Health Literacy workshop


Health literacy –challenges for the future

An introduction to the workshop

by Ringsberg KC, Olander E, Tillgren P, From D-M, Thualagant N. Trollvik A

June the 22nd 10.45-11.45

Power point presentation from the meeting 


The concept of Health Literacy was first mentioned in 1974 in a scientific article entitled Health Education as Social Policy. The article focused on health education in the US and included a discussion on health education as a political issue in relation to the importance for a country to have an educated population. Simultaneously the health promotion approach was introduced with the Lalonde Report in Canada, 1974 (Lalonde, 1974). These documents indicate education, both general and focused on health, as a key determinant of health. At the Ottawa conference in 1986 (WHO, 1986) the former president of WHO, Halfdan Mahler, stressed that Health Literacy is an important aspect of health promotion and an important social investment to promote and maintain the health of a population. However, it was not until 2009 and 2013 at WHO:s global health promotion conferences in Nairobi and Helsinki that Health Literacy was paid specific attention (Ringsberg, Olander, Tillgren, Chap 1, 2014).

During the 1990s, the concept of Health Literacy was used increasingly in the health sector in Canada, the UK, Australia and the US. The issues were mainly focused on how to reach out to the population, and to ensure the effects of patient-related information from different professional groups. As a consequence of the increased interest in and the understanding of the importance of the relationship between health and literacy, WHO introduced the concept in The Health Promotion Glossary 1998 (WHO, 1998). European health strategies have earlier mainly been based on research conducted in the US and Canada, as there was a lack of base knowledge on population Health Literacy in Europe. This lack of empirical evidence from Europe led to the development of the project The European Health Literacy Project (HLS-EU), 2009-2012 (Sørensen, 2013). The project developed a measuring instrument and measured Health Literacy in European and Asian countries (Sørensen, 2013, 2015). A definition of Health Literacy and a conceptual model was also formulated (Sørensen, 2012).
In 2012, the new European strategy for health was presented, Health in 2020, (WHO, 2012). In this document Health Literacy is a key dimension, seen as both a means and a result of efforts to promote empowerment and participation. In Health 2020, Health Literacy is described as an action-oriented concept based on the dynamic interaction between individuals and the environment in which they live and work. Thus, Health 2020 emanates from a meaning of Health Literacy that includes basic and functional, communicative and interactive as well as critical health literacy. In 2013 WHO stress the importance of Health Literacy (Kickbusch, Pelikan, Apfel & Tsouros (2013).

Definition of health literacy
Since the 1990ies several definitions with varying concepts, meaning and focus has been presented (WHO, 1998; Kickbusch & Maag, 2005; Rootman & Gordon-El-Bihbety, 2008; Sorensen et al., 2012; Australia Byreau of Statistics, 2006; Freedman et al., 2009; Paakari & Paakari, 2009; Ratzan, 2000; Zarcadoolas, 2005). Health Literacy is composed of the two concepts health and literacy. These concepts are in constant development and defined in relation to context, society and time period. Therefore, the perceptions and points of departure of the concepts of health and literacy affect the meaning given to the concept of Health Literacy and how it is defined, perceived, interpreted and applied in practical public health work and its applicability in relation to the principles of health promotion.

The concept of Health Literacy is defined in the Health Promotion Glossary as: “Health literacy represents the cognitive and social skills which determine the motivation and variability of individuals to gain access to, understand and use information in ways which promote, maintain good health “(WHO, 1998). Nutbeam (2000, 2008) suggests three dimensions: basic and functional literacy, communicative and interactive literacy, and critical literacy. According to Nutbeam, basic and functional literacy means to have the skills necessary to read and understand health information in order to function effectively in everyday situations. A communicative and interactive literacy means more advanced skills, which together with social skills gives opportunity to actively participate in daily activities, obtaining information from various forms of communication and to apply new information to promote and maintain health. A critical literacy involves advanced cognitive abilities that together with basic and functional abilities and social skills can be used to critically analyse information and use this information to gain greater control over life events and life situations. Nutbeam states that a higher dimension of literacy, in the sense of critical literacy, is needed in order to strengthen both individual empowerment and community empowerment, i.e. the ability to influence and participate in what is happening in society.


State-of the art in Health literacy research in the Nordic countries

During the period from the 1970s to the 1990s, only a few scientific articles on Health Literacy were published and these were principally written by researchers from the US and Canada. From the early 2000s there has been a gradual increase in the number of articles on Health literacy also from other countries and continents (Kondilis et al, 2008; Shapiro, 2010).

In order to get an overview over research on Health Literacy done in the Nordic countries a literature search was performed in spring 2016. The search was conducted in four different databases Scopus, Cinahl, Web of Science and PubMed. The search included title and abstract.and the search words were: health literacy* (i.e. two words that are linked to each other) and health literacy as a MeSH term (in PubMed since 2010), and Denmark, Finland, Iceland, Norway and Sweden.

Based on inclusion criteria the database searching resulted in 208 articles. After removing duplicates and articles that did not include health literacy in title, abstract or keywords, 71 articles remained. All these articles will be read in full-text and assessed for eligibility and included in a final qualitative and quantitative analysis. The analysis will focus on differences and similarities between the Nordic countries regarding level and perspective of health literacy, topic, kind of study, determinants of health, target group.

Preliminary results from the analysis of the abstracts shows that the Nordic research field on Health Literacy is a relatively new phenomenon that mainly emerged in the 2010s. The majority (2/3) of the articles were written by Swedish or Norwegian researchers. Denmark and Finland had about the same frequency and Island had one article written in cooperation with other Nordic countries. About 10 articles were written in cooperation with other Nordic countries and Norway was the leading country. Most articles focused on adults, a few on children and one on elderly. There was a mixture of theoretical, empirical, review and methodological studies. Mental health, life style factors, oral health, youth and migrants´ understanding of health were common topics.


Health Literacy in the conference workshop

After a short introduction built upon the content above, the workshop will continue with group discussions aiming to highlight critical Health Literacy issues and concerns and pinpoint future challenges in theory, research and practice in order to strengthen supportive environments for Health Literacy. The discussion-groups are prearranged according to e.g. lifespan or settings. The participants select group after interest. In the groups the participants will discuss and reflect on issues, concerns and future challenges in research and practice from their own experiences and perspectives.


Australian Bureau of Statistics. (2008). Health Literacy in Australia 2006, report. Canberra: The Australian Government Department of Health and Ageing.

Freedman, D.A., Bess, K.D., tucker, H.A., Boyd, D.L., Tuchman, A.M. & Wallston, K.A. Public health literacy defined. (2009). American Journal of Preventive Medicine, 36(5), 446–451.

Kickbusch, I. & Maag, D. (2008). Navigating health: The role of health literacy. International Encyclopedia of Public Health, Vol 3, 204–211.

Kickbusch I. (2001). Health literacy: Addressing the health and education divide. Health Promotion International, 16(1), 289–297.

Kickbusch I, Pelikan JM, Apfel F & Tsouros AD (Eds). (2013). Health Literacy – The solid facts. Copenhagen: World Health Organization, The Regional Office for Europe.

Kondilis,B.K., Kiriaze, I.J., Athanasoulia, A.P., Falagas, M.E. (2008). Mapping health literacy research in the European Union: a bibliometric analysis. PLoS ONE 3(6), e2519.

Lalonde M. (1974). A New Perspective on the Health of Canadians. A Working Document. Ottawa: Goverment of Canada.

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.

Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67, 2072–2078.

Paakari, L. & Paakari, O. (2011). Health literacy as a learning outcome in schools. Health Education, 112(2) 133–152.

Ratzan, r.S. (2001). Health literacy: Communication for the public good. Health Promotion International, 16(2), 207–2.

Ringsberg KC, Olander E, Tillgren P..Health literacy. Teori och praktik i hälsofrämjande arbete (In English: Health literacy. Theory and practice in health promotion). Eds: KC Ringsberg, E Olander, P Tillgren. Lund: Studentlitteratur, ISBN 978-91-44-08915-7, 2014.

Rootman, I. (2001). Introduction to the book. I I. Rootman, M. Goodstadt, B. Hyndman, D. W. McQueen, L. Potvin, J. Springett & E. Ziglio (red.), Evaluation in Health Promotion. Principles and Perspectives, s. 3–6. Copenhagen: WHO regional Publications, European Series, No. 92.

Rootman, I. & Gordon-El-Bihbety, D. (2008). A Vision for a Health Literate Canada. report of the Expert Panel on Health Literacy. Ottawa: Canadian Public Health Association.

Sørensen, K., Van den Broucke, S., Pelikan, J., Fullam, J., Doyle, G., Slonska, Z. & Brand, H. (2013). Measuring health literacy in populations: Illuminating the design and development process of HLS-EU-Q. BMC Public Health, 13;13:948.

Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z. & Brand, H. (2012). Health literacy and public health: A systematic review and integration of definitions and model. BMC Public Health, 12, 80.

Sørensen, K., V Pelikan, J., Röthlin, F., Ganahl, K., Slonska, Z., Doyle, G., Fullam, J., Kondilis, B., Agrafiotis, D., Uiters, E., Falcon, M., Mensings, M., Tchamov, K., Van den Broucke, S., & Brand, H. (2012). Health literacy in Europé:comparative results of the European health literacy survey (HLS-EU).

WHO (1986). The Ottawa Charter for Health Promotion. Geneva: World Health Organization.

WHO. (1998). Health Promotion Glossary, WHO/HPr/ HEP/98.1. Geneva: World Health Organization.

WHO/Europe (2012). Health 2020: A European Policy Framework Supporting Action Across Government and Society for Health and Well-Being. Copenhagen: World Health Organization. Regional Office for Europe.

Zarcadoolas, C., Pleasant, A. & Greer, D. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20(2), 15–203.


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