"Skills-based views of health literacy have encouraged information developers to
design resources that reflect the comprehension skills of the service users"
Interest in health literacy has developed alongside policies which position patients
and their family members as active players who can make important contributions to
their health care and whose values should shape that healthcare.
Health literacy is increasingly recognised as somehow relevant to efforts to ensure
people can keep themselves healthy, manage their minor illnesses and long term
conditions, share in decision-making about any professionally regulated treatments
they might have, and help ensure their safety as they use health services. But it is
often unclear how health literacy is related to health promotion, self-management,
shared decision-making, and patient involvement in patient safety. This is partly
because the concepts can all be understood in different ways. The different ways of
understanding these concepts have important practical implications (Entwistle, Cribb
and Watt, 2012; Entwistle and Cribb, 2013). We focus here on health literacy, shared
decision-making and self-management.
Health literacy is often understood as a combination of information-related skills that
are somehow useful for health (Sorenson et al, 2012). The table shows three widely
used definitions that reflect this skills-based view of health literacy. The ‘skills’
components are presented separately from the ‘purpose’ components.
Source of
‘Skills’ component of definition of ‘Purpose’ component of
definition
health literacy
definition of health literacy
World Health
The cognitive and social skills
in ways which promote and
Organization,
which determine the motivation
maintain good health.
1998
and ability of individuals to gain
access to, understand and use
information...
American Medical A constellation of skills, including required to function in the health
Association, 1999 the ability to perform basic
reading and numerical tasks...
care environment.
Institute of
The individuals' capacity to
needed to make appropriate
Medicine, 2004
obtain, process and understand health decisions.
basic health information and
services...
Efforts to support shared decision-making and effective self-management of health
conditions often focus strongly on information provision – to inform choice in the
case of shared decision-making and to inform behaviour in the case of selfmanagement. Adoption of skills-based views of health literacy has usefully
encouraged information developers to design resources that reflect the reading and
comprehension skills of the people who are supposed to use them. A number of
examples of more widely accessible and usable information decision-aids and selfmanagement support materials have been developed as a result.
Information and information-related skills are not the only things that matter,
however, and it is important to consider other important values that could be
associated with health literacy, shared decision-making and service support for selfmanagement.
Informational interventions that are supposed to support shared decision making or
self-management sometimes reflect quite particular beliefs about what is good for
people. They implicitly steer people towards particular treatments, behaviours or
health-related goals without recognising that those treatments, behaviours or goals
are not consistent with everyone’s priorities. The ‘purpose’ components of several
skills-based definitions of health literacy can be interpreted in ways that support
narrowly biomedical judgements, for example about which health decisions are
appropriate and what counts as good health. These can support the application of
skills-based understandings of health literacy in ways that discourage the kinds of
responsiveness to individuals that are valued in the ideals of person-centred
approaches to shared decision-making and support for self-management.
Careful attention to the purpose components of definitions and understandings of
health literacy could clearly help address some concerns about the values that are in
play in discussions and activities relating to health literacy, shared decision-making
and support for self-management. To some extent, considerations of purpose are
evident in ideas about the different levels of health literacy that might be aspired to.
Don Nutbeam, for example, encouraged us to look beyond basic information-related
skills such as reading and writing (functional health literacy), to include more
interpersonal communication skills (interactive health literacy) and more critical
evaluative and advocacy skills (critical health literacy for personal and community
empowerment) (Nutbeam, 2000).
Other ways of thinking about health literacy consider the literacy demands that
health services place on the people who use them, and the literacy practices that
people adopt as they negotiate and seek to make best use of services (Papen,
2009). These ways of thinking about health literacy, which are less individualistically
oriented, can provide a valuable contrast and complementary insights to skills-based
views of the concept.
Ways of thinking about health literacy that take seriously its situationally specific,
socially constituted and dynamic nature can better encourage us to think not just
about how health literacy (skills) can help people participate in shared decision
making and self-management, but also about how health services and staff can
approach the sharing of treatment decision-making and the provision of support for
self-management in ways that avoid placing unnecessary demands on people and
enhance their health literacy (skills and practices) in ways that enable them to
contribute to healthcare and goals that are good on their own terms.
Vikki Entwistle
Vikki conducts research into the ethical and social aspects of healthcare
provision to support improvements to healthcare policy and practice. She is
currently Professor of Health Services Research and Ethics at the University of
Aberdeen.
References
American Medical Association (1999) Health literacy: report of the council on
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Entwistle VA, Cribb A, Watt IS (2012). Shared decision making: enhancing clinical
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Institute of Medicine (2004) Health literacy: a prescription to end
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