THEORETICAL STUDIES
doi: 10.1111/j.1471-6712.2011.00900.x
Health literacy – a heterogeneous phenomenon: a literature
review
Lena Mårtensson OTR, PhD (Researcher)1,2 and Gunnel Hensing PhD (Professor)1
1
Social Medicine, Department of Public Health and Community Medicine, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden and
Institute of Neuroscience and Physiology/Occupational Therapy, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
2
Scand J Caring Sci; 2012; 26; 151–160
Health literacy – a heterogeneous phenomenon: a literature review
Background and aim: A growing responsibility on the part of
individuals to make decisions in health issues implies the
need of access to health information and personal skills to
comprehend the information. Health literacy comprises
skills in obtaining, understanding and acting on information about health issues in ways that promote and maintain health. A lack of health literacy may have effects at
both the individual and societal levels. There are thus
reasons for health care professionals to gain a comprehensive understanding of health literacy. The aim of this
review was to explore how health literacy is described in
the scientific literature and to give a synthesis of its different meanings.
Methods: The review was based on approximately 200 scientific articles published 2000–2008. The analysis process
was inspired by the methods of narrative literature review.
Findings and conclusions: Two different approaches to health
literacy became visible, one in which health literacy is
expressed as a polarized phenomenon, focusing on the
extremes of low and high health literacy. The definitions of
Background
Access to information is becoming increasingly important
for individuals’ health decisions. Recovery after illness,
sickness absence and rehabilitation also involve decisions
that are likely to be better if based on relevant information.
Furthermore, there seems to be a growing and sometimes
implicit obligation on the part of individuals to search for
information themselves, to understand rights and responsibilities and to make decisions in health issues (1). The
purpose in this approach is to enable individuals to promote
Correspondence to:
Lena Mårtensson, Enheten för Socialmedicin, PO Box 453, S 405
30 Göteborg, Sweden.
E-mail: [email protected]
health literacy in this approach are characterized by a
functional understanding, pointing out certain basic skills
needed to understand health information. The other
approach represents a complex understanding of health
literacy, acknowledging a broadness of skills in interaction
with the social and cultural contexts, which means that an
individual’s health literacy may fluctuate from one day to
another according to the context. The complex approach
stresses the interactive and critical skills needed to use
information or knowledge as a basis for appropriate health
decisions. We conclude that health literacy is a heterogeneous phenomenon that has significance for both the
individual and society. Future research will aim at the
development of assessments that capture the broadness of
skills and agents characteristic for health literacy as a
complex phenomenon.
Keywords: client centred, decision-making, health
behaviour, health education, health information seeking,
literature review, participation, person centred, public
health.
Submitted 26 May 2010, Accepted 20 February 2011
health or solve health problems by themselves or to be an
active partaker and negotiator in health care interventions
and decisions (2). Decisions in health issues may be complicated, as described by, e.g. Länsimies-Antikainen et al.
(3), however, considering the increasing amount of
information available about health, illness and health care.
A crucial feature of an individual’s access to and benefit of
health information is his or her level of health literacy,
defined by the WHO as the cognitive and social skills that
determine the motivation and ability of individuals to gain
access to, understand and use information in ways that
promote and maintain good health (4). In concrete terms,
health literacy may involve, e.g. understanding reasons for
medical examinations or surgery or grasping the meaning
of information about consent, prevention, diagnosis and
treatment (5, 6). It also includes reading and understanding the text on medicine labels, appointment slips, medical
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151
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L. Mårtensson, G. Hensing
instructions, insurance forms and other kinds of healthrelated information (6–10). Basically, health literacy
involves the ability to read and the numerical skills needed
to act on information or advice on health issues in ways
that promote and maintain health (5, 11, 12).
A lack of health literacy may have effects at many levels,
from the individual to the societal. Examples are incorrect
use of medications/assistive aids, lack of knowledge in
health decisions, misinterpretation of instructions or
symptoms, absence from booked health care visits,
unnecessary examinations or surgery, increased need of
hospital treatment and security risks at home, at work or in
society (13, 14). Studies suggest that health literacy is less
common in specific population groups, e.g. elderly persons, individuals with short or uncompleted education,
immigrants and prisoners (8, 15), and an analysis published in 1998 estimated US health care costs resulting
from low health literacy at more than 50 billion dollars per
year (16). Thus, there are reasons for the health care system and its professionals to reflect on how health information is communicated and whether health promotion
and preventive health interventions are carried out in
ways such that groups with different levels of health literacy may be reached. Furthermore, interest in health
literacy has increased during the past decade. According to
the Scopus database, the number of articles that include
‘health literacy’ in their titles has increased from 13 in
1999 to 171 in 2009, which suggests that health literacy is
an emerging issue among health care professionals.
To be able to take a systematic approach to health care
problems that may be associated with individuals’ skills in
obtaining, understanding and interpreting health-related
information, it is necessary to gain a comprehensive
understanding of health literacy.
Aim
The aim of this literature review was to explore how health
literacy is described and used in the contemporary scientific literature and to give a synthesis of its different
meanings to make a comprehensive delineation of health
literacy.
Methods
This review had a narrative, integrative approach, inspired
by Baumeister (17), Green et al. (18), Broom et al. (19)
and Whittemore & Knafl (20). The intent of narrative and
integrative reviews is to summarize primary studies or
theoretical literature to provide a comprehensive understanding of a specific phenomenon (17, 19, 21, 22). The
goal of the analysis process in these forms of reviews is a
qualitative synthesis of the data rather than a separation
into its constituent parts (Polkinghorne 1995). This
involves interpretation based on published findings rather
than primary data, and the results are qualitative rather
than quantitative (20, 23). Our review included the different stages in Whittemore’s and Knafl’s framework for
integrative reviews (20) of which four are accounted for in
the method section. The stage of problem identification is
included in the introduction, and the stage of presentation
is treated in both the results and method sections (Tables 1
and 2).
Literature search and data evaluation
The literature search and the extraction process were
guided by Green et al.’s (18) summarized instructions for
writing narrative literature reviews. The process started
with a literature search using the search word health
literacy* in electronic databases with the limitations that
the term should be found in the title (and in the abstract,
when this was possible) of articles published 2000–2008.
Databases used in the search were Cinahl, Pubmed/Medline, PsycINFO and Eric. The search strategy was deliberately designed to capture a broad range of references.
These database searches resulted in a total of 592 findings
in the four databases.
The next step was to locate the texts’ interest in health
literacy, based on geographical origin and the professional
field in question. The majority of the articles found in the
literature search were written in the United States. Other
countries represented with more than single articles were
Australia, New Zeeland, Canada and the United Kingdom.
One article written in Scandinavia was found. The greater
Table 1 Results of the database search
Key concept
Origin of publication
Health literacy
Database provider
Free search
In title
US
Australia/
New Zealand
Canada
UK
Asia
Europea
Cinahl
Pubmed/Medline
ERIC
PsycINFO
575
556
582
1407
142b
268
41
141b
112
202
34
97
7
23
4
22
10
17
3
5
3
6
7
11
3
9
5
6
6
a
Beyound UK.
In title and abstract.
b
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Health literacy
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Table 2 Results of the database search, distributed on basis of the journal’s field of concern
Field of concern
Database
provider
Health promotion
prevention education
behaviour science
Cinahl
PsycINFO
ERIC
36
46
2
Nursing
Health/medical
care
Paediatric
care
Geriatric
care
Mental
health
care
School
health
care
Other field of
concerna or other
form of publicationb
23
6
40
41
8
3
2
6
8
2
5
20
2
2
2
17
22
15
16
a
Technology, pharmacology, library science et cetera.
Books, policy documents, dissertation abstracts et cetera.
b
proportion of the findings was published in scientific
journals with an emphasis on health, more specifically,
health promotion, health and patient education. Another
large part of the findings was published in journals connected to nursing or caring, sometimes related to specific
diagnoses. Journals in the fields of paediatrics, geriatrics
and school health were represented by only a few articles.
Occasional articles were found in journals in the fields of
library science, ethics, radiology, pharmacology and
odontology. The classification of interest in health literacy,
based on geographic origin and professional field, is given
in Tables 1 and 2.
The evaluation and extraction process started with a
prescreen of the articles by one reviewer (the first author).
The purpose of this extraction process was to assess the
relevance of each article identified according to questions
based on the aim of the review. These questions, which also
served as inclusion criteria, concerned how and when the
concept of health literacy was used and how it was understood. Other questions had to do with the measurability of
health literacy, levels of health literacy and empirical findings related to the concept. After this prescreening for relevance, a total of 200 articles remained. This constituted the
body of the literature used for the analysis process.
Data analysis
The focus in the stages of data analysis was on how the
different aspects of the phenomenon relate to one another,
based on the aim of creating an informative understanding
of the phenomenon (20, 24). The methods developed for
qualitative design are used for data analysis in reviews
with an integrative approach (20), and the basis for our
analysis was the methods described by Whittemore (20),
Patton (25) and Starrin & Svensson (26). The phases in the
analysis with an integrative approach are data reduction,
data display, data comparison and conclusion drawing and
verification (20). Data reduction includes dividing the data
into logical subgroups as well as extracting and organizing
data, i.e. relevant data of each subgroup classification are
extracted from all primary data sources. Data display
means converting the extracted data from individual
sources into displays that visualize patterns and relationships and serve as a starting point for interpretation. Data
comparison involves an iterative process of examining data
in and out of context to identify patterns, themes or relationships. Finally, conclusion drawing and verification
moves the interpretive effort from the description of patterns and relationships to higher levels of abstraction (20).
The first step of our analysis was a more careful examination of the text on the basis of the questions named
above. The articles were considered in full in this step and,
during the examination, some new literature appeared,
generated by statements or comments that were given
references in the articles. The additional literature had the
form of official and policy documents, screening instruments, Internet websites et cetera and was added to the
literature examined. On the other hand, in several articles,
the understanding and use of the concept ‘health literacy’
referred to the same origins or definitions. This was the
main reason for exclusion of articles or other form of literature in the analysis. Other reasons for exclusion in this
step were that the articles did not give any answers to the
questions named above or insufficient descriptions/definitions of the term health literacy or were written in other
language than English.
The examination of the texts continued until the literature no longer generated new variations of answers to the
questions compared with the literature considered to that
time. This occurred after considering approximately twothirds of the articles. The next step was to re-screen the
remaining one-third of the literature identified to ensure
that no further variations appeared. As this did not happen,
this step of the analysis was stopped. The first author was
responsible for the major part of the analysis up to this
point, and the data were in this step in the form of fragments
of text and comprised outcomes of scientific investigations,
conclusions, definitions, statements, discussions et cetera.
The third step of the analysis process was to gain an
overall understanding of health literacy as it had been
described; here, the text fragments were considered both
de-contextualized and in their original context. They were
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L. Mårtensson, G. Hensing
also compared to find similarities and differences. This
process of searching for relations and patterns prepared the
way for the final step, which comprised a formulation of
qualitative categories and an identification of two different
ways of approaching health literacy (27). Although the
first author carried out the major part of the analysis, there
was a continuous exchange throughout the process
between the two authors about the content of the discussions, the interpretations and the themes that emerged.
Results
It became clear during the analysis process that the concept
of health literacy was used, explained and understood in
different ways in the literature. However, our analysis
resulted in a division along two approaches, ‘health literacy as a polarized phenomenon’ and ‘health literacy as a
complex phenomenon’. In the following, we give an
account of these approaches and attempt to shed light on
these two different ways of viewing health literacy.
groups with low health literacy are identified by assessing
the computation and reading comprehension needed to
understand health concepts or terms as they appear in
patient information, medicine labels and prescriptions,
informed consent forms et cetera (8, 10, 11, 15, 33, 41, 42).
On the grounds of this polarized approach and this form of
assessment, it is claimed that immigrants, older people,
prisoners or persons with few years of school are more
likely to have low health literacy (42).
The assessments used to identify low or high health literacy most frequently named in the literature are the Test
of Functional Health Literacy in Adults (TOFHLA) (37), the
Rapid Estimate of Adult Literacy in Medicine (REALM)
(38) and the Health Activities Literacy Scale (HALS) (43).
All these tests were judged to be reliable and easy to
administer (44). The TOFHLA self-assessment is a multiple
choice test that measures the comprehension of healthrelated concepts described in a medical context, e.g. patient
information (37). REALM is used to identify patients with
low health literacy and assesses the reading comprehension of 66 de-contextualized health-related words (38).
Health literacy as a polarized phenomenon
The extremes of low/inadequate and high/adequate health
literacy were often confronted with each other in the
studies to offer explanations for and draw conclusions
about causes and effects (10, 11, 28–34). The contrast
between the extremes was in fact the point of departure in
several of the studies (10, 11, 29–31). This polarization is
possible as a result of a functional understanding of health
literacy, which was described to be comprised of individual
basic skills needed to understand health information and to
navigate in the health care system (11, 35). The approach
to health literacy as a polarized phenomenon will be
accounted for in three themes – ‘Focusing on personal
skills’, ‘Focusing on extremes’ and ‘A narrow outlook’.
Focusing on personal skills
Characteristic of the approach towards health literacy as a
polarized phenomenon was its focus on basic functional
skills such as reading, writing and numeracy (11, 14, 36).
The definitions of health literacy that represented this
approach were uncomplicated and emphasized the need of
such skills to understand or act on health care information
or to function in the health care environment (5, 11, 12,
14, 36). The focus on personal skills suggests that health
literacy in this approach was understood as something that
belongs to the individual, and the form of information
mentioned, e.g. labels on pill bottles, dosing schedules,
health insurance forms, instructions for chronic disease
management et cetera, locates this view of health literacy
to a medical context (10, 11, 29, 30, 33, 37–40).
The skills mentioned provide the basis for identifying
persons’ health literacy, and persons and population
Focusing on extremes
States of low/inadequate and high/adequate health literacy were confronted with one another in the literature,
and further examples are given of research that investigates relations between these two extremes and results of
health interventions, health care utilization et cetera (29,
31, 39, 40, 45). Relations are reported between health
literacy levels and knowledge of diseases, symptoms, selfcare strategies or complications, e.g. in hypertension and
diabetes (39, 40). An example of this is a comparison of
patients with diabetes, in which almost all (94%) of those
with adequate health literacy recognized symptoms of low
glucose levels, whereas only half of those with inadequate
health literacy had the same knowledge (39). Other
research on distinctions between states of the extremes
reports low ratings of health and an increased risk of
hospitalization or health care use among people with low
health literacy as compared with those with high health
literacy (29–31, 33, 34, 46). Low health literacy is also
described as corresponding to poor adherence to medication regimens and a lack of use of preventive health
services compared with states of adequate or high health
literacy (10, 42). It is furthermore stated that low health
literacy should be associated with risks for medical
mistakes owing to problems in distinguishing objective
information from incorrect, misleading information or
information with a commercial interest (6). On the other
hand, high health literacy is associated with good knowledge about diseases and health and to adherence to advice
on care and self-care (1, 5, 16, 47, 48).
Based on the approach of health literacy as a polarized
phenomenon, conclusions are drawn in the literature that
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Health literacy
low health literacy is discouraging for both individuals and
the society as a whole (16, 48). On the individual level,
low health literacy may lead to unnecessary suffering
owing to inappropriate decisions in health care matters. On
the societal level, it may mean economic loss as a result of
expenses for health care (16, 48) in the form of, for
example unnecessary health care visits and increased use
of inpatient care or emergency room care (33, 39, 46).
Some articles discuss the contribution of health literacy to
well-founded decisions and empowerment, and conclusions are drawn that high health literacy has a positive
influence in these areas while low health literacy has the
opposite effect (1, 13, 47, 49, 50).
A narrow outlook
The focus on functional skills, which characterizes health
literacy as a polarized phenomenon, is criticized in the
literature for its narrow outlook. The literature shows
examples of research that argue that this functional view
of health literacy is influenced too heavily by medicine
and does not take sufficient note of cultural aspects or
communication skills. A conclusion is that medical jargon
or vernacular issues are ignored, and, for these reasons,
this narrow outlook places the responsibility of functioning communication on the patient rather than focusing on
shared responsibility (51). Criticism of the functional
approach as a narrow outlook is expressed in more ways,
with claims that, in this perspective, patients are expected
to learn areas of expertise and behaviours that are
provider-defined, instead of health care issues being
communicated using the patient’s base of knowledge (52).
The forms of measurements used are also criticized for
underrating skills in understanding other forms of information than written text and because of their emphasis on
reading comprehension rather than on skills in communicating, analysing and valuing health information (43,
53, 54).
Health literacy as a complex phenomenon
Following this approach means acknowledging health literacy as a dynamic phenomenon with multidimensional
interrelations, depending on the social or cultural context.
Besides functional skills, this approach stresses the interactive and critical skills needed to use information or
knowledge as a basis for appropriate health decisions. The
complex approach to health literacy will be described in
three themes – ‘Acknowledging the complexity’, ‘The significance of the context’ and ‘Shared responsibility’.
Acknowledging the complexity
Research representing this nonreductionist approach both
acknowledges and emphasizes the complexity of health
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literacy, which is articulated in terms of skills, knowledge,
capability and actions. In this complex approach, abilities
to interpret, use and communicate information about
health, health care and other services are seen as a basis for
appropriate health decisions (5, 11, 14, 35, 36, 49). Specific
skills pointed out are critical thinking, analysis, decisionmaking and problem solving used in combination with
social skills in communicating and questioning (14, 35).
These skills are described as decisive for an individual’s
ability to act in ways that promote and maintain health
and to increase both personal and public health (5, 11, 35).
This complex view suggests that health literacy is located
in a health or social context, in which individuals or groups
act autonomously on the basis of information from all
directions.
One example of a definition that acknowledges the
complexity of health literacy is WHO’s (35), which
describes it as the achievement of a level of knowledge,
personal skills and confidence that makes it possible to take
action to improve personal and community health by
changing personal lifestyles and living conditions. The
definition further emphasizes that health literacy means
more than reading comprehension and understanding
figures and clarifies the influence of health literacy as a
determinant of peoples’ personal, social and cultural
development (35). Another definition that emphasizes
complexity states that health literacy concerns a wide
range of skills and competence needed to make informed
choices and decisions to reduce health risks and increase
quality of life (55). The skills mentioned in this definition
represent four different domains: fundamental literacy,
science literacy, civic literacy and cultural literacy. Examples of skills or knowledge included in these domains are:
skills in reading, speaking and writing; knowledge of scientific concepts; an understanding of technology; and
uncertainty about the absolute truth of scientific information. Focusing on the complexity of health literacy also
means including abilities that enable persons to become
aware of public issues, to become involved in the decisionmaking process and to have an awareness that health
decisions can impact public health (55, 56).
The significance of the context
The definitions found in the complex approach to health
literacy make it clear that the skills mentioned must not be
regarded in isolation. Rather, as health literacy varies
depending on the context and setting, the context is
decisive for whether a person’s skills contribute to health
literacy. Thus, it is possible for the same individual to be
health literate in one context or society but not in another
(1, 11, 57). This means that deficiencies in health literacy
may be quiet and hidden, difficult to discover, which in
turn may mean that persons with deficiencies risk being
given prejudiced or discriminating treatment (58–60).
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Expressions of the significance of the context were
found in debate articles, reports and statements. An
example of this is the report of the Committee on Health
Literacy at the US Board on Neuroscience and Behavioral
Health, 2004 (1), which states that health literacy should
be seen from an ecological perspective as individuals
interact with educational systems, health systems and
social and cultural factors. Thus, health literacy is an issue
for society as a whole instead of a view in which the
responsibilities for increasing health literacy lie solely on
the individual and the health care system (1). In a debate
article, one researcher claims that health literacy may be
seen as an issue of social justice as the benefit of the health
information provided depends on its readability and cultural sensitivity (57).
Shared responsibility
When health literacy is approached as a complex phenomenon, the responsibility to make improvements of the
health literacy level is not only to be borne by the individual but also by the health care system and as a commitment in adult education (57). In discussions,
researchers criticize the health care system for placing the
responsibility for obtaining and understanding health
information on the persons seeking care (10, 57, 61).
Those researchers also argue that health professionals use
unfamiliar words and instructions and that health-related
information is presented in a way that is beyond the
reading comprehension of many adults, which may mean
that clients must deal with information about unfamiliar
things in an unfamiliar, scientific language (10, 57, 61).
Measures to improve health literacy mentioned in the literature include, e.g. the development of more readable
health information materials, strategies aiming at changing
attitudes and using new technology (45, 52, 62–64). The
effects of such measures are contradictory (65, 66). However, the use of education videos and pictograms to impart
health information to women with low literacy was
effective (45, 63).
Discussion
The large number of scientific studies and policy
documents found in the literature to date indicates the
significance of health literacy in the medical and public
health perspectives. Furthermore, interest in the issue is
increasing.
The two approaches that describe health literacy either
as a polarized or a complex phenomenon with its own
characteristics indicate that health literacy or a lack of
health literacy may appear in many different forms and
situations. Following the polarized approach may mean
viewing states of health literacy as a permanent condition,
difficult to improve, while the complex approach offers
possibilities to view health literacy as a dynamic phenomenon that fluctuates depending on the state of the
individual, the situation, the culture or the environment.
Following that approach would be more appropriate and
make more sense in a changeable world in which health
research outcomes in the form of explanatory models are
replacing previously accepted and understood knowledge
from one day to the next. Such rapid changes may put
health literacy abilities out of the running, leading to
uncertainty about health decisions and, at worst, inappropriate or inaccurate decisions.
Greenberg (51) questions the benefit of making distinctions between low and high health literate persons.
Our suggestion, in agreement with Greenberg, is that it
would be more adequate to understand health literacy as
a dynamic continuum ranging between the polarities of
high and low health literacy. The largest part of the
population, at least in countries such as in Scandinavia
that have a high general literacy (15), probably represents
not only individuals with low/inadequate or high/adequate health literacy. Rather, most people almost certainly
have a health literacy level somewhere between the two
polarities. Viewing health literacy as a complex and
dynamic phenomenon transfers it from the medical context to a context of public, everyday health. Thus, in
practice, it may be misdirected to concentrate the identification of persons with low health literacy to persons
from specific population groups (8, 15). Hence, professionals involved in individuals’ issues that concern their
health must be aware of the fluctuating health literacy of
every individual and reflect over their own contribution
(negative or positive) to an individual’s level of health
literacy in the specific situation. The approach of a complex view of health literacy may also mean that the
medical perspective loses force as a real solution to health
problems. Instead, it opens a more client or individualdriven cooperation or negotiation in communication
about health issues, where questions and treatment suggestions are based on the individual’s knowledge acquired
from, for example the Internet, TV, magazines, personal
communication or experience. A shared responsibility in
such communication would be to make the most of the
health literacy that exists in the specific situation. This is
in accordance with a client or negotiation centred perspective, whose essence is respect for the individual’s own
thoughts and implies the individual’s active participation,
with interventions guided by interactions built on respect,
shared power and negotiation (67, 68). Health literacy is
described as having an influence on self-efficacy and
empowerment (1, 13, 47, 49, 50) but, reasonably, this
does not solely depend on functional abilities to read and
comprehend medical information but rather on the possibilities to discuss health issues and the commission of the
individual to make well-founded decisions based on his or
her own knowledge.
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A more dynamic and complex view of health literacy
may prepare the way for an openness to different perspectives that may influence health for the single individual. According to our findings, however, health literacy
is also a matter for society, as a health literate population is
important for public health as a whole and consequently
for public finances (1, 4). Population-based surveys have
been conducted to study health literacy but, to the present,
have used the polarized approach to the phenomenon,
using, e.g. the National Assessment of Adult Literacy
(NAAL) (69). This assessment measures literacy, i.e. reading comprehension of texts and documents concerning
clinical matters, preventive health care and health care
navigation in the health care system (69). Using this kind
of measurement means neglecting the complexity of
health literacy as described in our results and agrees with
the criticism of a narrow-minded concentration on the
ability to understand written information instead of
focusing on verbal communication, an ability to analyse
and value information et cetera (43, 53). However, efforts
are being made to develop instruments to also measure the
critical dimension of health literacy. The European Health
Literacy Survey (70) project is developing a measurement
instrument that includes the dimension of critical health
literacy. The instrument will be used to measure health
literacy in European regions, which so far has not been
carried out.
A world in continuous change means increasing
demands on both individuals and professionals to understand and follow recent research in the health field. Not
only new research findings, but also changes in the welfare system, can influence decisions about health, and
new principles in social security may at the worst affect
the situation of both individuals and families. With adequate health literacy, it would be possible for individuals
to follow and understand the meaning of changes from
the viewpoint of their own social situation. Interventions
to improve health literacy discussed in the literature (45,
52, 62–64) focus primarily on the readability of health
information. A recent research project that studied the
experiences of factors contributing to women’s health
literacy and informed decisions during sick leave showed
that being coached was perceived as promoting health
literacy and informed decision-making (L. Mårtensson and
G. Hensing, unpublished data). Coaching, when it was
most supportive, was performed by a spokesperson or
advocate who was independent of and neutral in the
association with the social insurance office, the health care
system and the workplace. Adequate health literacy may
thus be achieved in various ways. According to the same
study, significant others are also viewed as contributing to
health literacy and informed decision-making (Mårtensson and G. Hensing, unpublished data). These results
agree with the complex approach, suggesting that health
literacy is a context-dependent phenomenon. Thus,
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creativeness is needed to develop interventions and methods that aim to increase and, if possible, stabilize individuals’ health literacy level. A health literate individual in the
full sense would probably have greater opportunities and
abilities to make well-founded decisions and make appeals
against the decisions of authorities, e.g. a certain form of
compensation, disablement benefit or allowance for home
equipment. Such support may influence health and in turn
increase health literacy even more.
Health literacy is a concept related to other concepts. The
most obvious seems to be mental health literacy, which is
an extension of the idea as compared to viewing health
literacy as a functional ability. Besides reading and calculating skills, it includes knowledge about perceptions of
psychiatric diseases and ideas about how and where these
diseases can be treated (71, 72). Another related concept is
health competence, which involves healthy behaviour and
a health promoting lifestyle, e.g. effective solutions to
health problems, self- maintenance for a healthy life,
successful ways to improve health, the fulfilment of health
goals et cetera (73, 74). Health competence seems to deal
with motivation and strategies for lifestyle and behaviour
rather than the ability to obtain, read, interpret, understand and act on health information. A third concept with
a close relation to health literacy is health education. From
the perspective of the complex approach, this might be
included in health literacy as a part of the individual’s
context (35). However, according to health literacy as a
functional ability, health education might be seen as a
strategy to improve low health literacy.
Methodological considerations
As the intent of the study was to gain a comprehensive
understanding of the meaning and use of the concept of
health literacy, a systematic literature review method was
not useful. Neither would a concept analysis have been
appropriate, as our research questions had to do with
health literacy in a broader sense, as the aim also included
measurements and empirical findings related to health literacy. The method chosen, which is inspired by a narrative
literature review (17), is thus judged to be appropriate.
Questioning texts written for other reasons than the
purpose of a particular study involves a risk of misinterpretation or misunderstanding. However, the aim of the
review, i.e. to gain a comprehensive picture of health
literacy, was kept in focus during all parts of the study
process. Furthermore, the text fragments remained
unmodified in the analysis process, where the intention
was to find similarities and differences and to search for
relations and patterns, rather than to interpret the essential
meaning of the fragments. The analysis process gave the
impression of concordant views of the phenomenon, and
we therefore suggest that our results give a true picture of
health literacy as it is understood and used.
Ó 2011 The Authors
Scandinavian Journal of Caring Sciences Ó 2011 Nordic College of Caring Science
158
L. Mårtensson, G. Hensing
The body of literature included scientific articles, policy
documents, Internet websites et cetera that correspond to
the broad research questions and the narrative form
employed for the review. This broadness may influence the
credibility of the results, however, and there is a risk that
health literacy, as it is presented in the results section, is
understood on a superficial level. The literature extraction
process was stopped although one-third of the total body of
literature remained. This means that we may have limited
the possibilities to find patterns in the way that health
literacy is understood or that we missed some variations in
the use of the concept of health literacy. Further, our
intention to examine health literacy from a broad perspective may mean that we made interpretations and
generalizations without sufficient evidence.
Conclusions
On the basis of the review of contemporary scientific literature and policy statements, we can conclude that health
literacy is a heterogeneous phenomenon with relations to
different fields. Two different approaches to health literacy
became visible – one in which health literacy is expressed
as a polarized phenomenon and the other that has a more
a complex understanding of the phenomenon. The former
approach seems to be seen in a medical context, where
certain personal skills decide whether an individual is
health literate or not. The other approach means
acknowledging a broadness of skills in interaction with the
social and cultural contexts. Thus, in this complex
approach, an individual’s health literacy may fluctuate
from one day to another according to conditions and
contexts. The most important skills in this understanding
of health literacy are interpretation, valuation, communication and interaction skills because of their significance in
decision-making.
According to the literature, improving health literacy, on
the basis of a complex view of the phenomenon, is a
responsibility to be shared between society and individuals/groups. Thus, interventions aimed at improving health
literacy need to be directed to the individual, the general
population, health care professionals and policy makers to
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