The Interconnected Role of Communication and Health Literacy in Public Health

Health promotion, defined as “the process of enabling people to increase control over and to improve their health” ¹, highlights the fundamental role of communication and health literacy as essential components in empowering individuals and populations. They serve as crucial pillars of public health, closely tied to the promotion of well-being, health protection, and the reduction of inequities ².

Health literacy was defined in 1998 by WHO and it “implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions.” Thus, health literacy means more than being able to read pamphlets and make appointments. It entails the improvement of people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment. Since its initial definition in 1998, the concept has evolved, leading to the development of various relevant definitions, as well as health promotion strategies ^3-5.

Given the Society for Health Communication’s definition, which characterizes health communication as “the science and art of using communication to advance the health and well-being of people and populations,” it becomes evident that health communication is a “multidisciplinary field of study and practice that applies communication evidence, strategy, theory, and creativity to promote behaviors, policies, and practices that advance the health and well-being of people and populations.” Taking this comprehensive perspective into account, health communication involves cognitive interventions aimed at facilitating the improvement of individuals’ and populations’ health. The ability to comprehend and apply health information is a fundamental aspect of health literacy, which can have a significant impact on health behaviors and outcomes ^6,7.

While there is a substantial body of evidence underscoring the significance of communication and health literacy in healthcare ^2,6,8, it is imperative to emphasize their practical applications in both individual and population-based healthcare approaches. The practical implications are far-reaching, encompassing the need for tailored patient education, culturally sensitive communication, and strategies that address health disparities. Additionally, it is crucial to recognize the challenges that can limit individuals’ health literacy, such as access to information, provider-patient dynamics, and the influence of social determinants of health. This was further shown in two studies that utilized the European Health Literacy Questionnaire, validated for the Portuguese population, which allowed us to understand the specific vulnerable groups with the most limited health literacy in Portugal: those with lower incomes; lower educational levels; greater self-perception of their health as bad; those that utilize healthcare services multiple times, hospitalized patients, premature deaths, or the most illiterate populations ^9,10.

Importance of Health Literacy Promotion

Health literacy is crucial in empowering citizens and providing them with autonomy regarding their own health. It does so by providing individuals with new knowledge, greater self-efficacy, and positive health attitudes and behaviors, all of which contribute to better health outcomes ^6,8. Low health literacy, on the other hand, can directly affect an individual’s health, limiting personal and social development, as well as education, income, housing, transportation, and many other factors, accounting for a biopsychosocial view. It is closely related to negative health outcomes, worse disease management, lower adherence to medication, and overutilization of health services. This, in turn, can lead to rising hospitalization rates, morbidity, and premature death ^8,11. Low health literacy is also associated with lower comprehension of how health services operate, disregard for disease prevention, and a higher risk of chronic diseases, such as cardiovascular diseases and cancer ¹². Conversely, higher levels of health literacy are associated with better health outcomes, higher levels of well-being, better utilization of health services, active and informed participation in healthcare, lower healthcare expenditures, and a reduction of health inequities ^2,10.

Recent data have shown a positive trend in health literacy levels in Portugal ¹³, which is attributed to investments in health planning, policies, and customized communication strategies ¹⁴. Despite this, the same studies show that the navigability within Portugal’s health system has also been shown to be one of the worst in Europe. The inability of individuals with low health literacy to navigate the health system reinforces the importance of health communication in health literacy strategies. The COVID-19 pandemic also underscored the need for clear, accessible, and trustworthy health information. It highlighted the significance of adapting communication strategies to rapidly changing circumstances and addressing misinformation. Moreover, it demonstrated the pivotal role that health literacy plays in promoting public health and informed decision-making ^15,16. The lessons from the pandemic emphasize the urgency of sustained efforts to enhance health literacy and communication in healthcare, both in Portugal and worldwide. As such, it is of utmost importance to promote health literacy in both national and local health plans, as well as invest in capacity building among health professionals to be agents for public health literacy.

Communication in Health: Boosting Health Literacy

Considered a key factor in promoting health literacy, communication is an instrument that empowers individuals to access, understand, and utilize health information for making informed decisions about their well-being. However, it is essential to note that health communication extends beyond its association with health literacy to inform, influence, and enhance health-related knowledge and decisions. While person-centered care is often viewed as individual interactions between healthcare professionals and patients, health institutions have a responsibility to facilitate person-centered communication, using communication strategies to inform and influence individual and community decisions that enhance health ^17,18. This includes creating health messages and campaigns, developing educational materials, and improving organizational culture, while engaging with the audience or stakeholders through communication, to help understand and sustain newly adopted behaviors and practices, with the goal of increasing knowledge and understanding of health-related issues and improving the health status of the intended audience ¹⁹. It is also important to educate the population about how to access and use health information, which requires healthcare professionals to have strong communication skills, emphasizing people interaction ^18,20, as these are essential in promoting health literacy among the population ¹.

When it comes to risk communication, it is of utmost importance to disseminate information about individual and population-based health risks ²¹. Effective communication is key to improving the health of a population, particularly when health information is difficult to understand or not tailored to the needs of the population. In such situations, confusion and hopelessness can arise, hindering informed decision-making ¹⁶.

Citizens are increasingly expected to take an active role in managing their own health ^2,15. Making informed decisions about health requires access to understandable, accessible, and relevant information that is tailored to their needs and sociocultural context. Although healthcare professionals are often seen as reliable sources of health information ⁸, the proliferation of health information on social media and the internet means that other sources are now widely available. In this digital era, the competencies needed to engage with health and wellbeing are becoming increasingly complex, including not only health literacy and digital literacy but also social determinants of health ²². Social determinants of health refer to the social, economic, and environmental conditions in which people live that can have a significant impact on their health and well-being. These determinants can include factors such as income, education, employment, housing, access to healthcare, social support networks, and exposure to environmental hazards. By addressing social determinants of health and promoting health literacy and effective health communication, we can work toward reducing health disparities and improving health outcomes for all individuals, regardless of their background or circumstances ²³.

Communication in Health: New Challenges

The COVID-19 pandemic has highlighted the importance of health communication and presented new challenges for health professionals and institutions, making it increasingly necessary to create transparent and effective health communication strategies ²⁴. One of the main challenges is the infodemic, which includes misinformation, disinformation, and fake news, exacerbated by the current digital era, especially social media. Even opinions expressed by influential individuals or opinion makers may require clarification as they must be based on scientific evidence. These challenges make it crucial for health professionals to act and communicate efficiently, clarifying and aligning scientific messages with the best evidence for the population ^6,13,24.

Therefore, the health sector needs to adapt to the new digital reality by equipping multidisciplinary teams with new competencies and strategies that not only consider the current situation but also incorporate monitoring and adaptation of conveyed information ²¹. This ensures equitable information transmission for everyone and leaves no one behind. Finally, the most challenging task is to achieve person-centered health communication by actively listening to individuals’ real needs and searching for effective solutions that empower both individuals and populations ¹⁷. Communication emerges as a central element in the dimensions of health literacy, playing a crucial role in translating knowledge into health-promoting behaviors and well-being. Table 1 provides a summary of these new challenges and points to some opportunities to improve communication in health literacy.

Table 1 Summary of challenges and opportunities of communication in health literacy