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Health literacy: an essential skill for the twenty-first century

Ilona Kickbusch

Kickbusch Health Consult, Brienz, Switzerland




Purpose – The purpose of this paper is to examine the impact of low health literacy and identify how this can have detrimental effects on citizens and their health. It looks at the current overload of information about health in today’s society, how that leaves many confused and unsure of the correct advice to follow, and how governments and other decision makers can take steps to address this problem. Design/methodology/approach – Previous research and statistics have been examined and the author offers ideas on how the situation can be changed. Findings – The paper notes that a substantial proportion of the thousands of marketing messages each person receives every day concern health and it is a topic about which citizens proactively seek information. This variety of sources and their respective advice can lead to confusion and too much information, which can prevent action being taken. Health literacy is fundamentally important to maintaining a population’s health, but levels are often low. The paper concludes that action is needed in three areas: increasing health literacy of citizens, improving communications skills of professionals, and increasing readability of systems. Many can contribute to this goal, but there is a special responsibility for governments, for example in implementing health literacy programmes in schools and special support for people with low health literacy. Citizens must also become more active to build an essential life-skill that provides a building-block for health. Originality/value – This paper contains new thoughts and conclusions and is of value to a variety of agencies, including government, as well as individuals looking to increase health literacy levels.

Keywords Health literacy, Information, Life expectancy, Responsibility, Citizenship

Paper type Research paper

Introduction – overload of information It has been estimated that the average person receives almost five thousand marketing messages every day (Yankelovich Partners, Inc., 2005): of these, a substantial proportion are about health. The messages come from both public and private sources and address such issues as health behaviours and products and how these promote or endanger our health. People have a very high interest in health information and proactively seek it out because they are faced with decisions and questions about health in almost every aspect of their lives. They seek this information from a variety of sources including the internet, TV and radio broadcasts, newspapers, their friends and family, doctors, patient associations, governmental institutions, pharmaceutical companies, health care providers, insurers and self-help literature. The increasing demand for information is matched by an increasing choice in services and treatments that can be administered to

This article was developed in association with Pfizer.

to This article was developed in association with Pfizer. Health Education Vol. 108 No. 2, 2008

Health Education Vol. 108 No. 2, 2008 pp. 101-104 q Emerald Group Publishing Limited


DOI 10.1108/09654280810855559




enhance health and more and more avenues through which health care can be provided. Bearing these factors in mind, it is no surprise that many citizens are left feeling confused about how best to look after themselves, which advice to follow and what behaviour, treatments or products may ultimately be beneficial for them. This can in turn lead to detrimental consequences for their health in both the long and short term. But there is also a need to understand the way in which healthcare is financed and provided, the medicines and treatments citizens of a particular country have access to, as well as understanding the nature of the political debates in relation to health. Information overload is often most prevalent in some of the simplest areas of our health. This includes knowledge about the correct amount of exercise, the best diet, how much sleep is optimal, how to deal with stress most effectively, how much fluid to drink each day, how to keep the mind as active as possible and when is best to visit a doctor to ask questions about our health. At the same time clear and easy to understand information is often lacking on food products or on medicines.

Health literacy The underlying cause of the problem of confusion for many people is a low level of health literacy. Literacy skills in general are the strongest predictor of an individual’s health status, more so than their income, age, education level or employment status (Kellerman, 1999). Around 960 million people across the world are unable to read and write (Committee on Employment and Social Affairs, 2002) and in 1998, 10 per cent of people living in the European Union are unable to understand and use the printed and written matter necessary to function in society (Office of National Statistics, 1998). Literacy enables us to achieve personal goals and understand printed information in daily activities at home and in the community. Health literacy is a concept rooted in the field of general literacy. It refers to the capacity to make sound health decisions in the context of everyday life. For the average citizen, it is an essential life skill that provides a building block for health. It is also part of a wider economic issue, as the consequences of a lack of health literacy can have significant economic ramifications. If more citizens were health literate, they would be able to make sounder decisions about their health, interact more productively with health care providers and respond to political decisions about health with more acumen. A higher level of health literacy would – at population health level – impact on healthy life expectancy, improve disease management, and be a strong factor in the efficient and safe delivery of health care. Some studies (National Society on an Ageing Society, 2007) indicate that significant savings could be generated, particularly within the health system, through an increase of patients’ health literacy combined with better communication skills by professionals and a greater readability of the systems themselves.

Consequences of low health literacy People who have lower levels of health literacy often report poorer overall health (Pirisi, 2004). This is due to a wide range of health determinants, including low income and difficult living environments. They are also less informed about ways in which they can improve their health and less likely to make use of life-saving facilities such as screening programmes. This leads them to visit physicians when they are in the later

stages of disease and therefore less likely to recover fully. Their lack of understanding about their treatment means they are less likely to adhere to medical regimens, which can also negatively impact their recovery. This means that they are subject to a double inequity in health – even in systems with universal access – as the health system and its professionals are also not geared towards supporting patients with low literacy levels (Williams, 1995). The lack of health literacy is almost certainly more prevalent than it is generally considered to be. To take two of the most developed countries in the world, it is estimated that one in five UK adults do not have the literacy skills required to understand simple information that could lead to better health (NCC, 2004, 2005) while one in two US adults do not understand basic health information (Institute of Medicine, 2004). Health professionals in these countries are frequently not aware of just how large that number is. This means that people are less able to take control over and responsibility for their health and also seek out information about their health that would be beneficial – it leads to a medical care system where most health decisions are made for patients rather than by them or with them. Three steps to health literacy are as follows:




Take the time to investigate health issues and treatments.


Consider the best and most effective ways of improving simple areas of health


such as diet and exercise. Select your health information from the most reliable and trusted sources.

Improving health literacy There are three main points of intervention, which can all contribute to an improvement in health literacy amongst citizens. They are culture and society, the health system and the education system. Our culture and society can encourage and foster a way of operating that values a high level of health literacy amongst its members. Health systems play a role in informing patients as to the best way of looking after themselves and ensuring that they utilize the health resources that are at their disposal in the most efficient and effective way – again this means dealing with the triad of increasing patients’ health literacy, the communication skills of health professionals and the readability of systems. Finally the key role of the education system must be underscored – it can make sure that people develop health skills from an early age so that they are empowered to make decisions that impact positively on their health. Being able to navigate the complex health systems of the twenty-first century implies the interface of all three aspects. The current lack of health literacy and its resulting negative consequences, for both an individual and society as a whole, require action. First of all, the actual extent of health literacy in countries around the world needs to be accurately assessed. Measures now exist on how to do this and have been applied in a number of countries such as the USA, Canada and Switzerland. First attempts have also been made to analyze the societal and economic cost of health literacy. In order to tackle the problem, there needs to exist closer cooperation between public health and consumer protection – for example in relation to the labeling of consumer goods – and comprehensive resources and guides for professionals, patients, consumers and citizens so that they feel sufficiently informed to tackle their health and navigate the health system. This can be followed by health literacy programmes for




different segments of society, depending on their needs. For example, the needs of a construction worker may be different from those of an office worker, those of a recent migrant different from a young mother. Above all, health literacy should be, and needs to be, an active part of a person’s citizenship and it is a key component of social inclusion. We should all take it upon ourselves to ensure we are as health literate as we possibly can be and make use of the courses and opportunities that are on offer. However, governments and other authorities have a critical role to play too – particularly for disadvantaged groups. At a time when most countries are investing in a number of initiatives for senior citizens, such as enhancing their computer skills, they also need to make sure that people are equally equipped to make healthy choices in supermarkets, restaurants, or when talking with their physicians. This will help safeguard the health of citizens into the future.

References Kellerman, R., (1999), “Health Literacy: Report of the Council on Scientific Affairs”, Journal of the American Medical Association , Vol. 281 No. 6, pp. 552-7. National Society on an Ageing Society (2007), “Low health literacy skills increase annual health care expenditures by $73 billion”, Factsheet , Vol. 10, July, available at: www.agingsociety. org/agingsociety/publications/fact/fact_low.html (accessed 10 July 2007). Pirisi, A. (2004), “Low health literacy prevents equal access to care”, The Lancet, Vol. 356 No. 9244, December, p. 1828. Williams, M.V. (1995), “Inadequate functional health literacy among patients at two public hospitals”, Journal of the American Medical Association , Vol. 274, pp. 1677-82. Yankelovich Partners, Inc. (2005), Marketing Receptivity Study, available at: www.yankelovich. com/thought/TL2005MarketingReceptivityStudy.pdf (accessed 10 July 2007).

Further reading Carey, S. (1999), The International Adult Literacy Survey in a European Context , Office of National Statistics, London. Hermange, M.-T. (2002), Report on Illiteracy and Social Exclusion , Committee on Employment and Social Affairs, European Parliament, Brussels. Nielsen-Bohlman, L., Panzer, A.M. and Kindig, D.A. (2004), Health Literacy: A Prescription to End Confusion , Institute of Medicine, Washington, DC. Sihota, S. and Lennard, L. (2004), Health Literacy: Being Able to Make the Most of Health , National Consumer Council, London.

Corresponding author Ilona Kickbusch can be contacted at:

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