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Health Literacy and Health Promotion

I Introduction
II Proposed Redefinition of Health Literacy
III Reasons for caution
IV Reasons to proceed
V Conclusion

Submitted by Irving Rootman, Michael Smith Foundation for Health Research Distinguished Scholar and Professor, Faculty of Human and Social Development, University of Victoria

Don’t forget that we now publish a Letters to the Editor column featuring your feedback on our articles. If you have a resource or point of view to add to Dr. Rootman’s article, let us know by writing to A full introduction to this new section is in the OHPE News of 268.0 and can be viewed on our website at

Readers may also be interested in Michelle Black’s recent article, “The 5 C’s: Areas to consider for making your health messages accessible to a wider population,” from OHPE258.1,

I Introduction

Although the term “health literacy” was first used in health education about thirty years ago (Ratzan, 2001), it has only recently been proposed as an important concept in health promotion as a whole (Nutbeam, 2000; Kickbusch, 2001). There is, however, a debate starting regarding whether or not it should be redefined for use in this context (Tones, 2002). The proposed redefinition of the term will be presented here as well as the arguments in favour of and against its use in health promotion.

II Proposed Redefinition of Health Literacy

The redefinition of the term first officially appeared in a revised WHO glossary of health promotion terms (Nutbeam, 1998). It suggested that

“Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.”

In addition, the glossary notes that

“Health literacy means more than being able to read pamphlets and successfully make appointments. By improving people’s access to health information and their capacity to use it effectively, health literacy is crucial to empowerment.”

Thus, this definition represents a considerable expansion of functional definitions of health literacy such as “being able to apply literacy skills to health related materials such as prescriptions, appointment cards, medicine labels, and directions for home health care” (Parker, et al., 1995), or the following the U.S. National Library of Medicine definition of health literacy put forward in a previous OHPE Bulletin article by Michelle Black: “the degree to which people can obtain, process and understand basic health information and services they need to make acceptable health decisions” (OHPE 258.1).

The scope and nature of the expansion becomes clearer when we consider Nutbeam’s differentiation between three types or “levels” of literacy — basic/functional, communicative/interactive and critical (Nutbeam, 2000). His definitions are

  • basic/functional literacy: “sufficient basic skills in reading and writing to be able to function effectively in everyday situations;”
  • communicative/interactive literacy: “more advanced cognitive and literacy skills which, together with social skills, can be used to actively participate in everyday activities, to extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances;” and
  • critical literacy: “more advanced cognitive skills which, together with social skills, can be applied to critically analyse information, and to use this information to exert greater control over life events and situations.”

In particular, the latter two types or “levels” of literacy suggest the expansion of the notion of health literacy into the domain of health promotion through their connection with the concept of “empowerment.”

Moreover, these ideas have been expanded even further as a result of a series of meetings or workshops on the conceptualization of health literacy including one at the 5th WHO Global Conference on Health Promotion that

“resolved to widen the glossary definition to include dimensions of community development and health related skills beyond health promotion, and to understand health literacy not only as a personal characteristic, but also as a key determinant of population health” (Kickbusch, 2001).

All this expansionary thought leads to the question of whether or not it is really a good idea to transform the concept of health literacy beyond its original scope.

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III Reasons for caution

One person who clearly believes that it is not a good idea is Keith Tones, the editor of the journal Health Education Research, who, in a recent editorial entitled “Health literacy: new wine in old bottles,” argues strenuously against such a transformation. According to him “the kind of territorial expansion involved in translating limited, but clearly defined concepts into much broader, semantically unrelated constructs is both unnecessary and counter productive” (Tones, 2002).

In support of this view, he challenges Nutbeam’s distinction of “interactive literacy” on the grounds of “whether or not it is appropriate to use the term ‘literacy’ to describe competent social interaction — even as a metaphor” (Tones, 2002).

In his opinion “it is certainly not necessary, since there is a considerable, well developed and theoretically sound literature already available to illuminate and guide practice” (e.g., Trower, 1978).

Similarly, with regard to critical literacy, “the kinds of capability and skill involved in this process of critical analysis have already been described in a more sophisticated and detailed fashion within the field of cognitive and social psychology” (e.g., Gagne, 1985; Janis and Mann, 1977).

Thus, according to Tones, there seems to be little advantage in coining a new term when “existing terms are more than adequate” (Tones, 2002). Moreover, he suggests that “there is even more reason to do so [sic] if the new terminology is lacking in precision” (Tones, 2002), which he feels it is.

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IV Reasons to proceed

On the other hand, the proponents of the redefinition of health literacy have suggested a number of reasons why it should be pursued. Here are the key reasons:

  1. Health literacy is a “key outcome from health education” (Nutbeam, 2000) and one that health promotion could legitimately be held accountable for;
  2. Expansion of the concept is consistent with current thinking in the field of literacy studies (Nutbeam, 2000);
  3. It “significantly broadens the scope and content of health education and communication” (Nutbeam, 2000), both of which are critical operational strategies in health promotion;
  4. The expanded definition implies that “health literacy” not only leads to personal benefits, but to social ones as well, such as the development of social capital (Nutbeam, 2000);
  5. It helps us to focus on overcoming structural barriers to health (Nutbeam, 2000);
  6. It helps strengthen the links between the fields of health and education (Kickbusch, 2001)’
  7. “Health literacy as a discrete form of literacy is becoming increasingly important for social and economic development” (Kickbusch, 2001);
  8. “Measuring health literacy could be the first major step in constructing a new type of health index for societies” (Kickbusch, 2001);
  9. The typology of three different levels emphasizes the need for public participation in policy development (Kickbusch, 2001); and
  10. The typology allows us to consider the ambiguities of the fit between health promotion strategies and wider social trends (Kickbusch, 2002).

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V Conclusion

I have presented a proposed redefinition of health literacy in the context of health promotion as well as some arguments regarding why we should or should not proceed along these lines. In my view, the debate is only beginning and is certainly a worthwhile one whatever the outcome because it raises profound questions that go to the heart of what health promotion is all about. I would urge you to review the materials cited (see below and OHPE 270.2) and join the debate.

VI References Cited

Gagne, R.M. (1985) The Conditions of Learning Theory and Instruction, 4th edn. New York: Holt-Saunders.

Janis, I.L. and Mann, L. (1977) Decision Making: A Psychological Analysis of Conflict, Choice and Commitment. New York: Free Press.

Kickbusch, I. (2001) Health Literacy: addressing the health and education divide. Health Promotion International, 16, 289-297.

Kickbusch, I. (2002) Health Literacy: a search for new categories. Health Promotion International, 17: 1, 1-2.

Nutbeam, D. (1998) Health promotion glossary. Health Promotion International, 13, 349-364.

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.

Parker, R.M., Baker, D.W., Williams, M.V., Nurss, J.R. (1995) The test of Functional Health Literacy in Adults: a new instrument for measuring patients’ literacy skills. Journal of General Internal Medicine, 10: 537-541.

Ratzan, S.C. (2001) Health literacy: communication for the public good. Health Promotion International, 16: 207-214.

Tones, K. (2002) Health literacy: new wine in old bottles? Health Education Research, 17: 3, 287-290.

Trower, P., Bryant, B. and Argyle, M. (1978) Social Skills and Mental Health. London: Methuen.