From Competence to Community: What’s Health Literacy Got to Do with It?

This year’s CBRC Summit theme was about health literacy: “the ability to access, comprehend, evaluate and communicate information—as a way to promote, maintain and improve health— in a variety of settings, across the life-course”. According to PHAC, an estimated 55% of working age adults and 88% of adults over 65 have less than adequate health literacy.

Poor health literacy often translates to poor health outcomes and is usually correlated with a range of other social determinants such as stigma, poverty, and racism. So, does it make more sense to target literacy or the social factors?

Existing research about health literacy and gay men is scant. The Summit’s keynote Paul Flowers’ work (2013) looked at sexual health knowledge and testing among gay men in Scotland. Results indicated that more attention was needed to improving gay men’s sexual health literacy.

In Quebec, researchers studying LGBT health websites found that 2/3 of users believed that online information was useful and easy to understand. However, they found certain content underrepresented, especially mental, emotional, and social health. Regrettable for the 40% of study participants who were troubled by mental health issues (Lévy et al., 2009).

In Switzerland, researchers investigating mental health literacy among gay men found that while respondents were able to identify feelings of depression, their trust in medicines, knowledge of alternative therapies, and use of social supports were low (Wang et al., 2014).

As a primer for further work in health literacy, I draw upon global health scholars Donald Nutbeam (2000) and Ilona Kickbusch (2001) to provide an overview of three approaches to health literacy: functional, interactive, and critical. While each have different strengths, exploring health literacy as an approach to gay men’s health, I suggest, eventually turns the conversation back to health equity.

Functional literacies

Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (National Institute of Medicine, 2004)

Developed and practiced in the US, functional literacy focuses on improving patient decision-making, medication adherence, and self-management of disease. Taking a deficit approach framing poor health literacy as a ‘‘risk’’, questions we might ask include:

  • Can patients read and understand consent forms?
  • Can they act on the information given to them by care providers?
  • Can they make appointments and follow treatment schedules?

While these represent baseline capacities that provide targets and goals for service providers, one concern is its narrow focus. Is health literacy only important once we become patients? How might we be able to use it to enhance overall health and wellness?

Interactive literacies

Health literacy has been defined as the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health (WHO, 2009)

Developed from health promotion approaches and practiced in Canada, UK and Australia, interactive models go beyond the ability to read pamphlets and make appointments. Taking an ‘‘asset-based’’ approach emphasizing individual empowerment, interactive literacies construct health as a process where knowledge and skills intersect. In this way of thinking, we might ask:

  • Do people have the skills to actively and fully participate in their own health?
  • Are they well-positioned to exert a higher degree of control over everyday events?

In contrast to functional perspectives, interactive ones place health literacy on a continuum, framing health as a lifestyle issue that all of us can work toward. While empowering individuals is important, this model underemphasizes the importance of social change in improving community health.

Critical literacies

Education either functions as an instrument which is used to facilitate integration of the younger generation into the logic of the present system and bring about conformity or it becomes the practice of freedom, the means by which men and women deal critically and creatively with reality and discover how to participate in the transformation of their world.” (Freire, “Pedagogy of the Oppressed”)

Treating indigent learners as co-creators of knowledge through dialogue, Brazilian educator Paulo Freire (1970) used literacy to make a difference in the world of marginalized peoples. The critical educator acts as facilitator, raising consciousness about the political nature of everyday life. The legacy of Freire’s “critical literacy” is embedded in the history of community HIV/AIDS activism, where citizen engagement in controlling a health crisis was born of necessity.

Kickbusch (2001) borrows from the work of philosopher Martha Nussbaum, suggesting that we should shift from a functional to a capabilities approach. This approach asks:

  • How is health knowledge created and shared within a community?
  • How easy is it to access or deploy the health resources of the community?
  • What defines the dominant health culture of the community?

Health equity

Critical approaches to health literacy are important because the understandings of literacy as functional, interactive or critical differ in their intents and outcomes. Consider how social inequities influence health decision-making, for example, in the following scenarios:

Income: Paul is a single man in his 50’s who must deal with acute side effects associated with his cancer treatment regime. He is on a fixed income and his insurance does not cover medications for side effects. Given his situation, what does he do?

Health Services, Geography: Christopher is a young man who lives in rural Manitoba, three hours away from a gay-friendly service provider. He finds himself in a situation where he needs to access PEP. How might time and distance affect how quickly he is able to access care, and his decision to get treatment?

The images below illustrate the crux of the problem. While the first suggests that we simply need to give everyone the same skills, the second suggests that we must first compensate for the barriers people are facing before we can get there.

Image credit: United Way of Columbia-Willamette

As we move forward, considering these diverse perspectives will help us better understand the best ways that we can continue to support the health and well-being of gay men’s communities.

Maggie MacAulay is a PhD Candidate in the School of Communication at SFU. Her research interests are in health, the Internet, gender/sexuality, and science and technology studies. Her in-progress dissertation is a qualitative study of gay men, HIV prevention, and the Internet in Vancouver and San Francisco. Her hobbies include yoga, aquafit, and riding her scooter, Rhonda the Honda. She tweets at @magsmacaulay.

Further Reading:
Flowers, P., McDaid, L. M., & Knussen, C. (2013). Exposure and impact of a mass media campaign targeting sexual health amongst Scottish men who have sex with men: an outcome evaluation. BMC Public Health, 13(1), 737.

Freire, P. (1970). Pedagogy of the oppressed. New York: Herder and Herder.

Kickbusch, I. S. (2001). Health literacy: addressing the health and education divide. Health Promotion International, 16(3), 289–297.

Lévy, J. J., Ryan, B., Thoër, C., Léobon, A., & Dumas, J. (2009). Internet-based health promotion programs for sexual minorities in Canada: A study of the components, objectives and future developments. Retrieved from

Nutbeam, D. (2000). Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259–267.

Wang, J., Häusermann, M., & Weiss, M. G. (2014). Mental health literacy and the experience of depression in a community sample of gay men. Journal of Affective Disorders, 155, 200–207


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Community-Based Research Centre (CBRC) promotes the health of people of diverse sexualities and genders through research and intervention development.
From Competence to Community: What’s Health Literacy Got to Do with It?
From Competence to Community: What’s Health Literacy Got to Do with It?
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