Health Promotion International, Vol. 15, No. 3, 183-184,
September 2000
© Oxford University Press 2000
Editorial |
Advancing health literacy: a global challenge for the 21st century
Regional Editor, Western Pacific and
Chair of Editorial Board
The most recent United States health objectives for the nation, published in Healthy People 2010, contain for the first time an objective to improve health literacy. This objective forms part of an entirely new chapter on Health Communication in the report. The objective is very general— to improve the health literacy of persons with inadequate or marginal literacy skills—and it is presented as a ‘developmental’ objective on the basis that there is no established measure of health literacy which could be used to monitor progress in relation to this target (Department of Health and Human Services, 2000
).
This is not the first time that a government has targeted improvements in health literacy. For example, in 1993 a Report to the Australian Government, ‘Goals and Targets for Australia's Health in the Year 2000 and Beyond’ recommended three goals for health literacy. These concerned improving general language skills and literacy levels in the population; improving knowledge and ‘health literacy’ to enable people to make informed choices about health; and improving knowledge and ‘health literacy’ in ways that enable people to take an active role in bringing about change in environments which influence their health (Nutbeam et al., 1993).
More recently, the British Government public health policy ‘Saving Lives: Our Healthier Nation’ identified the range of social determinants of health and inequalities in health. The report clearly identifies the connection between educational status, literacy and health:
While the roots of health inequality run deep, we refuse to accept such inequality as inevitable. Moreover, we fully accept the responsibility of Government to address such deep-seated problems. That is why we are committed to a wide-ranging programme of action, right across Government, to tackle them ...Education is vital to health. People with low levels of educational achievement are more likely to have poor health as adults. So by improving education for all we will tackle one of the main causes of inequality in health (Department of Health, 1999
These efforts to advance health literacy have common roots. Each reflects the fundamental and long-established relationship between access to education, population literacy levels and health status. Each recognizes that improving overall levels of literacy in the population will do much to improve people's capacity to make healthy choices. Each recognizes that ‘health literacy’ represents a specific set of cognitive and social skills related to health decision-making—whether this is making best use of health services, adopting healthy lifestyles, or taking an active role in addressing the social determinants of health.
These relations between access to education, literacy and health are valid for both developed and developing countries. The 1993 World Bank World Development Report identified access to education, especially for girls, as being one of the most fundamental actions which could be taken to improve public health in the world's poorest countries (World Bank, 1993). Research has continually shown a strong correlation between access to education and subsequent literacy levels and other social development indicators, including health and nutrition, life expectancy and fertility. In all countries limited access to education means reduced health and well-being. In the developing countries this can be as deadly as the lack of access to vaccines. Literacy is one of the foundations of other life skills and has special importance for the empowerment of women. It also shows a very special intergenerational effect: women with education care better for their families and the girls of educated mothers do better on a number of social indicators. Literacy programs for women, that combine development of literacy skills with other social objectives, e.g. health, show a high success rate, and high rates of private and social return on investment.
Despite the evidence and the advocacy, advancing health literacy has generally failed to find political or community ‘traction’. Tangible actions to advance health literacy are hard to observe internationally following the World Bank report, or in individual countries, such as Australia where detailed proposals were made. Responses to these challenges may have been put aside because the concept of health literacy has been considered too hard to define and measure in terms of providing a practical basis for programmatic responses. In addition, where such responses have been developed, they may have tended to be rather narrowly conceived as health mass communication campaigns.
As social and economic inequities increase between countries and within countries so too do inequities in health. There is a great urgency to act. The new global disease threats must be addressed not only with medical means, they must be complemented by ‘support-led strategies’. Such strategies focus on strengthening factors for development, of which education, health and the empowerment of women are the central components. To this end the efforts of health organizations, led by WHO towards the goal of ‘Health for All’, will need to join forces with education organizations, led by UNESCO towards the goal of ‘Education for All’.
Progress is dependent upon a range of political and technical developments. Part of this will necessitate better definition and measurement of health literacy, and improved evidence from practical examples of the effects of actions to advance health literacy. Commencing with this issue, Health Promotion International will publish a series of articles which are intended to meet this challenge. These papers will advance understanding of the concept of health literacy, consider issues relating to definition and measurement, and provide practical examples of programmes which advance health literacy in specific populations. They will include papers from developed and developing countries examining different perspectives to health literacy, and practical applications of the concept for different population groups.
Under the theme of ‘health literacy’, the first two papers are included in this edition. They address issues of concept, definition and measurement (Nutbeam, 2000), and consider the application of the concept in China to address the problem of schistosomiasis control (Wang, 2000). Other papers in the series will examine the development of health literacy for patients, parents and school-aged children, and consider the concept in addressing different problems, e.g. diarrhoeal disease, and HIV/AIDS.
Through this series of publications we hope that the concept will gain political traction, and will feature more centrally in health, economic and social development debates in all countries. There are many success stories to build on. We hope that this new initiative of Health Promotion International will help to build the momentum necessary for substantial and sustained action to address these important determinants of health.
REFERENCES
Department of Health and Human Services (2000) Healthy People 2010. DHHS, Washington DC. http://www.health.gov/healthypeople/document/html/volume1/11healthcom.htm
Department of Health (1999) Saving Lives: Our Healthier Nation. HMSO, London. http://www.official-documents.co.uk/document/cm43/4386/4386.htm
Nutbeam, D., Wise, M., Bauman, A., Harris, E. and Leeder, S. (1993) Goals and Targets for Australia's Health in the Year 2000 and Beyond. AGPS, Canberra.
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, 259–267.
Wang, R.T. (2000) Critical health literacy: a case study from China in schistosomiasis control. Health Promotion International, 15, 269–274.
World Bank (1993) World Development Report: Investing in Health. World Bank, Washington DC.
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