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| Feature | No.65 October 2013 |

Physical Literacy and its Association with Health

Len Almond

Introduction

In this article I propose first to explore the relationship between purposeful physical pursuits and health benefits, and secondly, the relevance of recent discussions on health literacy to physical literacy.

The conclusion will summarise the key messages that we can take from a discussion of the health benefits associated with purposeful physical pursuits and a clearer understanding of health literacy.

Physical Activity and Health

In an analysis of documents that examine the relationship between physical activity and health (BHFNC, 2013a; WHO, 2010; Department of Health, 2011; Public Health England, 2013) there is very clear evidence that inactivity and sedentary behaviour are detrimental to a person’s health and wellbeing. They go on to propose that the promotion of physical activity in different forms is good for a person’s health and wellbeing and needs to be recognised as a key component of public health. In support of this argument there is clear evidence that getting the nation to be more active has major economic benefits (BHFNC, 2013b) and this represents a significant factor in the current austerity climate.

Yet, a recent survey by the ESRC (Farrell et al, 2013) of physical activity levels paints a very bleak picture, Professor Propper (Bristol University) says that 80% of adults fail to meet national government targets1. It is quite obvious that many adults do not recognise the value of being active in purposeful physical pursuits on a regular basis.2 In the same way, the physical activity levels of children are low which indicates that most children are not getting the health benefits of appropriate physical activity. This evidence for the United Kingdom (BHFNC, 2013c)3 mirrors a similar trend in other countries (WHO, 2010).

There are many ways to define health but the World Health Organisation’s definition, ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity’ (WHO, 1948) is seen as a classic example. Since then, the Ottawa Charter (WHO, 1968) has put an emphasis on health as a resource for everyday life and the Bangkok Charter (WHO, 2005) adds a qualification by recognising the determinants of the quality of life. More recently, the Department of Health’s Outcomes Framework (Department of Health, 2012) adds increasing life expectancy and the reduction of health inequalities as important outcomes.

In a discussion on health activism, Laverack (2013; p.4) identifies four elements from the definitions of health. The first is the experience of health -how it is perceived and what it means to people, the second is people’s social interactions and the networks to which they belong are part of health, the third is people’s capacities, capabilities and resources, and the fourth is physical functioning and the recognition that health is embodied. He goes on to say that the discourse of health has tended to be defined by interpretations of illness and disease.

This is a crucial point because the role of physical activity is usually identified in terms of preventing ill-health and treating specific conditions. Thus, the value of purposeful physical pursuits is often seen in terms of the prevention and treatment of specific medical conditions. Physical activity is seen as an instrumental tool to support preventative and therapy (treatment) programmes – the treatment of specific conditions. Therapy programmes are valuable and primary care teams need to ensure that effective programmes are in place, but, this approach alone is inadequate and we need to reconsider how the prevention message can be promoted.

There is a powerful case for promoting the idea that more people should be more active more often and of course this leads decision makers to highlight the role of a prevention agenda especially when it is linked to reducing health care costs. There is a major problem with the prevention agenda because it tends to be associated with a negative message: ‘if you don’t exercise regularly you put yourself at risk from acquiring a number of medical conditions which could reduce your life expectancy, constrain your ability to maintain your health at an optimal level and influence your wellbeing’. People are warned of the dangers of ill-health caused by lifestyle factors that can be avoided.

It would appear that this approach has failed because large numbers of people have not been convinced that they should become more active. If a positive message and a different image of purposeful physical pursuits is promoted, it could be possible to address the prevention agenda without the association with negative messages. There is a need for a more positive message that reaches individual people, engages their interest and convince then of the need to be more active.

In the evaluation of a workplace health project (Sport England, 2007) that promoted physical activity with sedentary adults to encourage them to become more active and maintain a commitment over a year, the evaluation revealed that the main reason for staying with the project was “I have more energy now”. This represents a positive message and a very powerful argument. The association of ‘having more energy’ and gaining ‘a sense of vitality’ with being active on a regular basis provides a key to persuading inactive adults that this can be important for their wellbeing as well as their health. The idea that engaging in purposeful physical pursuits can energise lives and enable people to feel that they have more vitality and dynamism is a positive message that may have far more currency than a message that says physical activity can reduce your risk for a number of medical conditions.

In support of this argument for a positive message, we need to promote also that a commitment to purposeful physical pursuits has the potential for enriching lives. They can widen people’s perspectives about what they can do in their lives, extend their expectations of what they are capable of doing and engender a ‘feel good’ factor about what they have achieved. Such engagements will often be in a social context and they can lead to building new social networks and generating a sense of belonging to something that people value.

It is this involvement, I would argue, that leads to feelings of vitality, energy and dynamism and the achievement of a wellbeing resource. Such a resource provides also the enabling conditions for enriching lives in other ways e.g. a feeling that one has the capacity to volunteer to work with disadvantaged groups, developing other capabilities and enabling people to feel good and flourish well.

If people can be attracted to purposeful physical pursuits and develop a commitment because it energises and enriches their lives, they will find that their risk of chronic disease is reduced which is an added health value. For some people there is a further additional value because certain forms of exercise can help to restore people’s physical capacity and aid recovery following ill-health, an operation or a condition that inhibits a person’s normal way of life. It can also be seen in another way; people may not be able to recover the good health they once had but purposeful physical pursuits and certain forms of exercise can help them to be as good as they can be or better than they would otherwise have been.

What is the relevance of this discussion to physical literacy? Developing a commitment to being active on a regular basis and maintaining such a commitment over the life course is central to the definition of physical literacy. However, what are the elements of physical literacy that need to be considered and how can an understanding of physical literacy increase levels of physical activity so that health and wellbeing can be enhanced? In order to address these questions I would like to turn to a discussion of health literacy and draw some implications for a more complete understanding of physical literacy.

Health Literacy

Peerson and Saunders (2009) in their paper on Health Literacy Revisited highlight the importance of healthy literacy to the health prevention agenda and health promotion. They address first the meanings attributed to literacy

such as the ability to read and write and propose that a ‘literate person’ is someone ‘who can with understanding both read and write a short simple statement on his [or her] everyday life’ (United Nations Educational, Scientific and Cultural Organization, 2005, p. 15). However, they suggest that ‘literacy’ can also be given a broader interpretation such as the ability to grasp meaning and develop critical judgement (United Nations Educational, Scientific and Cultural Organization, 2005). They suggest also that it can refer to a person's knowledge of a particular subject or field, such as nutritional literacy, computer literacy, cultural literacy, media literacy, scientific literacy and medical literacy and they identify papers to support their argument (p.287). Their discussion is really useful and provides a clear insight into the debate.

Frisch et al (2011) in their paper on defining and measuring health literacy say that in an exploration of health-promoting behaviour, the concept of health literacy is deemed to be a factor of major influence. Yet they suggest that ongoing discussions about health literacy reveal that no agreement exists about which dimensions to include in the concept. As a result, Frisch et al (2011) undertook a critical analysis of different examples of the literacy domains and revealed seven distinct dimensions: functional literacy, factual and procedural knowledge, awareness, a critical dimension, an affective dimension and attitudes.

Nutbeam (2000) identifies three types of these dimensions in his account of health literacy: functional health literacy (basic reading and writing skills to be able to understand and use health information), interactive health literacy (more advanced cognitive and literacy skills to interact with health-care providers and the ability to interpret and apply information to changing circumstances) and critical health literacy (more advanced cognitive skills to analyse critically information to exert greater control over one's life). There is an implication in Nutbeam's three-tiered concept of health literacy that the more advanced skills within critical health literacy will lead to greater autonomy and personal empowerment that can enhance health.

However, Peerson and Saunders (Peerson and Saunders, 2009) recognise that current health literacy concepts implicitly include motivation as a vital part of health literacy [e.g. (Kickbusch et al., 2005; Nutbeam, 2008)]. They also claim that the motivational dimension should be regarded separately from health literacy in order to explain discrepancies between the ability to engage in health-promoting behavior, and behaviour that is actually observed. In line with this consideration, attitudes and emotions should be treated as standalone dimensions rather than considered implicit parts of health literacy.

In a recent article Sørensen et al (2012) aimed to capture the evidence-based dimensions of health literacy in order to develop a more integrated model and definition of health literacy. They provide a very comprehensive table of definitions of health literacy (p.4) as well as a further table of conceptual models (p.6-7). They propose that in recent years four understandings of literacy have emerged from the debate, the notion of: 1) literacy as an autonomous set of skills; 2) literacy as applied, practised and situated; 3) literacy as a learning process; and 4) literacy as text” (p.1).

While acknowledging that health literacy entails different dimensions, they argue that the majority of the existing models are rather static and do not explicitly account for the fact that health literacy is also a process. According to their ‘all inclusive’ definition, this process requires four types of competencies: (1) access refers to the ability to seek, find and obtain health information; (2) understand refers to the ability to comprehend the health information that is accessed; (3) appraise describes the ability to interpret, filter, judge and evaluate the health information that has been accessed; and (4) apply refers to the ability to communicate and use the information to make a decision to maintain and improve health (p.9).

They go on to say that as contextual challenges and demands change over time, the capacity to navigate the health system will depend on cognitive and psychosocial development as well as a person’s previous and current experiences. The skills and competencies of health literacy will evolve and unfold during the life course and are associated with life long learning. As health literacy develops it will progressively allow for personal empowerment and greater autonomy. In this way the process of health literacy can be seen as part of a personal journey towards improved quality of life.

Their integrated model (figure 1, p.9) provides a detailed framework that portrays a new conceptual model that illustrates the inter-relationships within health literacy. They propose that h ealth literacy, in their understanding, should be regarded as an asset for improving people’s empowerment within the domains of healthcare, disease prevention and health promotion.

In the above discussion there appears to be some common factors. Health literacy is more than factual and procedural knowledge about health information; it can refer to a person's knowledge of a particular subject or field, but also to the development of critical judgement that will lead to greater autonomy and should therefore be seen also as an asset for improving personal empowerment that can enhance health.

Conclusion

In order to address this topic, it was important to outline the benefits of regular physical activity in the form of purposeful physical pursuits. There is strong evidence to argue that being active on a regular basis can generate significant health benefits. It is felt that negative messages are inappropriate and there is a need for positive messages that highlight the role that purposeful physical pursuits can play in enriching lives as well as energising lives. Physical activity as therapy also has a key role in helping adults to restore their capacity in order to enhance the quality of living and enable them to participate more fully in everyday life. In order to enjoy these benefits it is important that purposeful physical pursuits are engaged in on a regular basis and therefore developing a commitment and learning to value them is a central motivation for maintaining this engagement over the life course.

The discussion on health literacy provides insights into how we can view our understanding of physical literacy. It is very clear that critical judgement, autonomy, agency and personal empowerment (and responsibility) are important and we need to consider carefully how we recognise their significance within physical literacy. The article by Sørensen et al (2012) on an integrated model deserves our attention because it could help to refine our understanding of physical literacy.

1 However, in this case the national government targets are not the same as the UK Physical Activity Guidelines (CMO, 2011). In the ESRC survey they see the target as performing moderate physical activity on at least 12 times a month that is 8 less than the CMO report. In this case there are likely to be considerably less adults meeting national health guidelines.

2 See the article, What is the relevance of Physical Literacy for Adults? In this Bulletin for more discussion on this point.

3 See also http://www.bhfactive.org.uk/young-people-resources-and-publications-item/373/index.html for further information on the three other home countries.

References

1. BHF National Centre (2013a) Making the case for physical activity: evidence briefing.

2. http://www.bhfactive.org.uk/userfiles/Documents/makingthecase.pdf

3. BHF National Centre (2013b) Economic costs of physical inactivity: evidence briefing.

4. http://www.bhfactive.org.uk/userfiles/Documents/eonomiccosts.pdf

5. BHF National Centre (2013c) Physical activity patterns – Children and young people in England: fact sheet

6. http://www.bhfactive.org.uk/userfiles/Documents/PApatternschildrenEngland.pdf

7. The Department of Health (2011) Start active, stay active: A report on physical activity for health from the four home countries’ chief medical officers. London, England: The Department of Health.

8. Department of Health (2012) Healthy Lives, Healthy People: improving outcomes and supporting transparency.

9. Farrell, L, Hollingsworth, B, Propper, C, Shields, M.A. (2013) The Socioeconomic Gradient in Physical Inactivity in England’ Working Paper No. 13/311. CMPO University of Bristol

10. Frisch, A-L. Camerini, L. Diviani, N. and Schulz, P.J. (2012) Defining and measuring health literacy: how can we profit from other literacy domains? Health Promot. Int. 27 (1): 117-126.

11. Laverack, G. (2013) Health Activism: Foundations and Strategies. London: Sage Publications Ltd.

12. Kickbusch I., Maag D., Saan H. Enabling Healthy Choices in Modern Health Societies. Badgastein, Austria: European Health Forum; 2005.

13. 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, 15:259-267

14. Nutbeam D. (2008) The evolving concept of health literacy. Social Science & Medicine, 67:2072-2078.

15. Peerson A, Saunders M. (2009) Health literacy revisited: what do we mean and why does it matter? Health Promot Int, 24(3):285-296.

16. Public Health England (2013) How healthy behaviour supports children’s wellbeing.

17. https://www.gov.uk/government/

18. Sørensen, K. Van den Broucke, S. Fullam, J. Gerardine Doyle, G., Jürgen Pelikan, J. Slonsk, Z. and Brand, H. (2012) Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12:80.

19. Sport England (2007) Evaluation of the £1 million Challenge, Manchester: North West Sport England Region

20. United Nations Educational, Scientific and Cultural Organization (2005) Education for All Global Monitoring Report. http://portal.unesco.org/education/en

21. World Health Organization (1948) Preamble to the Constitution of the World Health Organisation as adopted by the International Health Conference, New York, 19-22 June.

22. World Health Organization (1986) Ottawa Charter for Health Promotion. Geneva: WHO.

23. World Health Organization (2005) ‘The Bangkok Charter for Health Promotion in a globalized world’. Sixth Global Conference on Health Promotion, Bangkok. Geneva: WHO.

24. World Health Organization (2010) Global recommendations on physical activity for health. Geneva, Switzerland: WHO.

Contact

Len Almond
6 Cottesmore Drive
Loughborough
LE11 2RL
United Kingdom

http://www.icsspe.org/