The political ecosystem of health literacies

This journal, its editors, but most of all its authors have been at the forefront of liberating and empowering views of health literacy (Nutbeam, 2000; Kickbusch, 2001; Parker, 2000; Ratzan, 2001). The contents of this issue are a testament to the continuity of the arguments that have been advanced in earlier volumes of Health Promotion International [e.g. (Mogford, Gould and DeVoght, 2011)]. We are publishing reports on the take-up and implementation of measurements and actions for health literacy (Begoray and Kwan, 2012; Frisch et al., 2012; Ko et al., 2012; Thomson and Hoffman-Goetz, 2012) and also present further evidence to show that schools are the key stepping stones for health competencies through life, in particular through the Health Promoting Schools approach (Gleddie, 2012; Joronen et al., 2012; Williams et al., 2012). The notion of health literacy was originally conceived in a biomedical perspective on health and illness. In the earliest publications around the issue, one could easily read the frustration of disease system personnel that patients failed to comply with all the good advice they received. Finding the secret of what determined compliance parameters in patient education was, for some at least, the holy grail of disease service research in the 1970s and 1980s. Some of the findings of this body of work were directed at improving supply-side behaviour in the service delivery (e.g. communication and skills training). The bulk of the research, however, was aimed at framing interventionist solutions that would improve the take up of medical advice by the ‘demand’ side of the equation. Nutbeam has framed this—predominantly North American—approach to the relation between literacy and health as a ‘risk factor’ perspective, but we might label this perhaps as ‘first generation health literacy development’—the development by health and disease experts of tools and mechanisms that would educate and train patients to acquire and appreciate discrete bits of health knowledge the individual required to return to health (Nutbeam, 2008). The realities of the disease system, however, continue to be rather different from this simple doctor/nurse–patient equation. The emancipation of both the patient into the consumer/client as well as the medical doctor into an all-round social health operator have meant that the second generation of health literacy development had to take on board issues of equity, equality and empowerment. Nutbeam recently labelled this approach, advocated by WHO, as the asset-based perspective on health literacy (Nutbeam, 2008). This perspective is where our Journal joined the debate, rigorously applying concepts of the Ottawa Charter to what is required to get individuals, groups and communities to take further control over the determinants of their health, including the personal skills and knowledge to navigate a complex care delivery system. But do people really see themselves as co-producers of their own health? In a study by Lloyd et al. (Lloyd et al., 2001), it was demonstrated that a preference for ‘patient’ increased with age, with 2001 favourites in the Lloyd et al. sample being client (preferred by 34% of respondents), 28% preferring consumer, 23% preferring patient and 15% making other choices such as ‘mate’ or ‘man’. In earlier studies reviewed by Lloyd et al., the preference for ‘patient’ among visitors of health services was as high as 87%, and medical doctors used to favour the term unequivocally. Perhaps for reasons of political correctness (i.e. the adoption by public policy pronouncements of the ‘consumer’ and ‘client’ rhetoric) doctors seem to shift towards ‘client’. Interestingly, Deber et al. (Deber et al., 2005) find that many care recipients in fact reject the client or consumer labels and find the classic ‘patient’ designation the least objectionable; this then puts some of the onus back on the deliverers of care. The awareness of the importance of these responsibilities is reflected, for instance, in the attributes formalized for Canadian medical professionals. The CanMEDS Framework (Figure 1) explicitly highlights physician roles and competences as communicators and health advocates. CanMEDS framework of essential physician competencies (Copyright © 2009 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds. Reproduced with permission). Some of our recent editorials (Catford, 2011; de Leeuw, 2011; Sparks, 2011), and certainly the work published in this issue suggests, however, that we are on the brink of a third generation of health literacy development. Peerson and Saunders explained that the (health literacy) capacity to navigate the health system requires skills traditionally associated with patient advocacy and empowerment (Peerson and Saunders, 2009). But similarly, we would argue that health system literacy is something that should not, or possibly least, be attributed to or owned (in a real or rhetorical sense, see for instance Gusfield, 1981) by patients. This third wave in health literacy, which we could define as the skills, capacities and knowledge required to access, understand and interact with social and political determinants of health and their social discourse also requires a new appreciation of the political ecosystem in health promotion. Very much consistent with the findings and recommendations of the WHO Commission on Social Determinants of Health (2008), health system literacy should be a human attribute that enhances our capability to create and sustain supportive environments for health. In a sense, we are all of course health experts. But this expertise needs to move from (i) the introspective, behavioural and human biology driven perspective, through (ii) a stage in which care providers and patients strive to optimize their relationship with a view to attain best health and well-being outcomes for all, to (iii) a new order in which every health expert can be heard and is entitled, individually or as a community, to efforts to shape society in its most healthful state. This democratization of health (Löfgren et al., 2011) comes in many guises and with profound challenges. At a global level, it is interesting to see that political ecosystems have seen some dramatic shifts, some as a result of pressures due to economic collapse (the new ‘business’ or technocratic cabinets in Greece and Italy), others as a result of populism and sometimes haphazard governance structures (The Netherlands, Myanmar) and yet others as an expression of genuine desire for peoples' voice to be heard (most of Latin America). The volatility of these developments, and the shifts in (and sometimes disappearance of) political elites could be construed as an opportunity for health experts to further develop all types of health literacy identified above. Health experts (Figure 2) should be considered scholars in their own right, developing and exploiting lay and practice knowledge to pursue social justice and equity in health; they would be compelled to adopt and adhere to professional and ethical standards commensurate with traditional health professional groups (but perhaps without the protectionism and undue authority that sociologists of professionalization have always associated with the phenomenon); they would endeavour to be inclusive, compelling, truthful and engaging communicators; have the skills sets and capabilities to collaborate for and manage astutely the social and political determinants of health discourse; and most of all advocate for health. Each of these practice competencies establishes opportunities to bridge gaps not just in health but between those with and those without risk and asset-driven health literacies. Essential competencies for health experts advocating health literacies (Copyright © 2009 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds. Adapted with permission). But let us not have any illusions. This is a social entrepreneurial role in a deeply political environment. The health expert cannot get away with simple quick fixes (unless they cleverly massage the political game!). The health system literate health expert judiciously enables, mediates and advocates for equitable health for all. Upon a critical review of what I wrote above, I realized that perhaps nothing ever appears new, and that I may be suffering from a severe case of (health) illiteracy myself. In 1989, I wrote [(De Leeuw, 1989), p.26]: Health education type I gives information on personal hygiene and sanitary matters. Health education type II is concerned with the transmission of information, and behavior modification with regard to services and the use of resources. Draper et al. (1980) propose a health education type III, which would aim efforts at education and information of the public on the positive or adverse effects of regional, national or international policies. Finally, in the context of health promotion, we propose a health education type IV. Type IV health education would aim at education and information of politicians, policy-makers, corporate leaders, public pressure groups, lobbyists, etc. about the ‘environments of health’. That is, about factors and actors, powers and pressures, politics and plans which shape prerequisites and conditions for health in the widest sense. Let's move on—and continue to engage profoundly and substantially with more work on health literacy development.