Critical health literacy: A review and critical analysis

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Abstract

Though there has been a considerable expansion of interest in the health literacy concept worldwide, there has also been criticism that this concept has been poorly defined, that it stretches the idea of “literacy” to an indefensible extent and more specifically, that it adds little to the existing concerns and intervention approaches of the better established discipline of health promotion. This paper takes as a starting point the expanded model of health literacy advanced by Nutbeam (2000) and addresses these concerns by interrogating the concept of “critical health literacy” in order to draw conclusions about its utility for advancing the health of individuals and communities. The constituent domains of critical health literacy are identified; namely information appraisal, understanding the social determinants of health, and collective action, and as far as possible each are clearly delineated, with links to related concepts made explicit. The paper concludes that an appreciation of work undertaken in a range of different disciplines, such as media studies, medical sociology, and evidence-based medicine can enhance our understanding of the critical health literacy construct and help us understand its usefulness as a social asset which helps individuals towards a critical engagement with health information. There is some evidence that aspects of critical health literacy have indeed been found to be a resource for better health outcomes, but more research is needed in this area, both to develop quantitative and qualitative approaches to evaluating health literacy skills, and to offer convincing evidence that investment in programmes designed to enhance critical health literacy are worthwhile.

Introduction

This paper examines the concept of “critical health literacy” in the context of the ever-expanding corpus of research into health literacy. Whilst many, including the World Health Organisation and researchers and theorists in health promotion and public health have responded enthusiastically to the growth of this field (Paasche-Orlow et al., 2009, Rootman and Ronson, 2005, WHO., 2009), others have argued that the generation of such new terms has unhelpfully overstretched the concept of “literacy” and simply puts “old wine in new bottles” by recycling health promotion concepts such as “empowerment” and “patient involvement” (Tones, 2002, Wills, 2009) which themselves remain somewhat contested and open to multiple interpretations.

In the light of these criticisms and in order to bolster the utility of “critical health literacy” as a conceptual tool for health promotion, the following requirements need to be met: first, that “critical health literacy” be clearly defined, and its constituent domains identified; second, that critical health literacy be open to measurement and appropriate assessment tools developed; and third, that the links between critical health literacy and individual and community level health outcomes be delineated and evaluated. Health literacy researchers have tended to stay within traditional discipline boundaries either of medicine, examining health literacy as a patient “risk factor” with relation to health outcomes, or within health promotion and health education, with interventions to improve the clarity of health information. They have overlooked some important work in areas such as medical sociology, social psychology and media studies which would not be automatically associated with the health literacy field, but has been written by researchers whose concerns overlap with the issues raised by the critical health literacy concept.

Section snippets

Background

Health literacy research and theory-building has been expanding at a rapid rate, with a ten-fold increase in the number of journal articles published between 1997 and 2007 (Bankson, 2009). Though there is still no universally agreed definition of the concept, the formulation used by the UK National Consumer Council (2004), ‘the capacity of an individual to obtain, interpret and understand basic health information and services in ways that are health-enhancing’ (Joint Committee on National

Information appraisal

An approach to critical health literacy defined in terms of information appraisal is common to researchers in Japan (Ishikawa et al., 2008, Ishikawa et al., 2008), Germany (Steckelberg et al., 2009, Steckelberg et al., 2009) and Israel (Levin-Zamir & Peterburg, 2001). Ishikawa et al. are among the few health literacy researchers to explicitly attempt to assess critical health literacy defined in terms of information appraisal (Ishikawa et al., 2008, Ishikawa et al., 2008). Their approach has

Understanding the social determinants of health

Being able to read a food label is one thing, understanding why a Macdonalds is so cheap, filling and ubiquitous is another (Wills, 2009: 4)

Expanded definitions of health literacy include understanding the social determinants of health as an important component of critical health literacy (Nutbeam, 2000, Wang, 2000). The social determinants framework looks beyond individual health behaviours to investigate how structural factors such as income, education, social exclusion, and social

Collective action

An antidote to the potentially demoralizing impact of awareness of social determinants for community and public health minded researchers is the translation of this knowledge into collective organizing and action. Definitions of critical health literacy extend to the skills and competencies that facilitate these activities, at times under the alternative headings of “civic” or “citizen” health literacy:

The cognitive and skills development outcomes which are directed towards supporting effective

Conclusions

Tones’ criticism of the health literacy research as simply putting “old wine in new bottles” ends with the warning that such an exercise has few benefits either for the wine (key health promotion concepts) or the bottles. This paper goes some way towards refuting Tones’ challenge, by demonstrating that critical health literacy can be seen as a concept made up of interconnected domains which relates to other important constructs, but which nevertheless retains a key focus on the interaction

Acknowledgements

Funding for the work undertaken for this article was provided by Tower Hamlets Primary Care Trust Research and Development Committee. I would like to thank staff working in Tower Hamlets Community Health Services, particularly members of the Primary Care Psychology and Counselling Team, led by Lucy Marks and Maria Casey, for their support for the Tower Hamlets Health Literacy project. I am grateful to the anonymous reviewers who contributed detailed and insightful comments on an earlier draft.

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