Gellert & Tille health knowledge and health literacy

original article

What do we know so far? The role of

health knowledge within theories of
health literacy
Paul Gellert Health knowledge has referred to as functional HL), broader definitions
Charité Universitätsmedizin been linked to health for instance by the WHO (1998) describe HL as
Berlin literacy (HL) frequently, “the cognitive and social skills which determine
Florian Tille yet the role of health the motivation and ability of individuals to gain,
National Association of knowledge remains to access, to understand, and to use information
Statutory Health Insurance theoretically inconclu- in ways which promote and maintain good
Physicians sive and empirically health” (comprehensive HL).
understudied. A sele- Part of this disaccord between the various
ctive overview on the role of health knowledge definitions of HL concerns health knowledge in
within HL theories is presented. Three existing relation to HL. Though health knowledge has
reviews of HL theories have been inspected with been typically treated as an outcome of functional
regard to the role of health knowledge within HL (Berkman, Sheridan, Donahue, Halpern, &
these reviews. Summarising the reviews, health Crotty, 2011; Berkman, Sheridan, Donahue,
knowledge is conceptualised either as an Halpern, Viera, et al., 2011) in HL theories the
antecedence, a dimension HL, or a consequence position of health knowledge is mixed. Health
of HL. The present paper argues that there is a knowledge serves either as an antecedence (e.g.,
need for disentangling health knowledge from HL von Wagner, Steptoe, Wolf, & Wardle, 2009), as
and other sub-concepts to develop a clear and an integral dimension of HL itself (e.g.,
shared language on what is meant by HL and how Freedman et al., 2009), or as a consequence of HL
these sub-concepts are interrelated. This might (e.g., Speros, 2005).
open a road to better conceptualise, measure, and What does health knowledge mean exactly?
ultimately alter health knowledge, HL, as well as Health knowledge denotes facts, information,
health outcomes. and skills acquired through experience or
education, as well as the theoretical or practical
understanding of a subject related to health and
Health literacy (HL) and health health-care (Chin et al., 2011). Schulz and
knowledge Nakamoto (2005) further subdivide the concept
into declarative health knowledge (factual
There is a clear association of low HL with knowledge related to health issues, e.g. to
inefficient use of health-care services and identify symptoms of an health condition),
adverse health outcomes (Berkman, Sheridan, procedural health knowledge (‘know-how’ to
Donahue, Halpern, & Crotty, 2011). Less clear is apply factual knowledge and use health
the definition of HL itself (Martensson & information in a specific context), and judgment
Hensing, 2012). While narrow definitions refer to skills (the ability to judge based on factual
HL as the ability of reading, writing, and knowledge necessary to deal with novel
numeracy in the health-care setting (usually situations). In their model, the authors define

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Gellert & Tille health knowledge and health literacy

functional HL skills as a possible antecedence of into the role of health knowledge, four of the
the acquisition of health knowledge (Schulz & theories which have been reviewed
Nakamoto, 2005). conceptualised health knowledge as a dimension
Empirical studies have examined the relation of HL. Eight theories named increased health
of health knowledge and HL. For instance, knowledge as a consequence of increased HL.
disease-specific health knowledge in relation to Although five theories named education as a
HL was reported on hypertension and diabetes predicting factor explicitly, only four of the
(Williams, Baker, Ruth, & Nurss, 1998), chronic models referred to health knowledge as an
pain (Devraj, Herndon, & Griffin, 2013), oral antecedent of HL. Sørensen et al. summarise the
health (Hom, Lee, Divaris, Baker, & Vann, 2012), 12 theories by conceptualising health knowledge
and HIV (Ciampa et al., 2012). as a dimension of HL next to competencies and
motivation.
Frisch et al. (2012) took an explicit focus on
Health knowledge within systemic health knowledge within their review of literacy
reviews on HL theories theories. They reviewed 863 articles on other
literacy domains (e.g. media literacy and
Three recent systematic reviews on HL information literacy) on the existence of sub-
theories (Frisch, Camerini, Diviani, & Schulz, concepts of literacy to inform HL theories,
2012; Martensson & Hensing, 2012; Sørensen et detecting functional literacy, factual knowledge,
al., 2012) are inspected on the role of health and procedural knowledge among the most
knowledge within HL theories. frequently named sub-dimensions of literacy.
Martensson and Hensing (2012) narratively
reviewed 200 articles (including books, policy
documents, and dissertation abstracts) on HL Process models of social cognitions
theories. Based on this narrative review we could in relation to HL and health
not identify the role of health knowledge clearly, knowledge
as descriptions of the single theories were
presented without any detail. Authors solely HL and health knowledge have also been
classified the articles and documents into two incorporated into process-oriented social-
broad categories that they labelled ‘HL as a cognition models – see Nutbeam (2008), von
polarised phenomenon’ (most similar to Wagner et al. (2009), and Baker et al. (2006).
functional HL) and ‘HL as a complex Nutbeam’s (2008) model of HL is one of the
phenomenon’ (most similar to comprehensive most cited as well as one of the most
HL). comprehensive ones. HL was defined as a
Sorensen et al. (2012) systematically studied person’s ability to access, understand, and use
and reported on twelve HL theories within health information (comprehensive HL). Three
seventeen articles on HL theories and generated hierarchical HL-levels (functional, interactive,
an integrative model based on their theory and critical) were introduced on an individual,
review. Table 1 summarises the 12 theories and social, and societal level. Prior knowledge was
the role of health knowledge within this theories established as an antecedence of HL (Nutbeam,
(based on the Sørensen et al. paper as well as on 2008). Improved knowledge of health risks and
our re-reviewing of the original papers). Looking health services and compliance with prescribed

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actions were consequences of improved influence health-related actions. Both theories

functional HL. Next to others, improved capacity describe a circular function of health knowledge
to act independently on knowledge was a in relation to HL and beliefs.
consequence of improved interactive HL.
Baker (2006) assumed prior knowledge
(vocabulary and conception of health and health- Knowledge and beliefs about
care) to be influential on functional HL, which consequences
creates new knowledge, positive attitudes,
greater self-efficacy, and behaviour change. Von According to von Wagner (2009), knowledge
Wagner et al. (2009) – similarly to von Wagner et will create beliefs about consequences of acting
al. – conceptualised health knowledge as an on certain health information, which in turn will
antecedence of functional HL, which again is an form an intention to act on that health
antecedent of subsequent knowledge and information. Baker (2006) and Nutbeam (2008)
understanding as a part of the motivational mention knowledge and attitudes next to each
phase of their model. Thereby, knowledge and other without making the type of interrelation
understanding create beliefs and attitudes, which explicit, e.g. whether they influence each other
further – beside system factors and volition – directly, whether they work in parallel, or

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Gellert & Tille health knowledge and health literacy

whether they interact in a certain way. Although or act on health information (e.g. HLS-EU-
not mentioned explicitly an assumed sequence questionnaire). They are easier to administer and
from knowledge to attitudes might be most likely more context- and disease-general. Perceived
in their models. health knowledge measures a person’s beliefs
In some cases, knowledge may work in parallel about to act on knowledge and not knowledge
next to beliefs about consequences. Certain itself. Therefore, it might be worth measuring
knowledge domains, e.g. correct identification of both perceived and actual knowledge as they
disease symptoms or knowing the number of the refer to different entities and might predict
emergency medical service correctly, might be health and health-care independently of each
related to behaviour not via beliefs about other.
consequences or attitudes but more directly The attempt of the present article to
(Dombrowski et al., 2015). In contrast, general disentangle health beliefs and health knowledge,
health knowledge such as knowledge on the link as well as different measures of health
between regular physical exercise and improved knowledge, aimed at contributing to the
health outcomes might work indirectly by clarification of the conceptual overlap between
formation of beliefs about consequences of health knowledge and HL.
exercising regularly which in turn creates Outlook and implications
behavioural intentions. The provision of health information to
increase health is an integral part and often the
very starting point of most interventions
Measures of health knowledge followed by fostering motivation, self-regulation,
and skills, which are critical components to
Perceived knowledge is the belief about promote health behaviour change. Nevertheless,
capacities to have acquired, to get access to, to the provision of information as part of
understand or to apply health information. intervention packages should be guided by health
Actual knowledge is the capability to recognise or knowledge theories and should be tailored to a
recall correct health information. While the first patient’s needs accordingly. Provision may be
one is merely a belief about one’s own capability, considered an interactive act, including an active
the second is a capability itself. Perceived and recipient. Both sides – the individual and the
actual knowledge are interrelated concepts, but it individual’s environment – but also the features
is important to distinguish them on a conceptual and skills of health-care professionals and the
level as well as in terms of measurement. health-care system in providing health literate
Measures of actual knowledge test the knowledge information should be taken into account. In this
based on false and correct answers. They are context, it may be assumed that particularly
context- and disease-specific and therefore hard health literate systems and care providers reduce
to compare across studies and diseases. Although pressure on the individual health-care seekers to
there are few measures of disease-specific health increase health-related knowledge for improved
knowledge tests available (Schulz & Nakamoto, health outcomes, and vice versa.
2005), there is a clear lack of studies examining
the relation of actual health knowledge,
comprehensive HL, and social cognitions. Conclusion
Measures of perceived knowledge refer to the
self-reported perceived capability to understand The aim of the present paper was to shed light

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Gellert & Tille health knowledge and health literacy

on the interrelation of HL and health knowledge. doi:10.1111/j.1525-1497.2006.00540.x

Summarising the views of the role of health Berkman, N. D., Sheridan, S. L., Donahue, K. E.,
knowledge from systematic reviews of HL Halpern, D. J., & Crotty, K. (2011). Low health
theories, most of the theories include health literacy and health outcomes: An updated
knowledge and HL as related concepts. Theories systematic review. Annals of Internal Medicine,
that conceptualise HL in a narrow way, i.e. 155(2), 97-107. doi:10.7326/0003-4819-155-2-
functional HL, mostly refer to health knowledge 201107190-00005
as a consequence of HL. This is in line with Berkman, N. D., Sheridan, S. L., Donahue, K. E.,
systematic reviews focusing on the effects of low Halpern, D. J., Viera, A., Crotty, K., . . .
Viswanathan, M. (2011). Health literacy
levels of functional HL which has been linked to
interventions and outcomes: An updated
low health knowledge. Theories of HL that follow
systematic review. Evidence Report/Technology
a broader, more comprehensive approach of HL
Assessment, 199, 1-941.
conceptualize health knowledge mostly as a
Chin, J., Morrow, D. G., Stine-Morrow, E. A.,
dimension of HL although there is more
Conner-Garcia, T., Graumlich, J. F., & Murray,
variability between theories in their use of health
M. D. (2011). The process-knowledge model of
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motivation, and competencies as key Journal of Health Communication, 16(Suppl 3),
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antecedence as well as consequence of Rothman, R. L., Vermund, S. H., & Vergara, A.
(functional) HL. Nutbeam (2008), Baker et al. E. (2012). The association among literacy,
(2006) and von Wagner et al. (2009) for instance numeracy, HIV knowledge and health-seeking
establish a causal chain from prior knowledge via behavior: A population-based survey of
HL and via acquired knowledge to beliefs and women in rural Mozambique. PLoS One, 7(6),
attitudes. To conclude, health knowledge plays an e39391. doi:10.1371/journal.pone.0039391
important role within theories of HL, though its Devraj, R., Herndon, C. M., & Griffin, J. (2013).
exact position varies across models and Pain awareness and medication knowledge: A
definitions. This largely reflects the health literacy evaluation. Journal of Pain &
inconsistency between different theories and Palliative Care Pharmacotherapy, 27(1), 19-27.
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knowledge might be a step to structuring the Dombrowski, S. U., Ford, G. A., Morgenstern, L.
diversity of HL theories and help us to better B., White, M., Sniehotta, F. F., Mackintosh, J.
E., . . . Skolarus, L. E. (2015). Are there
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