This section contains the key findings of the combined analysis and includes the most significant contextual variations that emerged as part of the process.
Attributes: what are the key characteristics of critical health literacy?
Key characteristics include having advanced personal and social skills including confidence, social and communication skills, self efficacy and interpersonal skills. As Wang [38] states:
‘It implies a significant level of …personal skills and confidence.’ [38] p 271]
It also involves the ability to access, manage, assess the credibility, understand and critically appraise information on health related issues:
“Being able to decipher information, decode, but on top of that to have an understanding, a critical awareness of what underlies that information, so it would be a conceptual awareness.’ (participant 4)
This entails having a level of health knowledge including a level of familiarity with health terms and medical terminology, being informed about health issues and understanding these issues:
‘It’s about whether individuals have an understanding around a wide range of issues to do with health’ (participant 21)
Another characteristic of critical health literacy is being able to contextualize information, apply it to one’s own situation, judge risk, act on information and thus share the decision making with health professionals. The focus on an ability to contextualise information was captured by Kickbush [39]:
‘…involves understanding and ability to judge, sift and use information provided in the context of one’s own life – this is the key element of critical health literacy…’[39] p292]
Whilst these characteristics relate to individual abilities, critical health literacy is also seen as arising from the relationship between services and individuals and an ability to interact effectively. This involves an ability to navigate services but beyond this to advocate and articulate oneself confidently when communicating with a health professional and where necessary question or challenge a professional in a constructive way as one participant demonstrated in their reflection on their own experience as a patient:
‘I don’t just receive information, sitting there quietly absorbing it and making sense of it. What I need to do is also question, including occasionally challenging.’ (Participant 20)
This level of effective interaction is not only dependent on the skills of the individual but also on the skills of the professional who must be able to explain things clearly and provide information that is appropriate for patients. The contextual analysis showed a variation on this point between the colloquial and theoretical data. The professional participants placed an emphasis on the skills and role of the health practitioners in the creation and existence of critical health literacy. This was a theme that was only touched upon within the academic literature but which was central to the colloquial sample who stressed that critical health literacy would only exist if there was a commitment from health practitioners to provide accessible information and to engage in shared decision making.
Another characteristic of critical health literacy can be broadly described as empowerment by which a person has an understanding of the determinants and the policy context of health, an understanding of opportunities to challenge these determinants and policy and motivation and actual action at apolitical and social level. The most frequently cited reference to this point was that made by Nutbeam [7]:
‘…the cognitive and skills development outcomes which are oriented towards supporting effective social and political action…’[7] p 265]
This empowerment may exist at an individual level but may also demonstrate collective understanding and exist at a population or community level. As such it represents an asset rather than a deficit or lack of skills in an individual or community. The contextual analysis showed, however, quite stark variation in how this theme was understood and prioritised within the different contexts analysed. While this characteristic of empowerment was a strong and clearly articulated attribute within some of the academic articles [7, 38, 40, 41] and by some of the colloquial sample, it was not universally emphasised. The analysis of theoretical literature shows that there has been a decrease in reference to empowerment, action at a social and political level and the conceptualisation of critical health literacy existing at a population as well as an individual level over the last five years. The contextual analysis also demonstrated that sources from a medical discipline were less likely to identify political and social action as an attribute of critical health literacy than were public health sources which focused more on cognitive critical analysis and decision making skills [42, 43]. None of the empirical articles that derived from original research identified this as an attribute while theoretical articles [7, 44–47] were much more likely to.
The final attribute is that of critical health literacy being a learned and movable state that may change with time or the circumstances of peoples lives:References: what is critical health literacy used to refer to?
‘I think the main things are that, you know, that I feel people can maybe move up and down the levels. Depending on the kind of situation they’re in.’ (participant 14)
The concept of health literacy is most commonly used in reference to individuals and is seen as a set of skills or competencies. For some [7, 48, 49] it could also refer to communities or population groups as well as individuals and some (largely within the colloquial sample), also used it in reference to a relationship between individuals and professionals.
Antecedents: what needs to be in place for critical health literacy to occur?
Familiarity with health issues and services as well as an interest and motivation to find out more about health issues is a precursor of critical health literacy:
‘even well educated people can struggle with health literacy because of the lack of familiarity and very often going very long periods without even having to engage with health services or think much about personal health.’ (participant 20)
This motivation may be triggered by personal experience of particular health issues, through social influences or through personal determination.
In order for critical health literacy to emerge an individual would have a wide skill set of literacy and language skills, critical appraisal skills, cognitive skills, personal and social skills and functional and interactive health literacy skills. While the majority of the theoretical and colloquial data argued that functional and interactive health literacy skills and actual literacy and language skills needed to be in place in order for critical health literacy to emerge, there were a minority who strongly opposed this position. For this minority, who often referred to a the Frierian approaches of critical consciousness raising [12] as indeed did Nutbeam’s original article [7], the existence of functional literacy skills of individuals was a less important area of focus:
‘..they may be great at speaking and listening, they may be able to stand up for themselves quite well and may have an understanding of critical health literacy that isn’t dependent on their reading and writing… so those basic literacy reading and writing skills are a building block for critical health literacy but not an absolute requirement in some cases’ (participant 4)
For critical health literacy to be developed there would be formal, structured but supportive learning environments with a change in focus for health education programmes away from information giving to skills development and understanding of health inequalities and the determinants of health based on principles of community development:
‘Within this paradigm, health education may involve the communication of information, and development of skills which investigate the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health.’[7] p 265]
Another antecedent was political will, that is political recognition of the value of critical health literacy as well as the drive and resources coming from a political level to support the development of critical health literacy skills:
‘But I think it needs – it does need – if there was a policy drive. If there was a condition around a policy drive to bring together people who matter, people who sign up to it.’ (Participant 39)
The contextual analysis again showed some mixed understandings and emphasis in this area. Professionals were far more likely to emphasise the theme of political will in creating critical health literacy including the need for any work to develop critical health literacy to be resourced and led at a political and strategic level in order for it to be effectively implemented. This was an area that received very little discussion in the academic literature.
The development of communication skills amongst health professionals to ensure information is presented in an understandable way and that there is a commitment to shared decision making was seen by professionals and policy makers to be important.
Consequences of critical health literacy: what happens as a result of critical health literacy?
The consequences of critical health literacy that were identified in the literature and by professionals and policy makers were supposed or anticipated rather than demonstrated through research and four themes were identified. The first theme was an increase in self efficacy including increased levels of personal involvement, action and control over health issues that affected an individual’s life, shared decision making and self management of care as captured by Ishikawa and Yano [49].
‘…may be related to perceived control over one’s health and self-efficacy to participate in the health care process directly.’ p118
Critical health literacy would also result in improved quality of life, health behaviour and outcomes:
‘Being able to kind of look after your health and respond to your own health issues. So, my personal point of view, obviously better health outcomes.’ (participant 14)
A critically health literate person would make more effective and efficient use of services:
‘Critical health literacy as a compass, guiding patients successfully through complex and non transparent health markets.’ [50] p38]
Critical health literacy was also seen as an individual and population outcome in which there would be increased levels of social capital, understanding and questioning of the determinants and inequalities of health and increased levels of social and political action and change. The contextual analysis again showed that this has been identified as a consequence less frequently in papers published in the last five years. The contextual analysis also identified that theoretical data from Public Health sources identified a far broader set of consequences, including empowerment and political action, than those in the medical literature which focused far more on improved heath related behaviour and outcomes as well as use of services.
Surrogate terms – do the characteristics mirror those of another concept?
It is possible that the characteristics of a concept may mirror those of other concepts which become known as surrogate terms. While the literature and professionals identified several surrogate terms, none emerged frequently or consistently suggesting there is no other term that captures the same characteristics of this term.
Resemblant terms – do the characteristics resemble those of other concepts?
Again, the literature and participants referred to a large number of terms that reflected some, though not all of the attributes, antecedents and consequences of critical health literacy. Those that emerged most frequently and appear to have the most in common with critical health literacy were empowerment, self-efficacy, health literacy, critical appraisal, critical consciousness and advocacy.