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Canadian Public Health Association

Health Literacy and Public Health

Carolina Jimenez, RN

Increasingly complex health care systems require individuals to assume a high degree of autonomy and employ self-management strategies to achieve their best health. Health literacy is one primary skill useful in navigating such complex systems. To date, there is no commonly accepted definition of health literacy in either academic or grey literature. It is a relatively new concept and ambiguities prevail. 

Originally defined as literacy skills such as reading, writing and numeracy in the health domain, some sources claim that health literacy has evolved into a more fluid and multidimensional concept. For example, older concepts of health literacy often oppose newer progressive models, which posit that cognitive-affective and decision-making skills are vital. These information-processing skills extend beyond a clinical setting into health literacy practices that recognize culture, context and language. Health literacy discourse is conflicting, and no conclusive agreement exists about the appropriate scope of its definition.

This patchwork of definitions and incongruences is problematic. Health illiteracy is associated with high levels of morbidity at the individual and societal levels (Speros, 2005). People with limited health literacy report a poorer understanding of and adherence to medical regimes, and poorer overall health. As such, they are more likely to be hospitalized, increasing demand on public services (Frisch, Camerini, Diviani & Schultz, 2012, p.117). Although data interestingly shows  “health literacy is a stronger predictor of health status than socioeconomic status, age, or ethnic background” (Speros, 2005, p. 633), it must be acknowledged that health literacy and demographic attributes such as socioeconomic status, age and ethnic background do not work independently to predict health. Health illiteracy can be a detriment to the entire health care delivery system. A better understanding of health literacy and its constructs to date will enable public health workers and administrative staff to adapt health promotion initiatives and education programs. It will also facilitate adjusting health-related information and services to improve comprehensiveness and accessibility. 

Public Health Model of Health Literacy

Newer definitions propose a broader definition of health literacy heavily founded in public health theory, highlighting health literacy as a personal and community asset. The perspective also has its roots in health promotion, biostatistics, epidemiology, environmental health sciences and the social and behavioural sciences (Smith, 2009). In the public health model of health literacy, its primary aim is to enable individuals and communities to exert greater control over the range of personal, social and environmental factors that promote health (Nutbeam, 2000). Here, health literacy is seen as of equal importance to community and clinical settings, and population and individual health (Smith, 2009). Health literacy not only enables the individual to “engage in a wider range of health enhancing actions which result in improved health outcomes,” but also enables a wider range of options and opportunities for health (Smith, 2009, Page 53-54). In this broader perspective, health literacy is a product of health promotion and education efforts, which fluctuate with time, opportunity, experience and resources (Frisch et al., 2012; Smith, 2009; Speros, 2005). It applies a very practical sociocultural view where health literacy is irrevocably shaped by critical reflection both at the individual and societal levels (Smith, 2009). Under this public health lens, the concept of cultural capital is highly applicable to health literacy: culture-related factors such as beliefs, behaviours and customs structure an individual’s and a community’s health accessibility and choices (Rustvold, 2012). 

Using the Public Health Model of Health Literacy to Promote Health 

We can consider health literacy from the public health standpoint as a personal and community asset to be built through health education and promotion interventions (Nutbeam 2008; Smith, 2009). Specifically, there is notable opportunity for community-based interventions to promote functional health literacy using the public health model of health literacy. Public health professionals should consider the public health model of health literacy when designing outreach programs, policies and community initiatives. By using such a model, they can create interventions that require stakeholders to apply health-related knowledge to maintain and promote health, instead of simply holding that knowledge (Smith, 2009). Interventions then should be centred on health education and promotion methods to promote functional health literacy, which can be measured and evaluated as health functioning level (Smith, 2009). 

The foundation for physical, cognitive, social and emotional health is built in the early years of life (National Academy of Science/National Research Council, 2000). As such, investments in health promotion and educational initiatives directed at children have the opportunity to improve long-term health behaviour, and economic and civic outcomes (Smith, 2009).  This is an important consideration as public health professionals have the opportunity to enhance and protect the health literacy of those at risk of developing health illiteracy. By the same token, public health professionals should consider who progresses to higher levels of health functioning and subsequently tailor interventions to those at risk of delayed or limited health functioning (Smith, 2009). Avenues for intervention should focus on impoverished environments, such as those that lack cognitive and affective stimulation, regardless of income since such settings are predictors of unhealthy behavior (Smith, 2009). 


The evolution of health literacy from a concept that examines objective attributes such as reading and numeracy skills, to a holistic definition, as offered by WHO (2009) ,emphasizing the functional aspect of health literacy and basic literacy skills, is marked in both grey and academic literature (Oldfield, 2010). It is evident that as social and political conditions evolve, so too does the definition reflected in the literature. Basic literacy skills should not be undermined as they are fundamental to more recent and holistic definitions. However, clinical health literacy’s narrow view does not readily consider social and system factors in health, which we now know to be paramount to population health (Smith, 2009). 

The public health model of health literacy shows promise in addressing individual and community disparities in complex and rapidly changing health systems; however, data supporting this notion is immature and often vague (Department of Health, New Brunswick, 2016). Birtler (2014), suggesting that integrating evidence-based aspects of cognitive behavioral science into public health education programs will increase the likelihood of individuals acting upon the information offered. Overall, there remains a lack of awareness and little agreement on the meaning of health literacy among practitioners, policy makers, adult literacy learners and the public (Canadian Public Health Association, 2008). Improving health literacy and health behaviours requires structured interventions with the support of these key stakeholders (Rustvold, 2012). Health literacy is a significant factor in health care disparity and equity, and must be addressed in health care reform. To support this change, providers must engage with and be accountable to key stakeholders, including patients and the population at large. We must be accountable for the determinants, such as health illiteracy, that impede access to timely and efficient primary care and health care. 


Birtler, E.R. (2014). Group Therapy and knowledge of neuroplastic principles: The impact of health literacy on client locus of control in a therapy setting. (Thesis). Retrieved from PQDT OPEN. UMI Number: 1527888

Canadian Public Health Association.(2008). A Vision for a Health Literate Canada: Report 
of the Expert Panel on Health Literacy. ISBN: 978-1-897485-00-2

Department of Health (2016). Health inequities in new Brunswick: A Report from the Chief Medical of Health.  ISBN 978-1-4605-0981-4. Fredericton: NB, CA.  

Frisch, A., Camerini, L., Diviani, N., & Schulz, P. J. (2012). Defining and measuring health literacy: how can we profit from other literacy domains?. Health Promotion International, 27(1), 117-126.

Mancuso, J. (2008). Health literacy: a concept/dimensional analysis. Nursing & Health Sciences, 10(3), 248-255.

National Academy of Science, National Research Council & Institute of Medicine. (2000). Shonkoff, J.P., & Phillips, D.A. (Eds.) From neurons to neighborhoods: The science of early child development. Committee on Integrating the Science of Early Childhood Development. Washington, DC: National Academy Press. 

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, 259–267. 

Oldfield, S., & Dreher, H. (2010). The concept of health literacy within the older adult population. Holistic Nursing Practice, 24(4), 204-212. doi:10.1097/HNP.0b013e3181e90253

Rustvold, S.R. (2012). Oral Health Knowledge, attitudes and behaviours: investigation of an educational intervention strategy with at-risk females. Retrieved from PQDT OPEN. UMI Number: 3548162 

Speros, C. (2005). Health literacy: concept analysis. Journal of Advanced Nursing, 50(6), 633-640. doi:10.1111/j.1365-2648.2005.03448.x

Smith, S. (2009). Promoting Health Literacy Concept, Measurement & Intervention (Doctoral Dissertation). Retrieved from PQDT OPEN. UMI Number: 3375168 

Walker, LO. & Avant, KC. Strategies for theory construction in nursing. 4. Pearson Prentice Hall; Upper Saddle River, NJ: 2005.   

World Health Organization (WHO) (2009) Background Note: Regional Preparatory Meeting on Promoting Health Literacy. 

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Pat Martz (not verified)

Tue, 06/12/2018 - 10:30

Well written and an excellent article to build the case for health literacy as part of our Kindergarten to Grade 12 curriculum/programs of study. To quote from Alberta's The Guiding Framework for the Design and Development of Kindergarten to Grade 12 Provincial Curriculum (Programs of Study) "Literacy and numeracy are critical in helping students make meaning of the world around them. They open doors and opportunities for individuals to acquire the knowledge they need to achieve personal goals and build a better quality of life. Literacy and numeracy lay the foundation for lifelong learning and for active participation in society. Literacy and numeracy begin at birth and develop throughout one's lifetime." Healthy and physical literacy are foundational concepts that contribute to the healthy and wellbeing.
Thank you.

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