Key research papers on health literacy

How the literature is organised

Nutbeam (2008) traces the concept to two roots, clinical care and public health, and that split still organises the reading list. On the clinical side sit the Test of Functional Health Literacy in Adults (Parker et al., 1995), the Institute of Medicine's 2004 report, and studies tying literacy to disease control such as Schillinger and colleagues (2002), who found inadequate health literacy independently associated with worse glycaemic control and higher rates of retinopathy among primary care patients with type 2 diabetes.

On the public health side, Nutbeam (2000) set out a health outcome model in which health literacy is a key outcome of health education, and distinguished functional, interactive and critical health literacy. Sørensen et al. (2012) systematically reviewed definitions and models — 17 definitions and 12 conceptual models — and proposed an integrated one, which then underpinned the eight-country European survey reported in 2015.

Berkman et al. (2011) updated an earlier systematic review of outcomes and found low health literacy consistently associated with more hospitalisations, greater use of emergency care, lower receipt of mammography screening and influenza vaccine, poorer ability to take medications appropriately and, among elderly persons, higher mortality.

Main debates

Nutbeam (2008) describes health literacy as a clinical "risk", which supports screening for poor literacy skills in clinical care, and as a personal "asset", rooted in adult learning and health promotion, and concludes that both conceptualisations matter. Where the responsibility sits is the live question: Sørensen et al. (2021) argue for building capacity in systems — a health literate workforce, health literate organisations, data governance, leadership — rather than relying on individual behavioural change alone. Measurement is contested too. Baccolini et al. (2021) found that the assessment method significantly changed the pooled prevalence of low health literacy in EU member states: self-reported comprehension items and reading or numeracy items both produced higher rates than word-recognition items, and their pooled estimate ranged from 27% to 48% depending on the method.

Where recent work is heading

Digital health literacy accounts for four of the six recent reviews listed here: van Kessel et al. (2022) call it a super determinant of health and treat digital, health and civic literacy as its predictors; Estrela et al. (2023) meta-analysed the sociodemographic determinants across 36 studies and found a negative effect of age, no statistically significant effect of sex, and positive influences of education, income and social support; Xie et al. (2022) review health-related outcomes among older adults; and Yang, Hu and Qi (2022) map the field bibliometrically. The pandemic connected the topic to misinformation and vaccine acceptance: Montagni et al. (2021) found poorer fake-news detection and lower health literacy scores associated with vaccine hesitancy in a French online cohort, and Naeem and Kamel Boulos (2021) review the strategies proposed against COVID-19 misinformation. Santana et al. (2021) explain the updated definitions adopted for the US Healthy People 2030 objectives, which distinguish personal from organisational health literacy.