Original Article A review of health literacy: Definitions, interpretations, and implications for policy initiatives LeslieJ.Malloy-Weira,*,CathyCharlesb,AmiramGafnib,and VikkiEntwistlec aCollegeofMedicine,UniversityofSaskatchewan,104ClinicPlace,Saskatoon, Saskatchewan,CanadaS7N5E5. bDepartmentofClinicalEpidemiologyandBiostatistics,CentreforHealthEconomics andPolicyAnalysis,McMasterUniversity,Hamilton,Ontario,Canada. cHealthServicesResearchUnit,UniversityofAberdeen,Aberdeen,Scotland. *Correspondingauthor.E-mail:lem074@mail.usask.ca Abstract Definitions and interpretations of ‘health literacy’ have important implicationsforthedeliveryofhealthcareandforhealthpolicy-relatedinitiatives. We conducted a systematic review and critical analysis to determine the extent to whichdefinitionsofhealthliteracydifferintheacademicliterature,thesimilarities and differences across definitions, and possible interpretations for the most com- monlyuseddefinitions.Weidentified250differentdefinitionsofhealthliteracyand groupedthemintothreecategories:(i)mostcommonlyuseddefinitions(n=6),(ii) modified versions of these most commonly used definitions (n=133), and (iii) ‘other’ definitions (n=111). We found the most commonly used definitions to be opentomultipleinterpretationsandtoreflectunderlyingassumptionsthatarenot alwaysjustifiable.Attentionisneededtothewaysinwhichdifferingdefinitionsand interpretations of health literacy may affect patient care and the delivery of health literacy-relatedpolicyinitiatives. JournalofPublicHealthPolicyadvanceonlinepublication,19May2016; doi:10.1057/jphp.2016.18 Keywords: healthliteracy;healthpolicy;literaturereview Introduction How terms are defined and interpreted has important implications for the delivery of health care and for health policy-related initiatives. Researchers have sought to bring attention to policy-relevant terms for ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 www.palgrave.com/journalsMalloy-Weiretal which different definitions or meanings exist, for example, medical neces- sity,1shareddecision-making,2healthgovernance,3andhealthdisparities.4 This review focuses on ‘health literacy’ – a term that has garnered increasing attention in the academic literature. To illustrate, an English language search of MEDLINE (Ovid) using ‘health literacy’ as a key word returns only 50 records published in the decade 1991–2000, compared with 1310 in the decade 2001–2010. Health literacy has also become more prominent on the health policy agendas of a number of countries, and efforts to promote it have multiplied. The term appears, forexample,inthe2010UnitedStatesPatientProtectionandAffordable CareAct,inprovisionsthatsupportdevelopmentandtestingofdecision aids for patients with, among other things, “diverse levels of health literacy”. Given these developments, it is notable that, in 2006, Baker argued that the term health literacy had “come to mean different things to various audiences”,5 p. 878. Other authors have identified, analyzed, and in some cases classified, different definitions of health literacy to helpclarifyitsmeaning,proposeaneworintegrateddefinitionofhealth literacy, and/or develop a conceptual model of health literacy.6–9 Little attention, however, has been paid to words, phrases, and underlying assumptions that may encourage differing, and potentially problematic, interpretations. Such attention is important because definitions and interpretations have practical implications. The existence of different definitionsofhealthliteracy,andtheinterpretationsthatmaybepossible for any given definition, may create challenges for the development, implementation, and evaluation of health literacy-related policy initia- tives.Thus,wesoughttoanswertheseresearchquestions: 1. To what extent are different definitions of health literacy used in the academicliterature? 2. Whatarethesimilaritiesanddifferencesacrossdefinitions? 3. What kinds of interpretation are possible for the most commonly useddefinitions? Methods We performed a systematic review of definitions of health literacy using the approach described by Petticrew and Roberts.10 To locate ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 335Reviewofhealthliteracy definitions of health literacy, we used the same search strategy as IshikawaandYano9andapplieditfrom1January2007(tofollowon from their review) to 25 September 2013. This search was of MED- LINE and used the key word ‘health literacy’. MEDLINE is the “… world’s most comprehensive source of life sciences and biomedi- calbibliographicinformation”.11Thissearchreturnedatotalof1882 articles in English. After de-duplication, 1749 articles remained: 167 of the articles were published in 2007; 153 in 2008; 237 in 2009; 327 in 2010; 432 in 2011; 326 in 2012; 107 in 2013 (up to September 25). We screened articles for relevance using a two-step process. In the first step, the first author (L M-W) used the ‘find’ key to locate any mention of the term ‘health literacy’ in either the abstract or body of PDF files of articles, or visually scanned articles for the same. We included a total of 1606 articles that contained the term ‘health literacy’ and passed them to the next step. We excluded the 141 articles that did not mention the term health literacy in the abstract or body of the paper, along with two articles that could not be retrieved through the McMaster University library. Inthesecondstep,thefirstauthorreadtheremaining1606articlesto determine whether or not the author(s) provided or cited a definition of ‘health literacy’ in either the abstract or the body of the article. We used the Oxford Advanced Learners Dictionary’s,12 p. 401 definition of the term ‘definition’ (“an explanation of the meaning of a word or phrase, especially in a dictionary; the act of stating the meanings of words and phrases”) to guide our assessment. We considered any one or more statement(s) of or explanation of the meaning of the term ‘health literacy’ to be a definition of health literacy. A total of 774 articles contained one or more definitions of health literacy and 832 articlesdid not. Amatrix13facilitatedthesystematicextraction,display,andorganiza- tion of different definitions of health literacy (Table 1). We compared each definition of health literacy that we had extracted to definitions already entered into the matrix. We grouped definitions identical in wordinginthesamerowinthematrix.Weassigned‘other’todefinitions that differed in wording. This allowed us to count: (i) how often any given definition of health literacy was used, and (ii) the different definitions of health literacy used in the academic literature. We used 336 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352Malloy-Weiretal Table1: Exampleofmatrixusedtoorganizedefinitionsofhealthliteracy 1 2 3 4 5 Journal Definitionsofhealth Definition(s)ofhealth Howdothe Comments literacyextractedfrom literacyextractedfrom definitionsin MEDLINEarticlesand source(s)citedin Columns2and3 source MEDLINEarticlesand compare? source Pharmacy “thecognitiveandsocial “thecognitiveandsocial Same Identically World& skillswhichdetermine skillswhichdetermine worded Science themotivationand themotivationand abilityofindividualsto abilityofindividualsto gainaccessto, gainaccessto, understandanduse understandanduse informationinways informationinways whichpromoteand whichpromoteand maintaingoodhealth”,14 maintaingoodhealth”,15 p.465 p.10 resultsfromthecomparativeanalysistoorganizedefinitionsintooneof thethreecategories: (a) Definitions that appeared identically worded a total of five or more times in our sample (now referred to as the most commonly used definitionsofhealthliteracy); (b) Modifiedversionsofthemostcommonlyuseddefinitions,definedas those that were similar, but not identical, in wording to those identifiedinthefirstcategory;or (c) ‘Other’ definitions ofhealth literacy, definedasthose thatdidnotfit intoeitherofthefirsttwocategories. To answer the third research question, we focused on the most commonly used definitions and performed a critical analysis,16 asking threequestions: 1. Whatdoesthedefinitionimplya(more)healthliteratepersonis? 2. Aretherewordsinthedefinitionthatarevagueorambiguous? 3. Whatassumptionsareinherentinthedefinition? Weenteredintothe matrixthe firstauthor’s answerstothese questions; thentheotherauthorsreviewedandinsomecasesexpandeduponthese answers. ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 337Reviewofhealthliteracy Results Towhatextentaredifferentdefinitionsofhealthliteracyusedinthe academicliterature? Intotal,weextracted250differentdefinitionsofhealthliteracyfromthe 774 articles included and grouped them as follows: (i) ‘most commonly used definitions’ (n=6); (ii) modified versions of the most commonly used definitions (n=133); and (iii) ‘other’ definitions of health literacy (n=111). As shown in Table 2, Ratzan and Parker’s17 definition was the most commonly used, followed by the definitions put forth by the World Health Organization or WHO15; the Ad Hoc Committee, American Medical Association or AMA18; Zarcadoolas and colleagues7; Kickbusch and colleagues19; and Rootman and Gordon-El-Bihbety.20 We list examples of ‘modified versions of the most commonly used definitions’inColumn2ofTable2andexamplesof‘other’definitionsof healthliteracyinColumn3ofTable2. Whatarethesimilaritiesanddifferencesacrossdefinitions? One striking similarity was that each of the most commonly used definitionstreatedaperson’sabilities(orskills)ascentraltotheconcept ofhealthliteracy.Therewasvariability,however,intermsofthenumber and types of abilities (or skills) and/or actions believed to comprise health literacy; the context and/or time frames in which the various abilities and/or actions are believed to be important; and thus what eachimpliesahealthliteratepersonis.Althoughsometypesofabilities, suchastheabilityto‘obtain’and‘understand’,werecommontofourof the six definitions authors mentioned them in terms of their application to different things; such as, “basic health information and services”,17 “information”,15,20and“healthinformationandconcepts”.21Theactions associatedwith,andtheimpliedsourcesofthevalueof,healthliteracy (that is, what it was deemed useful for) also varied across definitions, for example: “to make appropriate health decisions”17; to “promote and maintain good health”15; “to function in the health care environ- ment”18; “to make informed choices, reduce health risks and increase quality of life”21; and “topromote, maintain, and improvehealth”.20 A comparison of the most commonly used definitions with the modifiedversionsofthesamedefinitionsrevealedsomeconsistencywith 338 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 339 weiversihtnideifitnediycaretilhtlaehfosnoitinifedfoseirogetaC :2elbaT dna,ecruosrieht,snoitinifed’rehtO‘ dnanoitinifeddesuylnommocfosnoisrevdeifidoM ycneuqerfdna,ecruosrieht,snoitinifeddesuylnommoctsoM reperutaretilcimedacaniesufoycneuqerf detceles(raeyreperutaretilcimedacaniesufoycneuqerf raeyreperutaretilcimedacaniesufo )selpmaxedetceles(raey )selpmaxe cisabdnatsrednuotelpoepfoytilibaeht“ htlaehdnatsrednudna,ssecorp,niatbootyticapaceht“ iv.p71,rekraPdnanaztaR htiwetacinummoc,noitamrofnihtlaeh ekamotdedeenslairetamdnanoitamrofni esuylreporpdna,srenoititcarphtlaeh 3Sp22,”htlaehs’enognidragersnoisicedetairporppa otyticapacehtevahslaudividnihcihwoteergedeht“ 773.p32,”secivreshtlaeh )9=n(0102+)6=n(9002+)8=n(8002+)6=n(7002 noitamrofnihtlaehcisabdnatsrednudna,ssecorp,niatbo terpretnidnadnatsrednuotytilibaeht“ 78=)2=n(3102+)82=n(2102+)82=n(1102+ ”snoisicedhtlaehetairporppaekamotdedeensecivresdna ninoitamrofnihtlaehfogninaemeht 1nmuloCninoitinifedfosnoisrevdeifidomtnereffid 0102+)26=n(9002+)43=n(8002+)63=n(7002 wohdnamroflatigidronekops,nettirw 3102+)94= n(2102+)26=n(1102+)66=n( roecarbmeotelpoepsetavitomsiht dedrowyllacitnedisemit523=)61=n( 42,”htlaehotgnitalersnoitcadragersid 441.p ,snoitcurtsnidnatsrednuotytilibaeht“ esudna,dnatsrednu,otsseccaniagotytilibas’tneitapa“ 01.p51,OHW etaitogenotytilibaehtdna,snoitcerid 52,”htlaehevorpmiotnoitamrofni 21.p62,”smetsyserachtlaehxelpmoc 2e.p ehtenimretedhcihwsllikslaicosdnaevitingoceht“ 9002+)4=n(8002+)5=n(7002 )1=n(0102+)4=n(9002+)3=n(8002+)0=n(7002 ,otsseccaniagotslaudividnifoytilibadnanoitavitom )02=n(1102+)22=n(0102+)51=n( 71=)0=n(3102+)5=n(2102+)4=n(1102+ etomorphcihwsyawninoitamrofniesudnadnatsrednu 111=)61=n(3102+)92=n(2102+ 1nmuloCninoitinifedfosnoisrevdeifidomtnereffid ”htlaehdoogniatniamdna ,sitaht(snoitinifed’rehto‘tnereffid )01=n(0102+)41=n(9002+)8=n(8002+)2=n(7002 1snmuloCniesohtmorftnereffid semit06=)5=n(3102+)01=n(2102+)11=n(1102+ )2dna dedrowyllacitnedi dnatsrednudnadaerotytilibaehtsadenifedyldaorb“ 355.p81,AMA eveihcaotredroninoitamrofnihtlaehlaitnesse 72,”semoctuohtlaehevitisop mrofrepotytilibaehtgnidulcni,slliksfonoitalletsnoca“ 8.p ninoitcnufotderiuqersksatlaciremundnagnidaercisab )4=n(0102+)1=n(9002+)1=n(8002+)2=n(7002 ”tnemnorivneerachtlaeheht 61=)0=n(3102+)3=n(2102+)5=n(1102+ )6=n(0102+)4=n(9002+)3=n(8002+)1=n(7002 1nmuloCninoitinifedfosnoisrevdeifidomtnereffid semit81=)0=n(3102+)2=n(2102+)2=n(1102+ dedrowyllacitnedi Malloy-Weiretal340 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 niesuelpoepseicnetepmocdnaslliksfoegnarediweht“ 791–691.pp12,latesaloodacraZ esudna,etaulave,dneherpmoc,tuokeesotredro 82,”stpecnocdnanoitamrofnihtlaeh elpoeptahtseicnetepmocdnaslliksfoegnarediweht“ 933.p esudna,etaulave,dneherpmocdnatuokeesotpoleved )1=n(0102+)0=n(9002+)1=n(8002+)0=n(7002 demrofniekamotstpecnocdnanoitamrofnihtlaeh 5=)0=n(3102+)0=n(2102+)3=n(1102+ ”efilfoytilauqesaercnidnasksirhtlaehecuder,seciohc 1nmuloCninoitinifedfosnoisrevdeifidomtnereffid )3=n(0102+)1=n(9002+)3=n(8002+)1=n(7002 semit31=)0=n(3102+)3=n(2102+)2=n(1102+ dedrowyllacitnedi ehtnisnoisicedhtlaehdnuosekamotytilibaeht“ 8.p91,latehcsubkciK 0081.p92,”efilyadyrevefotxetnoc )0=n(0102+)0=n(9002+)0=n(8002+)0=n(7002 txetnocehtnisnoisicedhtlaehdnuosekamotytilibaeht“ 2=)0=n(3102+)0=n(2102+)2=n(1102+ ehtta,ytinummocehtni,emohta–efilyadyrevefo 1nmuloCninoitinifedfosnoisrevdeifidomtnereffid dnaecalptekrameht,metsyserachtlaehehtni,ecalpkrow ”aneralacitilopeht )0=n(0102+)5=n(9002+)0=n(8002+)0=n(7002 semit11=)1=n(3102+)3=n(2102+)2=n(1102+ dedrowyllacitnedi tcadnadnatsrednu,niatbootslaudividnifoytilibaeht“ 11.p02,ytebhiB-lE-nodroGdnanamtooR etairporppaekamotdnanoitamrofnihtlaehnopu ehtgnieblaogetamitluehthtiw,snoisicedhtlaeh dnaetaulave,dnatsrednu,sseccaotytilibaeht“ esaesidfotnemeganamehtrohtlaehfoecnanetniam niatniam,etomorpotyawasanoitamrofnietacinummoc 154.p03,”esruoc-efilehtssorcasgnittesfoyteiravani ehtssorcasgnittesfoyteiravanihtlaehevorpmidna )1=n(0102+)1=n(9002+)1=n(8002+)0=n(7002 ”esruocefil 6=)0=n(3102+)1=n(2102+)2=n(1102+ )2=n(0102+)1=n(9002+)0=n(8002+)0=n(7002 1nmuloCninoitinifedfosnoisrevdeifidomtnereffid semit7=)0=n(3102+)3=n(2102+)1=n(1102+ dedrowyllacitnedi ReviewofhealthliteracyMalloy-Weiretal respect to the terms and/or phrases that authors opted to delete, modify, and retain. In general, authors tended to retain the abilities (or skills) specified in the most commonly used definitions. Statements or phrases that preceded the abilities (or skills) tended to be deleted, whereas descriptors of thepurposes to which health literacy was put tendedto be modified. The WHO,15 for example, defined health literacy as, “… the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”. Bell,25 p. 2 cited the WHO publicationbutdefinedhealthliteracyas“apatient’sabilitytogainaccess to,understand,anduseinformationtoimprovehealth”.Itisevidentthat Belldidthreethings25:(i)deletedthephrase“thecognitiveandsocialskills whichdeterminethemotivation”;(ii)retainedtheabilities(orskills)“gain accessto,understand,anduseinformation”;and(iii)modifiedthephrase “in ways that promote and maintain” to “to improve”. The word “individuals”wasalsomodifiedbyBellto“apatient’s”. A within-group comparison of the 111 ‘other’ definitions revealed variability in terms of the number and types of abilities (or skills) specifiedand/oractionsbelievedtocomprisehealthliteracy.Ofthetypes of abilities or skills specified, however, “understanding” appeared most frequently – in 60 of 111 (or 54 per cent) of ‘other’ definitions and was mentioned in association with 31 different types of information. The word “knowledge” appeared in 14 ‘other’ definitions, again with different types of knowledge mentioned, but it did not appear in any of the most commonly used definitions of health literacy. Finally, some ‘other’ definitions of health literacy included specification of a more advancedsetofskillsand/oractionsthanthoseidentifiedinthefirsttwo categoriesofdefinitions,forexample,theabilityto,“negotiatecomplex healthcaresystems”,26p.12.Thereason(s)forthespecificationofthese skillsand/oractionswas(were)notprovidedbytheauthor(s). Whatkindsofinterpretationsarepossibleforthemostcommonlyused definitions? Table 3 summarizes the critical analysis of the most commonly used definitions of health literacy. It illustrates how different interpreta- tionsof definitionsarepossibledue tothepresenceof vague/ambiguous wording and/or the presence of underlying assumptions that may ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 341Reviewofhealthliteracy generate misunderstandings. We focus here on four concerns about interpretation. First, there are inbuilt assumptions that information can be used to promote or maintain health,15,20 or that health information and con- cepts can be used to reduce health risks and increase quality of life.21 Although these assumptions may hold in some contexts, they may not holdin others,forexample, forindividualswhosufferfrom terminalor degenerativeconditions,andforthosepeoplewhosehealthisnegatively influenced,orconstrained,bystructuralfeaturesofsociety. Second,somedefinitionsincorporateassumptionsaboutrelationships between: (i) the “capacity to obtain, process, and understand health information and services”17 AND the making of “appropriate health decisions”,17and(ii)betweenhealthliteracyANDthemakingof“sound health decisions in the context of everyday life”.19 Again, while these assumptions may be valid for some people in some contexts, health- related decision-making is influenced by a much broader set of factors, including, but not limited to, personal values and beliefs, life context, andtheacceptabilityofthedecision-makingoptions.31 Third, what can be considered to be “sound” and “appropriate” decision-makingcanbejudgedondifferentcriteria.Somedefinitionsdo not rule out the possibility that assessments of health literacy could be based on normative judgements about the appropriateness of people’s choices. Finally, as noted in Column 2 of Table 3, the wording used in at least three of the most commonly used definitions can imply that the onus of achieving health literacy falls on the “individual”.15,17,21 The authors, and users, of these definitions may not mean to imply this, but the wording used in these definitions does not rule out this interpretation. This leaves scope for the neglect of non-modifiable individual-level factors (for example, poor health), structural features of society (for example, dominant languages, health care financing arrangements, and otherfactorsaffectingcare),aswellasfeaturesofhealthcareprovisions (for example, overly complicated provision of information or stigmatiz- ing communication by health professionals and so on). Whereas many contemporary advocates of health literacy recognize the importance of systems and other social considerations beyond individuals, influential definitions seem to reflect, and perhaps perpetuate, more individualistic ideas, obscuring the barriers that individuals may face (for example, to obtain,process,andunderstandbasichealthinformationandservices). 342 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 343 weiversihtnideifitnediycaretilhtlaehfosnoitinifeddesuylnommoctsomehtfosisylanalacitircehtmorfsgnidniffoyrammuS :3elbaT 5 4 3 2 1 stnemmoC snoitpmussagniylrednutahW noitinifedehtnisdrowerehterA ninoitinifedehtseodtahW dnaycaretilhtlaehfonoitinifeD ?noitinifedehtnitnerehniera ?suougibmaroeugaverataht htlaeh)erom(aylpmi1nmuloC ecruos ?sinosrepetaretil laudividniehtnosunodeilpmI dedeensiycaretilhtlaeH nidlobnismreteeS etaretilhtlaeh)erom(A iv.p71,rekraPdnanaztaR ycaretilhtlaeheveihcaot ”etairporppa“ekamot 1nmuloC )retaerg(asahlaudividni snoisicedhtlaeh otyticapacfoeerged hcihwoteergedeht“ ,epyt,levelehtneposevaeL dna,ssecorp,niatbo yticapacehtevahslaudividni ,tnuoma,ecruos,ytilibacilppa htlaehcisabdnatsrednu dna,ssecorp,niatboot foytilibidercdna,ytilibatpecca secivresdnanoitamrofni htlaehcisabdnatsrednu noitamrofnihtlaehcisabeht etairporppaekamotdedeen secivresdnanoitamrofni ”dedeen“secivresdna snoisicedhtlaeh etairporppaekamotdedeen ”snoisicedhtlaeh esohw)1(:raelcnU si”deen“ro”gnidnatsrednu“ senimretedohw)2(ro,deulav snoisiced”etairporppa“tahw tahtairetirctahwro,era nodesabsinoitanimreted tnuoccaotniekattonseoD yamtahtsrotcaflautxetnoc ’gniniatbo‘tneverp/timil ”etairporppa“nosucoF aycaretilhtlaehekamsnoisiced tpecnocevitamronylralucitrap Malloy-Weiretal344 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 otlaudividniehtnosunodeilpmI rodetomorpebnachtlaeH nidlobnismreteeS etaretilhtlaeh)erom(A 01.p51,OHW ycaretilhtlaeheveihca htlaehhtiwdeniatniam 1nmuloC foerom(sessessoplaudividni noitamrofni laicosdnaevitingoceht)eht sllikslaicosdnaevitingoceht“ atonrorehtehwraelcnU ycaretilhtlaehfopihsnoitaleR ehtenimretedhcihwslliks ehtenimretedhcihw htlaehrofstsixedlohserht nolanoitidnocsihtlaehot ytilibadnanoitavitom foytilibadnanoitavitom ycaretil dnaevitingocgnissessop ,otsseccaniagotslaudividnifo sseccaniagotslaudividni snoitinifedrehtomorftnereffiD ehtdnasllikslaicos noitamrofniesudnadnatsrednu esudnadnatsrednu,ot asedulcnitiesuaceb otytilibadnanoitavitom dnaetomorphcihwsyawni hcihwsyawninoitamrofni tnenopmoclanoitavitom esudna,dnatsrednu,ssecca htlaehdoogniatniam niatniamdnaetomorp ,epyt,levelehtneposevaeL evitingoC.noitamrofni ”htlaehdoog ,tnuoma,ecruos,ytilibacilppa meessllikslaicosdna foytilibidercdna,ytilibatpecca erarehtegottubyrassecen ”noitamrofni“ eveihcaottneiciffusyeht ?ycaretilhtlaeh esohwyficepstonseoD deulavsi”gnidnatsrednu“ tnuoccaotniekattonseoD yamtahtsrotcaflautxetnoc ,otsseccagniniagtneverp/timil gnisurognidnatsrednu tnuoccaotniekattonseoD neewtebstsixepihsnoitalerA 1nmuloCnidlobnismreteeS etaretilhtlaeh)erom(A 355.p81,AMA /timilyamtahtsrotcaflautxetnoc slliksfotesafonoissessopeht )foerom(sessessopnosrep gninoitcnuftneverp htlaehehtni”gninoitcnuf“dna ehttonrorehtehwraelcnU ,slliksfonoitalletsnoca ,slliksfonoitalletsnoca“ tnemnorivneerac sadeweiveraslliksdeifitnedi mrofrepotytilibaehtgnidulcni otytilibaehtgnidulcni atonrorehtehwraelcnU tneiciffusroyrassecen laciremundnagnidaercisab dnagnidaercisabmrofrep etauqedarofstsixedlohserht ycaretilhtlaeheveihcaot ehtninoitcnufotderiuqersksat deriuqersksatlaciremun nigninoitcnufroycaretilhtlaeh tnemnorivneerachtlaeh htlaehehtninoitcnufot tnemnorivneerachtlaeheht ”tnemnorivneerac Reviewofhealthliteracy” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 345 deunitnoC :3elbaT 5 4 3 2 1 stnemmoC snoitpmussagniylrednutahW noitinifedehtnisdrowerehterA ninoitinifedehtseodtahW dnaycaretilhtlaehfonoitinifeD ?noitinifedehtnitnerehniera ?suougibmaroeugaverataht htlaeh)erom(aylpmi1nmuloC ecruos ?sinosrepetaretil ot’elpoep‘nosunodeilpmI dnanoitamrofnihtlaeH 1nmuloCnidlobnismreteeS nosrepetaretilhtlaeh)erom(A 7-691.pp12,latesaloodacraZ ycaretilhtlaeheveihca ecuderotdesuebnacstpecnoc slliksfoegnarediwehtsessessop ytilauqesaercnidnasksirhtlaeh tonrorehtehwraelcnU elpoeptahtseicnetepmocdna dnaslliksfoegnarediweht“ tonrorehtehwyficepstonseoD efilfo eraslliksdeifitnedieht dnatuokeesotpoleved elpoeptahtseicnetepmoc htlaehrofstsixedlohserhta royrassecensadeweiv esudna,etaulave,dneherpmoc dnatuokeesotpoleved ycaretil eveihcaottneiciffus stpecnocdnanoitamrofnihtlaeh dna,etaulave,dneherpmoc ,level,ecruosehtneposevaeL ycaretilhtlaeh ,seciohcdemrofniekamot dnanoitamrofnihtlaehesu ,tnuoma,ytilibiderc esaercnidnasksirhtlaehecuder demrofniekamotstpecnoc ytilibacilppadna,ytilibatpecca efilfoytilauq sksirhtlaehecuder,seciohc dnanoitamrofnihtlaehfo ”efilfoytilauqesaercnidna stpecnoc esohwyficepstonseoD deulavsi”noisneherpmoc“ tnuoccaotniekattonseoD yamtahtsrotcaflautxetnoc ,gnikeestneverp/timil ,gnitaulave,gnidneherpmoc ro,sksirhtlaehgnicuder,gnisu efilfoytilauq Malloy-Weiretal346 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 senimretedohwyficepstonseoD ehthtiwycaretilhtlaehsetauqE nidlobnismreteeS nosrepetaretilhtlaeh)erom(A 8.p91,latehcsubkciK era”snoisicedhtlaehdnuos“tahw snoisiceddnuosekamotytiliba 1nmuloC htlaehdnuosekamotelbasi dnuosekam“otytilibA fotxetnocehtnisnoisiced txetnocehtnisnoisicedhtlaeh snoitinifedrehtomorftnereffiD neessiycaretilhtlaeh ehtni,emohtaefilyadyreve efilyadyrevefo siycaretilhtlaehesuaceb emasehtsihtsI”ytiliba“nasa ni,ecalpkrowehtta,ytinummoc ,ytinummocehtni,emohta stxetnocelpitlumottnaveler ?lliksroyticapacasa eht,metsyserachtlaeheht ehtni,ecalpkrowehtta tnuoccaotniekattonseoD lacitilopehtdnaecalptekram eht,metsyserachtlaeh yamtahtsrotcaflautxetnoc anera lacitilopehtdnaecalptekram htlaehdnuos“tneverp/timil ”anera ”snoisiced ,ecruos,epytehtneposevaeL syawnidesuebnacnoitamrofnI nidlobnismreteeS nosrepetaretilhtlaeh)erom(A -lE-nodroGdnanamtooR ,tnuoma,ytilibiderc,level dnaniatniam,etomorpot 1nmuloC ,sseccaotytilibaehtsessessop 11.p02,ytebhiB foytilibacilppadna,ytilibatpecca htlaehevorpmi dnaetaulave,dnatsrednu noitamrofni ehttonrorehtehwraelcnU asanoitamrofnietacinummoc ,sseccaotytilibaeht“ sadeweiveraslliksdeifitnedi dnaniatniam,etomorpotyaw dnaetaulave,dnatsrednu esohwyficepstonseoD tneiciffusroyrassecen foyteiravanihtlaehevorpmi sanoitamrofnietacinummoc deulavsi”gnidnatsrednu“ htlaeheveihcaotsnoitidnoc esruocefilehtssorcasgnittes niatniam,etomorpotyawa ycaretil anihtlaehevorpmidna snoitinifedrehtomorftnereffiD ehtssorcasgnittesfoyteirav txetnochtobseificepstiesuaceb ”esruocefil emarfemitdna tnuoccaotniekattonseoD yamtahtsrotcaflautxetnoc ,gnisseccatneverp/timil ,noitaulave,gnidnatsrednu ,noitomorp,noitacinummoc gnivorpmiro,gniniatniam htlaeh ReviewofhealthliteracyMalloy-Weiretal Discussion This review shows that there has been a notable increase in the number of different definitions of health literacy provided by authors in the academic literature since 2007. There is no single, commonly accepted definition – a finding that has been reported elsewhere.5,6 No single commonlyuseddefinitionofhealthliteracyappearstobemore(orless) precise,clearintermsofitsmeaning,orusefulthanothers. The existence of so many definitions of health literacy, and the various interpretations that are possible for the most commonly used definitions, is problematic for policymakers, practitioners, and researchers. First, it is not clear which definition of health literacy is best in any given context or by which criteria this should be judged. Second, if policymakers understand definitions differently than others who are implementing and evaluating health literacy-related initia- tives, theremaybe confusionand misunderstandings.Third, ifpolicy- makers act on assumptions that are not fully supported by empirical research,itmayleadtounintendedorunwantedconsequences.Action by policymakers, for example, on the underlying assumption that a positive relationship exists between an individual’s “capacity to obtain, process, and understand health information and services”17 ANDanindividualmaking“appropriatehealthdecisions”17maylead tothedevelopmentofpolicies,programs,and/orpracticesthatconflict with other valued goals (for example, wanting individuals to make ‘autonomous’ health decisions versus health decisions that are exter- nally defined as ‘appropriate’). The apparent emphasis on individual abilities may also lead to the neglect of other important factors that facilitatehealth-relateddecision-makingandaction. While the use of different definitions of health literacy, and the murkiness surrounding its meanings, may be well-tolerated, and to a largeextentencouragedbyacademics (thatis, throughthemodification of older definitions or through the development of new definitions), Hughes,16p.46arguesthat: [F]or many specific purposes, such as doing research or enacting legislation,itmakesgoodsensetostipulatetheprecisemeaningthat istobeattachedtokeywords.Aslongasthisstipulatedmeaningis explicitly stated, there is no risk of misunderstanding, and there is anobviousgaininclarityandprecision. ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 347Reviewofhealthliteracy Although words can always be variously interpreted, our findings challenge those seeking to develop, implement, and evaluate health literacy-relatedpolicyinitiatives. We support the need to develop a shared understanding of the health literacy that was articulated by McCormack et al.32 Our findings raise twoimportantquestionsinthisregard. 1. Which definition(s) should be adopted for the purposes of develop- ing, implementing, and evaluating health literacy-related policy initiatives – the definition(s) for which a valid and reliable empirical measure exists, the definition that is most commonly used in the academicliterature, thedefinition(s)that best fitswith agiven policy context and agenda, or some combination of these and/or other criteria? 2. Whoshouldbeinvolvedininterpretingthemeaningofanydefinition that is adopted into policy – researchers, policymakers, and/or those who have the potential to be positively and/or negatively affected by the adoption, and interpretation, of any given definition (for exam- ple,patients)? Allpartiesmustgrapplewiththesequestions. Pleasant and colleagues,33 p. 18 have proposed an agenda that would actively engage “the public (e.g., adult learners, patients) and policymakers” to “help assure validity, relevance, and utility for a new comprehensive approach to measuring health literacy”. Whilethisapproach holds promisefor the development,implementa- tion, and evaluation of health literacy-related policy initiatives, it requires that all parties must, first, grapple with the two questions we raised. While we made every effort to ensure the accuracy of this review, some limitations exist. First, only one of us identified and extracted the definitionsofhealthliteracy.Toreducethechanceforbias,wedeveloped inclusion criteria and applied these systematically to every article. Then the entire research team reviewed and analyzed the definitions. We acknowledge that it is possible to identify interpretations of defini- tions beyond those in this study. Second, our search was limited to English-language only articles. Reviews, similar to that conducted by SorensenandBrand,34mayhelptogaininsightsintohowhealthliteracy isdefinedinnon-English-speakingcountries. 348 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352Malloy-Weiretal Definitions of health literacy continue to emerge, and it is particu- larly important to note that the WHO35 recently adopted a newer, and much longer, integrated definition of health literacy from the one shown in Tables 2 and 3. This newer definition (see the defi- nitions Appendix at the end of the text) did not meet the criteria for inclusioninTables2and3(thatis,didnotappearidenticallyworded a total of five or more times in our sample). In it WHO integrates a number of components taken from other existing definitions, but the wording is still open to varying, and potentially problematic, inter- pretations that are not clarified in the accompanying integrated model.35 Before this review, the extent to which different definitions of health literacywereusedintheacademicliteraturewasunknown.Ourfindings have highlighted not only the huge range of definitions published in English but also the potentially problematic assumptions and implica- tions that are built into those that are most widely used. Careful attention is needed to the definition(s) of health literacy adopted in practice; the differing, and potentially problematic, ways in which definitions may be interpreted; and the way(s) in which differing interpretations may affect the delivery of health literacy-related policy initiatives. About the Authors Leslie J. Malloy-Weir, PhD, is a Post-Doctoral Fellow in the College of MedicineattheUniversityofSaskatchewan. Cathy Charles, PhD, was a Professor emeritus at McMaster University with expertise in qualitative social research, communication and media, andsocialpolicy.Shediedin2015. Amiram Gafni, PhD, is a Professor in the Department of Clinical Epide- miology and Biostatistics, and a member of the Centre for Health Eco- nomics and Policy Analysis at McMaster University (E-mail: gafni@ mcmaster.ca). Vikki Entwistle is a Professor of Health Services Research and Ethics at the University of Aberdeen, Scotland (E-mail: vikki.entwistle@abdn .ac.uk). ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 349Reviewofhealthliteracy References 1. Charles,C.,Lomas,J.andGiacomini,M.(1997)MedicalnecessityinCanadianhealthpolicy: Fourmeaningsand…afuneral?MillbankQuarterly75(3):365–394. 2. Charles,C.,Gafni,A.andWhelan,T.(1997)Shareddecision-makinginthemedicalencounter: Whatdoesitmean?(orittakesatleasttwototango).SocialScience&Medicine44(5):681–692. 3. 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WorldHealthOrganization.(2013)Healthliteracy:Thesolidfacts.7February, http://www .euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf,accessed7February2016. ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 351352 ” 2016 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 37, 3, 334–352 xidneppA ycaretilhtlaehfonoitinifed)3102(OHW :1AelbaT 5 4 3 2 1 stnemmoC gniylrednutahW sdrowerehterA 1nmuloCninoitinifedehtseodtahW ecruosdnaycaretilhtlaehfonoitinifeD erasnoitpmussa noitinifedehtni ?sinosrepetaretilhtlaeh)erom(aylpmi ehtnitnerehni roeugaverataht ?noitinifed ?suougibma ,epyt,levelehtneposevaeL htlaeH dlobnismreteeS nosrepetaretilhtlaeh)erom(A 4.p53,OHW ,ecruos,ytilibacilppa nacnoitamrofni 1nmuloCni dnanoitavitom,egdelwonksessessop ycaretilotdeknilsiycaretilhtlaeH‘ dna,ytilibatpecca,tnuoma otdesueb ,dnatsrednu,sseccaotsecnetepmoc ,egdelwonks’elpoepsliatnedna htlaehfoytilibiderc roniatniam htlaehylppadnaesiarppa otsecnetepmocdnanoitavitom noitamrofni ytilauqevorpmi ekamotredroninoitamrofni dnaesiarppa,dnatsrednu,ssecca efilfo nisnoisicedekatdnastnemegduj otredroninoitamrofnihtlaehylppa esohwraelcnU ,erachtlaehgninrecnocefilyadyreve snoisicedekatdnastnemegdujekam dna’gnidnatsrednu‘ htlaehdnanoitneverpesaesid htlaehgninrecnocefilyadyreveni deulavera’stnemegduj‘ evorpmironiatniamotnoitomorp htlaehdnanoitneverpesaesid,erac esruocefilehtgnirudefilfoytilauq evorpmironiatniamotnoitomorp atonrorehtehwraelcnU ’esruocefilehtgnirudefilfoytilauq htlaehrofstsixedlohserht ycaretil Reviewofhealthliteracy