Health literacy is vital to good health and wellbeing. It is fundamental to achieving the Sustainable Development Goals by 2030 and is a crucial tool to deliver universal health coverage. People need to know how to prevent disease and navigate health-care systems to ensure good health outcomes. However, many are not able to make healthy choices, even in countries with the strongest health systems. Why is this? Traditionally, health literacy has focused on an individual's ability to access, understand, appraise, and use information to maintain good health. Of course, such knowledge is important. But this approach neglects the societal and structural forces that shape our choices. In many parts of the world, health decisions occur within the family. The health of communities is often dictated by social and environmental factors outside the control of individuals. Research progress in these areas has been slow, and many health interventions still leave people behind. The result has been a health failure.
However, change is beginning to happen. Health literacy was recognised as a critical determinant of health in the WHO Shanghai Declaration in 2016, and has been recast as a collective practice of a community working to enable and build knowledge, rather than placing responsibility on the individual. A new WHO report on health literacy, published on Nov 6, advances this approach for non-communicable diseases, but its lessons apply across health care. The report calls for co-designed approaches, whereby the voices of users and of those who deliver interventions are incorporated into the design of the services. To deliver these services and make the health-care system more user friendly and accessible, front-line health and social workers must be better trained to engage and interact with the populations they serve. The report also calls for an integrative approach to develop health literacy interventions that involve a range of community-based organisations—not just medical centres—including schools, churches, sports groups, and workplaces. For example, health literacy programmes should be introduced in childhood and should be part of school curriculums. They should be designed and adapted to the needs of individual communities, through the involvement of local students and teachers. Ensuring health literacy must be a whole-of-society endeavour—at the individual, community, and national level—and work across sectors, not just health.
This approach is right, but the WHO report glosses over fundamental challenges to this vision of health literacy; in particular, the commercial determinants of health—ie, the corporate influence on health behaviours. The private sector sets research agendas, shapes narratives, and markets its products in ways that compromise health literacy, not only by misleading individuals, but also by fostering unhealthy communities and societies. The most egregious examples come from the manufacturers of tobacco, alcohol, and junk food. Over the past five decades, the tobacco industry has actively given false information and used its power to increase profits, regardless of the consequences to health. Health-care stakeholders have often struggled to amplify their voices over the messages of the private sector. Alongside this challenge is the rise of misinformation, particularly on social media. False information, spread regardless of the intent to mislead, can leave people in a state of epistemic helplessness. Even the most rational individual cannot make sensible, healthy decisions when bombarded with incorrect information. How can people, families, and communities know which sources of information to trust amid contradictory advice? How can WHO and other health stakeholders ensure that their information is the source that is amplified and used? How can health literacy be achieved in a world awash with false and misleading information?
We urgently need effective responses to these questions. Every person has a right to health. The ability to realise that right depends on everyone understanding their health, being able and empowered to make healthy choices, and being able to access effective interventions. Without understanding the ways that neglected communities learn, more people will be left behind. Most importantly, policy makers need to understand health literacy and how their decisions will impact different populations. A whole-of-society approach to health literacy is needed to remedy these issues. But it will be doomed to failure if it does not account for and address the fundamental drivers of what shapes our understanding of health and what makes our societies unhealthy in the first place—not least, the commercial determinants of health.