made more accessible to researchers, and an abbreviated
version will need to be developed in parallel with its
continued use as a benchmark measure.
Even the HALS test still reflects a view of the measurement
of health literacy as a derivative of the measurement
of literacy, rather than as a distinctive, independent
concept. If we accept the idea that health literacy is an
independent concept that reflects the skills and capacities
that enable people to exert greater control over their
health, this has important implications for measurement.
In this conceptualization of health literacy, much work
remains to be done to develop more comprehensive
measures that will assess individual health literacy in terms
of a person’s ability to access, understand and use health
information in ways that promote and maintain good
health.
It is highly likely that different measurement tools will
be required for different ages and stages in life – even if the
structure of the concept remains constant. This will take
into account the different social contexts in which health
literacy is relevant, recognized explicitly in the Institute of
Medicine definition, and implicitly in the WHO definition.
For example, assessing the health literacy of students in
school will require different questions compared to
assessing the health literacy of older people with chronic
disease. Different measures will be required to distinguish
between functional, interactive and critical health literacy.
These measures will need to include assessment of
a person’s ability to
gain access to age and context specific information from
a variety of different sources,
discriminate between sources of information,
understand and personalise health information that has
been obtained,
appropriately apply relevant health information for
personal benefit.
Assessing interactive and critical literacy will require
additional assessment of oral literacy and social skills such
as those involved in negotiation and advocacy.
These are not totally new challenges in the social
sciences, but will require systematic development and
testing in the same way that the existing TOFHLA and
REALM measures have been developed.
Where to from here?
The two conceptualizations are similar in some respects
but distinctly different in others. Both are dependent on the
underlying base of literacy and numeracy, and are context
and setting specific. In the asset model, health literacy is
a distinct concept, an outcome to health and patient
education. In the risk model health literacy is a ‘‘prior
6. Improved
Health Literacy
2. Tailored information,
communication, education
10. Improved health outcomes,
healthy choices
and opportunities
5. Skills in
negotiation and
self management
1. Prior understanding of individual
capacity - reading fluency, numeracy,
existing knowledge
3. Developed
knowledge
4. Skills in and capability
social organization
and advocacy
9. Participation in
changing social
norms and practices
8. Engagement in
social action
for health 7. Changed health
behaviours and
practices
Fig. 2. Conceptual model of health literacy as an asset.
2076 D. Nutbeam / Social Science & Medicine 67 (2008) 2072–2078
made more accessible to researchers, and an abbreviatedversion will need to be developed in parallel with itscontinued use as a benchmark measure.Even the HALS test still reflects a view of the measurementof health literacy as a derivative of the measurementof literacy, rather than as a distinctive, independentconcept. If we accept the idea that health literacy is anindependent concept that reflects the skills and capacitiesthat enable people to exert greater control over theirhealth, this has important implications for measurement.In this conceptualization of health literacy, much workremains to be done to develop more comprehensivemeasures that will assess individual health literacy in termsof a person’s ability to access, understand and use healthinformation in ways that promote and maintain goodhealth.It is highly likely that different measurement tools willbe required for different ages and stages in life – even if thestructure of the concept remains constant. This will takeinto account the different social contexts in which healthliteracy is relevant, recognized explicitly in the Institute ofMedicine definition, and implicitly in the WHO definition.For example, assessing the health literacy of students inschool will require different questions compared toassessing the health literacy of older people with chronicdisease. Different measures will be required to distinguishbetween functional, interactive and critical health literacy.These measures will need to include assessment ofa person’s ability to gain access to age and context specific information froma variety of different sources, discriminate between sources of information, understand and personalise health information that hasbeen obtained, appropriately apply relevant health information forpersonal benefit.Assessing interactive and critical literacy will requireadditional assessment of oral literacy and social skills suchas those involved in negotiation and advocacy.These are not totally new challenges in the socialsciences, but will require systematic development andtesting in the same way that the existing TOFHLA andREALM measures have been developed.Where to from here?The two conceptualizations are similar in some respectsbut distinctly different in others. Both are dependent on theunderlying base of literacy and numeracy, and are contextand setting specific. In the asset model, health literacy isa distinct concept, an outcome to health and patienteducation. In the risk model health literacy is a ‘‘prior6. ImprovedHealth Literacy2. Tailored information,communication, education10. Improved health outcomes,healthy choicesand opportunities5. Skills innegotiation andself management1. Prior understanding of individualcapacity - reading fluency, numeracy,existing knowledge3. Developedknowledge4. Skills in and capabilitysocial organizationand advocacy9. Participation inchanging socialnorms and practices8. Engagement insocial actionfor health 7. Changed healthbehaviours andpracticesFig. 2. Conceptual model of health literacy as an asset.2076 D. Nutbeam / Social Science & Medicine 67 (2008) 2072–2078
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