A critical review of population health literacy assessment

BACKGROUND Defining health literacy from a public health perspective places greater emphasis on the knowledge and skills required to prevent disease and for promoting health in everyday life. Addressing health literacy at the community level provides great potential for improving health knowledge, skills and behaviours resulting in better health outcomes. Yet there is a notable absence of discussion in the literature of what a health literate population looks like, or how this is best assessed. DISCUSSION The emphasis in assessing health literacy has predominantly focused on the functional health literacy of individuals in clinical settings. This review examines currently available health literacy assessment tools to identify how well suited they are in addressing health literacy beyond clinical care settings and beyond the individual. Although public health literature appears to place greater emphasis on conceptualizing critical health literacy, the focus continues to remain on assessing individuals, rather than on health literacy within the context of families, communities and population groups. When a population approach is adopted, an aggregate of individual health literacy assessment is generally used. Aggregation of individual health literacy fails to capture the dynamic and often synergistic relationships within communities, and fails to reflect societal influences on health knowledge, beliefs and behaviours. We hypothesise that a different assessment framework is required to adequately address the complexities of community health literacy. We assert that a public health approach, founded on health promotion theories provides a useful scaffold to assess the critical health literacy of population groups. It is proposed that inclusion of community members in the research process is a necessary requirement to coproduce such an appropriate assessment framework. We contend that health literacy assessment and potential interventions need to shift to promoting the knowledge and skills essential for critical health literacy at a societal level. The challenge for researchers is to negotiate the myriad of complexities associated with each concept and component required for this task.