Defining and measuring health literacy: what can we learn from literacy studies?

Previous contributions to this series of editorials and otherrecent papers have highlighted the growth in interest inhealth literacy, as well as continuing debate about its def-inition, measurement and importance (Kickbusch 2009;Wills 2009; Abel 2008; Nutbeam 2008; Coulter and Ellins2007). In further advancing these debates there is much tobe gained from an appraisal of the underlying concept ofliteracy.Literacy is an important but complex concept. Generallyit is acknowledged as having two distinctive elements:those that are task-based, and those that are skill-based(National Assessment of Adult Literacy 2003). Task-basedliteracy focuses on the extent to which a person can per-form key literacy tasks such as read a basic text and write asimple statement. Skill-based literacy focuses on theknowledge and skills an adult must possess in order toperform these tasks. These skills range from basic, word-level skills (such as recognising words) to higher levelskills (such as drawing appropriate inferences from con-tinuous text).It follows that literacy can be measured in absoluteterms by distinguishing between those who can read andwrite basic text and those who cannot, and in relative termsby assessing the skill differences between adults who areable to perform relatively challenging literacy tasks andthose who are not.The reason why we care so much about literacy is thateven the most basic functional literacy skills enable peopleto better develop their knowledge and improve the poten-tial to achieve personal goals, and through this toparticipate more fully in society, both economically andsocially. Given this background, it is not surprising to findthat literacy levels in a population are associated bothdirectly and indirectly with a range of health outcomes.Low literacy is often linked to poor socio-economic cir-cumstances, and in turn with adverse effects on health thatare independent of other risk factors (Jahan 2008). This isespecially the case in the relationship between female lit-eracy and maternal and child health outcomes (Schell et al.2007). People with poor literacy tend to be less responsiveto health education, less likely to use disease preventionservices, and to successfully manage chronic disease(Dewalt et al. 2004).Responding to low levels of literacy in a populationinvolves improving access to effective school education,and providing adult literacy programs for those in need.Achieving high levels of literacy in a population is not onlya vital development goal, but will also produce substantialpublic health benefits.To better understand health literacy as a distinct concept,it is helpful to delve into current discourse on different‘‘literacies’’, recognising that literacy is both content andcontext specific. This is especially the case in relation to‘‘new literacies’’ emerging in response to new informationtechnologies (Coiro 2003), and context-specific literaciessuch as media literacy and financial literacy (Primack andHobbs 2009; Kozup and Hogarth 2008). This furtherrefinement in the concept reflects the fact that individuals