The Calgary Charter on Health Literacy:
Rationale and Core Principles for the Development of Health Literacy Curricula

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• Introduction

• Health Literacy Defined

• Health Literacy for Individuals and Systems

• Rationale and core principles of health literacy curricula development and evaluation

• Authors of this document

• Signatories to this document

Introduction:

In October 2008 The Centre for Literacy of Quebec co-hosted the Calgary Institute on Health Literacy Curricula with Bow Valley College and the Health and Learning Knowledge Centre (CCL). The institute drew participants and presenters from Canada, the United States, and the United Kingdom. After three days of discussion, participants concluded that there is a need to identify core principles to underpin new and adapt existing health literacy curricula. One year later, this document formally establishes those principles and urges all individuals building or evaluating health literacy curricula to incorporate the principles into their work.

 Health literacy curricula can address a variety of audiences and a number of goals. For example: 

• health care workers and students to introduce and advance health literacy 
• adult basic education learners for immediate application to daily life
• students in grades K-12 and beyond to improve the health literacy of future generations

We, the undersigned, propose the following definition and understanding of health literacy and a set of core principles for curricula development and evaluation. These principles are intended to support the development of curricula and evaluation tools that improve the health literacy of the public and of those who work in any capacity in health care or related fields.

Health literacy defined:

• Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information.
• Health literacy is the use of a wide range of skills that improve the ability of people to act on information in order to live healthier lives. 
• These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills.

Health literacy for individuals and systems:

 
Improving health literacy can contribute to more informed choices, reduced health risks, increased prevention and wellness, better navigation of the health system, improved patient safety, better patient care, fewer inequities in health, and improved quality of life.

 
The health literacy skills and abilities of individuals contribute to the health literacy of a health service system or organization. For instance, one individual with a high level of health literacy can enhance a system's performance. However, a system or organization that has low health literacy can overwhelm a health-literate individual or diminish the effect of a well-written document. 

 
The health literacy of a society can be improved both by developing the skills of individuals and by lowering the barriers created by health service personnel and systems. Prior definitions have largely identified health literacy as relating to the patient, and have under-emphasized the role of health system personnel. One of the goals of a health literate society is to have a more equal power relationship between those who work in the health system and those who use it.

 
Health literacy applies to all individuals and to health systems. For example:

• An individual can be health literate by using the skills needed to find, understand, evaluate, communicate, and use information. 
• Health care professionals can be health literate by presenting information in ways that improve understanding and ability of people to act on the information.
• Systems can be health literate by providing equal, easy, and shame-free access to and delivery of health care and health information.

 
Health literacy is expressed differently in different contexts, but is always based on the same underlying skills and abilities. Situations in which health literacy is critically important for individual users, health care professionals, and health systems include health system reform efforts, understanding health issues, preventing poor health, communicating complexity, culturally appropriate communication, behavior change efforts, health promotion, and navigation of health systems.

 
Health literacy and communication are related but distinct. Health literacy is the use of a set of skills and abilities. Communication is the process of exchanging information.  Some, but not all, of the skills required for communication, are the same as health literacy skills. For example, a person could have excellent communication skills, but not be very health literate. However, to communicate effectively about health, one would have to be health literate. Both health literacy and communication should be addressed, measured, and evaluated.

 

Rationale and core principles of health literacy curricula development and evaluation:

 
Rationale: Ideally, curricula and associated evaluation tools will be evidence-based. However, because health literacy is a relatively new way to explore the connections among individuals, communities, systems, cultures, and health outcomes, research and evaluation have not yet examined outcomes of interventions in all these areas. Thus, curricula developers, researchers, and evaluators have an obligation to contribute to that evidence base.

While the field of health literacy needs to advance the evidence base about how health literacy leads to better health and how health literacy interventions work, the field knows enough to justify a range of changes to the health care and connected systems.

Principles:

• Health literacy curricula should be based on the current evidence base for health literacy interventions.
• The use and application of health literacy curricula should actively participate in furthering the development of the evidence base for health literacy interventions by using sound methodological approaches to evaluation.

Rationale: Health literacy curricula can be written for all people, regardless of educational level, culture, or literacy skills. All people, not only those with low literacy skills, will benefit from improving the health literacy of individuals, health system personnel, and health systems.

Principles:

• Development and use of health literacy curricula and evaluation/ measurement tools should
• Use a participatory approach by involving the intended audience at all stages
• Be based on, and designed to advance, theory about health literacy.
• Be based on the same underlying understanding of health literacy, even though they may target different health conditions and groups of individuals (e.g. health care professionals or adults with low literacy). This consistency will allow comparison across contexts.

Rationale: Many current health literacy curricula primarily teach health communication or plain language.  Plain language is one means to communicate effectively, but plain language, health communication, and health literacy are not synonymous. Health literacy encompasses much more than plain language, reading, writing, numeracy, and effective communication between health professionals and the public.

• Health literacy includes an awareness of and ability to navigate differences between the cultures of the health system and the public. It also includes an awareness of and ability to minimize the power imbalances between the health system and the public. 
• Health literate health professionals and systems are those that allow and encourage patients to feel welcome and empowered to ask questions, that deliver information in ways that people can use, and that proactively take the steps to prevent ill health and provide treatment to all people in need.
• Health literacy encompasses more than an individual’s literacy skills. A health literate individual possesses some basic knowledge of science and health, an understanding of the health system they are using, and a confidence that they have the right to ask for what they need in order to stay healthy.

Principles:

A health literacy curriculum should:

• Take an integrated approach to the social, cultural, political, economic, and environmental determinants of health in order to most effectively help people and health systems address the complex paths to better health
• Attempt to take account of the skills and abilities associated with individual health literacy and the cultural, social, economic, and policy issues associated with health systems.