Health literacy plays a crucial role in shaping individual’s health, well-being, and standard of health care. Most Australians are unaware of informed choices to consider when they are making healthcare decisions. According to Australian Bureau of Statistics (ABS), around 60 percent of adult Australians have low individual health literacy (Australian Bureau of Statistics (ABS), 2006). Research has shown that the low levels of people’s health literacy are associated with high levels of health services and poor health outcomes (Berkman, Sheridan, Donahue, Halpern, Viera, et al., 2011). There is also a correlation between low health literacy and inadequate participation in prevention of chronic diseases in Australia (Adams et al., 2013).
In other words, low health literacy is a risk factor for poor health, it can affect people’s ability to do things like planning their health system, understand medical instructions, and seek support from health professionals. This can cause an increase in emergency care patients, being hospitalized, mismanaging their medication and not understanding their health conditions. Therefore, while the healthy development of a person can be predicted by the level of literacy, the appropriate interventions that address the social determinants of health can have a positive influence on person’s overall health outcomes.
The people’s ability in a community to be able to manage preventable diseases and their health conditions plays a major contributory factor for healthy society. Green, Bianco, and Wyn (2007, p. 21) affirm that “having the capacity to manage health and wellbeing, and demonstrating that self-efficacy and capacity, have become central components of citizenship in post-industrial societies”. Therefore, in order to minimize health disparities and improve the health status of individuals and population groups in Australia, health literacy needs to be enhanced. This report critically examines health literacy as a significant social determinant of health in Australia by reviewing the relevant extant literature so as to address the key priorities of enhancing health literacy and reduce the gap of health inequities in Australia.
2.0 What does health literacy mean?
Despite records of a documented array of research studies on health literacy (Australian Bureau of Statistics (ABS), 2008; Kanj & Mitic, 2009; Keleher & Hagger, 2007; Nutbeam, 2000), there is no universally accepted definition of the concept. Most of the known definitions refer to individual’s ability or skills to obtain, process and interpret health information and services to make reliable healthcare decisions (Green et al., 2007; Ratzan, 2000; Sørensen et al., 2012). For example, one of the most popular definitions according to Nutbeam defines health literacy as “The personal, cognitive and social skills which determine the ability of individuals to gain access to, understand, and use the information to promote and maintain good health” (Nutbeam, 2000, p. 264). Health literacy is defined in a more detail as the personal characteristics and social resources acquired by individuals and population groups to analyse, understand, evaluate and utilize information and services in order to make decisions about health (Dodson, Beauchamp, Batterham, & Osborne, 2014). In summary, health literacy refers to the ability of both individual and population groups to communicate, assert and make appropriate health-related decisions.
Meanwhile, Freedman et al. (2009) propose a reconceptualization of health literacy into two components namely: (i) individual-level health literacy (focus on patients) which has been well explored by many researchers and (ii) public health literacy (focus on the public). Public health literacy is defined as “the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community” (Freedman et al., 2009, p. 448).
3.0 The dimensions of Health Literacy
Nutbeam (2000) categorises health literacy into three dimensions: functional, interactive, and critical health literacy. The Nutbeam’s model of health literacy unpacks the progress of these dimensions at different levels of cognitive, interpersonal and social skills (Chinn, 2011). The three dimensions of health literacy are purposely developed to enhance people’s capability to reach the level of independence and personal empowerment to have control over everyday circumstances.(Nutbeam, 2008).
(i)Functional/basic health literacy represents foundational skills in reading and writing that are required to be able to perform effectively on daily activities concerning health-related decisions. Adequate functional health literacy means being able to apply literacy skills to health-related materials such as prescriptions, appointment cards, medicine labels and direction for home health care (Nutbeam, 2000).
(ii)Interactive/communicative health literacy refers to the combination of more developed cognitive and literacy skills, as well as social skills to participate efficiently and effectively in the day-to-day activities (Nutbeam, 2000). An ability to access information and derive meaning from varieties of communication, as well application of new information to evolving situations.
(iii)Critical health literacy applies more advanced cognitive and social skills to critically examine health care information and make right decisions on new events in the most effective manner. Procedural knowledge and judgment skills also form part an individual’s ability to know what to do and consequently apply the knowledge and skills to a new situation (de Wit et al., 2018; Nutbeam, 2008).
Many scholars in the field of public health and health promotion investigated critical health literacy (Chinn, 2011; Freedman et al., 2009; Nutbeam, 2000). Critical health literacy concept has a tendency to address health disparities in a more detailed approach than other dimensions of health literacy approaches (Nutbeam, 2000). It represents abilities and actions on the social determinants of health to manage health at both individual and community level (de Wit et al., 2018). Critical health literacy was classified into three interrelated components in terms of an array of skills and knowledge (Nutbeam, 2000, 2008). These include the critical analysis of information, an understanding of the social determinants of health and, engagement in collective action.
4.0 Health literacy as a significant social determinant of health in Australia
Studies have revealed that inadequate literacy and illiteracy are the major barriers to empowerment and participation of Aboriginal and non-English-speaking population groups (Hecker, 1997; Schwab & Sutherland, 2004). Likewise, as health literates have more capacity to access information easily (Highet, Luscombe, Davenport, Burns, & Hickie, 2006). According to World Health Organization (WHO) (2015), health literacy plays a very crucial role in how individuals and communities can access the health system effectively and receive acceptable quality care.
The term ‘social determinant of health’ is usually referred to social, economic and environmental circumstances that influence health (Marmot et al., 2008). These social determinants include factors such as income, education, employment and social support which act to strengthen or lessen the health of individuals and communities.
The comprehensive understanding of the social determinants of health is a vital component of critical health literacy (Chinn, 2011; Nutbeam, 2000; Wang, 2000). According to Chinn (2011), the social determinant model should not be solely about the investigation on individual health and how socioeconomic factors (such as education, income, and social exclusions) influence health outcomes. The breadth and width of health literacy should be expanded to accommodate the ability to acquire, comprehend, assess, and communicate information on the social determinants of health (Marmot et al., 2008).
This paper has critically reviewed the relevant existing literature on health and its association with social determinants of health in order to know the level of importance as a social determinant of health in Australia. Many researchers have acknowledged through their evidenced-based research that health literacy is a key social determinant of health (Berkman, Sheridan, Donahue, Halpern, Viera, et al., 2011; Freedman et al., 2009; Nutbeam, 2008; Sørensen et al., 2012; Von Wagner, Steptoe, Wolf, & Wardle, 2009). It is evident that health literacy demonstrates strong relationship with other social determinants such as income, education, poverty and marginalisation (Marmot et al., 2008; Pelikan, Röthlin, Ganahl, Brand, & Sorensen, 2012; Rowlands, Protheroe, et al., 2015), its interventions to improve communication will have the potential to address health outcomes (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; Keleher & Hagger, 2007).
A systematic approach proposed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) aimed to serve as a pacesetter for greater improvement in addressing health literacy as a vital social determinant of health in Australia (Australian Commission on Safety Quality in Health Care (ACSQHC), 2014). The commission designed three action plans: (i) Embedding health literacy into systems (implementation of relevant policies). (ii) Ensuring effective communication (enhancing communication and interpersonal relationships), and (iii) Integrating health literacy (educating consumers and health providers).
In Australia and the rest of world, the focus should be “improving health and reducing inequities by empowering both individuals and communities to make informed, ethical decisions about their health” (Pleasant & Kuruvilla, 2008, p. 158). To tackle the key health priorities in Australia such as obesity, smoking, alcohol abuse, and mental illness, attention needs to be focused on health literacy. Therefore, since health literacy is an important social determinant of health, a new model could assist in designing health literacy interventions to prevail over the obstacles that go along with consequences of social determinants of health (Berkman, Sheridan, Donahue, Halpern, Viera, et al., 2011; Rowlands, Shaw, Jaswal, Smith, & Harpham, 2015). Therefore, with the documented evidence reviewed in this report, health literacy interventions could and should have the potential to address obstacles that influence health outcomes.
Adams, R. J., Piantadosi, C., Ettridge, K., Miller, C., Wilson, C., Tucker, G., & Hill, C. L. (2013). Functional health literacy mediates the relationship between socio-economic status, perceptions and lifestyle behaviours related to cancer risk in an Australian population. Patient education and counselling, 91(2), 206-212.
Australian Commission on Safety Quality in Health Care (ACSQHC). (2014). Health literacy: Taking action to improve safety and quality: ACSQHC Sydney.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of internal medicine, 155(2), 97-107.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A., Crotty, K., & Viswanathan, M. (2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. Rockville, MD: Agency for Healthcare Research and Quality.
Chinn, D. (2011). Critical health literacy: A review and critical analysis. Social science & medicine, 73(1), 60-67. doi:https://doi.org/10.1016/j.socscimed.2011.04.004
de Wit, L., Fenenga, C., Giammarchi, C., di Furia, L., Hutter, I., de Winter, A., & Meijering, L. (2018). Community-based initiatives improving critical health literacy: a systematic review and meta-synthesis of qualitative evidence. BMC Public Health, 18(1), 40.
Dodson, S., Beauchamp, A., Batterham, R., & Osborne, R. (2014). Information sheet 1: What is health literacy. Ophelia Toolkit: A step-by-step guide for identifying and responding to health literacy needs within local communities. Part A: Introduction to health literacy.
Freedman, D. A., Bess, K. D., Tucker, H. A., Boyd, D. L., Tuchman, A. M., & Wallston, K. A. (2009). Public health literacy defined. American journal of preventive medicine, 36(5), 446-451.
Green, J., Bianco, J. L., & Wyn, J. (2007). Discourses in Interaction: The intersection of literacy and health research internationally. Literacy and Numeracy Studies, 15(2), 19-38.
Highet, N. J., Luscombe, G. M., Davenport, T. A., Burns, J. M., & Hickie, I. B. (2006). Positive relationships between public awareness activity and recognition of the impacts of depression in Australia. Australian & New Zealand Journal of Psychiatry, 40(1), 55-58.
Kanj, M., & Mitic, W. (2009). Health literacy and health promotion: Definitions, concepts and examples in the Eastern Mediterranean region. Paper presented at the 7th Global Conference on Health Promotion Promoting Health and Development: Closing the Implementation Gap.
Marmot, M., Friel, S., Bell, R., Houweling, T. A., Taylor, S., & (CSDH), C. o. S. D. o. H. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The lancet, 372(9650), 1661-1669.
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(3), 259-267.
Nutbeam, D. (2008). The evolving concept of health literacy. Social science & medicine, 67(12), 2072-2078.
Pelikan, J., Röthlin, F., Ganahl, K., Brand, H., & Sorensen, K. (2012). Comparative report on health literacy in eight EU member states. The European Health Literacy Survey HLS-EU.
Pleasant, A., & Kuruvilla, S. (2008). A tale of two health literacies: public health and clinical approaches to health literacy. Health promotion international, 23(2), 152-159.
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Rowlands, G., Protheroe, J., Winkley, J., Richardson, M., Seed, P. T., & Rudd, R. (2015). A mismatch between population health literacy and the complexity of health information: an observational study. Br J Gen Pract, 65(635), e379-e386.
Rowlands, G., Shaw, A., Jaswal, S., Smith, S., & Harpham, T. (2015). Health literacy and the social determinants of health: a qualitative model from adult learners. Health promotion international, 32(1), 130-138.
Schwab, R., & Sutherland, D. (2004). Literacy for life: A scoping study for a community literacy empowerment project. The Fred Hollows Foundation and the Centre for Aboriginal Economic Policy Research. Canberra: Australian national University, 200.
Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., & Brand, H. (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12(1), 80. doi:10.1186/1471-2458-12-80
Von Wagner, C., Steptoe, A., Wolf, M. S., & Wardle, J. (2009). Health literacy and health actions: a review and a framework from health psychology. Health Education & Behavior, 36(5), 860-877.
Wang, R. (2000). Critical health literacy: a case study from China in schistosomiasis control. Health promotion international, 15(3), 269-274.
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An overview of the report demonstrating my compliance with the University’s Academic Honesty policy
In the course of writing my report (Assessment 1) on ‘Health literacy as a significant social determinant of health in Australia’, I reviewed several relevant literature in order to gain a better understanding of the available evidence concerning health literacy and social determinants of health in Australia. I conducted my pursuit of knowledge honestly and responsibly in order to contribute to a culture of academic integrity and supports the University of Sydney’s reputation in education and research. In view of this, I am responsible for taking part in my education in an honest and authentic manner and not to obtain academic advantage for myself or for others (including in all my assessment or publications of my work) by dishonest or unfair means.
With the understanding of the above, I have produced this essay solely by me and not a resubmission of work that somebody has previously submitted for assessment in the same or in a different unit of study. All my citations have been adequately referenced and acknowledged appropriately, thus, I am not engaging in plagiarism. For example, in page three of my report, a quotation [“The personal, cognitive and social skills which determine the ability of individuals to gain access to, understand, and use the information to promote and maintain good health” (Nutbeam, 2000, p. 264)] that represents the definition of health literacy was used in my report and appropriately cited by including the author’s name and page.
In conclusion, in order to critically examine the key issues in the report, I read many peer-reviewed journals and I duly acknowledged all the authors. For example, in my conclusion, all researchers that affirmed the health literacy as a key social determinant of health were cited appropriately within the body of the report (Berkman, Sheridan, Donahue, Halpern, Viera, et al., 2011; Freedman et al., 2009; Nutbeam, 2008; Sørensen et al., 2012; Von Wagner et al., 2009) and they were also included in the reference list.