2025/07/01 by Don Nutbeam · 1 voice · 2 citations
Health Professions · Business, Management and Accounting · #Health Literacy and Information Accessibility #Mobile Health and mHealth Applications #Global Public Health Policies and Epidemiology
paper · pdf · doi:10.1093/heapro/daaf119
Twenty-five years ago, Health Promotion International published a paper on Health literacy as a public health goal: a challenge for contemporary health education and communication. The paper offered my reflections on the evolution of health education and health promotion; and proposed a conceptualization of health literacy that extended beyond relatively narrow definitions that had emerged around this time, primarily from the USA. The paper identified health literacy as a measurable outcome from health education and drew upon concepts that originated from mainstream literacy studies to describe progressive learning and skills development that were classified as functional, interactive, and critical health literacy in the paper (Nutbeam 2000). Initially the paper attracted relatively little academic interest with few citations. Perhaps the most significant was a lengthy rebuttal of some of the ideas presented in the paper by a colleague from the UK, Keith Tones. In a 2002 editorial, he described the paper as an ‘unnecessary exercise in re-branding’ (Tones 2002). Tones accused the ‘health literacy movement’ of ‘territorial encroachment’ that was adding little to ‘many well-researched models that describe empowered health-related decision making’. Surprisingly, and despite Tones’s reservations, the ideas in the paper began to attract academic interest and have been subjected to broader academic examination and practical testing over many years, especially the concept of ‘critical health literacy’ as described in the paper (see, e.g. Zarcadoolas et al. 2005; Ishikawa et al. 2008; Chinn 2011; Mogford et al. 2011; Heijmans et al. 2015; van der Heide et al. 2015; de Wit et al. 2018; Abel and McQueen 2021; Jenkins et al. 2023). ‘Health Promotion International’ has been at the forefront of this evolution offering a platform for a wide range of critical analyses and reporting on experimental applications of the concepts described in the paper over the following 25 years (see, e.g. Peerson and Saunders 2009; Morony et al. 2018; Stormacq et al. 2019; Serbim et al. 2020; Peralta et al. 2022; Larrotta-Castillo et al. 2023; Al-Adhami et al. 2024; Candelario and Castillo 2025). Similarly, despite the rather negative inferences about the ‘health literacy movement’ in the Tones paper, the past 25 years have seen phenomenal growth in academic, policy, and practical interest in health literacy. This is most easily observed in the increase in the volume of academic papers on health literacy but can also be seen in relevant government policies and in professional education and training in health literacy (Kaper et al. 2018; Trezona et al. 2018). Throughout this period, new concepts and definitions of health literacy have proliferated. The scope of practice has expanded beyond all recognition from our more limited models 25 years ago. The ideas, innovations, and debates that flow from this extraordinary period of activity have greatly enriched our understanding of the contribution that improved health literacy might make to personal and public health; and in addressing inequities in health (see, e.g. Stormacq et al. 2019; Nutbeam and Lloyd 2021). Despite this progress, we are now at a stage of evolution that also exposes some risks. The first risk, echoing the concerns expressed by Keith Tones, is that the concept and definition have become so diffuse and all-encompassing that it risks being meaningless. Any cursory examination of the scientific literature over the past decade reveals the danger for health literacy as a concept and practical discipline. Not only are there numerous definitions of health literacy [For the purposes of transparency the author has proposed a number of definitions of health literacy since 1993. Two of these definitions were adopted by the World Health Organization in 1998 and 2021, respectively (Nutbeam 1998; Nutbeam and Muscat 2021).], but also a growing range of subcategories, e.g. reflecting different settings (health literate hospitals, schools, etc.), diseases (cancer literacy, mental health literacy, etc.), media (digital health literacy and mHealth literacy), and health topics (food literacy and alcohol literacy). While it is important to recognize that most of these variations have contextual legitimacy, the fundamental purpose of the concept of health literacy—to support knowledge and skill development that benefit individuals, communities, and broader society—can get lost through the confusion of ideas, theories, models, and consequential academic debate. The risk is that health literacy can become a theoretical panacea for all public health problems, but a practical solution for none. If each of us means something different when we use the term ‘health literacy’ it becomes increasingly difficult to find a common basis for scientific enquiry and public advocacy for health literacy. Finding a framework of common purpose in health literacy is fraught with difficulty. Each of us has conceptual preferences and many of us have a personal investment in our preferred definitions and orientation. Mindful of the irony in using this editorial to present my own preferred approach, I urge continued recognition of the two distinctive dimensions that reflect the core elements of most contemporary concepts and definitions of health literacy. Firstly, that health literacy has core conceptual roots in our understanding of literacy—an observable set of personal (and societal) skills that enable individuals to find, understand, and use information to make health decisions and take actions in a range of circumstances in their everyday lives. These health literacy skills are built on the foundations of established ‘literacy’ skills in reading, writing, and numeracy. Health literacy skills can be objectively observed, measured, and classified. These skills are transferable (capable of application and adaptation to changes in context) and necessarily change across the life course. Importantly, as is the case with basic skills in reading and numeracy, these skills can change and be developed through exposure to different stimuli in the environment, especially through planned health communication and education. These are personal and transferable ‘skills’, not simply advances in knowledge. Secondly, individual capacity to use existing skills is fundamentally moderated by the context in which they are applied. Recognizing the impact of these environmental demands and complexities focusses attention on interventions that create more supportive environments, especially for those with lower health literacy skills. Understanding the impact of these different contexts on health literacy has led to a variety of responses to modify different settings—to make access to understandable, trustworthy information easier; and to support different tasks and skills-based actions referred to above. These two dimensions provide an inclusive framework for more consistent examination of the concept of health literacy and its practical application. They should be routinely considered and reported on, not only in scholarly works but also in government policies and in professional education and training in health literacy. The second and related risk from the past 25 years of health literacy is that the dispersion of the concept and attendant scholarly debate drains attention, political interest, and subsequent resources away from the development of policy and testing of practical interventions that are designed to improve personal and public health—the ultimate purpose of health literacy. In undertaking research for this paper, I identified that there are close to 250 papers that have ‘health literacy’ in the title or as a keyword that have been published in ‘Health Promotion International’ the 25 years since the original article (and none before). Having reviewed them all and taking a generous view of what constitutes an ‘intervention’, no more than 10% actually describe or assess interventions designed to improve health literacy for people or in organizations. This estimate includes reviews of interventions. Ninety percent of all scholarly contributions on health literacy in ‘Health Promotion International’ are descriptive in nature, examining associations between health literacy and other variables; presenting reviews of this work; proposing, testing, and validating measurement tools; and providing critical conceptual analysis of health literacy. In truth, this is a higher ratio of interventional studies than you would typically find in a public health and social sciences oriented journal (Rychetnik et al. 1997), and there is great merit in the quality of the individual contributions that make up the 90% noninterventional studies. It has been previously observed that the concept and rhetoric relating to health literacy have excited the interest of public health researchers, practitioners and policymakers, but that this interest has not yet been converted into substantive advances in public health interventions (Nutbeam et al. 2018). The evidence to support the implementation of national policies and programmes, and the intervention tools required by clinical and community practitioners is not emerging as quickly as needed. The reasons for this are not hard to identify. Intervention research is often complex and messy. Its findings are frequently ambiguous and contested. Creating a manageable environment for research often results in narrowly defined interventions with highly selected populations—often making it difficult to generalize findings. Despite these challenges, there is a clear need for more interventional research to move health literacy forward. This not only includes studies that refine our understanding of ‘what to to’, but also studies of ‘how to get it done’. The focus of the former is on specific approaches to improving health literacy with people; and the latter is on how to create a supportive environment that makes implementation easier and more effective—reflecting the two domains described above. Overall, the evidence to support the implementation of national policies, supportive ‘health literate environments’ and practical programmes; and the intervention tools required by clinical and community practitioners are not being generated at the pace required. This should be addressed as a matter of priority by researchers and the agencies that fund them. None declared. None declared. No data used in the article.