Critical Health Literacy

by

Susie Sykes, Thomas Abel

• LAST MODIFIED: 26 May 2023
• DOI: 10.1093/obo/9780199756797-0216

Introduction

Inequalities in health, or the systematic difference in health status across different population groups and communities, persist globally and are, in some cases, increasing. While some inequalities are linked to behavior, the majority are attributable to social, economic, and environmental factors, often referred to as the social determinants of health. Strategies to address the determinants of health have been central to public health and health promotion (see Oxford Bibliographies in Public Health article “Health Promotion” by Lawrence Green) for several decades and are enshrined in the Ottawa Charter (see Oxford Bibliographies in Module article “Ottawa Charter” by Evelyne De Leeuw). Understanding the structure and agency processes that determine the production and distribution of health is fundamental to all levels of public health action and a requirement for active citizenship with regard to health. More recently health literacy (HL) (see Oxford Bibliographies in Module article “Health Literacy” by Rima Rudd and Lisa Schubiner) has been suggested as an approach to tackle inequalities in health and does so with a focus on empowerment through informed health behaviors of individuals and on health literacy–friendly environments such as health care settings. This focus risks neglecting issues of agency and change at the structural level required to impact on determinants of health. The current public health landscape presents new and growing challenges such as pandemics, climate change, unprecedented displacement and migration, and commercial determinants of health including unsustainable practices of production and trade. This comes at a time when people have access to a burdensome excess of information, misinformation, and disinformation (often referred to as an infodemic). There is also a growing skepticism and lack of trust in scientific and political sources, and in an evidence base that can change quickly such as during the COVID-19 pandemic. Within this context, critical health literacy (CHL) with its focus on individual and community understanding, reflection, and equitable agency for change at a structural level may offer a potential approach that provides opportunities to tackle inequalities of health. The following bibliography presents key publications which explore conceptualizations of CHL, its theoretical foundations, how it might be measured, and work done to support interventions for the development of CHL. We would like to thank Richard Benkert and Catherine Jenkins for their contribution to the literature search in the development of this article.

Conceptualizations

CHL is situated within the concept of HL, and while being less well defined, applied, and researched than other types of HL, has attracted a sustained interest since it was introduced in Nutbeam 2000. Nutbeam suggested three domains of HL: functional health literacy, communicative/interactive health literacy, and critical health literacy, which he presents as the cognitive and skills development outcomes oriented toward supporting effective social and political action as well as individual action. Nutbeam’s introductory paper did not offer a specific definition of CHL but did include a definition of critical literacy, with a narrower focus on critically examining information to exert greater control, as the foundational concept upon which CHL was based. Sykes, et al. 2013 has illustrated that this is frequently cited erroneously as the definition of CHL. This often leads to a conceptually narrower understanding of CHL which focuses on the critical appraisal of information and loses sight of the important social justice element of political action. This appears, in particular, when CHL is applied in clinical environments where the focus remains on individuals and the reflections and actions required in the context of health care, as opposed to a public health context where there is a focus on populations and prevention and promotion of well-being. This lack of conceptual consensus may have impacted on the effective development of interventions and measurement tools. Further work to delineate the concept and emphasize the importance of the sociopolitical element has been undertaken in Chinn 2011, which identifies three elements within CHL: critical appraisal of information, understanding of social determinants of health, and collective action. Sykes, et al. 2013 identifies the key attributes of advanced personal skills, health knowledge, information skills, effective interaction between service providers and users, informed decision making, and empowerment including political action, and positions health empowerment as a similar but distinct concept. This work also emphases the opportunity for CHL to exist at a community as well as at an individual level, echoing points raised by Nutbeam that CHL might be the domain of HL that is most obviously linked to population benefits. Understanding that characteristics of CHL may vary in different contexts has been highlighted in Sykes, et al. 2013, while Abel and McQueen 2021 is an example of its application within the specific context of the Covid-19 pandemic (CHL-P). This focuses on the actions that were urgent in the pandemic context—namely understanding the complexity of the pandemic, recognizing the need for community action, taking actions based on advice from scientific experts, and translating that into one’s own living conditions and practicing adequate personal behaviors. The contextual conditions during the Covid-19 crisis featured special challenges such as uncertainty in emerging scientific knowledge about the disease, political uncertainties, “infodemics,” and propaganda, all indicating the need for increased CHL at the population level.

• Abel, T., and D. McQueen. 2021. Critical health literacy in pandemics: The special case of COVID-19. Health Promotion International 36.5: 1473–1481

  DOI: 10.1093/heapro/daaa141

  This paper addresses the challenges of using participation of the public as a strategy within the pandemic by examining the role of CHL within this context. It presents a case for a definition of CHL in a pandemic (CHL-P) which, it argues, can help professionals to support individuals and communities as active agents within a pandemic.

• Chinn, D. 2011. Critical health literacy: A review and critical analysis. Social Science and Medicine 73.1: 60–67.

  DOI: 10.1016/j.socscimed.2011.04.004

  This paper interrogates the concept of CHL in order to draw conclusions about its utility for advancing the health of individuals and communities. It identifies constituent domains of CHL and makes explicit the links to related concepts.

• 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 15.3: 259–267.

  DOI: 10.1093/heapro/15.3.259

  This paper presented for the first time HL as a outcome of health education and argues for HL to be seen as critical to empowerment. It offers an important contribution through novel distinctions among functional, interactive, and critical health literacy, including a discussion on the characteristics of CHL and implications of this for health education.

• Sykes, S., J. Wills, G. Rowlands, and K. Popple. 2013. Understanding critical health literacy: A concept analysis. BMC Public Health 13.1: 150.

  DOI: 10.1186/1471-2458-13-150

  This paper analyzes the concept of CHL and identifies its antecedents, attributes, consequences, and relationship to other concepts. It concludes that CHL is a unique concept but that some of its key attributes, including empowerment and social and political action, have been lost in more recent representations.