Keywords

6.1 Introduction

New innovations are driving a transformation of health systems from provider-driven marketplaces to people-centric health eco-systems, moving away from reactively treating and preventing illness to promoting health and well-being proactively. Increasingly, patients are becoming engaged and responsible for their own health through the added value provided by new technologies. Digitalisation has transformed relationships within the health sector as patients become more self-reliant, better-informed, and comfortable finding information independently. More than two billion searches are launched on Google daily, with healthcare being the second most searched topic (Luxembourg 2018). This interest encourages health-care providers, insurance companies, pharmaceutical industries, and the health eco-system in its entirety to become more ‘Smart!’

6.2 Smart Health!

With the development of information technology, the concept of Smart healthcare has gradually evolved. Smart health is recognised as a new form of healthcare, which pertains to devices, sensing, computing and communication technologies, software/hardware modelling, and system architectures towards personalised, pervasive, participatory, predictive, preventive, programmable, and perpetual healthcare. Smart health builds on the new generation of information technologies, such as the internet of things (IoT), big data, cloud computing, and artificial intelligence, to transform the traditional medical system in a comprehensive way, making healthcare more efficient, more convenient, and more personalised (Tian et al. 2019). The key approaches of Smart health covers eHealth and mHealth services, electronic record management, smart home services, and intelligent and connected medical devices. However, to fully benefit from Smart health, and avoid any detrimental impact from challenges such as the infodemic, the development of new competencies and capacities is necessary among populations, as well as among professionals working in the health eco-system.

6.2.1 eHealth

A key concept used in health systems today includes eHealth, which, according to the World Health Organization, can be defined as, ‘the use of information and communication technology (ICT) for health. Examples include treating patients, conducting research, educating the health workforce, tracking diseases and monitoring public health’ (World Health Organization 2016). The European Medical Association highlights the value of eHealth as beneficial for ‘the entire community by improving access to care and quality of care and by making the health sector more efficient. This includes, for example, information and data sharing between patients and health service providers, hospitals, health professionals and health information network, electronic health records, telemedicine services, portable patient-monitoring devices, operating room scheduling software, robotised surgery and blue-sky research on the virtual physiological human’ (European Medical Association 2021). ‘The goal of the EU concerning eHealth is the improvement of EU residents’ health by using eHealth tools that provide instrumental information between countries when needed. To guarantee this improvement, the EU wants to enhance eHealth tools and make them more effective, user-friendly, and more widely accepted by patients and professionals. Moreover, the EU aims at increasing the quality of healthcare and enabling better access by incorporating eHealth into general health policy (ActiveAdvice 2017). However, according to the World Health Organization, the successful investment in eHealth entails far more than just the acquisition of technology. A holistic view is needed with regards to the impact and changes required to organizational processes, structures, roles, standards and legislation, as well as consideration of the specifics of human resources, education, reimbursement and the culture of those who will be utilizing the eHealth services – any of which can serve to derail initiatives if neglected (WHO 2016, p. xi).

6.2.2 mHealth

The term mHealth is short for mobile health. According to the World Health Organization, the use of mobile wireless technologies for public health, or mHealth, is an integral part of eHealth, which refers to the cost-effective and secure use of information and communication technologies in support of health and health-related fields (World Health Organization 2018). Moreover, the WHO Global Observatory for eHealth (2011) describes mHealth to be the ‘medical and public health practice supported by mobile devices, such as mobile phones, patient-monitoring devices, personal digital assistants (PDAs), and other wireless devices’. Besides using mobile phones to make calls and send text messages, mHealth includes the use of more complex technical features and applications such as telecommunications (3G and 4G), GPS, and Bluetooth technology. The increase of mobile telephone subscriptions across the world is predominantly happening in low- or middle-income countries – countries in which people are more likely to have access to a mobile telephone than to clean water, a bank account, or electricity (World Health Organization 2018).

6.2.3 Building Capacity: Opportunities and Challenges in the Information Age

The challenge of capacity is complicated by the challenge of change, with new technologies for information and communication regularly redefining what it means to be literate. The exponential digital development has a profound impact on how people are enabled to find, understand, appraise, and apply information in all forms to manage health and navigate health services, as well as deal with the magnitude of information available. There is a need for the acquisition of a new set of knowledge and skills to accommodate the challenges and opportunities that arise with the evolution of the digital space, including

  • Health literacy.

  • Science literacy.

  • Digital literacy.

  • Information literacy.

  • Media literacy.

Applied to the field of health, all these literacies are closely associated with each other. As relational concepts, which can be considered from both an individual perspective and a system perspective, they are cultural-sensitive and vary between and within countries.

This chapter aims to introduce and explore why health, science, digital, information, and media literacy are all key to facilitating Smart health and creating new models of health based on personalised, pervasive, participatory, predictive, preventive, programmable, and perpetual health services. Teaching and the maintenance of a variety of literacies in the population is one of the long-term strategies to ensure it remains resilient in the face of the infodemic and is better equipped to achieve appropriate health behaviours.

6.3 New Competencies to Accommodate Health in the Twenty-First Century

‘Traditionally, literacy has referred to the ability to read and write. A literate person can communicate effectively through writing and assimilate information from reading. However, in today’s technology-driven world, the word literacy has expanded to encompass an ability to communicate effectively and absorb information through a variety of mediums. The term multiple literacies (also called new literacies or multi-literacies) recognises that there are many ways to relay and receive information and that students need to be proficient in each one’ (Bales 2019). Therefore, ‘to become fully literate in today’s world, [people must adapt and] become proficient in the new literacies of 21st-century technologies’ if they are to be empowered and enabled to engage actively in society at all levels (International Reading Association 2009).

‘There is extensive debate about what [these] new literacies are, [with] terms being used to mean different things to different people. However, there are at least four common elements that apply to nearly all of the current perspectives being used to inform the broader dimensions of new literacies research (Coiro et al. 2008):

  1. 1.

    The Internet and other ICTs require new social practices, skills, strategies, and dispositions for their effective use.

  2. 2.

    New literacies are central to full civic, economic, and personal participation in a global community.

  3. 3.

    New literacies rapidly change as defining technologies change.

  4. 4.

    New literacies are multiple, multimodal and multifaceted; thus, they benefit from [the application of] multiple lenses when seeking to understand how to better support students in a digital age’ (International Reading Association 2009).

For the sake of meeting the demands related to digitisation of health services, and to deal with the increasing threats from infodemics, the various identified categories of literacies (Sect. 6.2.3) are introduced and explained.

6.3.1 Health Literacy

Health literacy is a composite term to describe a range of outcomes of health education and communication activities. It encompasses people’s knowledge, motivation, and competencies to access, understand, appraise, and apply health information to form judgements and make decisions in everyday life concerning healthcare, disease prevention, and health promotion in order to maintain or improve quality of life (Sørensen et al. 2012). It is a modifiable determinant of health, which is often negatively associated with various adverse health outcomes such as higher health-care costs, financial deprivation, low education, and social status (Sørensen et al. 2012). Health literacy develops over the life course and is influenced by personal, situational, and societal factors. Literacy is associated with health service use and health costs, health behaviour and health outcomes, participation, and empowerment, equity, and sustainability (Sørensen et al. 2012) (Fig. 6.1).

Fig. 6.1
A concentric circle diagram of health literacy to promote health care. It prevents diseases through accessing, understanding, appraising, and applying health information through knowledge, competence, and motivation.

The conceptual model of health literacy derived from the European Health Literacy Project (Source: Sørensen et al. 2012; Adapted from Sørensen et al. 2012. Figure 1. Some modifications were made. https://doi.org/10.1186/1471-2458-12-80, licensed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/2.0))

Full size image

For instance, health literacy empowers people to handle health information in all its forms and participate in health communication through various channels. Understanding and making informed decisions about health issues requires strong health literacy skills based on the ability to obtain, communicate, process, and understand health information and services (Nutbeam and Muscat 2021). Health literacy also includes such health behaviours as knowing how to describe symptoms, where to find adequate help for health issues, how to understand medical information, and how to safely manage the use of medication (Paasche-Orlow and Wolf 2007).

Another commonly used approach considers health literacy from three perspectives: functional health literacy, interactive health literacy, and critical health literacy (Nutbeam 2000, 2008).

  • ‘Functional health literacy reflects the outcome of traditional health education based on the communication of factual information on health risks and on how to use the health system. Such action has limited goals directed towards improved knowledge of health risks and health services, as well as compliance with prescribed actions.

  • Interactive health literacy is focused on the development of personal skills in a supportive environment. This approach to education is directed towards improving personal capacity to act independently on knowledge, specifically to improve motivation and self-confidence to act on advice received.

  • Critical health literacy reflects the cognitive and skills development outcomes, which are oriented towards supporting effective social and political action, as well as individual action,’ thus including taking social responsibility and thinking beyond one’s personal perspective (Nutbeam 2000, p. 265).

Poor health literacy is an under-estimated, global challenge. Poor health literacy has been described as the silent epidemic and a public health challenge in itself (Sørensen et al. 2015). There is substantial evidence of the relationship between health literacy and health outcomes from Asia, Europe, and North America, indicating that 20–60% of these region’s populations may possess limited health literacy skills (Duong et al. 2017; Rudd 2007; Sørensen et al. 2015).

The Information Age, which is characterised by the idea that access to, and the management of, information is a defining factor for human knowledge, attitudes, and behaviour, puts a heavy demand on people and systems. Health literacy is necessary to make sense of the magnitude of information. In addition, it may have both direct and indirect enabling and hampering effects on an individual’s health. People’s personal world of information is constantly evolving through time and has a significant influence on behaviour (Azzopardi-Muscat and Sørensen 2019).

6.3.2 Digital Literacy

Digital health literacy and internet connectivity have recently been acknowledged as ‘super social determinants of health’ in that they have implications for the wider social determinants of health (Sieck et al. 2021). Digital literacy can play a powerful role in helping people connect, learn, and engage with their community and create more promising futures. Digital literacy is the ability to navigate our digital world using reading, writing, technical skills and critical thinking. It is using technology such as a smartphone, PC, or e-reader to find, evaluate, and communicate information. According to WHO, the term ‘digital health’ refers to ‘the field of knowledge and practice associated with any aspect of adopting digital technologies to improve health and incorporates the subdomains of eHealth, medical informatics, health informatics, telemedicine, telehealth and mHealth, as well as data-analytics, big data and artificial intelligence’ (World Health Organization 2021). To build digital capacity in organisations and communities, it is recommended that there is a focus on six action areas (Beetham 2015):

  • ICT proficiency (Functional skills).

  • Information, data, and media literacies (Critical use).

  • Digital creation, problem solving, and innovation (Creative production).

  • Digital communication, collaboration, and participation (Participation).

  • Digital learning and development (Development).

  • Digital identity and wellbeing (Self-actualising).

Digital technologies can be used to strengthen health institutions and systems (USAID 2020), including:

  • Client-oriented technologies – such as those that provide compliance reminders for appointment and treatment, transmit health-event alerts, and/or transmit payments or vouchers.

  • Provider-oriented technologies – such as those that support the identification and registration of clients, clients’ health records, communications, and decision-making for health-care providers, referrals, planning and scheduling, training, and the management of laboratory tests and results, diagnostics, imaging, and ‘virtual health’, including remote monitoring and telemedicine.

  • Manager-oriented technologies – such as those that support the management of human resources, supply-chains, notifications of public health events, civil registries and vital statistics, public- and private-sector health funds, and facilities.

  • Data-services-oriented technologies – such as those that enable the collection, management, analytics, coding, exchange, interoperability and use of data, and location-mapping (USAID 2020).

6.3.3 Information Literacy

Access to relevant, reliable, unbiased, up-to-date, and evidence-based health-care information is crucial for the public, patients, and health personnel for every aspect of health. It is related (but not limited) to health education, informed choice, professional development, safety and efficacy of health services, and public health policy (World Medical Association 2019). However, health information is only useful if it is timely, updated, understandable, accurate (Royston et al. 2020), and it is aligned with individual and cultural values. If public health information and knowledge has no meaning for certain populations, it is likely that they will not use it to inform their health decisions. Achieving this understanding requires empowerment of the public and patients, as well as health workers, with the information literacy they need to recognise and take up their rights and responsibilities to access, use, and provide appropriate services and to promote health and prevent, diagnose, and manage disease (World Medical Association 2019).

Information literacy is the ability to think critically and make balanced judgements about any information we find and use. It empowers us as citizens to reach and express informed views and to engage fully with society (Wilson et al. 2011). As seen in relation to related literacies, the field of information literacy has also undergone a discursive shift from perspectives based on functional skills to a perspective that sees information literacy as a sociocultural practice, where becoming information literate is mediated though interactions in social settings (Lloyd et al. 2014). Meeting the information needs of the public, patients, and health-care providers is a prerequisite for the realisation of the UN Sustainable Development Goals, quality universal health coverage, and mitigation of the hampering impact of infodemics.

6.3.4 Media Literacy

Within their ‘Media and Information Literacy’ framework, UNESCO provides a curriculum for teachers and education professional to address media literacy and information literacy learning in schools. Media literacy can be defined as understanding and using mass media in either an assertive or non-assertive way, through an informed and critical understanding of media, the techniques they employ, and their effects. Moreover, it can be described as the ability to read, analyse, evaluate, and produce communication in various forms of media, such as television, print, radio, and computers. It is also explained as the ability to decode, analyse, evaluate, and produce communication in a range of forms (Wilson et al. 2011).

Often the various types of literacies are seen as closely linked or used interchangeably. The British Library and Information Association through their Information Literacy Group, for instance, highlight that if the concept of information literacy is applied to any given health context, it is a synonym for health literacy (Coonan et al. 2018). In practice, it may also be combined and presented as media health literacy (Levin-Zamir and Bertschi 2018).

6.3.5 Science Literacy

Scientific literacy, or science literacy as it is often called, concerns the ability to use scientific frameworks to make decisions that are based on facts, research, and knowledge. More specifically, it can be defined as ‘the ability to creatively utilise appropriate evidence-based scientific knowledge and skills, particularly with relevance for everyday life and a career, in solving personally challenging yet meaningful scientific problems as well as making responsible socio-scientific decisions’ (Holbrook and Rannikmae 2009). Carlgren highlights problem-solving, critical thinking, oral and written communication, as well as the ability to interpret data as the four core aspects of science literacy (Carlgren 2013). Lastly, according to the OECD’s PISA 2015 Assessment and Analytical Framework, science literacy can be defined as ‘the ability to engage with science-related issues, and with the ideas of science, as a reflective citizen’ (OECD 2017).

With regards to conflicting information, scientific literacy is key to supporting people’s understanding of their environment and their own health processes, especially in current times when media and social media have an all-pervasive influence on people’s lives (Mohan et al. 2020). This concept includes inquiry concerning reviewing beliefs, accumulating the facts, being able to discern fact from opinion or myth, and using those facts to make an informed decision. Being scientifically literate enables people ‘to engage in reasoned discourse about science and technology [based on the] competencies to:

  • Explain phenomena scientifically – recognise, offer and evaluate explanations for a range of natural and technological phenomena.

  • Evaluate and design scientific enquiry – describe and appraise scientific investigations and propose ways of addressing questions scientifically.

  • Interpret data and evidence scientifically – analyse and evaluate data, claims and arguments in a variety of representations and draw appropriate scientific conclusions’ (OECD 2017, p. 15).

6.4 Expanding Capacity to Enhance Multiple Literacies

People and patient’s empowerment can be enhanced through smart technology that makes them less dependent on health professionals, enabling them to manage their health around the clock more easily, inform themselves, and share experiences. In this respect, education and taking ownership are the main drivers of patient engagement. Improving the capacity of people to utilise smart technology is necessary but nevertheless, of itself, insufficient (Luxembourg 2018). Capacity-building can be defined as the process of developing and strengthening the skills, instincts, abilities, processes, and resources that organisations and communities need to survive, adapt, and thrive in a fast-changing world. An essential ingredient in capacity-building is transformation that is generated and sustained over time from within; transformation of this kind goes beyond performing tasks to concepts of changing mindsets and attitudes (United Nations Academic Impact n.d.). Tapping into the digital world may help democratise people’s health through increased access to information regarding healthcare, disease prevention, and health promotion. From a societal point of view, however, it is paramount for everyone to build capacity at all levels – individual, organisational, commercial, technical, and political – so that people can withstand its inherent pitfalls (Azzopardi-Muscat and Sørensen 2019).

An example of applying a systemic approach to developing system capacity is laid out in the framework on health literate systems (Sørensen et al. 2021). This addresses eight systemic capacities – ‘the workforce, organisational structures, research and knowledge development, financial resources, partnerships, leadership and good governance, technology, and innovation – as well as people-centredness based on user engagement and enabling environments… [The outlined] systemic transformation can be multiplied and sustained over time’ (Sørensen et al. 2021). It has also been shown to be resilient in coping with ‘external trends and events rather than relying on individual behavioural change or organisational change alone to overcome the challenge of poor health literacy. Furthermore, an enhanced health literacy system capacity prevents system failure by ensuring a better match between the organisations, the context in which they work, and the needs they meet by addressing and enhancing the capacity’ of the eight identified systemic capacities (Sørensen et al. 2021).

Applying a systemic response requires bold leadership, built on rights-based approaches that secure individual dignity and rights, as well as facilitating societal sustainable development. Thus, ‘capacity-building related to public health entails the development of sustainable skills, organisational structures, resources, and a commitment to prolong and multiply health gains many times over’ (Hawe et al. 1997, as cited in Sørensen et al. 2021).

6.5 Conclusion

In earliest societies, literacy was perceived in a simple, pragmatic way; it was a way to record land, livestock, crops, and business transactions. Since then, there have been three major human contributions that have greatly influenced and developed the concept: the invention of writing, the invention of print, and the current dominance of ICT technologies (Abdallah 2008). Notably, literacy is one of the most perplexing concepts in the modern world, especially with the emergence of associated concepts of new literacies, digital literacies, and multiple literacies. Continuous and rapid development is needed within research, policy, education, and practice (Bales 2019) to accommodate the needs of present and future generations to ensure that they can benefit and contribute to healthy societies around the world. Thus, this calls on all involved stakeholders to help in bridging competency gaps across relevant sectors.

Apart from classroom integration, there are many resources that students can access to develop multiple literacies. Students will naturally use many of these resources, such as gaming, the Internet, and social media outlets. Many libraries now recognise multiple literacies and offer resources for students, such as free computer and internet access, e-books and audiobooks, tablet access, and digital media workshops. Multiple literacies can also be taught as part of post-graduate training. Moreover, media and science communities can be called upon to provide greater support by increasing the availability of valid and timely information for people to find, understand, appraise, and use to form judgements and make decisions in everyday life. Relevant disciplines working in the digital space are essential for the creation of user-friendly environments that are responsive to the needs related to multiple literacies when it comes to the facilitation of the development of healthier populations and societies.

The need for new literacies is apparent in the fast-evolving societies of today. According to futurist Alvin Toffler, the illiterate of the twenty-first century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn (1970). The demand is not any more the information overload but how to deal with the information overload and its impact on modern lives, especially in the attempts to maintain and promote health and well-being. As such, the acquisition of new literacies is becoming a pre-requisite for empowerment and active living in the digital age.