Television and older adults’ navigational health literacy: A qualitative study of media representations and Audience Reception

Introduction

Low health literacy has been consistently identified over past decades as a determinant of poorer health outcomes, inappropriate use of health care services, higher emergency department utilisation and recidivism, and increased costs for individuals and health systems, with evidence spanning both foundational and recent research (Berkman et al., 2011; Eichler et al., 2009; Okur et al., 2025; Shahid et al., 2022; WHO, 2025). The European Health Literacy Survey (HLS-EU), initiated in 2011, estimates that 50% of the European population has low levels of general health literacy. In Portugal, the HLS19-Q12 questionnaire placed this figure at 30% in 2021. As in other WHO European Region countries, the poorest scores were found in the dimension most critical for effective use of the health care system (HCS) – the ability to “find the right care at the right time in the right place” (WHO, 2015). Overall, 65.5% of the general population exhibited insufficient navigational health literacy (HL-NAV), with 44% in the lowest category of “inadequate” (Arriaga et al., 2022; Griese et al., 2020; Sørensen et al., 2015).

Health literacy is increasingly recognised as both a crucial attribute of health care users and policy lever for aligning cost containment with equity and quality in health systems. Consequently, it has become a central policy concern, regarding health information provision within and outside the health system. Effective communication strategies aimed at improving people’s capacity to stay away from the HCS as well as to effectively navigate it are essential, especially for vulnerable populations.

People’s understandings of health (and how to maintain and restore it) are shaped by lived experiences, social interactions with relatives, close contacts, health professionals, and media sources of various kinds. Improving health information sources is therefore critical (Marques Ribeiro et al., 2025; Özkan et al., 2021), while studies consistently show that vulnerable groups – such as older adults, people with chronic conditions and disabilities, and those facing socioeconomic hardship or social isolation - are overrepresented among those with low health literacy, undermining their engagement with health systems and outcomes (Doetsch et al., 2017; Gonçalves, 2020; MacLeod et al., 2017). In Portugal, the HLS19-Q12 questionnaire revealed that 80.6% of individuals aged 65+ have limited health literacy – more than double the national average (Costa et al., 2023). The DO-HEALTH study further showed that those aged 70+ had the highest rate of physical frailty among five EU countries (Gagesch et al., 2022). As an ageing society, where older adults already comprise a quarter of the country’s population and face multiple vulnerabilities, ensuring their access to appropriate care is therefore essential.

In European countries, television remains a key source of health-related information and representations, influencing the construction and circulation of knowledges on health (Burzyńska et al., 2015; Ferreira et al., 2017). Beyond being a major and trusted source of directly consumed information – as consistently reported by Eurobarometer, Statista, European Broadcasting Union, Reuters – television is a highly versatile medium, delivering health information through multiple formats, including news, talk shows, series, and advertisements (Hoffman et al., 2020; Munguía et al., 2025; Murphy et al., 2008; Scopelliti et al., 2021). Moreover, as social scientists have long argued on mass-mediated societies, “people do not have directly to consume specific media disseminated information for it to enter their lives. Like ripples in a pool, once entering social dialogue, fragments of media representations take on a life of their own” circulating second-hand through everyday conversations (Hodgetts et al., 2005: 126; Lewis, 2021). This highlights TV’s potential role as both strategic ally and potent barrier for health literacy across European countries, particularly among harder-to-reach populations with greater needs, such as older adults.

Despite this, limited research has examined the nature of health information conveyed by European televisions, particularly regarding its potential to support navigational health literacy (HL-NAV) among older adults. This study addresses this gap by exploring the role of television in mediating older adults’ health literacy in Portugal, with a focus on health care navigation, the poorest-performing dimension in HLS-EU assessments and one that is crucial for obtaining timely appropriate care. By combining analysis of televised health contents with older adults’ accounts within a qualitative sequential triangulation design, this study provides novel, context-sensitive evidence to inform health communication and policy interventions. It identifies frailties, strengths, and limitations of televised health information to support the development of context-specific communication strategies aimed at improving health literacy in European populations.

Study approach and methods

The study employs a sequential triangulation design, analysing televised health content followed by older adults’ responses to that content, with integration of both datasets. Both phases are qualitative in nature and are detailed bellow. The study focussed on two domains, also operationalised as research questions:

Results

Our study confirmed that television remains a regular source of health information for older adults in Portugal, across both public and private broadcasters, with at least one health-related segment broadcast daily on two of the four channels analysed. It was also the primary source of health information referred to by all participants (n =22/22), alongside personal experience and interpersonal exchanges with family, friends, and health professionals, in descending relevance. Regarding other mass media, only four participants reported using the internet for health information.

It was further established that TV plays a significant role in mediating health literacy among older adults. The analysis revealed substantial alignment between televised portrayals and participant accounts, alongside gaps and imbalances in understandings, and few divergences. Findings are presented through the key comparative patterns that emerged across the two datasets.

Discussion

Overall, the contribution of TV health-related narratives to audiences’ repositories of knowledge on how to navigate the HCS was found to be poor, fragmented, and unbalanced. Persistent trends of misrepresentation and bias, rooted in enduring national and international perspectives and unconscious, bias-based discriminatory media practices, were also identified (Leask et al., 2010; Lopes et al., 2012; Seale, 2002). At best, these narratives distort the current realities and complexities of the Portuguese health system and its approaches to care; at worst, they undermine audiences’ ability to determine what, when, where, and which health professionals’ expertise to seek, and therefore to navigate the HCS.

Epistemic oppression and asymmetry refer to the ways in which systems for producing and distributing knowledge generate disparities in authority and access, through inefficient or inadequate epistemic resources (Dotson, 2014; Holroyd and Puddifoot, 2022). Whether intended or not, biases in televised health narratives reinforce dominant authority figures while obscuring the perspectives and roles of a wide range of health professional knowledges, as reflected in the uneven visibility and allocation of authority to health professions, in which medical doctors remain disproportionately centred in relation to other professional groups. This, in turn, constrains audiences’ capacity to engage critically and effectively with health care services and with the diverse professionals responsible for their provision across the health system.

The promotion of lay expertise and of healthism were also notable framing mechanisms of TV narratives. As argued by Habermas (1987) and echoed by many later social theorists, the idea of an expert culture, whether in medicine or any other sphere of activity, is inherently anti-democratic. This has led to calls for the democratisation of knowledge, which in the health sciences and medical fields is manifested both in the increased recognition of lay people’s insights into health and illness and in the argument for considering these knowledges as equally valuable to professional expertise. These ideas converge in the 1990s concept of the “lay expert” – an oxymoron, referring to a person who, rather than possessing credentialed authority, has become an expert through experiential knowledge or self-directed learning. Our findings indicate, however, that the prominence of lay expertise in these televised narratives operates not as a genuine pluralisation of knowledge, but as a form of false democratisation that displaces the already marginal visibility of nearly all other non-medical health professions. Rather than expanding epistemic diversity, these representations reproduce a stratified field of credibility, further reinforcing the epistemic oppression of already subalternized health professional groups, in which medical doctors’ authority remains ultimately unchallenged.

As for healthism (Crawford, 1980), it emphatically prioritises individual responsibility for health, personal practices and lifestyle choices as key determinants of well-being, while obscuring the structural and political determinants of illness. Over the past four decades, this perspective has permeated public discourse, government documents, popular culture and media narratives. As evidenced in the data, this framing was consistently reproduced in the analysed television content across formats, where health-related messages emphasised individual prevention and self-management while offering limited guidance on health care system navigation, service organisation, or access pathways relevant to HL-NAV. In this way, health discourse is reframed from a basic human right of collective responsibility to a private duty (Hodgetts et al., 2005; Seale, 2002) and health literacy from a critical competence rooted in structural understanding and citizenship to the adoption of prescribed “correct” self-care to avoid illness.

Hospital-based and NHS failures dominated televised representations, while primary and long-term care were largely marginalised (<9% airtime), reinforcing a crisis-oriented and system-deficit framing. Collectively, study findings reveal a shared representation across television sources of a failing HCS – one that, according to the Portuguese Constitution, was meant to be universal and largely free at the point of delivery, but is now depicted as beyond recovery –, with individual responsibility positioned as the primary locus of action. The persistence of health promotion, healthism, lay expertise, self-management, and self-care discourses across the analysed media contents points to an underlying assumption: that the most viable responses to this systemic failure involve shifting responsibility onto individuals, encouraging them to minimise reliance on a system perceived as no longer capable of meeting the health needs of the majority.

Reflecting the predominance of these rhetorical frameworks, even the few health care professionals typically chosen for communication roles also exhibited similar ingrained framing biases, and the content featuring planned public health communication initiatives/campaigns overwhelmingly favoured individual-level preventive practices, focussing primarily on contributing to the “health promotion” and “disease prevention” domains of health literacy, rather than on “health care.” When it came to structured contributions to the general health literacy of audiences, HL-NAV was never considered. This individualising framing of responsibility for health and for seeking adequate information and care is particularly resonant in modern societies where health care systems are perceived as under strain, such as the Portuguese case. It forms part of a neoliberal welfare view that effectively relieves both governments and decision-makers from critical failures in health care provision and health care professionals from the duty to provide equal treatment (Doetsch et al., 2017). Above all, it absolves society of its responsibility to care for vulnerable populations, even when their vulnerability stems from systemic political decisions that they had no influence over (El Kheir-Mataria and Chun, 2024; Raphael and Bryant, 2022). These framing logics found in televised health narratives – strikingly uniform across public and private channels, news and talk shows – and mirrored in older adults’ accounts, ultimately act as a trap. By shifting attention away from structural factors or system-level accountability, they further obscure potential responses to health care system dysfunction, particularly in relation to navigation.

As highlighted by the HLS19 Consortium, widespread HL-NAV deficits across Europe – particularly among vulnerable groups – urgently demand accessible, trustworthy guidance and clearer pathways for navigating the health systems (Schaeffer et al., 2021). In line with other countries, Portugal has already in place The National Plan for Health Literacy and Behavioural Sciences 2023–2030, which acknowledges these gaps, including those affecting older adults. Yet, media strategies remain underdeveloped, with limited recognition of TV’s role. This gap highlights the need for research examining how television contributes to navigational health literacy among older adults, reinforcing the relevance of this work. Overall, the study demonstrates how televised health representations and older adults’ accounts intersect in shaping understandings and experiences of health care navigation.

Conclusion

This study reveals that both public and private Portuguese TVs’ narratives overwhelmingly depict a health system in crisis while promoting individualised solutions centred on self-management and self-care, reflecting broader neoliberal trends in public health communication. These framings – centred on health promotion, healthism, and lay expertise – fail to empower citizens with the knowledge needed to navigate health systems, instead reinforcing ideologies of responsibilisation. By prioritising preventive messages over structural understanding, at best, such portrayals offer no improvement in HL-NAV; at worst, they exacerbate health inequalities.

The examined interplay between televised portrayals and older adults’ accounts in this study reinforces the urgent need to formally integrate TV into national health literacy strategies. As a dominant and trusted information source for older adults, TV must be recognised not merely as a communication channel but as a strategic actor in shaping navigational health knowledge and practices.

From a practical perspective, these findings support the development of equity-oriented media and public communication strategies that explicitly address health care navigation (rather than focussing only on health promotion), and that better reflect the organisation, accessibility, and diversity of health care provision within the Portuguese health system.

The study limitations include its context-specific design, the limited sample of televised content and participants, and its qualitative interpretive approach, which constrains statistical generalisability. However, this design was intentionally adopted to enable in-depth understanding of mediated meaning-making processes and to identify frailties, strengths, and limitations in how televised representations intersect with older adults’ accounts, thereby informing context-specific TV communication strategies aimed at strengthening older adults’ health literacy in Portugal.

Overall, the study calls for targeted, equity-driven media engagement to counter the risk of deepening structural inequalities produced through individual culpability in systemic failures and the displacement of responsibility onto individuals.

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