et al. (2004) Literacy

and Health in America. Princeton, NJ: Policy Information Center by permission of the Educational Testing Service Policy Information

Center, Educational Testing Service the copyright owner.

Disclaimer: Permission to reprint ETS material does not constitute review or endorsement by Educational Testing Service of this

publication as a whole or of any other information it may contain.

208 Health Literacy

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Health Literacy as a Key Component of Health

Inequalities

However, an Inst itute of Medicine report finds that the

problem of low health literacy is greatest among older

people, those with limited education, or those with lim-

ited proficiency in English, such as immigrants (Institute

of Medicine, 2003). Further, women are disproportion-

ately affected by low health literacy problems. They inter-

act more with the health-care system and are consequently

more often exposed to the risk of not getting the treatments

they need, affecting their overall quality of life. In this

sense, health literacy is not equally ‘accessible’ to all of us.

While the well-educated encounter difficulties in navigat-

ing health, those without education have the most diffi-

culties, primarily due to the poor legibility of systems.

Education in this context has to be seen as general life

education – as the process of continuous learning with the

aim of being able to deal with system complexity.

Health Literacy and Its Economic Impact

Low health literacy may have consequences not only for

individuals or the health-care system but also for society

at large. The U.S.-based Natio nal Academy on an Aging

Society estimated in 1998 that low health literacy costs the

American economy up to $73 billion per year. The study

found that the primary source of higher health-care

expenditures for persons with low health literacy skills

are longer hospital stays. Data from Switzerland suggest

that 1.5 billion Swiss francs are spent on health care due to

limited health literacy (Spycher, 2006). Research on this

topic is still lacking in other European countries and in

Canada. In general, however, it can be stated that the

United States and Canada as well as Eur ope are spending

millions on the health-care sector that might be saved

with improved health literacy.

Improvement of Health Literacy

T he prevalence of limited health literacy is causing major

problems in a complex health-care setting. As health literac y

is more than the kno wledge and ability to adopt healthy

lifestyles and, increasingly, health skills are part of the life

skills needed in modern societies, a range of intervention

lev els must be considered for t he improv ement of health

literacy. For societ ies to become health literate, various actors

in v ol v e d need to increase their engag ement in health liter acy.

Interventions are to be rooted within domains of every d ay

life, and a varied approach is required to find the balance

betwe en policy action and other measures that increase

indi vidual kno wledge and skills to mak e healthy choices.

R esearch on the improv ement of health literacy is limited

at this stage. More research is needed to ev aluate systematic

interventions to the improv ement of health literacy as well as

to investigate the fields of patient counseling and health

communication in relation to health literac y improvement.

Policy Actions: The Readability of Systems

On the one hand, the responsibility for the improvement

of health literacy lies within systems. The Institute of

Medicine, for example, proposes three major sectors that

need to assume responsibility for the improvement of

health literacy (Institute of Medicine, 2003). These are

the educational system, the health system, and culture and

society. These sectors provide intervention points that are

Health literacy

Work

Health-care system

Education system

Culture/home and

community

Politics

Market

Health outcomes

and costs

Figure 6 Health literacy improvement. Adapted from Institute of Medicine (2003) Health Literacy: A Prescription to End

Confusion. Washington, DC: National Academy of Science. Reprinted with the permission from the National Academies Press,

Health Literacy 209

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both challenges and opportunities for improving health

literacy. However, as health literacy becomes relevant in

additional domains of everyday life, we complement these

intervention sectors with the sectors of work, politics,

and the market (Figure 6). These systems need to make

sure they provide navigation support and are readable for

community members, consumers, and patients.

As Table 3 shows, the responsibility for the improve-

ment of health literacy lies with a variety of professionals

such as practitioners of health education and health com-

munication as well as health-care providers. Only through

joint action, involving policy makers, governments, public

health agencies, employers, health professionals, social

services, insurers, nongovernmental organizations, the

media, and many more groups, will interventions aimed

at the improvement of health literacy be successful.

Individual Knowledge and Skills: Citizens’ and

Patients’ Responsibilities

On the other hand, people need to engage in lifelong

education and learning in order to meet the challenges

of an ever more complex health system. They need to

continuously learn about new subjects and unlearn out-

dated information. In this sense, they need to take over

responsibility for their lives and health. This implies

making decisions about health for themselves – not

merely responding to decisions made for them by others.

As citizens, they are required to be engaged for healthy

and health-promoting communities by standing up for

health issues within their communities.

As patients, they need to be truly engaged and empow-

ered to take on responsibility in care decisions. This sort

of patient empowerment is already happening all over the

world: The growing number of patient organizations

and self-help groups shows the increasing willingness of

patients to take par t in care-related decisions.

As employees in the workplace setting, they need to

be aware of health promotion issues within their compa-

nies. Actively promoting health in the workplace setting

involves being aware of health-related issues at the work-

place such as healthy canteen food, and actually opting

for the healthy choice if made available.

As consumers in the market, they need to engage in

informed decision making, opting for the healthy choice,

for example, in supermarkets.

As citizens, they need to participate in political debates

about health-related issues such as supporting the ban of

food marketing directed to children.

In sum, a health-literate society needs:

health-literate community members,

health-literate consumers,

health-literate patients,

health-literate health-care systems,

health-literate schools,

health-literate workplaces,

health-literate politics, and

health-literate markets.

See also: Consumerism: Overview; Literacy and Public

Health; Mass Media Interventions; Patient Empowerment

in Health Care; Public and Consumer Participation in

Policy and Research.

Citations

Ad Hoc Committee on Health Literacy for the Council of Scientific Affairs

and American Medical Association (1999) Health literacy. Journal of

the American Medical Association 281: 552–557.

Institute of Medicine (2003) Health Literacy: A Prescription to End

Confusion. Washington, DC: National Academy of Science.

Table 3 Health literacy improvement

Domains Focus

Education

system

Schools and continuing education institutes

play a major role in the fostering of health

literacy throughout nations. Children

should learn to opt for the healthy choice in

everyday life. In this sense, health literacy

needs to become a central element on

school agendas

Health-care

system

Health systems have to recognize that literacy

is an integral part of health care. It is

important that they be fully aware of

patients’ literacy problems and that health-

related materials are written in plain

language. Health professionals also need

to tailor their communication to meet the

needs of their patients

Home and

community

Communities need to support community

members by providing stable structures

and healthy environments and making the

healthy choice understandable and

available. For example, communities play a

major role in addressing health inequalities

related to low health literacy

Work

environment

Employers need to make sure that the healthy

choice is possible in the work environment,

for example, by providing healthy meals in

canteens or by introducing flexible work

schedules in order to allow employees to

engage in healthy free-time activities

Politics The notion and paradigm of health literacy

has to be integrated into policy and health

policy design as well as research agendas

and objectives for population health. The

United Kingdom, for example, has for this

purpose developed a new policy on healthy

choices, in which choice, responsiveness,

and equity are the main objectives

Market The market in order to be readable needs to

introduce clear and understandable

labeling – for food products, for example –

providing criteria for judgment

and facilitating the healthy choice to

consumers

210 Health Literacy

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Maag D (2005) Health literacy: Compendium of prior research. Studies

in Communication Sciences 5: 11–28.

Nutbeam D (2000) Health literacy as public health goal: A challenge for

contemporary health education and communication strategies into

the 21st century. Health Promotion International 15: 259–267.

Rudd R, et al. (2004) Literacy and Health in America. Princeton, NJ:

Policy Information Center.

Spycher S (2006) O

konomische Aspekte der Gesundheitskompetenzen.

[Economic considerations on health literacy]. Bern, Switzerland:

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UNESCO (2003) Literacy as Freedom. Paris, France: UNESCO.

White S and McCloskey M (2005) Framework for the 2003 National

Assessment of Adult Literacy (NCES 2006–473). (2005) In: White S

and Dillow S (eds.) Key Concepts and Features of the 2003 National

Assessment of Adult Literacy. (NCES 2006–471) Washington, DC:

National Center for Education Statistics.

World Health Organization (1986) Ottawa Charter for Health Promotion.

Geneva, Switzerland: World Health Organization.

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

Switzerland: World Health Organization.