The mandate for health literacy
Defining health literacy
Health literacy refers, broadly, to the ability of individuals to “gain access to, understand and use information in ways which promote and maintain good health”1 for themselves, their families and their communities. While different definitions are used2 and health literacy is an evolving concept, there is agreement that health literacy means more than simply being able to "read pamphlets", "make appointments", "understand food labels" or "comply with prescribed actions" from a doctor.3
Health literacy is also not just a personal resource; higher levels of health literacy within populations yield social benefits, too, for example by mobilizing communities to address the social, economic and environmental determinants of health. This understanding, in part, fuels the growing calls to ensure that health literacy not be framed as the sole responsibility of individuals, but that equal attention be given to ensure that governments and health systems present clear, accurate, appropriate and accessible information for diverse audiences.4
An important factor in improving health outcomes
The United Nations ECOSOC Ministerial Declaration of 2009 provided a clear mandate for action: “We stress that health literacy is an important factor in ensuring significant health outcomes and in this regard, call for the development of appropriate action plans to promote health literacy.”3 Indeed, knowledge and understanding remain powerful tools in health promotion.
Empowering citizens
Improving health literacy in populations provides the foundation on which citizens are enabled to play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity. Meeting the health literacy needs of the most disadvantaged and marginalized societies will particularly accelerate progress in reducing inequities in health and beyond.
While there is no specific target on health literacy within the Sustainable Development Goals (SDGs), efforts to raise health literacy will be crucial in whether the social, economic and environmental ambitions of the 2030 Agenda for Sustainable Development are fully realized. As Table 1 demonstrates, increased health literacy gained through health education and various forms of communication, as well as actions taken through health systems and other policies, have the potential to support achievement of targets related to SDG 3 on health while advancing a wide range of other SDGs.
Reducing health inequities
Health inequities are endemic to every region of the world, with rates of disease significantly higher amongst the poorest and most excluded groups. As a result, the populations least able to withstand the multidimensional costs of illness are also those most likely to endure them. This injustice is not mere coincidence – the poor are more likely to live, work, study and play in environments that are harmful to health. Health literacy efforts can uniquely reduce inequities in health and beyond, as the case studies in these pages illustrate.
From Ottawa to Shanghai & the sustainable development agenda
Thirty years ago, the Ottawa Charter for Health Promotion recognized the need to enable people to increase control over and to improve their health and well-being by ensuring healthier, sustainable environments where people live, work, study and play. Social justice and equity were highlighted as core foundations for health, and there was agreement that health promotion is not simply the responsibility of the health sector.
Subsequent WHO global health promotion conferences have reiterated these elements as key for health promotion.
The 2030 Agenda for Sustainable Development, the world’s ambitious and universal “plan of action for people, planet and prosperity”, includes 17 Goals, 169 targets and 231 initial indicators. The Agenda offers a new opportunity to involve multiple stakeholders to ensure that all people can fulfil their potential – to live in health and with dignity and equality.
With this in mind, the theme of the 9th Global Conference on Health Promotion, “Health Promotion in the Sustainable Development Goals” is both timely and necessary to ensure policy coherence and alignment of agendas for action. The slogan: “Health for All and All for Health” captures the commitment to leave no one behind and to involve all actors in a new global partnership to achieve this transformative Agenda.
1. Nutbeam, Don. 1998. “Health promotion glossary.” Health Promot. Int., 13 (4): 349-364. doi: 10.1093/heapro/13.4.349
2. Sørensen, Kristine, et al. 2012. “Health literacy and public health: A systematic review and integration of definitions and models.” BMC Public Health, 12:80. doi: 10.1186/1471-2458-12-80
3. ECOSOC. 2009. “MINISTERIAL DECLARATION – 2009 HIGH-LEVEL SEGMENT: Implementing the internationally agreed goals and commitments in regard to global public health.”
4. Rudd, Rima E. 2015. “The evolving concept of Health literacy: New directions for health literacy studies.” Journal of Communication in Healthcare, 8 (1): 7-9.
Health literacy and the SDGs
No poverty
People with higher levels of health literacy are more likely to adopt healthier behaviours and be able to receive and act on health information and services, including universal health coverage. In this way, health literacy enables
individuals to protect themselves, their family and their community from various shocks (e.g. poor health, extreme weather events, market volatility) which increase the risk of impoverishment due to, for example, inability to maintain working
or caring roles, and/or catastrophic out-of-pocket health expenditures.
Reduced poverty can improve health literacy in turn, considering for example that the poor face lower levels of access to education, the internet and other
platforms through which health messaging is often conveyed.
Zero hunger
People with higher levels of health literacy are far more able to understand available nutrition information and to be empowered to make healthier choices, which can combat both under-and over nutrition, and help end all forms of malnutrition.
Benefits can be achieved across the life course and intergenerationally.
For example, health literate mothers understand the nutritional benefits of breastfeeding and the nutritional deficits of sugar-laden baby formulas, thereby
enhancing infant and child health.
Quality education
Where adolescent girls have access to sexual and reproductive health information, often through peer education, they can better protect themselves from HIV, sexually transmitted infections and unwanted pregnancies. This keeps them in school and
counters gender gaps in education. Where students have the requisite information to adopt healthier diets and increase physical activity, their attentiveness, cognitive function and attainment can all improve.
Meanwhile, educational
settings advance health literacy indirectly, through improving students’ ability to read, write and think critically, and directly, through providing specific education on risky, health-harming behaviours. Because education can reach
students at a young age and en masse, it has unique potential to establish healthy behaviours early on that can remain throughout the life course.
Decent work and economic growth
Health promotion includes concerted efforts to elevate levels of health literacy amongst workers, including with messaging on how various work environments can impact upon health (e.g. asbestos,
agro-industry or extraction sectors). These efforts have potential to empower workers to demand better, safer working conditions.
Meanwhile, similar to educational settings, workplaces offer a strong delivery platform for health messaging, for example by providing workplace wellness programmes and/or counselling services.
Industry, innovation and infrastructure
Access to information, communications technology (including mobile health technologies) and the internet are all central to health literacy efforts, and thus improved health literacy
will advance these targets. Improvements in these areas will advance health literacy in turn.
For example, the internet provides people with access to near infinite information, and, unlike a pro-health advertisement, also allows
individuals to actively seek information.
Reduced inequalities
Low– and middle-income countries, and poor people in all countries, are disproportionately exposed to health-harming messaging, often as a result of targeted industry marketing of products such
as tobacco, alcohol and sugar-sweetened foods and beverages. Investments in raising health literacy in poorer populations can counter this pressure, to prevent widening of inequities both within and between countries.
Without strengthening
health literacy, particularly amongst the most disadvantaged and marginalized societies, poverty and inequality are sure to persist – poor health takes away people’s ability to work and earn income, while burdening individuals
and families with medical expenses, or even forcing them to forego care.
Peace, justice and strong institutions
Those with higher levels of health literacy are empowered to hold their governments accountable, whether for access to essential medicines, universal health coverage, removing environmental
air pollutants or tearing down discriminatory laws and practices. Nowhere has this been demonstrated more than in the AIDS response, where improved health literacy has led people to know their rights while demanding equal access to treatment
and preventive services.
Meanwhile, effective, transparent and accountable governments, by definition, provide their citizens with up-to-date, evidence-based information and services to support health.
Health inequities are endemic to every region of the world, with rates of disease significantly higher amongst the poorest and most excluded groups. As a result, the populations least able to withstand the multidimensional costs of illness are also those most likely to endure them.
This injustice is not mere coincidence – the poor are more likely to live, work, study and play in environments that are harmful to health. Health literacy efforts can uniquely reduce inequities in health and beyond, as the following case studies illustrate.
Noncommunicable disease health literacy and the SDGs
In the 2014 Outcome Document of the high-level meeting of the United Nations General Assembly on the comprehensive review and assessment of the progress achieved in the prevention and control of noncommunicable diseases6, governments committed to “continue to develop, strengthen and implement multisectoral public policies and action plans to promote health education and health literacy, with a particular focus on populations with low health awareness and/or literacy.”
This followed a similar commitment made in the 2011 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases.7 Guidance on how to realize these commitments made in 2011 – within a context of national programming for NCDs – are included in the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020.8
High impact of pictorial health warnings
Pictorial health warnings, especially on tobacco product packages, have emerged as a specific and cost-effective application of the basic function of health literacy. As compared with text-based warnings, large pictorial health warnings have been shown to have greater impacts in alerting consumers to the health harms (including severity and magnitude) of tobacco products, while overcoming literacy challenges, particularly amongst low literacy populations, children and young people. The tobacco industry often disproportionately targets these same populations to expand markets and users for its products. Well-designed health warnings and messages on tobacco product packages are therefore an important and proven policy measure to increase public awareness of the health harms of tobacco use, reduce tobacco consumption, and address inequities in health.9
Using pictorial health warnings on tobacco products to build people’s health literacy on the harms from tobacco use yields benefits far beyond health, given the multidirectional relationship between tobacco use and SDGs beyond health.10 Through improved health, these benefits include: reducing the likelihood of falling into poverty (SDG 1), shifting household spending from tobacco toward nutritious foods (SDG 2), preventing girls and boys from dropping out of school to care for sick relatives, or to offset lost income by finding work (SDG 4), and, with the poor benefiting most from pictorial health warnings, reducing inequities (SDG 10).
Traffic light labelling
Pictorial warnings are being used for other health harming products, with similar cross-SDG benefits expected. For example, Ecuador has introduced traffic light labelling for foods, while New York City has implemented warning labels for restaurant food with excess sodium. Traffic light labelling is nearly universally understood by consumers, bypassing language barrier issues inherent in written nutrition labelling or language warnings.
Graphic warnings on cigarette packages in Canada
In 2001, Canada introduced strong pictorial health warnings on the outside of cigarette boxes. One evaluation found that Canadian smokers who had read, thought about and discussed the new labels were more likely to have stopped, made an attempt to stop or reduced their smoking three months later, after adjusting for intentions to stop and smoking status at baseline.
Similar pictorial warnings have been adopted by about a quarter of countries worldwide.
Article 11 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) mandates Parties, within three years of acceding, to adopt and implement tobacco product health warnings that cover at least 30 percent, and preferably 50 percent, of the visible area on a tobacco product pack.
Article 11 WHO FCTC guidelines encourage countries to go beyond 50 percent11 and many countries have done so.12
6. Resolution adopted by the General Assembly. 2014. “Outcome document of the high-level meeting of the General Assembly on the comprehensive review and assessment of the progress achieved in the prevention and control of non-communicable diseases.” A/RES/68/300
7. Resolution adopted by the General Assembly. 2012. “Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases.” A/RES/66/2.
- 8. WHO. 2013. “Global action plan for the prevention and control of NCDs 2013-2020.
- 9. Batterham, RW, et al. 2016. “Health literacy: applying current concepts to improve health services and reduce health inequalities.” Public Health, 132: 3-12.
- 10. FCA. 2015. “Fact sheet – Tobacco: a barrier to sustainable development.”
11. Decision FCTC/COP3(10). 2008. “Guidelines for implementation of Article 11 of the WHO Framework Convention on Tobacco Control.”
Sexual and reproductive health literacy and the SDGs
Sexual and reproductive health information, especially when provided with complementary economic measures such as cash transfers, can support girls to delay sexual debut, choose ‘lower risk’ partners and better protect themselves during sex.
This, in turn, can reduce their risk for HIV, HSV-2 and other STIs, while preventing unwanted pregnancies and maternal mortality related to young age of child-bearing. Achieving higher levels of sexual and reproductive health literacy also yields multiple benefits beyond health. Health literacy is a form of empowerment, especially in situations where power relations (such as gender inequality) reduce the ability of certain groups to access information.
Potential pathways to improve health literacy
There are several potential pathways through which improvements in sexual and reproductive health literacy can contribute to gender equality (SDG 5), for example by helping girls to stay in school, reducing gender gaps in education (SDG 4), and improving future economic opportunities (SDG 8). By advancing access to better jobs and by delaying pregnancy, sexual and reproductive health literacy can also help break chains of intergenerational poverty (SDGs 1 and 10).
Nigeria’s radio serial drama ‘Gugar Goge’ (Tell It To Me Straight)
From 2006-2007, a 70-episode research-based radio serial was broadcasted over regional radio stations, depicting a 12-year-old girl who developed fistula because of obstructed labour but was able to access surgical treatment and lead a productive and happy life.
The drama aimed to increase information about fistula and its treatment, but more broadly provide information on sexual and reproductive health issues and increase women’s access to healthcare services.
Evaluation of the serial showed remarkable impacts, including a substantial increase in the number of women accessing services in the broadcast area, and female listeners reporting higher levels of condom use at last sexual intercourse as compared with female non-listeners.13
The role of governments in promoting health literacy
Greater focus needed on social, economic and environmental determinants of health
Health literacy can be improved through the provision of information, effective communication and structured education. Most communication and health education interventions remain focused on personal health and lifestyles. There is a real need to develop, implement and evaluate such interventions to improve knowledge, understanding and capacity to act on social, economic and environmental determinants of health.
Governments can take a strong leadership role in developing and implementing health literacy promotion policies by providing sustained funding, setting up special projects, coordinating action across sectors, and conducting health literacy surveillance regularly. Improving and measuring health literacy (both strengths and needs) is particularly important in poorer areas, such that vulnerable populations are empowered to engage in early and sustained health promoting actions, whether to prevent acute and chronic conditions or to promote active and curative treatments.
Strengthening participatory and representative decision-making
Strengthening participatory and representative decision-making about health literacy development and equity at all levels will promote individual and community action for health. While health literacy interventions are likely to be highly context specific, the process and impact of implementing them can enable decision makers from different government sectors to better understand the significance of health literacy, both to health and to their sector’s core objectives. This can scale up commitment to work across sectors, especially to achieve the SDGs.
SDGs can inform government action on literacy
There are multiple links between health literacy and the SDGs, providing several evidence-based action areas for government to take. The education sector, for example, can play an important role in promoting health literacy amongst school age children (Goal 4 and Goal 5) by integrating health into and across educational curriculum areas. The labour sectors might similarly enable/equip workplaces to make the healthy choice the easy choice. With potential for active public-private-partnerships to develop wider eco-friendly/organic farming, and other local employment opportunities, it is key to support greater awareness of such models to support higher participation rates, while taking proper safeguards regarding migration to already overpopulated metropolitan areas. Within the health domain, provision by governments of universal public health interventions and clinical services can contribute to improving equitable access of health literacy promotion services amongst all regions and cities (Goal 3 and Goal 10).
Awareness of health impact of all government activities
Governments must also take steps to increase and sustain their own health literacy. Large-scale capital projects, for example, have been shown to increase health risks in surrounding communities, with the potential to widen economic inequities – rather than bring intended inclusive economic growth – if the benefits from these projects accrue only amongst a few. Health impact assessments and integrating HIV, health and gender-related issues into environmental impact assessments14 can provide infrastructure planners and other key stakeholders with important information, raising their health literacy and encouraging them to co-design health-promoting environments with local workers, communities and the health sector.
National Health Literacy Promotion Project in China
In 2008, the Government of China issued the policy paper on Health Literacy for Chinese Citizens – Basic Knowledge and Skills, and started to implement the ongoing national health literacy promotion project. The project funding is more than 40 million USD annually.
The project covers the whole country but provides more support to the middle and western regions, where economic development is lagging behind the rest of the country.
The main interventions include public advertisement on the essential knowledge and skills through all kinds of media, health education and promotion activities in various settings including communities, health facilities and workplaces, and population-based surveillance.
The National Health and Family Planning Commission worked closely with Ministry of Education to add health literacy as a key curriculum area for primary, secondary and tertiary schools.
Through continuous interventions, the national health literacy surveillance data showed that the national health literacy level amongst Chinese residents rose steadily from 6.48 percent in 2008 to 9.79 percent in 2014. Amongst various aspects of health literacy, safety and emergency response literacy was highest (45.3 percent) and NCD literacy was lowest (9.2 percent).
Based on the initial success and areas still in need of improvement, the Government of China issued the new Strategic Plan on Health Literacy Promotion for Chinese Citizens (2014-2020) in 2014.
- 14. UNDP. 2013. “Integrating HIV and Gender-Related Issues into Environmental Assessment in Eastern and Southern Africa.”
Moving forward: A plan for the next fifteen years
The Agenda 2030 will require a new way of working, harnessing the considerable synergies across goals. Moreover, taking into account the ambition and broad scope of Agenda 2030, progress will only be achieved through a new global partnership bringing together a range of stakeholders, as envisioned in Goal 17.
Examples of roles for stakeholders in advancing health literacy and the SDGs include:
Government
Develop policies and plans on health literacy promotion, including sustained funding, systematic intervention and surveillance; work across sectors for win-wins and meet obligations to provide people with accurate, up to date information that is unbiased by undue influence from outside the health sector.
Civil society
Work together to bring different expertise, experiences and capacities to bear in community-based communication and health literacy efforts in all kinds of settings throughout the life course.
Media (including social media)
Serve as a critical platform for health literacy messaging, harnessing the idealism and enthusiasm of youth, and meeting an ethical threshold for accuracy to support, rather than subvert, people’s right to health.
Organizations of the UN system
Develop guidelines and tools for health literacy intervention and measurement; support governments to integrate health literacy promotion across sectors, including through the UNDG’s Mainstreaming, Acceleration and Policy Support (MAPS) approach to SDG implementation.15
Community leaders
Provide risk communication, particularly during times of crisis, as seen recently in the response to Ebola and Zika. WHO’s Framework for Country Action across Sectors for Health and Health Equity recognizes the importance of “training leaders in techniques to support and enable an informed community.”16
Research and academic institutions
Develop and improve methods to measure health literacy, collate and distribute examples of best practice in health literacy intervention development, and provide evidence of what works, in which contexts, and why.
Underpinning these roles are some critical strategies to better enable synergies in health and development planning. Important will be extending health literacy measurement beyond health-related reading ability and numeracy in clinical populations, building on recent attempts to develop valid and reliable tools that aim to more completely measure the broader health literacy concept in a range of populations which includes, for example, interaction with the health care system and critical appraisal of health information.
Making use of new technologies
Also key will be harnessing SDG 9, which includes a target on providing access to information and technology including the internet. The rapid expansion in access to new communications technology and use of social media offer new platforms for health literacy efforts (e.g. through mobile for health or ‘M-Health’ technologies). These can complement traditional platforms for health literacy, such as hospitals, health clinics, and schools, while harnessing the potential of using new settings: workplaces (health wellness programmes/public-private partnerships), places of worship, and other community settings.
Past assumptions that health promotion should be the responsibility of the health sector alone, or that health literacy should be confined to reading pamphlets or understanding labels, are long gone. With Agenda 2030, there is an opportunity to push for integration to ensure that health promotion cuts across sectors, and to show how it advances other sectors’ core objectives.
Other mutually reinforcing literacies
It is also important to take advantage of mutually reinforcing literacies. Health literacy often intersects with educational literacy, legal literacy, financial literacy (as called for in the Addis Ababa Action Agenda17), technological literacy and other forms of literacy. Efforts to reduce inequities caused by disparities in levels of education and literacy will contribute to health equity and broader human development progress.
- 15. UNDG. “Support to Resident Coordinators and UN Country Teams: MAPS – Mainstreaming, Acceleration and Policy Support: Elements in support of a future common approach for effective and coherent UN support to the implementation of the 2030 Agenda.”
- 16. Report of the Secretariat. 2015. “Contributing to social and economic development: sustainable action across sectors to improve health and health equity (follow-up of the 8th Global Conference on Health Promotion). A68/17
- 17. A/RES/69/13. “Resolution adopted by the General Assembly on 27 July 2015. 69/313. Addis Ababa Action Agenda of the Third International Conference on Financing for Development (Addis Ababa Action Agenda).” UNGA, 17 August 2015.