Health literacy and public health: a conceptual paper

T he concept of Health literacy is rapidly evolving from an individual to a public perspective, since it is nowadays clearer than in the past years that it is a fundamental dimension of appropriate use of healthcare services and, consequently, of the general healthcare status of the citizens’ community. Public health literacy is becoming more and more important in terms of developing life skills, and can contribute to promote a real change in lifestyles and life conditions; when referring to “life conditions” and “community health”, it would be meant how relevant health literacy can assume for the impact it can have in increasing the participation of the community, in making decisions that have a strong effect on the health of the population (critical health literacy), so giving way to the trespassing of this discipline in the field of community prevention and health promotion. T he concept of Health literacy was first introduced during the 70s and was linked to the individuals’ ability to read and understand written papers related to health. Interest in health literacy rapidly increased in the United States, due to the heterogeneity and multiculturality of the population: in fact, this often led to misunderstandings between healthcare professionals and patients regarding the management of the diagnosis, treatment, prevention or rehabilitation. After this first period of spreading in the US context, health literacy emerged also in Australia and Europe, where its application was not limited to a clinical competence but included also a population approach. During the last 20 years the term “health literacy” has been associated to a growing number of meanings and its definition included factors influencing the ability of an individual to access, understand and use information to engage with the demands of different health contexts. In 1998 the WHO, basing on Nutbeam’s work, gives health literacy a specific definition in its Health Promotion Glossary: “Health literacy represents the cognitive and social skills Qeios, CC-BY 4.0 · Article, November 27, 2018 Qeios ID: 167556 · https://doi.org/10.32388/167556 1/6 which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. [...] ”.[1]​ With this definition, the WHO places health literacy among the life skills, that can promote a real change in lifestyles and life conditions; when referring to “life conditions” and “community health”, it underlines how relevant health literacy can be, not only for individual health, but also for the impact it can have in increasing the participation of the community in making decisions that have a strong effect on the health of the population (critical health literacy), giving way to the trespassing of this discipline in the perspective of community prevention and health promotion. Public health literacy. T he first paper referring to public health literacy probably dates back to 2005, even if during the previous years other authors had already published articles in which health literacy was linked to public Health, for example relating it to Health Promotion or social marketing in public Health. Gazmararian et al (2005) questioned themselves about how ethic is for Healthcare professionals to provide information that are often centered on scientific topics, hard to find or understand for citizens/patients. [2]​ T his issue, addressed by many authors, is well described by Rowlands and Nutbeam as the so-called inverse information law (“... those with the lowest levels of health literacy have the least access to health information”).[3]​ Gazmararian’s paper continues with stating that, until the first decade of the new century, health literacy was predominantly limited to the Healthcare world, and its use was specifically destined to improve the communication between healthcare providers and patients. He proposes a new challenge the public health literacy as a new, higher level of health literacy through which the population could better understand health information related not only to the individual, but also to the community. Skills in public health literacy are essentials, for instance, to properly understand the meaning of the term “environmental risk factor”, and to acknowledge the role of this risk factor or to identify any distortion promoted by the mass media. Qeios, CC-BY 4.0 · Article, November 27, 2018 Qeios ID: 167556 · https://doi.org/10.32388/167556 2/6 Stating that “the quality of health information that Americans receive and their ability to understand and use that information is the key to building a healthier America. Closing the gap in health literacy, an issue of ethics and equity, is essential to reducing health disparities”, the authors find six priorities to achieve in order to live in a more health literate society: Define what is a “health literate population”; Develop studies and tools to assess the health literacy levels of a population; Critically evaluate the efforts that healthcare professionals spend in communication; Enhance healthcare professionals’ listening and communication skills; Accept that, except for health literacy, having strong theoretical basis on health topics is necessary but not enough in order to maintain and promote healthy behaviours; Develop extensive collaborations between public health and other professionals to achieve this goal. In 2008, Pleasant et al emphasized how the clinical approach to health literacy is totally different from the public health approach: the public health literacy knowledge scale inherently prioritizes the knowledge about population level health outcomes versus a clinical emphasis on individual outcomes. [4]​ In 2009, Freedman defines public health literacy 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”; something different from individual health literacy, but also related to it. [5]​T he author identifies three essential dimensions to deal with, in public health literacy: 1. the knowledge basis, that is the information; 2. the critical ability to obtain, process, evaluate and use the information; 3. the civic orientation. Sørensen et al developed an integrated model that summarizes the evidence-based dimension of health literacy and gives a new, detailed definition: “Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course”.[6]​ Dimensions and factors related to the health literacy are now part of a system (fig.1) Qeios, CC-BY 4.0 · Article, November 27, 2018 Qeios ID: 167556 · https://doi.org/10.32388/167556 3/6 Fig. 1: Integrated model of the health literacy (Source: Sørensen, 20126) T he central part of the model is occupied by the dimensions of health literacy; on the left it shows proximal and distal factors that influence health literacy (antecedents), while on the right it illustrates the outcomes (consequents). Antecedents. Many factors influence the level of health literacy of individuals and populations. T hese factors include age, gender, educational level, literacy rate, illnesses, socioeconomic status, occupation, knowledge of the language, cultural background, presence of physical disabilities or cognitive impairment, defects in sight or hearing and, furthermore, determinants linked to the context like the influence of family and peers and the social and environmental conditions in which the person lives. Specifically, life context and the context of treatment can, on one side, compensate the effects of a low health literacy level, promoting communication and usability of information related to health for those who struggle more and, on the other side, it can be the occasion to increase the level of health literacy of individuals and populations. Other authors have the same point of view. Specifically, Rowland refers to the fact that health literacy is also a set of cognitive and social abilities that can be actively developed through education to health and education targeted to the patient; this process relies not only on cognitive abilities (individual factors) but also on the exposure to different forms of communications and messages. T he Australian Commission on Safety and Quality in Health Care defines the concept of the “health literacy environment”: systems, organizations, political choices, procedures, protocols that are adopted on a national, regional and local level, that can make it easier Qeios, CC-BY 4.0 · Article, November 27, 2018 Qeios ID: 167556 · https://doi.org/10.32388/167556 4/6 for citizens to access, understand and apply information and services that are connected to health. In this environment, health organizations play a significant role and are defined as “health literate” if they recognise the value of health literacy and they integrate it in the process of treatment, in the organizational model and in communication processes, following what is described by the Institute of Medicine and then summed up in 10 attributes that health literate organizations should possess and apply.[7]​[8]​ Core: dimensions of health literacy. Knowledge, skills and motivations constitute the heart of the definition of health literacy, making it stand out from the simple acquisition of knowledge (based on superficial factual knowledge) or skills (abilities that are gained through training). Health Literacy aims to get access,

which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. [...] ". [1] With this definition, the WHO places health literacy among the life skills, that can promote a real change in lifestyles and life conditions; when referring to "life conditions" and "community health", it underlines how relevant health literacy can be, not only for individual health, but also for the impact it can have in increasing the participation of the community in making decisions that have a strong effect on the health of the population (critical health literacy), giving way to the trespassing of this discipline in the perspective of community prevention and health promotion.
Public health literacy.
T he first paper referring to public health literacy probably dates back to 2005, even if during the previous years other authors had already published articles in which health literacy was linked to public Health, for example relating it to Health Promotion or social marketing in public Health. Gazmararian et al (2005) questioned themselves about how ethic is for Healthcare professionals to provide information that are often centered on scientific topics, hard to find or understand for citizens/patients. [2] T his issue, addressed by many authors, is well described by Rowlands and Nutbeam as the so-called inverse inf ormation law inverse inf ormation law ("... those with the lowest levels of health literacy have the least access to health information"). [3] Gazmararian's paper continues with stating that, until the first decade of the new century, health literacy was predominantly limited to the Healthcare world, and its use was specifically destined to improve the communication between healthcare providers and patients.
He proposes a new challenge -the public health literacy -as a new, higher level of health literacy through which the population could better understand health information related not only to the individual, but also to the community.
Skills in public health literacy are essentials, for instance, to properly understand the meaning of the term "environmental risk factor", and to acknowledge the role of this risk factor or to identify any distortion promoted by the mass media. Stating that "the quality of health information that Americans receive and their ability to understand and use that information is the key to building a healthier America. Closing the gap in health literacy, an issue of ethics and equity, is essential to reducing health disparities", the authors find six priorities to achieve in order to live in a more health literate society: Define what is a "health literate population"; Develop studies and tools to assess the health literacy levels of a population; Critically evaluate the efforts that healthcare professionals spend in communication; Enhance healthcare professionals' listening and communication skills; Accept that, except for health literacy, having strong theoretical basis on health topics is necessary but not enough in order to maintain and promote healthy behaviours; Develop extensive collaborations between public health and other professionals to achieve this goal.
In 2008, Pleasant et al emphasized how the clinical approach to health literacy is totally different from the public health approach: the public health literacy knowledge scale inherently prioritizes the knowledge about population level health outcomes versus a clinical emphasis on individual outcomes. [4] In 2009, Freedman defines public health literacy 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"; something different from individual health literacy, but also related to it. [5] T he author identifies three essential dimensions to deal with, in public health literacy: 1. the knowledge basis, that is the information; 2. the critical ability to obtain, process, evaluate and use the information; 3. the civic orientation.
Sørensen et al developed an integrated model that summarizes the evidence-based dimension of health literacy and gives a new, detailed definition: "Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course". [6] Dimensions and factors related to the health literacy are now part of a system ( fig.1  Specifically, Rowland refers to the fact that health literacy is also a set of cognitive and social abilities that can be actively developed through education to health and education targeted to the patient; this process relies not only on cognitive abilities (individual factors) but also on the exposure to different forms of communications and messages.
T he Australian Commission on Safety and Quality in Health Care defines the concept of the "health literacy environment": systems, organizations, political choices, procedures, protocols that are adopted on a national, regional and local level, that can make it easier