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SUMMARYHealth education in China has been characterized bycentrally led, top-down messages and methods. This is ex-emplified by the Patriotic Health Campaign, established inthe 1950s and still operating today. Through this campaign,millions of Chinese were told what they should and shouldnot do in order to improve their health. These traditionalpublic health efforts have been successful in contributing to a reduction in some infectious diseases, but have hadlimited impact on others, notably in the control of schisto-somiasis. This paper argues that health education in Chinahas to further evolve to respond to social and politicalchanges over the years. Health literacy is introduced as a new concept which implies a more participatory andmore locally empowering approach to health education

and communication than was typical of past efforts.Improving the control of schistosomiasis is used as a casestudy to illustrate how improved health literacy can lead toimproved health outcomes. It is argued that health educationprograms aimed at increasing critical health literacyinvolve more than simply the transmission of healthinformation. They should also provide information onsocial, economic and environmental determinants of healthas well as assessment of opportunities to promote policy andorganizational change. The paper concludes by outliningsome of the challenges involved in adopting this newapproach, indicating that it will require formative researchand the re-training of health educators.

Critical health literacy: a case study from China in schistosomiasis control

RUOTAO WANG Union School of Public Health, Beijing, China

HEALTH PROMOTION INTERNATIONAL Vol. 15, No. 3© Oxford University Press 2000 Printed in Great Britain

Key words: China; health education; health literacy; schistosomiasis

INTRODUCTION

Health education encompasses opportunities for learning designed to improve health literacy,including increased knowledge and the develop-ment of life skills that lead to the improvement ofindividual and community health. This definitionof health education emphasizes the distinction ofits activities from others, e.g. social mobilizationand advocacy in health promotion. Social mobil-ization focuses on strengthening communityaction and re-orienting health services for a moresupportive environment for health, whereas ad-vocacy is designed to gain political commitment,policy and systems support, and social acceptancefor a particular health goal or program. Healthliteracy is defined by The World Health Organ-ization (World Health Organization, 1998) as:

The cognitive and social skills which determine themotivation and ability of individuals to gain access tounderstand and use information in ways which pro-mote and maintain good health.

This paper discusses three types of healthliteracy and uses a case study of schistosomiasisin China to illustrate how health literacy can beincreased for the improvement of individual andcommunity health.

CHANGING SOCIAL CIRCUMSTANCESAND HEALTH EDUCATION IN CHINA

In the 1950s, the Chinese government started a social movement called the Patriotic HealthCampaign headed by the Patriotic Health

Campaign Committee (PHCC) at both thenational and provincial/city level. The healtheducation curriculum was determined by theNational PHCC and then taught to the people.Thus, millions of Chinese were told what theyshould and should not do in order to improvetheir health. Health education programs weredesigned to achieve narrowly defined goalsrelated to increased knowledge and under-standing. As a part of the campaign, the govern-ment declared a war against ‘four devils—flies,mosquitoes, mice and sparrows’. People wereinstructed to clean their houses, schools andworkplaces, as well as to practice personalhygiene techniques every day. The PHCCcommittees organized inspections to check theimplementation of these actions, and appraisaland encouragement were given to those whoimplemented these actions well. This kind ofcampaign continued throughout the 1960s and1970s in China as the dominant form of healthpromotion. The main outcome was the control ofserious epidemics of infectious diseases, e.g.cholera, plague and malaria.

Since the early 1980s, mainly due to theinfluence of international health organizations,e.g. WHO and UNICEF, two-way communicationinvolving audience participation has been intro-duced to the public health movement, particu-larly in the fields of maternal and child health(MCH) and the expanded program of immun-ization (EPI). Although two-way communicationand more sophisticated health education prac-tices were integrated into health education pro-grams, the paradigm was still to teach the samecore messages and skills which were determinedat the national level and disseminated to thetarget population. The main work of the PHCCwas still limited to disseminating commands andorganizing inspections.

Since the early 1990s, government decentral-ization has drastically increased in China andmarketing principles have become more dom-inant in society. However, these changes have notbeen accompanied by an improvement in health.The World Development Report proposed bythe World Bank has declared that there is a needfor ‘investing in health’ in China (World Bank,1993).

Now China faces further challenges in publichealth. Pollution has increased tremendously,health inequality has increased, and the main-tenance of EPI and primary preventive healthcare has become more difficult due to the lack

of financial support. While the older infectiousdiseases are still threatening people’s health inmost parts of China, particularly in the economic-ally underdeveloped areas, newer infectious dis-eases, e.g. STDs and HIV are becoming seriouspublic health problems as well. Mortality due to chronic diseases and cancer has become theleading cause of death in the overall population.Many previously controlled infectious diseases,e.g. TB and schistosomiasis, have begun to riseagain. Social change is required within healtheducation in China in order to address theseproblems. The traditional top-down campaign isunsuccessful even with the use of more sophis-ticated health education concepts mentionedearlier.

A CASE STUDY IN SCHISTOSOMIASISCONTROL

Schistosomiasis has been a serious endemicinfectious disease throughout history in China. Inits various forms, it frequently leads to seriousphysical, social and economic disability and,together with the other major parasitic diseases,can seriously weaken the productive capacity of developing countries (World Health Organ-ization, 1990). Schistosomiasis is an intestinalparasitic infection caused by S. japonicum whichrequires snails to complete their life cycle inorder to cause disease. Eggs are discharged frominfected animals into water supplies. The eggsthen become ‘miracidia’ which enter the snail’sbody and turn into ‘cercariae’. It is the cercariaethat enter the body of humans and animals andcause the disease. This occurs when contact ismade with the contaminated water.

According to the national epidemiologicalsurvey carried out in 1989 there were ~1.5 millionpeople and 200 000 buffaloes infected withschistosomiasis in China [Jia, 1993; in (Wang,1997)]. Over 63 million people in China live inendemic areas and are still at risk of the infection[Chen, 1995; in (Wang, 1997)].

In the 1950s and 1960s, the Chinese centralgovernment and the National PHCC declaredthat snails were responsible for the transmissionof schistosomiasis. Therefore, in the schisto-somiasis epidemic areas, mass campaigns wereimplemented to eliminate snails with poisonousdrugs provided by the government. However,this strategy only achieved limited success ineliminating disease [Jia, 1993; in (Wang, 1997)].

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In the late 1970s and early 1980s, morbiditydue to acute schistosomiasis in China was stillincreasing in many endemic regions. In the early1990s, with the help of The World Bank, theNational Office for Endemic Disease Controlstarted a large campaign in these endemic areas.The Bureau of Endemic Diseases Control in Chinaissued the ‘criteria for control and elimination ofschistosomiasis in China’. Health educationprograms emphasized the importance of behav-iour change through dissemination of scientificknowledge and skills training.

However, evaluation again showed minimalsuccess in preventing children and adults fromcoming in contact with contaminated water (Wang,1997). Villages did not take the precautions, e.g.disposing of human excreta and treating infectedanimals, seriously (Wang, 1997). Nearly all thevillagers in the region were aware of the risk ofschistosomiasis and had the knowledge and skillsto perform the required preventive actions, yet they did not have the motivation to changetheir traditional lifestyle. They relied on thegovernment attempts to control the problem andhad already accepted the disease as part of their life and destiny. The Chinese felt powerless to the threat of schistosomiasis. At this point, healtheducators became confused and frustrated as to their role and the success of schistosomiasiscontrol. It seemed that providing information tothese people only furthered their feelings ofhopelessness in controlling the disease.

In order to respond to the social environmentin these areas of China, there is a need for newapproaches to health promotion in China. It isargued that this new approach should be bottom-up rather than top-down, should be participatoryand empowering rather than pre-determined, andshould be fully respectful of local needs. In add-ition, it should address the full range of healthdeterminants rather than be limited to the com-pliance with a few defined preventive behaviours.

HEALTH LITERACY TO IMPROVEHEALTH STATUS—BASIC,FUNCTIONAL OR CRITICAL?

As stated in the Introduction, health literacy isdefined by WHO as:

The cognitive and social skills which determine themotivation and ability of individuals to gain access tounderstand and use information in ways which promoteand maintain good health (World Health Organization,1998).

There are three types of health literacy: basic,functional and critical (D. Nutbeam, personalcommunication). Basic health literacy implies afundamental understanding of a health problemand the ability to comply with prescribed actionsto remedy the problem. Functional health liter-acy involves more advanced knowledge and skillsto function in everyday society and the ability toseek out information in order to respond to chan-ging needs. The most advanced level of healthliteracy is critical health literacy. It implies a sig-nificant level of knowledge, personal skills andconfidence to manage one’s health, and the abilityto take action to change the determinants of healthin the environment.

The goal of The Patriotic Public Health Cam-paign in China in the 1950s and 1960s was thecompliance of narrowly defined goals related toimproving health knowledge and understanding.In this case, a person with basic health literacy is the one who has knowledge about theelimination of snails as a cure for schistosomiasis.Information about carriers and transmission ofthe disease, as well as preventive strategies, is notunderstood.

More recently, health education programs inChina have used social marketing to increasehealth literacy, but are still limited to increasingcompliance rates. Mass media campaigns arecarried out and audio/visual materials are used toimpart certain knowledge and obtain complianceof particular behaviours. From the professionals’point of view, these health behaviours are simpleand easy to perform. These methods are aimed at promoting functional health literacy and a limited amount of two-way communication is used. However, they presume that health ishighly valued and that people are eager and willing to change their behaviour in order to improve their health. In the case ofschistosomiasis control, health education pro-grams were limited to the compliance of avoidingthe contaminated water, the treatment ofpatients and properly disposing of excreta. Littleattention was paid to helping communitymembers understand the importance of healthand address social determinants of health in theirown environment.

Social marketing, although it may increase func-tional health literacy, does not reach the desiredlevel of critical health literacy. Freire discussesthree major differences between education and a term he calls ‘the advertising slogan’ (Freire,1970a).

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(1) Health education consists of a wide range ofinformation. Social marketing consists of asingle significant message that is presented tothe people.

(2) Health education is a problem-solving processto be undertaken by the educator and com-munity together. Social marketing sends amessage that all people are expected to inter-pret in the same way to achieve desired results.

(3) Health education involves a high level ofcommunication. Social marketing involves aone-way message with no feedback fromthose receiving the message.

According to Freire, social marketing manipu-lates people rather than educates them. Peopleare treated as a homogenous group that all sharethe same environment and will respond appro-priately to the same messages. This is not a highlysuccessful initiative and should be replaced bymore participatory education designed to reach a level of critical health literacy in order toalleviate problems, e.g. schistosomiasis.

Critical health literacy is also different fromthe conventional meaning of literacy. The USOffice of Education (1986) defined literatepersons as those who have acquired the essentialknowledge and skills in reading, writing andcomputation required for effective functioning in society, and whose attainment of such skillsmakes it possible for them to develop newattitudes and to participate in their community(McLaren and Leonard, 1993).

If we transpose this perspective into healthliteracy, then it would be defined as the essentialknowledge and skills required in their society toparticipate in health-related behaviours in theircommunity. This most resembles our definitionof functional health literacy and is different fromthe WHO definition which describes a morecritical level of health literacy.

Referring to schistosomiasis control, recentlythe PHCC administered a health educationprogram aimed at changing behaviours of peopleliving in the epidemic area. Three preventivehealthy behaviours were proposed for the resi-dents: avoid contact with contaminated water;comply with treatment for prevention and infec-tion; and properly dispose of excreta. Knowledgeabout the dangers of unhealthy behaviours is provided and disseminated. The knowledgeand skills are pre-determined by professionals inorder to perfect the three behaviours recom-mended by the PHCC with a presumption that

people simply lack the knowledge to performthese healthy behaviours.

Lanksher [Lanksher, 1993; in (McLaren andLeonard, 1993)] discussed the differences betweencritical literacy and functional literacy.

(1) Functional health literacy is plainly under-written by the assumption that humans areadaptable, manageable beings. Functionalhealth literacy seeks a comprehensive rangeof knowledge and skills that will help illiter-ate people at the bottom of the social ladderoperate more effectively within the existinghealth care system, as well as within existingeconomic, social and legal structures.

(2) Functional health literacy reflects the assump-tion that people are eager for the health infor-mation being provided and will change theirbehaviour accordingly to improve their health.

(3) Development and implementation of ahealth education program to increase func-tional health literacy does not promotedialogue. Directions are given and expectedto be followed.

In contrast, the WHO definition of healthliteracy is a critical perspective with the emphasison empowerment and liberation. A person withcritical literacy is the one who is empowered withself-efficacy to use the information to engage inhealthier behaviours for their own interests aswell as to change unfavourable environmentalconditions to further promote health. As sug-gested by Paulo Freire, it requires the educator to undertake dialogue with the target group(Freire, 1970b). The people should decide, withthe assistance of the educator, what knowledgeand skills are essential that reflect the experi-ences in their environment and promote changesfor healthier lifestyles. In China, communitymembers should be included in the process ofidentifying behaviours which increase the risk ofschistosomiasis infection and in the developmentof solutions that take into consideration localnorms, beliefs and practices.

In summary, Table 1 shows the three differenttypes of health literacy. Basic health literacy is a traditional, top-down approach to the dissem-ination of information regarding ideal healthbehaviours. Functional health literacy, which isalso top-down, involves more educator trainingand skills development. Critical health literacy isa bottom-up approach to health promotion and is more participatory in nature. It empowers people to seek and analyse health information to

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promote self-management and improved healthoutcomes.

CRITICAL HEALTH LITERACY AS ABENCHMARK TO NEW HEALTHEDUCATION ACTIVITIES IN CHINA

China is changing from a strongly central-governed society to a more local-oriented groupof communities with different values and per-spectives, and from a state planning economy toa mixed market economy. Challenges in publichealth require new methods of health educationaimed at the achievement of critical health liter-acy rather than basic or functional health literacy.

However, health educators in China, influ-enced by the tradition of Patriotic Public HealthCampaign, lack the knowledge and skills toundertake participatory education in order toachieve critical health literacy in the population.Formative research is needed to explore thepractice of an empowering education process,especially in the underdeveloped areas. TheWorld Health Organization’s definition of healthliteracy could serve as a benchmark to guideresearchers and public health professionals.

Health literacy should be population andcontext specific. With this in mind, we would nothave to develop an instrument to measure healthliteracy universally, but rather, the measurementwould be left to each individual health programor community to satisfy their local needs.

Health educators in China are frustrated with the traditional approaches used in health

education over the last several decades. They areeager and are willing to try new approaches toprevent and control schistosomiasis. Becauseschistosomiasis is endemic throughout China, itis conducive to research and education as op-posed to diseases affecting mobile populations,e.g. migrants or sex workers.

In order to increase health literacy for thepurpose of schistosomiasis control, the emphasisshould be on the behaviours of people, ratherthan snails, as being responsible for the trans-mission of the disease. The following dimensionswith critical health literacy as its benchmarkshould be examined.

(1) The measurement of health literacy in aspecific context and the use of concepts, e.g.self-efficacy and decision-making.

(2) The use of WHO’s health literacy definitionas a benchmark to begin the transition fromtraditional methods of health education tomore participatory and empowering methods.

(3) Knowledge and skills to be mastered in orderto facilitate the promotion of health literacy.

(4) The differences between the bottom-upempowerment process and the traditionaltop-down education.

(5) Integration of other health promotion strat-egies, e.g. advocacy and social mobilization,and theories, e.g. stages of behaviour changeand the diffusion of innovation.

Formative research and the development ofspecific criteria for health literacy in schisto-somiasis control in Chinese communities should be undertaken, including monitoring and

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Table 1:

Health education Basic Functional Critical

Approach Top-down Top-down Bottom-up

Contents Limited in the pre-determined Limited in the pre-determined Unlimited; allow audience knowledge knowledge and skills participation to decide

Method Commending or manipulating Lecturing or banking Participatory and problem-posing

Objective Compliance of pre-determined, Compliance of pre-determined Self-determined action for simple behaviour behaviour in an ideal environment participants with perceived

benefits in changing theirhealth behaviours

Educator’s role Knowledge teacher Knowledge and skills trainer Facilitator and partner

Preparation of the Limited knowledge, and Limited knowledge and skills Knowledge and skills to educator advertising or propaganda skill in the subject and communication address all determinants of

in class training health in the people’senvironment

evaluation of health education components. It isimportant that development of measurementtools coincides with the development ofeducation methods and materials.

CONCLUSION

In response to the changing social environmentin China, there is a need to increase criticalhealth literacy in order to successfully addressproblems, e.g. schistosomiasis. To undertake thisnew approach requires formative research and there-training of health educators. Health educationprograms aimed at increasing critical healthliteracy involve more than simply the trans-mission of health information which has been the focus of health education in China in the past.It should also provide information on social, eco-nomic and environmental determinants of healthas well as assessment of opportunities to promotepolicy and organizational change. It is within ourcapabilities to raise the health literacy of com-munities in need such as those affected by schisto-somiasis in China. A commitment to workingwith communities to prevent and control diseasethat incorporates empowerment and the improve-ment of health literacy promises to improve thelives of those in China that suffer needlessly fromdisease.

Address for correspondence:Ruotao WangUnion School of Public HealthBeijingChina

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