Addressing health literacy among long-term unemployed persons: the FORESIGHT intervention study

BackgroundUnemployed persons are at high risk for low health literacy. Most studies addressing health literacy of unemployed persons focus on risk factors for low health literacy or correlates of health literacy, but studies on needs of unemployed persons regarding health literacy are scarce. We aimed to obtain better understanding of health literacy needs of unemployed adults by triangulating the results from a scoping review on health literacy needs in unemployed adults and additional in-depth qualitative interviews.MethodsScoping review: We searched six databases up to January 2021 as well as gray literature for relevant studies following PRISMA-ScR guidelines. Titles, abstracts, and full texts were screened independently by two researchers. Qualitative study: Ten participants of a job-reintegration program in Germany were interviewed following a guideline covering topics including health issues of interest to the participants, their sources of health-related information and the barriers/facilitators they experience when accessing health services.ResultsScoping review: After screening 2,966 titles and abstracts, 36 full texts were considered, and five articles fulfilled the inclusion criteria. Four focused on mental health literacy and outcomes, while the fifth assessed information-seeking practices. One additional report on health literacy was identified via the gray literature search. Awareness of one's condition was identified as a facilitator for mental health help-seeking, while fear of harmful effects of medication prevented help-seeking. Qualitative study: Participants were interested in and were generally well-informed about health topics such as nutrition and physical activity. The main challenge perceived was translating the knowledge into practice in daily life. GPs and the social services providers played an important role as a source of health information and advice. Regarding mental health, similar barriers, facilitators and needs were identified through triangulation of findings of the scoping review with those of the interviews.ConclusionsThere is need to address health literacy needs of long-term unemployed persons that go beyond mental health literacy. Public health interventions should not only aim at improving health literacy scores, but also focus on how to help participants translate health literacy into practice. Population groups of interest should also be involved in all processes of designing interventions.

Kidney Health for All: Bridging the Gap in Kidney Health Education and Literacy

Introduction: Adolescence is a crucial period for the development of mental health. Enhancing mental health literacy can reduce stigma and support early intervention and treatment. This study aims to examine the mental health status and mental health literacy among middle and late adolescents in a rural area of Mojokerto District, East Java, Indonesia. Methods: A total of 81 high school students from Mojokerto District participated in the study. The Depression Anxiety Stress Scale – Youth version (DASS-Y) was used to assess symptoms of depression, anxiety, and stress. Mental health literacy was measured using the Adolescent Mental Health Literacy Questionnaire (AMHL). The validity of the AMHL was tested on 30 students using Pearson correlation. Descriptive statistics were used to analyze the prevalence of mental health conditions and levels of mental health literacy. Inferential statistics were applied to explore associations between mental health status, literacy, and sociodemographic variables. Results: The results showed that 53% of students experienced symptoms of mental health problems. While most students demonstrated moderate to satisfactory mental health literacy, significant gaps remain. Enhancing literacy may help reduce stigma and improve knowledge and attitudes toward mental health. Sociodemographic factors and mental health literacy showed limited influence on mental health status. However, sex was significantly associated with both mental health literacy and mental health status (p = 0.016 and p = 0.032, respectively). Conclusion: Mental health during adolescence significantly influences adult well-being. Improving adolescent mental health literacy is crucial for early recognition, stigma reduction, and better access to mental health care.

Beyond the tip of the iceberg: Health literacy in older people.

OVER THE NEXT 3 YEARS, STATE AND LOCAL OFFIcials will be responsible for reaching out to and enrolling more than 30 million individuals in publicly funded or subsidized health plans offered through state insurance exchanges. Because low health literacy tends to be more prevalent in certain minority groups and among those with low income and education, the majority of the newly eligible individuals are likely to have low health literacy. Failure to meet enrollment goals will not only undermine the credibility and success of the Patient Protection and Affordable Care Act (ACA) but, more importantly, will do little to expand health insurance coverage and improve access to care among those at greatest need. Health literacy is “the degree to which individuals have the capacity to obtain, process, communicate, and understand basic health information and services needed to make appropriate health decisions.” A 2004 Institute of Medicine report estimated that 90 million Americans lack the skills needed to understand and act on health information and concluded that “ . . . efforts to improve quality, reduce costs, and reduce disparities cannot succeed without simultaneous improvements in health literacy.” Recent estimates suggest that more than half (53%) of currently uninsured adults—those who will become newly insured under the ACA—have “below basic” or “basic” literacy skills. Such individuals have difficulty with tasks such as finding the date of a physician’s visit on an appointment slip or explaining why someone should have a medical test using information from a clearly written pamphlet. Individuals with low health literacy are less likely to actively participate in health care decision making and more likely to struggle with health management tasks and to face significant challenges navigating the health system. Recent studies also document higher rates of mortality among patients with limited health literacy. This growing evidence base prompted the Institute of Medicine to select “improving the health literacy of the population” as one of 24 Healthy People 2020 objectives submitted to the Department of Health and Human Services to help guide the US health agenda. The ongoing evolution of the health care system is leading US households toward greater responsibility for their own well-being. With this responsibility, however, comes an increasing need to be able to find, trust, use, and act on relevant information to make informed choices. Yet there continues to be a substantial mismatch between the high literacy burden of health information materials designed to support such choices and the health and financial literacy skills of individuals who use them. For example, approximately 9 of 10 US adults (88%) cannot calculate an employee’s share of health insurance costs using a table based on income and family size. In the current economic and policy environment, low health and financial literacy remains a barrier to reducing gaps in health care, raising concerns about the health and well-being of those who are unprepared for the increasing responsibility of choice. Enrollment in a health insurance plan, particularly a government-funded or subsidized plan in which eligibility must be verified, is a complex task. Individuals must navigate the system to find accurate and usable information; understand eligibility guidelines, complete forms, and provide mandatory citizenship and financial documentation necessary for enrollment (and for periodic reestablishment of eligibility); understand concepts such as premiums, copayments, and benefits and be able to apply these concepts to their existing or anticipated health situation to select the most appropriate plan; understand which services are and are not covered; and complete additional paperwork to enroll in their selected plan. The steps must occur prior to an actual visit with their physician, during which patients may spend limited time obtaining the information that is essential for maintaining optimal health and managing acute and chronic health conditions. In addition to developing a consumer-friendly enrollment system, evidence from Massachusetts’ 2006 reforms suggest that financially supporting community-based organizations and health care practitioners to help consumers navigate the process and fill out applications is effective: of all successful subsidy applications, 60% were completed with personal assistance to the consumers by such organizations.

Serving Culturally and Linguistically Diverse Patients in Audiology-Part 2: Promoting Health Literacy

Nowhere more recently has limited health literacy been more apparent than with COVID-19.1 The pandemic has challenged individuals and communities to grasp the importance of handwashing, mask wearing, and physical distancing to prevent disease transmission. Undeniably, health literacy ranks among social determinants of health2,3—housing, environment, education, economic stability, social support, and access to health care. Within the intensive care unit (ICU), more than 5 million Americans receive monitoring and treatment each year4 for serious conditions or injuries. These high-acuity or critically ill patients regularly rely on family members to understand their condition, treatment, and prognosis so that the family members can step into surrogate decision-making roles as needed.Health literacy has been defined as "the degree to which individuals have capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."5 This complex process involves (1) oral literacy (listening and speaking), (2) print literacy (reading and writing), (3) numeracy literacy (interpreting quantitative content), (4) analytic and decision-making skills, and (5) navigating the health care system.6-8Roughly 52 to 74 million US adults have limited health literacy and numeracy, respectively.9 Among adult caregivers, up to 53% may have low health literacy.10 Many factors affect health literacy. Culture and ethnicity top the list as influencers of how people communicate, understand, and respond to health information.8,11 Lower education and socioeconomic status, older age, English as a second language, and learning disabilities are other associated factors.8,12-14 Health literacy may also be situational.15 Unfamiliar environments like the ICU with heightened stress/anxiety can impact one's ability to (1) grasp, retain, and accurately relay key information; (2) actively participate in care; (3) understand life-sustaining treatments in discussions of goals of care; and (4) make informed decisions about treatment and/or end-of-life care.13,15-18Few studies have assessed health literacy in critical care. Researchers in 2 studies estimated that between 32% and 44% of parents of infants in a neonatal ICU had low health literacy.12,19 Notably, health care professional (HCPs) may overrate health literacy,12 leading to misunderstandings of critical information and further communication difficulties. Limited health literacy increases odds of greater difficulty navigating health care services and communicating with HCPs by 2.5 times.7 It is also associated with increased hospitalizations and health care costs, as well as worse medication adherence and health outcomes.6,14,20 These issues led to the following PICO (patient/population/problem, intervention, comparison, and outcome) question for this synthesis: What practices are effective (I) in improving family members' (P) understanding of essential health information (O) during critical illness?The strategy included searching CINAHL and PubMed. Keywords included family members, caregivers, intensive care unit, critical care, health literacy, family communication, and education. The search was limited to the past 10 years.Few studies21-24 have evaluated the impact of health literacy interventions on knowledge acquisition of families in the ICU. Two studies explored usability of health literacy– friendly materials. In the first pilot study, low-literacy parents of infants in a neonatal ICU (N = 10) rated web-based education, incorporating visual aids (ie, photos, pictographs, voice-recorded text messages at a 5th-grade level) as understandable and easy to use.21 In a quality improvement study, 95% of family members (N = 56) reported that a brochure helped them understand their loved one's risk of ICU-associated delirium.22Researchers in other larger prospective studies evaluated whether ICU informational brochures23,24 and websites24 improved family understanding. Topics ranged from the health care team to daily meetings and common procedures/treatments. One study intentionally included emotional justification when explaining information to reduce worry and improve family resilience.24 In both studies,23,24 families receiving brochures had greater comprehension of their loved one's diagnosis, treatment, and prognosis (although poor prognoses were understood better than good ones were).24The collection of small studies in this synthesis indicate that health literacy–friendly brochures23,24 and web-based materials21,22 were easy to use and improved family members' understanding of conditions, treatments, and prognoses. However, with such limited evidence, health literacy continues to be an emerging topic and research field in critical care.In the broader arena, health-literate organizations recognize that all patients/families have health literacy needs25 (Figure 1). Therefore, universal health literacy precautions should be adopted to ensure comprehension of key information in every health care encounter.2,6 These needs are underscored by a recent qualitative ICU study where researchers found that HCPs co-created "relational health literacy" with families, exchanging health information in their unfolding relationships.3 This relational concept of health literacy extends traditional definitions5 beyond individual cognitive or functional capacities. As families accessed and processed information about their loved one's disease/condition/treatment and health care system, they grasped to understand a new language of illness, including technical language. Support from HCPs—especially nurses' relational presence—aided family members in understanding and participating in care. These findings reinforce that preparing the workforce is imperative (Figure 1). Nurses and HCPs must effectively use patient-centered communication skills to assist patients and their families in building functional and interactive health literacy to face the often-stressful ICU experience.26 Several studies have shown that training in clear communication skills improved knowledge/skills and HCPs' awareness of the health literacy problem.11,26-29 Best practices for clear communication that aid comprehension are outlined in Tables 1 and 2 and Figure 2. These practices should be integrated into health literacy education, along with cultural competence training owing to the strong influence that culture has on communication. The Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit11 includes a quiz and communication self-audit that may be useful in reinforcing health literacy principles.Health literacy is now also understood as a systems issue.8,34 Thus, clinicians need access to easy-to-understand written materials and resources to augment verbal face-to-face interactions with patients and families (Table 2). Decision aids are emerging tools designed to improve knowledge of issues such as advanced care planning and life-sustaining treatments (eg, mechanical ventilation, cardiopulmonary resuscitation) and thus decisional comfort of patients and families.11,18,30,35 As the science evolves in critical care, how can your unit enhance its health literacy environment?As strategies such as these mitigate system demands and complexities, critical care nurses can continue actively partnering with patients and their families to build the literacy they deserve to understand and make informed decisions about their health condition and thereby transform the patient/family experience. Nurses. Relational. Presence.

BackgroundEffective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations.MethodsWe reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.ResultsAim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.ConclusionLower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.

Background In recent years, health literacy has been acknowledged as crucial in context of school health promotion, prevention, and education. In 2020, the Schools for Health in Europe Network, linking the 53 WHO European Region Member States to collaborate on school health, released a milestone fact sheet on health literacy in schools, including an evidence synthesis on how health literacy impacts not only health goals but educational outcomes. In 2021, the World Health Organization Regional Office for Europe produced an evidence informed report, recommending the way forward regarding school health literacy in the realm of European public health. Organizational health literacy of schools is named a key responsibility for educational establishments alongside activities to address digitalization in education, climate and planetary health, the commercial determinants of health, the role of social media, and the aftermath of the Covid-19 pandemic. Achieving health literacy development throughout childhood and adolescence requires an early and systematic approach, ideally implemented in schools. Classroom learning and instruction by teachers qualified in health education are key to strengthen skills, behaviours, knowledge, and attitudes that schoolchildren will need to appropriately manage health information from various sources and form health decisions to promote their health in everyday life. Schools are widely accepted as the ideal setting for children to learn about and take responsibility for their own health and self-directed learning, bringing together all elements of health literacy including digital, mental, and organizational health literacy. Teaching materials and targeted sessions on health literacy, either embedded into a subject or as a cross-cutting topic, have several benefits: they reach all children regardless of their social, cultural or development background, they can be delivered over the course of a decade and longer, they can be repeated to enhance learning effects, with increasing grades the complexity and content can be expanded, and in schools it is possible to swiftly respond to contemporary health concerns of children. Objectives This workshop will present empirical findings and intervention research results from various school health literacy studies. (i) The first presentation will discuss findings of school principal's health literacy. (ii) The second presentation will provide key findings from the first ever study on organizational health literacy in schools. (iii) The third presentation will present the evaluation of a mental health literacy programme for students and teachers. (iv) The fourth presentation will introduce a digital health literacy intervention for schoolchildren. The format of this workshop will be 4x7-minute presentations followed by a 20-minute panel discussion, reflecting the relevance of the results to public health research, practice and policy. Key messages • School health literacy is an important topic within the context of school health promotion, prevention, and education. • Addressing health literacy as early as in schools will enable children and adolescent to become health literate, enabling them to face health challenges over the life-course.

Social inequalities in health care remain a pressing issue with direct consequences for treatment outcomes. One complex mechanism contributing to this inequality involves patient's health literacy - including their ability to perceive a medical need and understand the availability of care. This scoping review aims to examine whether economically disadvantaged groups are at greater risk of low health literacy and to identify potential intervention targets to improve health care access and equity. We systematically searched MEDLINE (Ovid) in May 2022 and again in November 2024 for peer-reviewed original studies (English/German; 2000-2024) from high-income countries that compared lower- versus higher-income groups on health literacy. Drawing on 179 peer-reviewed original research articles, the review found, in most cases, a consistent association between low income and limited health literacy, including general health literacy, mental health literacy, disease-specific knowledge (e.g., cancer, oral health), and eHealth literacy. Notably, individuals with chronic illnesses may possess greater condition-specific knowledge than the general population, regardless of income. However, inconsistent income classifications together with variation in the health-literacy constructs used undermine comparability. In summary, the results suggest that efforts to improve population health literacy must consider the circumstances of people living in poverty and develop strategies to reach them. Future research should explore additional social determinants of health literacy - such as education, occupation, or early-life adversity - using longitudinal approaches to better understand causal pathways. PROSPERO 2022 CRD42022334775.

Health Illiteracy Challenges Long-Term Care

Health literacy describes how people use health information to make informed decisions in context of healthcare, disease prevention and health promotion. Enhancing health literacy of populations is critical and in particular important at an early age, which is understood to be more sustainable because health literacy contributes to improved personal health and development. Low health literacy in child and adolescent populations has been linked to worse health outcomes and health disparities in Europe, making health literacy of children and adolescents an important public health topic. Developing and delivering target group specific interventions and services requires precise data generation on the state of health literacy in early age. In the past decade, several conceptual approaches have been undertaken but methodological sound, validated and reliable measurement tools are still scarce. Available systematic reviews show that most tools originated from North America and/or English speaking countries. However, in the past years European researchers have been involved with research on health literacy in childhood and adolescence, the result of which culminated into heavy progress regarding the development of health literacy measurement instruments, including generic health literacy, digital health and mental health literacy. These new developments lead to the availability of validated tools for school-aged children, including primary and secondary school children. The purpose of this workshop is to bring together five contemporary health literacy studies conducted in child and adolescent populations across Europe, including national and European-wide studies. Both methodological findings regarding the measurement tool and empirical data will be introduced. The first presentation emerges from the HLCA HL-Kids project, which has been conducted in Germany and focusses on primary schoolchildren, using the HLS-Child-Q15 tool. The second presentation originates from the Netherlands where the HLS-Child-Q15 tool was adapted to Dutch children. The third presentation aims at health literacy of adolescents in secondary school-age in Germany, by using the MOHLAA-Q tool. The fourth presentation originates from the WHO-led HBSC study, which has been conducted by using the HLSAC questionnaire. The final presentation will focus on the first digital health literacy measurement tool for secondary schoolchildren, which has been developed within a German study in schools. Each project will be given ten minutes to present their findings, including questions, which will be followed by Q&A and an open discussion with the audiences. This workshop offers a forum for researchers, practitioners and policy-makers interested in health literacy measurement in children and adolescents. By dialogue and two-way communication, vivid interaction will be ensured, allow building synergies, and facilitate networking and capacity building.Key messages• Health literacy contributes to improved personal health and development of children and adolescents.• The measurement of health literacy is key to public health intervention success and needs theory driven, validated and reliable instruments.

ObjectiveHealth literacy is a significant public health concern, particularly given the increased complexity of chronic disease health management and health system navigation, and documented associations between low health literacy and poor health outcomes. This study therefore aimed to identify the proportion and characteristics of outpatients visiting a specialist cancer hospital who report low health literacy and/or low cancer health literacy.MethodThis study used a cross-sectional survey administered verbally with patients attending a specialist cancer hospital located in Melbourne, Australia over a two-week period. Process data on conducting health literacy screening within a clinical setting was collected.ResultsThose identified with inadequate general health literacy were different to those identified with low cancer-specific health literacy, although overall both proportions were low. Cross-sectional screening of patients was difficult, despite utilising verbal surveying methods designed to increase capacity for participation.ConclusionHealth literacy screening using the tools selected was not useful for identifying or describing patients with low health literacy in this setting, given the disparity in those categorised by each measure.Practice ImplicationsUntil the theoretical construct of health literacy is better defined, measurement of health literacy may not be clinically useful.

Introduction: Specialized lifestyle programmes for patients undergoing metabolic-bariatric surgery (MBS) are provided to facilitate adjustment and adherence to a healthy lifestyle after surgery. However, pre-programme food and health literacy in MBS patients is often unknown. In the general population, approximately three-quarters of people exhibit sufficient health literacy. This study aimed to examine food and health literacy of patients awaiting MBS and to identify patient-specific factors associated with these literacies. Methods: Patients awaiting MBS completed questionnaires on food literacy (Self-Perceived Food Literacy scale) and health literacy (European Health Literacy Survey Questionnaire-16) at the start of a preoperative lifestyle programme. Linear and logistic regression analyses were used to identify associations between multiple variables and preoperative food and health literacy. Results: Among 216 patients, the preoperative mean food literacy score was 3.49 ± 0.44, on a five-point scale. Furthermore, 96.3% of patients showed sufficient health literacy, with scores of 13 or more out of 16. Patients with sufficient health literacy had higher food literacy scores (β 0.508; 95% CI: 0.208–0.809, p < 0.001). Conclusion: This study among people living with obesity awaiting MBS suggests that food literacy is comparable, and health literacy is higher than in the general population. These findings emphasize the complexity of the aetiology of obesity due to factors that extend beyond food and health literacy.

Prevalences of mental disorders are increasing worldwide. However, many people with mental health problems do not receive adequate treatment. An important factor preventing individuals from seeking professional help is negative attitudes toward psychotherapeutic treatment. Although a positive shift in attitudes has been observed in recent years, there is still substantial stigma surrounding psychotherapeutic treatment. First studies have linked higher health literacy with more positive attitudes toward psychotherapy, but more research is needed in this area. This study aimed to examine how general and mental health literacy are associated with attitudes toward psychotherapeutic treatment in Germany. Additionally, associations between sociodemographic factors, experience with psychotherapy, and attitudes toward psychotherapy were explored. A random sample was drawn from a panel representative of the German-speaking population with internet access in Germany and invited to participate in the study via email. Overall, 2000 individuals aged ≥16 years completed the web-based survey with standardized questionnaires in September and October 2022. Attitudes toward psychotherapy and both general and mental health literacy were assessed using the Questionnaire on Attitudes Towards Psychotherapeutic Treatment (QAPT) with 2 subscales ("positive attitudes" and "non-acceptance of society"), the European Health Literacy Survey instrument (HLS-EU-Q16) and the Mental Health Literacy Tool for the Workplace (MHL-W-G). Associations between the questionnaire scales were assessed with Pearson correlations. Additionally, basic sociodemographic information and information on personal and family experiences with psychotherapy were collected. Pearson correlations (age), ANOVAs (level of education and subjective social status), and t tests (experience with psychotherapy, gender, and migration background) were used to analyze how these relate to attitudes toward psychotherapy. More favorable attitudes toward psychotherapy and lower perceived societal nonacceptance were found in those with higher general (r=0.14, P<.001; r=-0.32, P<.001, respectively) and mental health literacy (r=0.18, P<.001; r=-0.23, P<.001, respectively). Participants with treatment experience for mental health problems (t1260.12=-10.40, P<.001, Cohen d=-0.49; t1050.95=3.06, P=.002, Cohen d=0.16) and who have relatives with treatment experience (t1912.06=-5.66, P<.001, Cohen d=-0.26; t1926=4.77, P<.001, Cohen d=0.22) reported more positive attitudes and higher perceived societal acceptance than those without treatment experience. In terms of sociodemographic differences, being a woman (t1992=-3.60, P<.001, Cohen d=-0.16), younger age (r=-0.11, P<.001), higher subjective social status (F2,1991=5.25, P=.005, η2=.005), and higher levels of education (F2,1983=22.27, P<.001, η2=.021) were associated with more positive attitudes toward psychotherapeutic treatment. Being a man (t1994=5.29, P<.001, Cohen d=0.24), younger age (r=-0.08, P<.001), and lower subjective social status (F2,1993=7.71, P<.001, η2=.008) were associated with higher perceived nonacceptance of psychotherapy. Positive associations between attitudes toward psychotherapy and both general and mental health literacy were delineated. Future studies should investigate whether targeted health literacy interventions directed at individuals with lower general and mental health literacy might also help to improve attitudes toward psychotherapeutic treatment and help-seeking behavior.