The Nexus Between Health Literacy and Empowerment

The aim of this article was to explore what is known about the assumed connection between health literacy and empowerment and how this connection is portrayed in the scientific literature. If empowerment is an outcome of health literacy, what are the mechanisms behind this process? A literature search conducted in 2013 yielded 216 hits, of which five met the inclusion criteria, and thus were read in depth and analyzed through a narrative-review approach. The findings indicate that health literacy might be regarded as a tool for empowerment but does not automatically lead to empowerment. Health literacy might be increased by health education. Crucial for empowerment is to achieve the critical level of health literacy including an ability to question and reflect on the prevailing power relations and societal conditions; increased senses of power, self-esteem, and self-efficacy; and an ability to utilize these resources to engage in social and political action for change. This article suggests that for health literacy to be critical to empowerment, there must be a focus on social health determinants and individuals’ subjective perceptions of health and health needs. The article proposes functional and interactive health literacy as a form of capacity building for health and empowerment and critical health literacy as a way to describe empowerment. This scoping review indicates a research gap and a need for future research examining the relationship between health literacy and empowerment.


Introduction
In the late 1980s, Wallerstein and Bernstein (1988) suggested that powerlessness is related to disease, whereas empowerment is related to health. Later, several studies confirmed this connection between empowerment and improved health outcomes (Wallerstein, 2006). A concept often seen in connection with empowerment is health literacy. Health literacy has been pointed out as a stronger predictor of health status than age, ethnic background, and socioeconomic status (Speros, 2005). Two main approaches to health literacy have been identified: a functional (individualistic) view and a dynamic, broader view encompassing the individual's social and cultural context (Mårtensson & Hensing, 2012). According to Nutbeam (2000), many health interventions fail because they mainly focus on health education and health communication, neglecting the importance of social and economic conditions. Rather than individual behaviors, attention should be given to personal forms of communication and the social determinants of health. Health literacy has been claimed to have a crucial impact on empowerment (Mårtensson & Hensing, 2012) through " . . . improving people's access to health information and their capacity to use it effectively . . ." (Nutbeam, 1998, p. 357). Still, an examination of what constitutes the relationship between the two and why empowerment might arise as an outcome of health literacy is missing from the literature. With an improved knowledge and understanding of the mechanisms underlying the connection between health literacy and empowerment, health initiatives and projects might have greater chances for success. The aim of this study is to visualize and analyze what is known about the assumed connection between health literacy and empowerment and how this connection is portrayed in the scientific literature. If empowerment is an outcome of health literacy, what mechanisms underlie this process?
Health Literacy Olander, Ringsberg, and Tillgren (2014) claim health literacy being a dynamic concept that has led to a development of a whole spectrum of health literacy definitions with different focus and meanings. The concept of health literacy derives 646410S GOXXX10.1177/2158244016646410SAGE OpenCrondahl andEklund Karlsson research-article2016 1 Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark from the word literacy, basically meaning being knowledgeable and educated (Sørensen et al., 2012). According to Sørensen et al. (2012), health literacy . . . entails the knowledge, motivation and competency to access, understand, appraise and apply health information to form judgment and make decisions in terms of healthcare, disease prevention and health promotion in terms of maintaining and promoting quality of life throughout the life course. (p. 3) The definition is adaptable, and by altering "health care, disease prevention, and health promotion" to "being ill, being at risk, and staying healthy," it encompasses an individual rather than a public health perspective. Health literacy is about the understanding of the determinants of health and the knowledge of how to handle them and how to place the health of the individual, family, and community in context. A health-literate person has the ability to take responsibility for both his or her own health and for the health of his or her family and community (Nutbeam, 2000;Sørensen et al., 2012). According to the World Health Organization's (WHO) definition of health literacy (Nutbeam, 1998), health literacy represents 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. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment. (p. 357) With this health-promoting foundation, health literacy is considered as more than just the ability to read written material and as crucial to empowerment (Nutbeam, 1998). Nutbeam (2000) states that increasing health literacy requires a reconceptualization of health education. Rather than individual behavioral factors, emphasis should be placed on the social, environmental, and economic determinants of health.
The conceptualization of health literacy as an asset means that health literacy is partly knowledge-based and can be developed through training (Nutbeam, 2008). The lowest level of health literacy, the basic/functional level (the abilities to read and write and to understand health information), is usually taught in primary school (or adult education). The higher levels of health literacy-the communicative and critical levels-are developed through continuous learning in different contexts and learning processes (Nutbeam, 2000).
Health literacy includes the orientations, attitudes, norms, and values that affect peoples' perceptions of health and disease (Abel, 2007). Lay knowledge regarding health and welfare, everyday experiences, and social engagement in broader health issues are essential (Abel & Bruhin, 2003). However, health literacy may take on different forms in different contents and contexts (Smith, Nutbeam, & McCaffery, 2013), developing over time as a dynamic continuum (Mårtensson & Hensing, 2012). A thorough analysis of European translations of "health literacy" (Sørensen & Brand, 2014) revealed that health literacy has yet to be regarded as a mainstream concept and that the various translations are influenced by underlying understandings of "literacy" as connected to "life skill," "functional literacy," and "competency." It was claimed that the choices that were made during the translation process affect the context in which the concept is applied. These perceptions may influence the discourse and agenda setting regarding health literacy and the application and integration of the term in European practice, policy, and research (Sørensen & Brand, 2014).

Empowerment
The roots of empowerment derive from the social action ideology of the 1960s and the self-help perspectives of the 1970s. Pioneering was Paolo Freire's (1996) work with the oppressed and illiterate adults in the slums of Brazil. With his consciousness raising, dialectic approach, and the proposal of a democratic problem-posing education, he paved the way for the bottom-up perspective which has come to be an essential characteristic of empowerment. A thorough review of the origins and early practices of empowerment, development of definitions, and theories of empowerment can be found, for example, in Eklund (1999).
Empowerment is to have the power and strength to fight oppression, gaining control over one's own life and the lives of one's groups and/or communities (Askheim, 2007). Empowerment is about initiating processes and activities, facilitating self-control, improving knowledge and skills, and strengthening self-esteem and self-image. Essential in this process is an increased awareness of the societal conditions holding people down and of the possibility of changing these conditions. The absence of empowerment might manifest as powerlessness and/or learned helplessness or as a general feeling of not having control over one's own life (Rappaport, 1984). According to Rappaport (1984), the absence of empowerment is easier to define than its presence, as empowerment is not a set state and thus might look different in different contexts and for different people. Therefore, the outcome of empowerment may vary. In addition to being an outcome, empowerment has been considered as a process (Rappaport, 1984;Tengland, 2008). Empowerment cannot be given from one person to another but must emerge from within (Laverack, 2007). Rappaport (1985) described empowerment in terms of psychological empowerment, encompassing the individual's beliefs in his or her own competencies, efficacy, and involvement in activities aimed at gaining environmental, political, and societal control. Accordingly, an empowered person is able to critically analyze political and social circumstances, enabling engagement in political and social action for change (Rappaport, 1985). Psychological empowerment, also called individual empowerment, includes a personal will and desire for change, along with a sense of connectedness to others and a concern for the common good (Zimmerman & Rappaport, 1988). Hence, Zimmerman and Rappaport (1988) claim that empowerment might be described in positive terms and not only as the absence of empowerment (powerlessness and helplessness). According to Zimmerman and Rappaport, empowerment is composed of personality, cognitive, and motivational aspects of personal competence and control. Israel, Checkoway, Schulz, and Zimmerman (1994) argued that to enhance people's impact and control over their lives, consideration must be given to the social, cultural, historical, economic, and political contexts in which they live.

Method
This study is a literature review. According to Arksey and O'Malley (2005), there is no single ideal method for conducting literature reviews. Rather, each of the various methods offers a set of tools. The purpose of the review was not to obtain a detailed and rigorous answer to a focused question but to acquire a better understanding of a phenomenon. Therefore, a scoping literature review was chosen to provide a broad perspective on the topic being reviewed (Arksey & O'Malley, 2005). Unlike systematic reviews, scoping reviews do not assess the quality or design of the included studies and thus may include studies with various approaches. According to Arksey and O'Malley, there are four main reasons for undertaking scoping reviews: examining the nature, extent, and range of research activity; determining whether a full systematic review would be valuable; summarizing and disseminating research findings; and revealing research gaps in the existing literature. The latter two were the goals of this literature review. As Arksey and O'Malley state, the identification of research and evidence gaps is essential and might lead to the undertaking of full systematic reviews.
The literature search was conducted from October to December 2013 using the electronic databases ERIC (via EBSCOhost; Academic Search Elite, ERIC, MEDLINE, CINAHL), PubMed, and Social Sciences Abstracts (SSA; PsykInfo, PsycARTICLES, Sociological articles) ( Figure 1). The keywords were empower* and "health literacy." Although the quotation marks were intended to ensure that only articles containing the whole term "health literacy" would appear in the results, the search engines also retrieved hits on the separate words "health" and "literacy." The initial inclusion criteria were that the articles should be peer reviewed, published in English, and available in full text and that they should include both keywords in the abstracts. In addition, the connection between health literacy and empowerment should be discussed in the abstract. In accordance with the form of scoping reviews, the inclusion criteria did not exclude any studies because of their study design or quality but included all relevant literature (Arksey & O'Malley, 2005). As the concepts are relatively new, no time limitation was used, resulting in matches from 1992 to 2013.
The first search on the keywords yielded a total of 216 matches (ERIC via EBSCOhost: 78, PubMed: 93, Social Sciences Abstracts: 45), although after duplicates were eliminated, 101 abstracts met the initial inclusion criteria. In reading the abstracts, in addition to the initial inclusion criteria, emphasis was placed on identifying articles that addressed the research question concerning what constitutes the relationship between health literacy and empowerment and/or the mechanisms that may causally connect health literacy to empowerment; however, no abstract met all of the inclusion criteria. Arksey and O'Malley (2005) argued that the process of a scoping review is iterative rather than linear. The researchers must be reflexive throughout the process, adjusting and repeating steps if and when necessary. Thus, an additional search was performed in EBSCOhost to check whether searching the body of the text and not only the abstract would yield more hits. This search applied the same inclusion criteria to detect papers that addressed the question other than as the main objective. This search resulted in 202 additional hits, but after closer examination, these articles were excluded as not meeting the inclusion criteria. The initial 101 hits were read in full to search for any content that might help in answering the research question, resulting in 78 excluded articles and 23 to be read in depth. The literature search indicated a lack of scientific papers addressing the connection between health literacy and empowerment. Thus, in reading the 23 papers, the only inclusion criterion was that the articles must explicitly mention any connection between health literacy and empowerment. Five articles were relevant to analysis through a narrative approach (Arksey & O'Malley, 2005).

Findings
The literature search did not reveal any articles explicitly addressing how health literacy and empowerment are connected; however, five articles (Mogford, Gould, & DeVoght, 2011;Nutbeam, 2000;Porr, Drummond, & Richter, 2006;Schulz & Nakamoto, 2013;Sykes, Wills, Rowlands, & Popple, 2013) were identified that address both health literacy and empowerment (Table 1). Nutbeam (2000) was a frequently used reference within the field of health literacy and was also used as the starting point of the analysis in the other four articles.
According to Nutbeam (2000), empowerment is the ultimate goal of health literacy. The concepts of health literacy and empowerment are regarded as distinct but closely connected through knowledge, skills, and power dimensions (Schulz & Nakamoto, 2013), yet the one does not automatically lead to the other (Porr et al., 2006;Schulz & Nakamoto, 2013). A person might have adequate skills and understanding (health literacy) yet lack power and the motivation to take control (empowerment) (Schulz & Nakamoto, 2013). Likewise, a person with the motivation and power (selfesteem and control) to behave and act according to his or her own decisions does not necessarily have the skills or knowledge required to do so. Porr et al. (2006) consider that the mediating effect of empowerment may be found in progressive levels of literacy and social and personal skills. As the authors view the issue, the important factors in the process are the individuals' competences and self-efficacy, along with critical thinking and reflection. Furthermore, health literacy is perceived as an educational tool to be used not only to empower but also to inform and enlighten individuals and communities (Mogford et al., 2011). A concept analysis identified critical health literacy as resembling empowerment (Sykes et al., 2013). Key attributes of critical health literacy were a.o., health knowledge, and advanced personal skills, for example, confidence, self-efficacy, and empowerment. Inconsistencies among practitioners, academics, and policy makers in how the concept is understood were also revealed. Sykes et al. (2013) were not able to identify any research demonstrating the consequences of critical health literacy; rather, their analysis showed that policy makers and professionals anticipated improved outcomes in relation to self-efficacy, personal participation, action and control over health issues, self-management of care, and shared decision making. Public health sources identified more consequences of critical health literacy, including political action and empowerment, whereas the medical literature tended to focus on health-related behaviors and the use of services.

Discussion
Although the connection between health literacy and empowerment has been acknowledged in the literature, to date, this connection has neither been verified by empirical data nor questioned and discussed in detail. Neither a systematic literature review identifying 17 different definitions on health literacy (Sørensen et al., 2012) did relate health literacy to empowerment in any new way. The purpose of this scoping review was to examine what is known about the nexus between health literacy and empowerment and the mechanism by which empowerment may emerge as an outcome of health literacy. The review, however, could not identify any articles describing this issue (Mogford et al., 2011;Nutbeam, 2000;Porr et al., 2006;Schulz & Nakamoto, 2013;Sykes et al., 2013).
The concepts of health literacy and empowerment have nonetheless been debated among researchers. Some have described health literacy as a way of "putting new wine in old bottles" (Tones, 2002, p. 289). Others have considered it as "some repackaging of established ideas concerning the relationship between education and empowerment" (Nutbeam, 2000, p. 265). As stated above, even though health literacy has been claimed to be crucial to empowerment (Nutbeam, 1998), the underlying mechanisms are yet to be described.
The problem addressed by Nutbeam (2000) regarding the lack of success of many health interventions might be viewed in relation to the individualistic perspective to health literacy that does not encompass the broader aspects of social, cultural, and economic conditions in the lives of people and/or their communities. Because of the focus on individualistic and behavioral aspects, the subjective perception of health is neglected. Thus, there is a risk that the health interventions will not be focused on the health issues as perceived by the individual/group/community in question but rather on the health issues presumed to exist from a "top-down" perspective. For people who lack basic needs, such as food, shelter, safety, a sense of worthiness, equality, belonging, and so on, a focus on individual health behaviors is a waste of resources; the problems they face in their everyday lives extend far beyond the negative effects of bad eating habits and smoking.
We suggest that for health literacy to be critical to empowerment, it must encompass the social determinants of health with an emphasis on the individuals', groups', and/or communities' subjective perceptions of health and health needs (Crondahl & Eklund Karlsson, 2015). Such a perspective will build on the genuine needs of the people involved. Hence, health literacy is about capacity building. This formulation is in line with the definition of Nutbeam (2000) and the WHO (Nutbeam, 1998): Health literacy represents 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 . . . By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment. (p. 357, emphasis added) According to Nutbeam (2000), health literacy is just a new way to talk about empowerment and education. We argue that what Nutbeam (2000) describes as functional and interactive health literacy is another label for capacity building To introduce an alternative health education curriculum as a means of action on the SDOH to achieve health equity.
Theoretical article describing a four-part curricular framework for teaching critical health literacy, providing examples of activities and actions conducted by the participants.
• • HL is an educational tool that can be used to empower, inform, and enlighten individuals and communities. Individuals and communities that both understand and have the skills to act upon the SDOH are more likely to take action at the policy and community levels. In this process, empowerment is an essential step. • • Successfully teaching Nutbeam's three-level CHL will lead to empowerment. CHL is a key step in empowering people for health equity.
HL as active tool/E as HL outcome Nutbeam, D. (2000). for health and empowerment. Critical health literacy might be considered another way to describe empowerment. Hence, health literacy might be regarded as a tool for empowerment (Crondahl, 2015;Crondahl & Eklund Karlsson, 2015;Eklund Karlsson, Crondahl & Ringsberg, 2016). Similar to Schulz and Nakamoto (2013) and Porr et al. (2006), we do not consider health literacy to automatically lead to empowerment. Health literacy as such might be increased by health education; the critical point is that health literacy must evolve to higher levels of critical consciousness, including questioning and reflecting; a sense of power, self-esteem, and self-efficacy; and an understanding of how to make use of all available resources to engage in social and political actions. We consider people empowered when they have reached this state of consciousness and engagement.

Limitations of the Study and Implications for the Future
That only five articles were identified as mentioning a relationship between health literacy and empowerment might be a result of bias, which possibly could have been reduced through a more systematic search; however, as stated earlier in the article, a systematic literature review was not considered the most appropriate approach for this study. Assuming that a scoping review was a suitable method for this study, the identification of only five relevant papers is an important finding, indicating a gap in the literature and the need for future research examining the relationship between health literacy and empowerment. Furthermore, one implication of the small sample was that out of the five reviewed articles, four were based on the same theoretical underpinnings of health literacy, Nutbeam (2000); this article was also one of the five reviewed articles. Moreover, the fifth article, the concept analysis by Sykes et al. (2013), represented only a U.K. perspective. Sykes et al. still claim that the study likely presents the use of the concept in policy and discourse. This claim is doubtful; a thorough examination of European translations of "health literacy" (Sørensen & Brand, 2014) concluded that health literacy has yet to be regarded a mainstream concept and that the various translations were affected by different underlying understandings of "literacy." Sørensen and Brand (2014) claim that this difference might influence the discourse and agenda setting regarding health literacy, affecting the application and integration of the term in European practice, policy, and research. Likewise, we argue that an additional limitation of this study is that it includes only articles written in English. Thus, the study does not necessarily include all the various discourses on the concept of health literacy or empowerment. Thus, further systematic review is needed.