The World Health Organisation has recently published a new definition of health literacy, describing it as ‘the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health’. There are many things I like about this new version.
For a start, it neatly moves away from the idea that health literacy is exclusively about the characteristics of an individual, and that low health literacy is therefore somehow their fault and something about them that needs to be fixed. Instead, by talking about social resources, it makes it clear that health literacy is also about the resources available to support people and how competent organisations are at meeting their needs. The Health Foundation’s Person-centred Care Resource Centre explores this issue of health literacy as a deficit in ‘the system’ not the individual in more detail.
For me, this is the iPhone way of thinking. Remember when PDAs like the Palm Pilot first came out and you had to learn a new alphabet to use the pen and screen? I’ve no idea why anyone would invent a new alphabet, when we already have a perfectly good one established through general use over thousands of years. The iPhone revolutionised the mobile phone and PDA market, by creating something you could use intuitively and without ever opening the manual. Now we need the same thinking in healthcare: you shouldn’t have to learn the language of healthcare to access and get the best out of health services; health services should be easy and intuitive to understand and use. And we need to accept that this means we will need different approaches for different populations, not a one-size-fits-all solution.
The next thing I like about the World Health Organisation definition is its recognition that individuals do not function in isolation – we are all part of a community in some form, and benefit or are disadvantaged by the knowledge, resilience and assets available to us within that community. The World Health Organisation’s definition highlights the role of communities in enabling people to manage their health, access the services they need and benefit optimally from using them. If we accept this role for communities, then there are implications for how we fund, support and develop voluntary and community organisations and how we link them into the care pathway.
Finally, the World Health Organisation definition explicitly sets out that health literacy, despite how it sounds, is not about reading, or the ability to understand information. It is much wider and deeper. It impacts on every step of the care pathway from how well people are able to manage their own health, to whether they can access the right service for them when they need it, to how involved they are in decisions about their treatment and care.
But this last point also creates a challenge – is ‘health literacy’ becoming a catch-all that is simply too extensive to address as a single issue? I recently went to a meeting about health literacy where we talked a great deal about improving health literacy in populations: how to increase people’s knowledge about healthy behaviours and encourage them to adopt them – basically the public health agenda. But we also talked about the importance of having services that are designed and provided in ways that ensure they meet the needs of people with a range of health literacy skills – for me, less an issue of health literacy and more about the fundamentals of a well-designed service. Finally we talked about the communication skills health professionals need to enable people to understand and be fully involved in decisions about their treatment and care – an issue of both clinical communication skills and how we implement shared decision making. Whilst these activities are certainly on a continuum, each requires a specific response from a different group of people.
The 2012 paper Attributes of a Health Literate Organisation by Brach et al. provides a good starting point for a multi-layered organisational response, as does the Ophelia process (OPtimising Health LIterAcy) developed by Professor Richard Osborne and colleagues. Gradually more thinking and tools are emerging to help health services respond to the health literacy agenda, but commissioners and services still need to make the shift from seeing health literacy as an individual issue to a system issue. When seen in this way, the role of the voluntary and community sector is much clearer: statutory services need their knowledge of and reach into local communities; and local people need their support to access and use services and better manage their own health.
Julie Fenner is an independent consultant working with the NHS and voluntary and community sector. She is a member of the team working with the Health Foundation on its online Person—centred Care Resource Centre.