From dimensions, levels and domains to context-specific conceptualizations of health literacy

Health literacy is one of the key determinants of health and pertains to individuals’ social and cognitive ability and competencies to obtain, understand, process, communicate, appraise and apply health-related information to attitudes, decisions and behaviors aimed at health promotion, disease prevention, and the maintenance and improvement of personal health (1, 2). Research has shown that lower levels of health literacy lead to poorer health knowledge, difficulties in managing health conditions and illnesses, inadequate use of health services, poorer health, shorter survival rate, and higher health care costs (3, 4). Accordingly, it is not surprising that increasing health literacy is one of the WHO’s preoccupations (5). Health literacy plays a crucial role also in current infodemic management plans (6) intended to protect people from an increasing overabundance of (in)valid information related to specific health topics, conditions or diseases in the physical and digital environment (7).

Like many other countries, Slovenia has joined the WHO Action Network on Measuring Population and Organizational Health Literacy (8). The recent project Dvig zdravstvene pismenosti v Sloveniji (Raising health literacy in Slovenia), which has for the first time investigated the level of health literacy in the Slovenian population, revealed that almost half (48%) of the Slovenian adult population has limited health literacy; not so much with regard to accessing and understanding health-related information but mostly with regard to appraising and applying relevant health information to various health-related practices (8).

Assessment (and exact measurement in particular) of health literacy is not an easy task. Health literacy is a complex, multidimensional and dynamic concept that incorporates different kinds of health-related skills and knowledge (2, 9). The majority of early studies on health literacy was conceptualized on the individual level, as an individual’s ability to understand health-related information and to make appropriate informed decisions (10). Newer research on health literacy emphasizes the need to move beyond the individual level and in an integrative approach to health literacy that encompasses its various levels, dimensions, and domains (2, 9).

The aim of this editorial is twofold. First, we briefly present the dimensions, levels, and domains of health literacy. Second, we discuss a growing need to acknowledge health literacy as a context-specific concept that includes various forms with context-specific conceptualizations. For example, a person can be very health literate with regard to vaccines, but rather illiterate with regard to mental health. Hence a tendency to develop issue-specific health literacy. In this editorial we will focus on three health literacy forms that are gaining attention, namely e-health literacy, vaccine literacy, and mental health literacy.

Health literacy refers to skills and knowledge that enable individuals to navigate health-related information environments, to function in healthcare systems and to practice behaviors that lead to better health outcomes (1, 11). According to Palumbo (9), the health literacy construct was formally introduced by Simonds (12) in the 1970s as one of the essential issues in social policy that connects education and health. According to the integrative approach to health literacy (2), this construct is multidimensional, consisting of four dimensions or four types of competencies; competencies to 1) access, obtain or search for relevant health information, 2) understand obtained health information, 3) appraise or process and thus assess and interpret accessed health information, and 4) apply or use gathered health information to make a decision to sustain or improve health. Each of these competencies is highly related to one’s ability to obtain (and assess) quality of information. Misinformation or wrongly interpreted and/ or used otherwise accurate information, i.e. “bad literacy” can lead individuals to inappropriate health-related choices, decisions, self-diagnosis, and treatments, which might result in negative health outcomes (13).

Thus, the four dimensions of health literacy are regarded as assets that unfold in domains of healthcare, disease prevention, and health promotion (2). In the healthcare domain, health literacy concerns the individual’s ability to access, understand, and assess information on medical or clinical issues and to use it to make informed health-related decisions. In the domain of disease prevention health literacy pertains to the individual’s competencies of obtaining, understanding, appraising and applying information on health risks. Health literacy in the domain of health promotion, on the other hand, focuses on individuals’ ability to make decisions based on an awareness of the determinants of health in the social and physical environment (2).

Besides on the individual level, health literacy can be observed also on a population level, and on an organizational level (2, 9). Functional interpretation on the individual level, for example, focuses on an individual’s ability to understand health information, and use it appropriately to navigate the healthcare service system (9). But there are conceptualizations of health literacy that go beyond medical contexts and individual competencies, and incorporate broader public health perspectives. Proponents of population health literacy usually view health literacy through Nutbeam’s (1) proposition that incorporates three sets of interconnected health-related competencies: functional, interactive, and critical health literacy. In this way, health literacy is viewed as one of the important factors that influence the use of health services, health-related behaviors, participation in self-care and the healthcare system, and has an impact on the equity in public health (2). However, low levels of health literacy should not just be observed as a personal fault of individuals (9). Often healthcare settings do not take into consideration individuals’ health literacy skills and as such prevent appropriate access to healthcare services and adequate use of available health resources (9). Thus, health literacy concerns also healthcare organizations. Organizational health literacy refers to the “ability of healthcare organizations to establish a clear and comfortable relationship with patients, in order to encourage their engagement in the design and delivery of care” (9).

Besides being a multidimensional and multilevel construct, health literacy is also a context-specific construct, differing with regard to health-related contexts and fields. The health literacy concept in general concerns general health-related competencies, but if we want to study and measure literacy in relation to specific health contexts, fields, topics, and even diseases, these forms of health literacy require more exact definitions; conceptualizations with regard to specific issues. Many forms of health literacy have been already defined and studied, such as navigational health literacy (14), communicative health literacy with physicians (8), pharmaceutical literacy (15), diabetes (health) literacy (16), to name just a few. All of these context-specific health literacies deserve more attention. However, in this editorial we aim to expose three: e-health literacy, vaccine literacy, and mental health literacy. All these context-specific health literacies are especially relevant for the infodemic debate and are gaining momentum due to the increased use of various digital and online resources to access and obtain health-related information (17) and due to complexities related to vaccination and mental distress that became increasingly discussed and politicized in the recent COVID-19 pandemic (18, 19, 20).

Health literacy is an evolving construct, especially with regard to context-specific health literacies. As advised by Pinheiro (28), more research is needed in the health literacy field; the field that draws theories and constructs from research traditions related to two major topics: health and literacy. Stronger conceptual foundations of health literacy are needed, as well as valid and reliable measurement instruments, especially for under-researched context-specific health literacies. Explanatory and predictive research requires valid and reliable scales, as they will shape our understanding of the topic, and measured results are often translated into public health policies and/or interventions. Except for the study of Wilhelmova et al. (29), research published in the Slovenian Journal of Public Health has so far not extensively engaged in this topic. It is hoped that this editorial has emphasized the importance of health literacy research for this journal in general, and is recognized as an invitation for further contributions in this field.