Health Literacy Policies Research Articles

4.X.1. Health literacy policies – how can they be developed and implemented?

Abstract In Europe and beyond, there is political recognition of health literacy being an important factor for good health and well-being. As health literacy is considered critical to achieving health and as limited health literacy is still a widespread phenomenon, the topic is steadily attracting more attention among policy and decision makers. To meet growing demand from decision makers, a policy guide was initiated by M POHL, the World Health Organization (WHO) Action Network on Measuring Population and Organizational Health Literacy. The guide aims to support awareness-raising, the building of commitment and the implementation of effective policies to improve health literacy. It mainly addresses decision-makers in health policy and administration, but may also inspire researchers and other relevant stakeholders in the health literacy area. Objectives of the workshop This skills building seminar seeks to contribute to capacity building and to offer time for exchange and discussion on health literacy policy work. More specifically, the objectives of the workshop are to: - provide an overview on national health literacy policy implementation; - increase the knowledge of participants on what countries are doing already and identify needs for further support; - support participants in reflecting, initiating, developing and implementing effective measures to improve population and organizational health literacy. Methods of the workshop The workshop will start off by a presentation introducing the guide “Health literacy policies - how can they be developed and implemented?’ and sharing some national experiences in implementing health literacy policies, strategies, and interventions. After these impulses attendees will be divided into groups to enable exchange. A checklist for self-assessment will be provided as a tool to guide the discussion and to identify and address potential challenges in implementing health literacy policies and interventions. The input and identified needs will be captured. They will support M-POHL’s continuing efforts to support policy makers and administrators in their work. Key messages • Health literacy is steadily gaining more interest from policy- and decision-makers. • In this seminar, participants will learn on how evidence-informed policies and practice can be supported.

A guide for policy and decision makers on health literacy policies

Abstract Supported by supranational organizations such as the WHO or the European Union, governments across the world have begun to work systematically on developing and implementing action plans, strategies and policies to improve the health literacy of their citizens and the health literacy friendliness/responsiveness of health organizations. In 2023, a first project on evidence-based policies and practices was initiated by the WHO Action Network on Measuring Population and Organizational Health Literacy (M-POHL) and financially supported by the Swiss Ministry of Health. In this project a guide on how health literacy policies can be developed and implemented was developed by an international working group. This guide brings together insights from existing literature on national health literacy strategies, action plans and interventions, including an expert snowball search within the M-POHL network and among other partners, experiences and case examples collected from M-POHL members and other countries. Feedback on the guide was collected in interactive webinars with policy representatives and decision-makers and addressed. The structure of the guide follows an adapted version of the Public Health Action Cycle model, assisting step-by-step action on health literacy policy development: situation analysis; agenda setting; developing policies, strategies and interventions; implementation; evaluation and monitoring. Each phase is described, and best practices and recommendations provided. The guide closes with a checklist for self-assessment which follows the structure of this document. It supports reflection on the state of policies in a country. This innovative guide contributes to supporting evidence-informed policies and practice. This can be of interest to experts and practitioners who have data on challenges relating to the health literacy levels of population groups and who wish to develop or adjust their policies, services and communications accordingly.

Associations between health literacy proficiencies and health-related quality of life and GP visits among young people in Norway: a population-based cross-sectional study.

Despite globally increased attention from policymakers and being recognised as a critical determinant of health, health literacy (HL) research in young people (YP) remains limited. This study aims to describe HL in YP across person factors and explore the associations between HL and health-related quality of life (HRQoL) and the number of visits to general practitioners (GP visits). Cross-sectional study. Population-based data collection applying country representative strata in Norway. 890 participants aged 16-25 years. Rasch modelling and Wright's method were used to identify statistically distinct levels of HL proficiency. Multiple linear regression and negative binomial regression models were applied to explore the associations between HL and HRQoL, and between HL and GP visits, respectively. Among YP, HL was statistically significantly associated with HRQoL and the number of GP visits, when adjusting for age, gender, education, self-perceived social status and financial deprivation. For every logit increase in HL, the number of GP visits decreased by 22%. Four statistically distinct levels of HL proficiency were identified for the 12-item HLS19-YP12 scale, started from a cut-point of 23, 30, 37 and 44 out of 48. Relatedly, 70% of respondents were observed at or below level 2 (30-36 points), indicating a varying lack of central skills. The span from lowest (1) to highest (4) HL level was associated with a decrease of 2.1 GP visits per year and an increase of .12 on the EQ-5D index. This study provides new empirical insights into the impact of HL in YP. Identified cut-points for the HLS19-YP12 may contribute to simplifying the process of adapting information and communication for various HL skills. The study also suggests the need for more efforts in HL policy and structural intervention development to enhance YP health and well-being.

Information and health literacy policies during pandemics: A narrative review.

The COVID-19 pandemic has compelled governments globally to formulate policies addressing the unique needs of their populations. These policies are critical in disseminating accurate information and enhancing health literacy during crises. This narrative review aims to identify and assess effective information and health literacy policies implemented during pandemics. A comprehensive literature search was performed across five electronic information sources (PubMed, Science Direct, ProQuest, Emerald Insight, Scopus), supplemented by Google Scholar. The analysis employed Walt and Gilson's health policy triangle framework to categorize and evaluate the findings. The review revealed that the policies could be grouped into several key categories: educational programs, laws and regulations, knowledge sharing, national programs, and different information sources. The development of these policies involved multifaceted processes influenced by political, scientific, economic, cultural and social factors, as well as the involvement of multiple stakeholders. This review offers significant insights and actionable recommendations for policymakers and stakeholders. By understanding the dimensions and components of effective information and health literacy policies, stakeholders can better prepare for and respond to future pandemics and similar health crises.

Re-energizing health literacy in Wales: a testbed for health, education and prosperity for all.

A growing body of evidence demonstrates the importance of enhancing health literacy for improved health outcomes, self-reported health, lower health services use and disease prevention. Importantly, improving health literacy has great potential to reduce health inequities and inequalities. The World Health Organization (WHO) has identified health literacy as a global priority, viewing it as a right and a fundamental competency necessary to function within modern society. Building health literacy foundations should begin in early childhood, including focus within educational frameworks and school curricula. The WHO advocate for governments to embed it as an explicit goal. In response, it has received significant international policy and strategy focus, in addition to the development of country-level action plans. In Wales, UK, it was identified as a priority in 2010, but despite wider developments spanning health and social care, well-being, economy and education policy, growth in health literacy has stalled since. Optimizing health literacy would act as an indirect enabler to a range of Welsh policies and strategies. A promising avenue for strengthening the health literacy of current and future generations is through ongoing significant national education reforms and the introduction of the new Curriculum for Wales. One of four overarching purposes of this curriculum is healthy, confident individuals, and health and well-being constitutes one of six statutory curriculum areas. Tracking the impact of this on children and young people's health literacy offers opportunities for Wales to model and gain traction as a national-scale health literacy policy testbed. This requires re-energizing health literacy as a national priority.

Spanish and Catalan Versions of the eHealth Literacy Questionnaire: Translation, Cross-Cultural Adaptation, and Validation Study.

The rise of digital health services, especially following the outbreak of COVID-19, has led to a need for health literacy policies that respond to people's needs.Spain is a country with a highly developed digital health infrastructure, but there are currently no tools available to measure digital health literacy fully. A well-thought-through questionnaire with strong psychometric properties such as the eHealth Literacy Questionnaire (eHLQ) is important to assess people's eHealth literacy levels, especially in the context of a fast-growing field such as digital health. This study aims to adapt the eHLQ and gather evidence of its psychometric quality in 2 of Spain's official languages: Spanish and Catalan. A systematic cultural adaptation process was followed. Data from Spanish-speaking (n=400) and Catalan-speaking (n=400) people were collected. Confirmatory factor analysis was used to confirm the previously established factor structure. For reliability, the Cronbach α and categorical ω were obtained for every subscale. Evidence of convergent and discriminant validity was provided through the correlation with the total score of the eHealth Literacy Scale. Evidence based on relations to other variables was evaluated by examining extreme values for educational level, socioeconomic level, and use of technology variables. Regarding the confirmatory factor analysis, the 7-factor correlated model and the 7 one-factor models had adequate goodness-of-fit indexes for both Spanish and Catalan. Moreover, measurement invariance was established between the Spanish and Catalan versions. Reliability estimates were considered adequate as all the scales in both versions had values of >0.80. For convergent and discriminant validity evidence, the eHealth Literacy Scale showed moderate correlation with eHLQ scales in both versions (Spanish: range 0.57-0.76 and P<.001; Catalan: range 0.41-0.64 and P<.001). According to the relationship with external variables, all the eHLQ scales in both languages could discriminate between the maximum and minimum categories in level of education, socioeconomic level, and level of technology use. The Spanish and Catalan versions of the eHLQ appear to be psychometrically sound questionnaires for assessing digital health literacy. They could both be useful tools in Spain and Catalonia for researchers, policy makers, and health service managers to explore people's needs, skills, and competencies and provide interesting insights into their interactions and engagement regarding their own experiences with digital health services, especially in the context of digital health growth in Spain.

Organizational Health Literacy in cancer care: the patients’ perspective

Abstract Introduction While earlier views of health literacy focused on patients’ skills, recent conceptualizations put the emphasis on matching individuals’ functional, communicative and critical skills to the information requirements of the health system. This paradigm shift has given rise to the concept of health-literate organizations. Yet while this concept is becoming better known, the barriers and facilitators to its implementation remain understudied. This study aims at understanding patients’ perspective of how their health literacy levels are being attended to by the healthcare system and enable their decision-making process. Methods The study took place at the oncology-hematology departments in two sites of a Brussels-based hospital, serving two different patient populations. The perceptions of 20 patients on existing health literacy policies and procedures were evaluated through semi-structured interviews based on the Enliven Organisational Health Literacy Self-Assessment Resource, CDC's attributes of a health-literate organization, and the International Self-Assessment Tool for Organizational Health Literacy Responsiveness of Hospitals. The models underlying these tools were used for the analysis of the results alongside the WHO health literacy policy model. Results Preliminary results revealed a weak understanding of the term health literacy and poor comprehension of the impact and importance of health literacy. The information given through oral or written measures was considered sufficient but poorly adapted to cultural and linguistic needs. Little or no involvement was perceived in patient-related approach strategies. Coordinating nurses were considered as the main source of information. Conclusions The weak ability of patients to understand the importance of health literacy and its impact calls for a health literate organization approach that allows the patient an accessible and level-adapted environment that caters to all HL levels. Key messages • Weak ability for patients to understand HL and it's importance shows how perception of adapted Health Literate approaches are impacted. • The need for health literate organizations through the creation of interventions that cater the needs of patients, health care staff and the organization.

Measuring Digital Health Literacy in Europe – Scope, determinants and consequences

Abstract Background Increasing access to health-related digital information/resources of varied quality warrants sufficient Digital Health Literacy (DHL) in the population. Public health researchers, practitioners, and policy makers need to consider DHL for improving people's ability to use digital resources. The M-POHL HLS19 study objectives were to construct and validate a DHL measure, and identify its determinants and consequences. Methods A scale was constructed with 8 items on dealing with digital health resources. Two additional items examined interactive use of resources. The scale was applied among a sample of 29,060 respondents in 13 countries using CAPI, CATI, CAWI, PAPI and mixed methods. A standardized score was calculated for DHL, range: 0-100. Results Appraising the reliability of digital resources was perceived particularly difficult. The scale showed acceptable reliability (Cronbach's α 0.7-0.87/country). A confirmatory factor model loading onto a single latent variable indicated an acceptable fit for all countries. The DHL scale was sufficiently unidimensional based on principal component analysis of Rasch model residuals combined with dependent t-tests. Linear regression models with 5 DHL predictors showed a social gradient with explained variance of 6% (2-23%/country). The highest predictor was financial deprivation: ß=−0.15 (0.08--0.27), then age: ß=−0.13 (0.15--0.26); self-assessed social status: ß=0.08 (0.05-0.13). General health literacy was a strong predictor: ß=0.51 (0.43-0.67). In linear regressions to explain variance in self-assessed health, the DHL coefficient was significantly different from zero in 9 countries (ß=−0.05-0.10). Conclusions The new DHL scale had acceptable psychometric properties. The relevance of DHL is reflected in the high proportions with lower DHL, a social gradient, and health consequences in most countries. The study offers an evidence base for tailoring DHL intervention strategies and organizational health literacy policy. Key messages • Digital Health Literacy of populations in Europe was estimated through a validated measure with associations that predict public health and healthcare consequences in most countries. • Public health practitioners and policy makers should be aware of populations with lower Digital Health Literacy (DHL), and both promote DHL while also adjusting interventions/services to DHL needs.

Shifts in Diabetes Health Literacy Policy and Practice in Australia-Promoting Organisational Health Literacy.

Improving organisational health literacy ensures people can navigate, understand and use essential health information and services. However, systematic reviews have identified limited evidence for practical approaches to implementing such organisational change, particularly at a national level. This study aimed to (a) investigate the approach taken by an Australian national diabetes organisation-Diabetes Australia, as the administrator of the National Diabetes Services Scheme (NDSS)-to improve organisational health literacy over a 15-year-period and (b) examine the impact of organisational changes on the health literacy demands of health information. We performed an environmental scan, examining the websites of the NDSS, Diabetes Australia and the Australian government for reports and position statements describing organisational health literacy policies and practices between 2006 and 2021. The Patient Education Materials Assessment Tool (PEMAT) was applied to consecutively published NDSS diabetes self-care fact sheets (n = 20) to assess changes in the health literacy demands (understandability and actionability) of these fact sheets over the same period. We identified nine policies resulting in 24 health literacy practice changes or projects between 2006 and 2021, applied using a streamlined incremental approach and group reflexivity. The incremental approach focused on (1) increasing audience reach, (2) consistency and branding, (3) person-centred language and (4) the understandability and actionability of health information. The PEMAT scores of fact sheets improved between 2006 and 2021 for understandability (53% to 79%) and actionability (43% to 82%). Diabetes Australia's information development process leveraging national policies, employing an incremental approach and group reflexivity has improved the health literacy demands of diabetes information and serves as a template for other organisations seeking to improve their organisational health literacy.

우리나라 헬스리터러시 국가정책 방향

Objectives: To suggest the direction of national policy for health literacy in Korea, this study compared and analyzed the health literacy policies of EU countries, China, United States, and Korea. Methods: In order to compare the health literacy policies of major countries, data on (1) general health literacy levels, (2) health literacy goals, (3) beneficiaries, (4) initiator, and (5) financial resources were collected and analyzed. Results: Although the levels of health literacy and the stage of policy development showed considerable differences among countries, the concept of health literacy and the strategies related to it have been continuously improved. In Korea, national policy for health literacy is now its infancy. Accordingly, goals and strategies need to be systematically prepared. Conclusion: The level of health literacy in Korea was estimated and the direction of national policy for health literacy was suggested. In Korea, national health literacy policies should be established to reduce health and social disparities, change structural conditions, strengthen cooperation in various fields, and enable participatory decision-making.

Strengthening the Case for Universal Health Literacy: The Dispersion of Health Literacy Experiences Across a Southern U.S. State.

Background:How individuals perceive their health literacy may differ based on demographic and individual characteristics.Objective:The purpose of this study was to understand the dispersion of health literacy across demographics in the state of Georgia in 2021 and to determine which factors influence health literacy.Methods:Study participants were age 18 years and older and completed an on-line Health Literacy Questionnaire (N = 520). The participant pool was stratified to mirror state-wide demographics of geography and race. Results were further collapsed into composite scales reflecting basic, communicative, and critical health literacy. Descriptive statistics, bivariate Pearson's correlations, and multiple regression analyses were used. A two-step cluster analysis was performed with the nine health literacy scales.Key Results:Rural county and no health insurance were negatively related to all three composite scales (rs = .093-.254, ps < .05). Demographic predictors accounted for 6.7% of the variance in basic (F[6, 439] = 5.287, p < .001), 10% in communicative (F[6, 438] = 8.154, p < .001), and 6% for critical (F[6, 439] = 4.675, p < .0010. In all scales, health insurance status was the strongest primary unique predictor (βs = .236, .295, .181, ps <.05, respectively). In a two-step cluster analysis only health insurance status differentiated the health literacy level clusters (X2(3) = 9.43, 34.51, ps = 024, <.001 respectively).Conclusion:Lacking health insurance is the most consistent and largest contributor to low health literacy across the state of Georgia; population demographics are not. Health literacy policies and practices should be developed for universal application and not focus on specific populations. [HLRP: Health Literacy Research and Practice. 2022;6(3):e182–e190.]Plain Language Summary:In this study, demographics that are usually associated with low health literacy like age, sex, race, educational attainment, and type of county (rural or urban) were not associated with; the only significant factor was lack of health insurance. This relationship strengthens the case for universal health literacy precautions that go beyond population demographics.

Health literacy: What lessons can be learned from the experiences and policies of different countries?

Adequate levels of health literacy (HL) are crucial to ensure good quality of health, social life and wellbeing. HL is a mediating factor in health disparities. Low HL hampers interaction with healthcare. HL is a shared responsibility of individuals and the healthcare system. Multi-dimensional programs and policies should be set up. To learn from current HL policies and action plans and to identify elements to consider for the development of national HL plans. Transversal analysis of HL policies in six countries, based on a preliminary scoping review. A combination of document analysis and key informant approach. Local experts validated and completed information for their country. A transversal comparison was performed. Several approaches were identified, often influenced by contextual factors, healthcare reforms and existence of centers of expertise. Some governments developed full-fledged, standalone plans, while others developed broader plans covering the entire health and care sector. Some took a conceptually driven, high level approach. Others took a pragmatic approach. And some did not have a governmental plan at all. Policy makers should analyse their state structure and health system, and search for local 'pockets of excellence', to develop a well-planned, substantiated HL approach for their country.

Differences in health literacy level of patients from public and private hospitals: a cross-sectional study in Turkey

ObjectivesPolicy-making based on a health literacy approach makes it a priority to develop people-centered public health strategies and programs, particularly in the time of COVID-19 across the world. This is the first study to assess health literacy levels of patients visiting public and private hospitals in Turkey and also compares these levels with sociodemographic and health-related variables by hospital type to suggest health policies aimed at improving the health literacy skills for patients with different socio-economic backgrounds. Study designThis is a cross-sectional study. MethodsThe study was conducted on 948 outpatients from both hospital types in 2018. Health literacy was assessed using the validated Turkish version of the European Health Literacy Survey Questionnaire with 47 items. The level of health literacy and sociodemographic factors influencing it were analyzed using correlation and binary logistic regression tests. Patients from private hospital had better health literacy index score compared with the public hospital. ResultsThe health-related variables, such as self-reported health and the presence of long-term illness, and sociodemographic characteristics, including education, age, and gender, were associated with health literacy for both public and private hospitals. Age and education were important predictors, whereas gender, long-term disease condition, self-reported health, and perceived income status were statistically significant variables for adequate health literacy in both hospital types. ConclusionsParticipants from private hospital had better health literacy than that of public hospital. These findings could be used to help health policy makers to improve the current health literacy policy for patients and develop strategies by stakeholders for reducing barriers to obtaining health-related information.

국민 건강수준 향상을 위한 국외 헬스리터러시 정책 동향 및 함의

Objectives: Health literacy has become an important issue in the filed of public health. The World Health Organization (WHO) recently established a strong global mandate for public policy action on health literacy by positioning it as one of three key pillars for achieving sustainable development and health equity in the Shanghai Declaration on Health Promotion. A number of countries implemented national health literacy policies, with many others expected to develop them in the immediate future. However, national policies and strategies for health literacy in Korea is still limited and underdeveloped. The aim of this study was to suggest policy directions to improve health literacy in Korean through reviewing international health literacy polices and strategies at the national level. Methods: In terms of the literature in U.S, Canada, Australia, and European countries, government policy reports and research papers were reviewed. For systematic comparison, the criteria for analyzing and extracting data from policy documents suggested by previous study was employed. Results: Based on the literature review, document review on international efforts to improve health literacy, and survey results, we suggest the following policy recommendations: (1) developing an official term of health literacy in the Korean language to help stakeholders and the public better understand the comprehensive, multi-dimensional concept, (2) monitoring of the health literacy level among Koreans, and (3) coordinating with government, healthcare sector, academia, etc. to develop intersectoral strategies aiming at improving health literacy as well as achieving health equity. Conclusions: For the development of effective health literacy policies and strategies at the national level, health literacy needs to be understood as a key determinant of health, and inter-sectoral efforts should be considered to improve health literacy.

Health and nutrition literacy in adults: Links with lifestyle factors and obesity

BACKGROUND: Low Health Literacy (HL) and Nutrition Literacy (NL) are associated with serious negative health outcomes. OBJECTIVES: The aim of this study was to investigate certain lifestyle factors and obesity, in relation to HL and NL. METHODS: This cross-sectional study was conducted in the urban area of the Attica region, in Greece. The sample consisted of 1281 individuals, aged ≥18 years. HL, NL sociodemographic characteristics and lifestyle factors (physical activity, smoking status, alcohol consumption,) were assessed. Mann-Whitney U, the Kruskall Wallis, Pearson chi-square tests and multiple linear regression models were used. RESULTS: Linear regression analysis has shown that smoking, alcohol consumption and physical activity, were associated with HL levels (–1.573 points for ex-smokers in comparison to smokers, p = 0.035, –1.349 points for alcohol consumers in comparison to non-consumers, p = 0.006 and 1.544 points for physically active individuals to non-active, p = 0.001). With respect to NL levels, it was also not associated with any of these factors. Obesity was not associated with HL and NL levels. CONCLUSIONS: Certain lifestyle factors, including physical activity, are predicting factors of HL levels, in Greek adults. The results contribute to the understanding of the relationship between lifestyle factors and HL and should be taken into account when HL policies are designed.

4.E. Workshop: Health literacy in Policies: European and National Perspectives

Abstract Health literacy is a key dimension of public and global health policy. In the wake of Health in all Polices (HiAP), the Sustainable Development Goals (SDGs), and health equity discussions, health literacy plays an important role in empowering citizens by increasing their capacities to deal with health information and make informed decision. In recent years, digitalization and digital transformation of societies and everyday environments have contributed to the increasing awareness of the role of health literacy for navigation of these new and often complex environments. Together, these developments have facilitated the establishment of health literacy as a critical policy item on agendas across the world. In Europe, a lively policy discussion has emerged within the last decade with countries developing their own national and local strategies addressing health literacy in public health and healthcare policies, directives on health promotion and prevention and even in educational policies to include health literacy to school practices. The WHO EURO Region with 53 Member States has been particularly active, launching the WHO “Solid Facts” report on health literacy and two “Action Networks on Health Literacy” - one on measurement and one NCD interventions. Politically, these initiatives were followed up strategically by the Health Literacy Roadmap and by a resolution to develop a European health literacy action plan. While the policy movement is steadily increasing, research on health literacy policies and policy making is still a developing field. This is concerned with policies both on children`s as well as on adult`s health literacy. In this context, the aim of this workshop is to: present research findings from recent health literacy policy initiatives, such as the WHO European health literacy roadmap and action plan and European national policies and initiate a critical discussion regarding future health literacy policy development in the European region and beyond. The 1st presentation will provide an overview on health literacy policy initiatives at WHO Europe with a focus on the development of a new European Action Plan. The 2nd presentation will focus on the WHO health literacy policy initiative focusing on school-aged children. The 3rd presentation will share policy recommendation by experts for promoting health literacy in children and adolescents. The 4th presentation offers a national policy and field application focusing on health literacy and cultural appropriateness. The 5th presentation provides an example of a national position paper on health literacy from a structural perspective presenting a possible path to equity in health. This workshop offers a forum for researchers, practitioners, policy-makers and public stakeholders interested in public health policy-making with a specific focus on health literacy, and will promote discussion of results, facilitate knowledge exchange, and support further synergies. Key messages Health literacy policy is an important cornerstone of the WHO European Region Public Health and Policy strategy and the UN Sustainable Developmental Goals. This workshop will address health literacy policy development on national, European and global levels in different populations.

Recommendations for a Health literacy Policy Plan for Belgium: Learning from experiences of other countries

Abstract Background In Belgium, the past decade has seen a large number of initiatives by various stakeholders to address health literacy (HL) at different levels, but an encompassing policy plan to coordinate efforts across sectors is missing. The Belgian Federal Public Service of Health, Food Chain Safety and Environment commissioned a study to investigate HL policy plans of other countries, with the intention to make recommendations for the development of a Belgian National Health Literacy Plan (NHLP). Methods To identify elements and criteria for a NHLP, a transversal analysis was performed of HL policies in Australia, Austria, Ireland, The Netherlands, Portugal, and Scotland, following a preliminary scoping review regarding the availability of relevant information. Information about HL policies was analysed using a combination of document analysis and key informant approach, structured by means of an analytical grid specifying methods, resources, goals, actors, beneficiaries, actions, timing, opportunities, threats, evaluation, monitoring and impact. Results Policy approaches and action plans on HL vary widely in scope, focus and depth. Three pathways to developing a national HL plan were identified: (1) a conceptual approach whereby targets are formulated at the national or federal level, showing the country's determination to improve HL throughout its political system, but with a weak leverage for action (A, AUS, P); (2) a pragmatic approach targeting the healthcare sector first but progressively broadening the scope towards other sectors (SCOT); (3) a delegated approach whereby the authorities delegate the initiatives regarding HL to an active and dynamic civil society (NL, IRL). Conclusions There is no single best way to coordinate efforts to address HL across sectors. Policy makers should consider the strengths and weaknesses within their country to develop a substantiated HL approach that best fits the country's situation.

Health Literacy Policy in Israel – Culturally Appropriate Health Systems

Abstract Background The diverse culture in Israel created the need for developing and implementing a national policy for culturally and linguistically appropriate health services. The need stems from trends in immigration to Israel, various levels of religiosity, and the ethnic diversity of the veteran population. Health literacy plays a prominent role in this policy. Methods A national policy directive was developed and disseminated by the Israel Ministry of Health calling for culturally appropriate health information to the public, communication while receiving healthcare including ongoing staff training, health promotion intervention, and research for needs assessment. Results The national policy has been implemented for the past five years in primary care, hospitals and non-governmental health organizations. Cultural health liaisons have been integrated into primary healthcare teams in over 30 community clinics caring for Ethiopian immigrants, telephone translation services are available for Amaharic/Tigrinia, Russian and Arabic speaking communities, quality healthcare standards defined on topics such as of diabetes, and training of staff on cultural sensitivity continuously conducted. Culturally appropriate printed and digital sources of health information are available for diverse ethnic and religious communities. Appropriate health promotion intervention is routinely implemented on healthy lifestyle, early detection, and self-care, focusing mainly on NCDs and system navigation, supported by applied research and evaluation. Conclusions The policy implementation was the result of significant investment by stakeholders at all levels and requires support for sustainability regarding health literacy, health behaviour and health outcomes. Resource allocation is necessary for assessment and outcome measurement, and for applying more participatory methods for policy development, training, implementation and evaluation.

Expert Recommendations for Health Literacy Policies addressing Children and Adolescents

Abstract Background There is an on-going and a well observable uptake of health literacy in the national and international agenda-setting pertaining to the development of new policy strategies to address the issue of promoting health literacy in whole societies. Therefore, the aim of this research is to analyse those policies on how they address children and develop recommendations for future policies. Methods Policy documents on national levels, published by February 2019 were retrieved using a two-pronged strategy: (1) systematic review methods (database and online search) and (2) expert consultation. Based on a SWOT analysis of these policies, an interview guide was developed and policy experts (N = 63) from 46 countries across the world were interviewed. Based on the qualitative analysis, a Delphi Study was developed to gather expert comments and validation. Results The search has identified 26 policies in 19 countries including case-laws and enacted statues, governmental strategies, polices driven by national key experts, and educational policies. The content of these informed the interview guide. The initial analysis of the interviews led to several recommendations pertaining to schools and the education sector, including principals, teachers and whole-school approaches, characteristics of different settings, such as policy, education and administration, economic perspectives, and the need for research and evidence in order to inform future strategies. Conclusions The results will be compiled into a recommendation report and a policy brief. In addition, those will be translated into other languages to share with the countries of the experts who participated in this project. While almost all policies address children somehow, several limitations make it difficult to evaluate the quality of the different policies. To secure and sustain more effective, child-focused policies, current knowledge gaps regarding research on children`s health literacy should be addressed.

Implementation and Long-Term Outcomes of Organisational Health Literacy Interventions in Ireland and The Netherlands: A Longitudinal Mixed-Methods Study.

Organisational Health Literacy (OHL)-interventions are needed to overcome health inequality. OHL-interventions have successfully identified communication barriers at the organisational level, but evidence is limited on the extent to which this leads to sustainable organisational change. This study aims to assess the implementation fidelity, moderators (barriers and facilitators), and long-term impact of OHL-interventions in hospitals in Ireland and The Netherlands. We used a longitudinal mixed-methods approach to assess two similar OHL-interventions in one Irish and three Dutch hospitals. The OHL-interventions concerned the improvement of navigation and implementation of health literacy-friendly communication throughout organisations. Participants were 24 hospital employees and 40 older adults who use hospital services. At six, eight, and eighteen months, we assessed the level of implementation, barriers and facilitators, and impact through questionnaires and in-depth semi-structured interviews. After older adults and professionals had identified a number of communication problems, we found that professionals had successfully implemented OHL-interventions to promote navigation and comprehensible communication. Limited resources and variation in organisational structures and procedures were perceived as barriers to implementation. The participation of service users, leadership support, and a stepwise implementation of interventions were perceived to facilitate implementation. In the long term, the OHL-interventions led to system-wide improvements, as shown by better embedding of health literacy policies, enhanced patient engagement, provision of plain language training and comprehensible information. Findings were similar for the two countries. Embedded OHL-interventions resulted in sustainable and system-wide health literacy changes in all four hospitals. Following implementation, OHL-interventions have the potential to promote health equity and empowerment among health service users.