Health Literacy Research Research Articles

How Do Scholars Conceptualize and Conduct Health and Digital Health Literacy Research? Survey of Federally Funded Scholars.

The concept of health literacy (HL) is constantly evolving, and social determinants of health (SDoH) have been receiving considerable attention in public health scholarship. Since a 1-size-fits-all approach for HL fails to account for multiple contextual factors and as a result poses challenges in improving literacy levels, there is a need to develop a deeper understanding of the current state of HL and digital health literacy (DHL) research. This study examined scholars' conceptualization and scope of work focused on HL and DHL. Using a search string, investigators (N=2042) focusing on HL, DHL, or both were identified from the grantee websites of the National Institutes of Health RePORTER (RePORT Expenditures and Results) and the Canadian Institutes of Health Research. The investigators were emailed a survey via Qualtrics. Survey questions examined the focus of work; whether the investigators studied HL/DHL in combination with other SDoH; the frameworks, definitions, and approaches used; and research settings. We analyzed survey data using SPSS Statistics version 28 and descriptive analysis, including frequencies and percentages, was conducted. Chi-square tests were performed to explore the association between the focus of work, settings, and age groups included in the investigators' research. A total of 193 (9.5%) of 2042 investigators responded to the online survey. Most investigators (76/153, 49.7%) were from public health, 83/193 (43%) reported their research focused on HL alone, 46/193 (23.8%) mentioned DHL, and 64/193 (33.2%) mentioned both. The majority (133/153, 86.9%) studied HL/DHL in combination with other SDoH, 106/135 (78.5%) conducted HL/DHL work in a community setting, and 100/156 (64.1%) reported not using any specific definition to guide their work. Digital tools (89/135, 65.9%), plain-language materials (82/135, 60.7%), and visual guides (56/135, 41.5%) were the top 3 approaches used. Most worked with adults (131/139, 94.2%) and all races and ethnicities (47/121, 38.8%). HL and DHL research largely considered SDoH. Multiple HL tools and approaches were used that support the examination and improvement of literacy and communication surrounding health care issues.

Involving children in health literacy research

Abstract Background The range of health literacy research related to children has not normalised children’s involvement as advisors in health literacy research about them. While research with children can be difficult to facilitate, the principles of involvement and engagement should guide all health literacy work. This presentation shares learning from convening a Children’s Advisory Group to consult children about health literacy research priorities, ethics and methods. Methods Children (n-8) aged 7-11, referred by adults whose networks included children, joined a Children’s Advisory Group as Child Advisors. Consultations focused on a proposed study of how children’s critical health literacy could be supported in a community setting. Child Advisors piloted methods for rapport-building and data collection to be adapted for use with child participants later. Child rights-informed evaluation forms captured children’s reflections on their involvement. Results Consulting with a Children’s Advisory Group has challenges and benefits. Despite equity-focused strategies, e.g. introductory phonecalls and postcard updates, seldom-heard children remained less involved and the extent of parent/caregiver support varied. Child Advisors valued independent consultations led by their interests. Contributions included child-friendly consent documents, livestreamed draw-and-describe inspired by favourite influencers, and a novel Interview to the Alien protocol designed to appeal to middle childhood. Conclusions Taking an equity-focused approach is relevant for research with children focused on critical health literacy. Consulting with Child Advisors provides a way to involve children in health literacy research that holds adult researchers accountable for acting on children’s contributions. It is important to offer Child Advisors more than one option to get involved in research so that their insights can be foregrounded in future health literacy research with children.

1.K. Scientific session: Health literacy of children and adolescents across Europe

Abstract Health literacy is developed throughout the life course. Enhancing health literacy at an early age is especially important since it may impact both current and future health skills and outcomes. 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 targeted interventions and services for these age groups requires insight and data on the development and state of health literacy in early age. However, child and adolescent health literacy is still an under-researched topic. This is partly due to a lack of appropriate measurement instruments and methods to involve children in research. In the past years, new studies on child and adolescent health literacy have emerged in several European countries. In this workshop, innovative studies from Germany, the Netherlands and the UK on HL in childhood and adolescence are introduced and discussed. Both methodological findings as well as empirical data will be presented. In Germany, an instrument to measure child health literacy was developed and validated for primary school children. This instrument, the HLS-Child-Q15, has been used both in Germany and in the Netherlands to study the relationship between children’s health literacy and their health behaviors and outcomes. In the UK, methods of involving primary school children in health literacy research were studied. Experiences with a Children’s Advisory Group will be shared. Another study in the Netherland focuses on the health literacy profiles and needs of adolescent patients with rheumatic diseases. The format of this workshop will be 4x10-minute presentations (including questions) followed by a 20-minute interactive discussion, reflecting on the relevance of these results to further research, health promotion and health services. which will be followed by Q&A and an open discussion with the audiences. This workshop offers a forum for researchers, health educators, practitioners and policy-makers interested in health literacy measurement and research in children and adolescents. Key messages • Child and adolescent health literacy is an important, yet under-researched public health topic. • Child health literacy is an important predictor of their health behavior and outcomes.

Navigating Co-design in Children’s Health Literacy Interventions in Schools

Abstract Today’s society exposes children to vast amounts of health-related information, presenting significant challenges in navigating this content. European health literacy (HL) research underscores the primary school’s role in educating children’s HL. Several HL interventions have been developed for a school setting and few have used co-design with adolescents. However less is known about co-designing HL activities with children. Therefore, this study aims to identify barriers and facilitators for co-designing HL activities with 9 to 12-year-old children in school settings. We use 4 phases of design-based research for the process of co-designing learning activities with multiple teams of 6-8 children in school settings. First, children Reflect on HL and empathize and define skills they want to design activities for. They Design activities through ideation and prototyping. We use a variety of creative methods for the sessions and analyses, such as body mapping and affinity mapping. The evaluation of the effectiveness regarding HL and learning outcomes will be performed in Test and Evaluate phases. Our preliminary results show that children need short and clear assignments for the sessions to reach the goals. Children are enthusiastic to participate and like the methods used in the session, although the concept of HL is sometimes difficult to comprehend. It is challenging for children to come up with creative and appropriate elements for activities without correct health information. We are awaiting results from Test and Evaluate phase on the effect on HL levels and learning outcomes. Children are able to co-design HL activities together with HL and health promotion researchers. By giving children a voice and hands-on experience in the design process, we are able to create activities that are suitable for the target population. This co-design process will be evaluated and adapted to an intervention for the “healthy school” program in the Netherlands. Key messages • By co-designing HL activities children actively learn about health literacy. • Children are important and capable co-designers for HL activities when working together with HL researchers.

11.K. Scientific session: Roots of public health: school health literacy to enhance population health outcomes in Europe

Abstract This workshop will present empirical results from three representative studies on health literacy and digital health literacy conducted in primary and secondary schools in Wales and Germany: (1) Digital Health Literacy in Schools, (2), HLCA HL-Kids, (3) WHO HBSC Wales. While research on child and adolescent health literacy has gained traction in the past decade, only a few studies focus on health literacy in schools. While the European Commission and WHO, as well as most European governments, highlight the importance of schools to support children’s health literacy, schools remain neglected as a research context. With only little evidence available, it is difficult to derive strategies and programs to promote health literacy in schools. We aim to provide practical novel knowledge and contribute to closing the school health literacy gap that is prevalent in Europe. In turn, this will also contribute to European public health development and population health outcomes. Levels of health literacy in child and adolescent populations across European countries and age groups are alarmingly low, making low health literacy a severe risk factor for health outcomes. Low health literacy is associated with worse health conditions and unhealthy behaviours, and in turn, impacts school attainment and educational outcomes. Evidence suggests that health literacy acts as a determinant of health and itself is influenced by other social determinants of health, such as education, intertwining health and education. All studies conducted so far provide evidence that low health literacy follows a social gradient, with children from less affluent families being more likely to have lower health literacy, widening preexisting health inequities observed in almost all health domains within Europe. While effective interventions on the individual and system levels are needed to enhance health literacy, implementation and evaluation research concerning children’s health literacy is rare. Workshop objectives The aim of this workshop is to present findings from three representative studies on health literacy and digital health literacy in primary and secondary schools: (i) The 1st speaker will introduce a study on health literacy and health behaviours of children aged 8-11 (ii) The 2nd speaker will discuss the influence of living environments on health literacy in 4th-grader school kids (iii) The 3rd presentation will have its focus on navigating the infodemic through digital health literacy in adolescent students (iv) The 4th speaker will show links between digital health literacy and health behaviour in adolescent students The format of this workshop will be 4x10-minute presentations followed by a 20-minute panel discussion with the audience, reflecting the relevance of the results to public health research, practice, and policy. The chairs will provide a brief introduction to the concept and moderate the presentations and panel discussion. Key messages • Our results show that health literacy should be addressed as early as in primary schools and that the places, households, and environments children grow up are critical social determinants of health. • Digital health literacy has proven to be a valid learning topic in secondary schools and is linked to digital and media literacy, allowing us to define it as a targeted curriculum item.

Does School Education Improve Children’s Health Literacy? Evidence from a Performance-Based Survey

Abstract Background Children begin using digital sources of health information at a young age and are quickly exposed to a variety of unmoderated health content. Health literacy helps children navigate, understand, evaluate, and act on this content. But is the educational system preparing young people for these tasks? This study develops a validated, performance-based measure of health literacy and applies it to a sample of 9- to 13-year-old children (grades 4 to 7). Methods A performance-based tool to measure children’s health literacy was developed through expert consultation and qualitative and quantitative pretesting. The tool uses vignettes and quizzes and captures three dimensions of health literacy: nutrition, physical activity, and psychosocial health. The validated tool was then used in a cross-sectional survey of Austrian children aged 9 to 13 years (n = 780): Diet, Physical Activity, and Psychosocial Health. Results Results show that the performance-based health literacy scores do not correlate with self-reported scores. Girls (vs. boys) and native speakers perform better on the performance-based literacy test, while boys and children reporting more robust financial backgrounds overestimate their literacy on self-reported questions. Most importantly, the data do not show meaningful increases in performance-based health literacy across grade levels. For nutrition literacy, the study even shows a slight negative trend across grade levels. Conclusions This study questions the heavy reliance on self-reported health literacy, which is often confounded with self-efficacy and social environment. Performance-based instruments are needed to measure health literacy as an educational outcome. This study presents one of the first validated instruments. Most importantly, the study shows that the current educational system may not produce meaningful increases in performance-based health literacy, calling for deeper educational reforms. Key messages • Performance-based health literacy is a distinct concept from the subjective health literacy measures that dominate current health literacy research. • Performance-based health literacy did not increase with grade level, indicating a poor performance of the education system in strengthening health literacy.

5.K. Scientific session: Health literacy in Ireland: A participatory action approach with Sláintecare Healthy Communities

Abstract This workshop offers a comprehensive exploration of the dynamics, challenges, and opportunities surrounding health literacy in Ireland. In 2023, Dublin City University and Sláintecare Healthy Communities, driven by a commitment to foster equitable healthcare access and outcomes, embarked on a research project aimed at deciphering the intricacies of health literacy and its implications for public health in Ireland. The series of interactive presentations will transparently share learnings from the process and outcomes of this project, which can be applied across different sectors, contexts, and countries. The workshop will begin with an overview of the rationale underpinning Sláintecare Healthy Communities’ engagement in this research project. This is one of the first pilot programmes of its kind. By transparently exploring the driving forces and strategic approaches of this organisation, participants will gain insight into the imperative of addressing health literacy from the perspective of a cross-government and multi-discipline initiative. Following from this, a series of presentations will detail the rigorous scientific approaches undertaken. This includes an umbrella review of international conceptualisations of health literacy and a systematic review of health literacy research conducted on the island of Ireland in the last decade. Findings from these reviews highlight the evolving challenges and emerging trends shaping health literacy practices nationally and internationally. It is also recognised that responsive health literacy development requires thoughtful involvement of diverse local communities. Programmes and actions that ‘leave people behind’ can exacerbate health inequalities. As a result, meaningful community based participatory research, including innovative design thinking approaches, were utilised throughout this project. The Sláintecare Healthy Communities Programme identified two contrasting areas to participate in this work, presenting both an urban and rural context. The health literacy strengths, needs and issues encountered in these communities will be presented in the community members own words. This workshop will close with the presentation of a series of co-designed, and crucially actionable, recommendations for evidence-based best practices in health literacy promotion in Ireland. Leveraging the synthesis of research findings and stakeholder insights, a number of actions aimed at enhancing health literacy proficiency and fostering health equity will be detailed. This presentation in particular will be interactive, and will challenge participants to identify health literacy promoting actions that may be suitable for their own contexts. This workshop offers a timely and pragmatic exploration of health literacy promotion in Ireland. By fostering dialogue, knowledge exchange, and collaboration, the workshop serves as a catalyst for transformative change, paving the way towards more inclusive, equitable, and health-literate societies, both in Ireland and beyond. Key messages • This workshop offers a timely and pragmatic exploration of health literacy promotion in Ireland. • Presenters from both practice and research will detail how the needs analysis was conducted, and how we suggest these co-designed recommendations can be actioned.

7.K. Round table: Approaching new public health frontiers: health literacy on a global level

Abstract This workshop will introduce the newly established WHO Collaborating Centre for Health Literacy (WHO CC HL) at TU Munich (TUM) in Germany and reflect on its goals and discuss the potential impact on European public health research, policy, and practice. With the launch of the WHO CC HL, TUM, WHO, and their collaborators, among which are the EUPHA Health Literacy Section, the International Health Literacy Association, and the Global Health Literacy Research Network, jointly aim at systematically developing health literacy as part of the WHO Sustainable Development and Well-being agenda. Health literacy represents the skills and attitudes to find, understand, appraise, and apply health information and services. Low health literacy is prevalent among all population and age groups and it is linked to worse health outcomes and health inequalities. Across the social gradient, people from low socioeconomic backgrounds are more likely to have low health literacy, which is why the European Commission and WHO both highlighted the need to invest in health literacy and, in particular, in school health literacy. Two emerging fields of study include data generation and interventions. Both of which are highly critical to monitoring change and providing evidence-based data on population and system-level health literacy within and between countries. However, there are no health literacy monitoring systems in place on a global scale nor is there robust evaluation data on school-based interventions. These shortcomings will be addressed through the WHO CC HL at TUM. In this round table workshop with five key health literacy and public health experts, the main goal is to present the WHO CC HL and its roadmap for the next four years and critically discuss how the work can influence European and Global public health: Dr. Faten Ben Abdelaziz, WHO; Anastasia Kyoylu, WHO/Europe; Dr Kristine Sorensen, Global Health Literacy Academy; Dr. Charlotte Marchandise, EUPHA; Prof. Dr. Orkan Okan, WHO Collaborating Centre for Health Literacy at Technical University of Munich. First, the chair will provide a short introduction to the WHO CC HL and will, together with the co-chair, facilitate the following panel discussion. The panel members will share a short 2-to-3-minute statement from their point of view in relation to planned activities of the WHO CC HL and highlight synergies to public health and health literacy development. Following the short statement, the chairs will prepare individual questions for each panellist and engage them in a discussion, which shortly after will open towards the audience for them to participate actively with the panellists in a 30-minutes discussion. Key messages • The round table workshop will introduce the newly established WHO CC HL, highlight its goals and impact on public health, and highlight collaboration opportunities. • The key experts will reflect about the WHO CC HL from their unique standpoints and reveal new perspectives on the way forward and how the work can benefit from ongoing public health initiatives. Speakers/Panelists Faten Ben Abdelaziz WHO, Geneva, Switzerland Anastasia Koylyu WHO, Copenhagen, Denmark Kristine Sørensen Global Health Literacy Academy, Risskov, Denmark Charlotte Marchandise EUPHA Orkan Okan Technical University of Munich, Munich, Germany

3.D. Round table: Improving equity in health: Understanding and responding to health literacy as a social determinant

Abstract Evidence of a social gradient in health literacy has been found in all reported national population surveys in Europe. This workshop will examine the explanations for this social gradient and explore ways to optimise the contribution that health literacy makes in mediating the causes and effects of established social determinants of health. This will include consideration of practical approaches to improving health literacy in socially disadvantaged populations as a contribution to reducing health inequities within and across European countries. The workshop will explore the concept of critical health literacy and the potential to improve public awareness of and capacity to act on the wider social determinants of health. It will also draw upon existing evidence from interventions that demonstrate the feasibility of improving health literacy among higher-risk and diverse populations. This will include consideration of approaches to improving frontline professional skills and support; approaches to organizational and systems health literacy, working directly with people to develop critical skills in accessing, understanding and applying health information; and ensuring that in public health policy, priority is proportionate to need - reaching and engaging the population groups disproportionately affected by low health literacy. Recognising that research remains underdeveloped and the effects of interventions on health inequity are largely untested, the workshop will also consider where the most important research gaps exist and where future health literacy research should be prioritised. The workshop chair will provide introductory and summary remarks to the workshop. The co-chair will manage the panel discussion and audience participation in the workshop. The individual panel members will make 3-minute introductions to key issues from different perspectives examining the mediating and moderating role of health literacy in addressing the social determinants of health. The panel is made up of individuals from academic and policy roles and at different career stages who can offer complementary perspectives on these issues. Following the presentations, the co-chair will present some follow-up questions to the panel before engaging directly with the workshop participants for an open discussion scheduled to last for 30 minutes of the workshop. Key messages • Improving health literacy is not a panacea for entrenched inequities in health but can help moderate the impact on health of other social determinants and provide an important practical response. • Public health policy and practice intended to improve health literacy should prioritise reaching and engaging the population groups disproportionately affected by low health literacy. Speakers/Panelists Gill Rowlands Newcastle University, Newcastle, UK Stephan Van den Broucke Université Catholique de Louvain, Louvain-la-Neuve, Belgium Ana Rita Pedro NOVA National School of Public Health, Lisbon, Portugal Christina Dietscher Austrian Ministry of Health, Vienna, Austria Susie Sykes London South Bank University, London, UK

Association of Social Determinants of Health With Hospital Readmission and Mortality: A Prospective Cohort Study.

The relative contributions of common patient-reported social determinants of health on 30- and 90-day post-discharge outcomes among patients with acute coronary syndromes (ACS) is unclear. The aim of this article is to examine the independent associations of social determinants with readmission or death, accounting for medical history. Participants included adults who were hospitalized with ACS at an academic medical center. Domains measured were social support, health literacy/numeracy, and socioeconomic status (SES) (including education and difficulty paying bills). We employed multivariable Cox proportional hazard models to study associations with time to all-cause readmission or death, up to 30 or 90 days after discharge, and adjusted for demographics and medical history (prior admissions and Elixhauser comorbidity index). Among 1,168 patients with ACS and no history of heart failure, more prior admissions, and higher comorbidity index (the medical history domain) were associated with higher rates of 30- and 90-day readmission or death (domain p values <.01 and <.0001, respectively). The social support domain was not associated with outcomes. Higher health literacy and numeracy were associated with lower rates of 30- and 90-day readmission or death (domain p values .016 and .002, respectively). Higher education and less difficulty paying bills (the SES domain) was marginally associated with lower rates of 90-day readmission or death (domain, p = .052). In addition to medical history, the domain of health literacy and numeracy was independently associated with readmission or death of patients with ACS during the 90 days after hospital discharge. [HLRP: Health Literacy Research and Practice. 2024;8(4):e212-e223.].

Exploring the Relation Between Health Literacy, Infodemic, and Acceptance of COVID-19 Vaccination in Iran: A Cross-Sectional Study.

Health literacy (HL) plays a crucial role in navigating the coronavirus disease 2019 (COVID-19) pandemic, especially with the abundance of conflicting information from unauthorized sources. This study aims to measure COVID-19 vaccine acceptability, COVID-19 HL, and COVID-19 infodemic and their predictors in Iranians. A cross-sectional study was conducted on the general population in Iran between August 20, 2021 to October 29, 2021. Data were collected using a valid questionnaire with four parts. Univariable and multivariable logistic regression models, generalized linear models, and ordinal regression with the Polytomous Universal Model were performed using SPSS version 26. The study revealed that 68.6% of the participants were willing to accept the COVID-19 vaccine, 45% had sufficient knowledge about COVID-19, and 52.2% were confused by false information during the pandemic. The results showed that having sufficient COVID-19 HL was significantly associated with higher acceptance of the vaccine (adjusted odds ratio = 1.52, 95% confidence interval (CI): 1.02, 2.12). Additionally, higher COVID-19 HL scores were associated with a higher adjusted odds of confusion by false information with an odds ratio of 1.12 (95% CI: 1 .11, 1 .13). This study exhibits low levels of COVID-19 HL in Iran, and the fact that higher COVID-19 HL is associated with higher vaccine acceptance. Because vaccination is an essential preventive measure to stop the COVID-19 pandemic, factors associated with low vaccine acceptance need to be addressed by public health strategies. [HLRP: Health Literacy Research and Practice. 2024;8(4):e184-e193.].

Health Literacy and Adherence to Therapy in Type 2 Diabetes: A Cross-Sectional Study in Portugal.

Therapy adherence is a key factor in the control of type 2 diabetes mellitus (T2DM). Optimal self-care requires skills in health literacy (HL). This study aims to analyze the relationship between HL and adherence to therapy and to understand the possible influence of other sociodemographic and disease variables. A multicenter, cross-sectional study was conducted in Portuguese in 13 different primary health care units in both rural and urban environments. A sociodemographic questionnaire and two validated instruments, "Medical Term Recognition Test" and "Summary of Diabetes Self-Care Activities," were applied. The last value of hemoglobin A1c (HbA1c) and the number of chronic medications were collected from clinical records. Descriptive statistics and bivariate correlations were performed as well as multivariable linear regression to assess the association between HL and adherence to therapy. Participants (n = 354) were on average age 63.67 ± 10.39 years, 57.1% male and 42.9% female, 68.4% with inadequate HL and an average HbA1c of 7 ± 1.18%. Better HL was correlated with higher adherence to the total of self-care activities, nonpharmacological therapy, and foot care. In multivariable linear regression analyses, better HL (β = 0.176, p = .003), less than minimum wage (β = -0.197, p = .001) and insulin therapy (β = 0.272, p = .001) were independently associated with increased adherence to overall self-care activities. In a representative sample of people with T2DM in Portugal, HL was a key factor for greater adherence to demanding self-care activities. [HLRP: Health Literacy Research and Practice. 2024;8(4):e194-e203.].

Health Literacy Directed Weight Loss Intervention in Primary Care Clinics.

Low income and low health literacy are associated with poorer health knowledge, health behaviors and poor health outcomes. The effectiveness of health literacy-directed weight loss treatment interventions in primary care clinics is lacking. The aim of this study was to conduct a pragmatic cluster-randomized trial (PROmoting Successful Weight Loss in Primary CarE in Louisiana ([PROPEL]) to test the effectiveness of a 24-month, patient-centered, literacy-directed obesity treatment program delivered within primary care in an underserved population. This study reports the association between health literacy and program effectiveness, examining potential correlates of weight loss related to patient adherence to the program. We randomly assigned 18 clinics to usual care (UC) or a health literacy-directed lifestyle intervention (HLI). The primary outcome was percent weight loss at 24 months. Of 803 adult participants (84% women; 67% Black), 31% had limited health literacy. Patients in UC lost an average of 0.44%of their enrollment weight after 24 months. Those with adequate literacy lost 0.57% and those with limited literacy lost 0.30%, which was not significantly different. The HLI patient group lost an average of 4.9% of their enrollment weight. Those with adequate literacy lost 5.2% and those with limited literacy, 4.7%, which was not significantly different. The advantage of adequate health literacy was consistent across the 24-month study period, though not significant. Patients in the HLI group with adequate health literacy had greater percent weight loss by a margin of 0.50 ± 0.75 (p = .50), while the UC margin was 0.27 ± 0.84 (p = .74). The percent weight loss difference between HLI and UC groups was 4.6 ± 0.8 (p < .001) among patients with adequate health literacy and 4.4 ± 1.0 (p < .001) among patients with limited health literacy. The difference in percent weight loss between the HLI and UC groups was 0.2 ± 1.1 (p = .84) higher for adequate literacy patients. A health literacy directed health coaching intervention in community clinics led to significant weight loss over 24 months but did not vary by level of patient health literacy. [HLRP: Health Literacy Research and Practice. 2024;8(4):e204-e211.].

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.

Qualitative Evaluation of a Health Literacy Program for Older Adults Who Live in a Community Dwelling in Brazil.

To address current gaps in health literacy research and practice in low-resource settings, the 'Alfa-Health Program' was designed to improve health literacy in older adults who live in a community dwelling in a socioeconomically disadvantaged community in North-East Brazil. In this longitudinal qualitative study, participants were interviewed before and after participating in the group-based program that was delivered November 2017 to December 2017 in the Primary Care Health Unit. Semi-structured interviews were guided by a previously validated health literacy instrument, translated and adapted for use in Brazil. Data was analyzed using Framework analysis. Of the 21 participants, the majority were age 60 to 69 years with a median of 4-years of school education. Our analysis identified self-reported improvements in health knowledge, behaviors, and skills that matched program content and indicated that participants were supported to manage their health conditions more autonomously. Other themes reflect the distributed nature of health literacy and the potential for group-based health literacy programs to facilitate feelings of social support and cohesion through co-learning. However, age-related deficits in memory and external and structural factors remained important barriers to program participation. This study provides insight into developing health literacy in low-resource settings with older adults, where health literacy is compounded by social determinants and cognitive and sensory changes that contribute to health disparities. Although the targeted Alfa Health Program addresses calls to ensure that priority is proportionate to need by reaching and engaging population groups who are disproportionately affected by low health literacy, further work is needed to adapt the program for people who are unable to read or write. [HLRP: Health Literacy Research and Practice. 2024;8(3):e140-e150.].

Profound Love and Dialogue: Paulo Freire and Liberation Education.

Paulo Freire, Brazilian philosopher and educator, proposed an educational method for adults based on what he called "the problem posing method." This method was based on dialogue that he deemed necessary for education and was not oppressive and controlling. Freire argued that traditional educational methods were inherently oppressive because they served the interest of the elite, instituted what he called "the banking method" in hopes to turn people into better workers. In contrast to this, Freire advocated for an education that was liberating and required dialogue. Dialogue, however, could only take place with profound love. This article reflects on Freire's call for profound love and dialogue within his pedagogical framework, and its necessity for social and political change. Further, this article explores what Freire meant by profound love and dialogue, and explores how love and dialogue are applicable to current and future health literacy and health education efforts. [HLRP: Health Literacy Research and Practice. 2024;8(3):e118-e120.].

Association Between Health Literacy and Understanding of Doctors' Explanations: The Yamagata Study.

In Japan, the doctor-patient relationship has traditionally been characterized by a power imbalance that may contribute to communication gaps. To date, however, the link between patients' health literacy levels and their understanding of doctors' explanations of medical conditions and treatment has yet to be fully examined in Japan. The purpose of this study was to investigate the association between patients' health literacy level and their understanding of doctors' explanations. This was a cross-sectional study analyzing data derived from 11,217 questionnaires collected in July 2021 from participants of the Yamagata Study, a community-based cohort study implemented by Yamagata University since 2009. The results showed lower health literacy was associated with poorer understanding of physicians' explanations, adjusting for potential confounding factors. In addition to low health literacy, factors associated with lower comprehension were being male, not having a regular family doctor, and having lower self-perceived levels of health and happiness. The results suggest that health care professionals need to communicate with patients according to their health literacy level and ensure they fully understand their medical condition and treatment. Medical providers need to create a better health-literate environment to enable patients and families to make decisions by themselves. [HLRP: Health Literacy Research and Practice. 2024;8(3):e175-e183.].

Communicate to Care: Implementing Health Literacy in a Pediatric Ears, Nose, and Throat Clinic.

Despite positive outcomes in controlled trials, organizations have been slow to adopt health literacy practices. The purpose of the Communicate to CARE (Clear Communication, Achieve Understanding with Teach-Back, Receptive to our patient family needs, Empathetic care delivery) study was to use theories and strategies from implementation science to scale up health literacy practices in a pediatric Ears, Nose, and Throat (ENT) clinic. Expanding on previous efforts that simply reflected on barriers, the CARE team identified barriers within the local context pre-implementation to select strategies to directly address barriers during health literacy implementation. The RE-AIM framework was used to evaluate the reach, effectiveness, adoption, implementation, and maintenance of health literacy practices. Over 18 months, the CARE team delivered multiple implementation strategies, including external facilitator, microlessons, preparing champions, audit and feedback, local consensus discussions, and small test of change. We tailored health literacy practices to clinic team roles to accommodate the clinic workflow. ENT team mean ratings on acceptability, appropriateness, and feasibility remained >4 indicating a high likelihood of successful implementation. Caregiver always ratings significantly increased from baseline to 12 months for easy-to-understand medication instructions (74%-96%), test results (54%-96%), know what to do if had questions (89%-96%), and encouraged to talk about health problems (76%-90%). Caregiver ratings dropped slightly at 18 months, indicating a need for booster training. While one third of caregivers reported Teach-Back practice across all time periods, the ENT team reported increased practice from baseline (42%), 6 (61%) and 12 months (70%). Over the first 12 months, the external facilitator delivered implementation strategies with weekly contact, tapering contact over the final 6 months. The local champion became engaged in the CARE study through a quality improvement project with meaningful outcomes for the clinic and an incentivization program for scholarly endeavors. Lunch and learn sessions helped build relationships between the CARE and ENT team to discuss and problem solve issues. The 5-item CAHPS health literacy composite proved to be sensitive to changes during implementation of health literacy practices. Integrating these items into standard follow up surveys with patients and families would help realize the return on investment for health literacy implementation. [HLRP: Health Literacy Research and Practice. 2024;8(3):e166-e174.].

Racial Composition of Past and Current Social Environments and Health Literacy.

Research is needed to understand the impact of social determinants of health on health literacy throughout the life course. This study examined how racial composition of multiple past and current social environments was related to adults' health literacy. In this study, 546 adult patients at a primary care clinic in St. Louis, Missouri, completed a self-administered written questionnaire that assessed demographic characteristics and a verbally administered component that assessed health literacy with the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R) and Newest Vital Sign (NVS), and self-reported racial composition of six past and four current social environments. Multilevel logistic regression models were built to examine the relationships between racial composition of past and current social environments and health literacy. Most participants identified as Black or multiracial (61%), had a high school diploma or less (54%), and household income <$20,000 (72%). About 56% had adequate health literacy based on REALM-R and 38% based on NVS. In regression models, participants with multiple past white environments (e.g., locations/conditions in which most of the people who live, go to school, work, and have leisure time are White) and (vs. 0 or 1) were more likely to have adequate health literacy based on REALM-R (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI]: 1.04-3.07). Similarly, participants who had multiple past white social environments were more likely (aOR = 1.94, 95% CI: 1.15-3.27) to have adequate health literacy based on NVS than those who had not. The racial composition of current social environments was not significantly associated with health literacy in either model. Racial composition of past, but not current, educational and residential social environments was significantly associated with adult health literacy. The results highlight the importance of examining the impact of social determinants over the life course on health literacy. The findings suggest that policies ensuring equitable access to educational resources in school and community contexts is critical to improving equitable health literacy. [HLRP: Health Literacy Research and Practice. 2024;8(3):e130-e139.].

The Influence of Dr. Rima Rudd's Organizational Health Literacy Scholarship in Maryland.

This article analyzes and reflects on Dr. Rima Rudd's organizational health literacy ideas and tools and their influence on the field generally and on four projects over 12 years in Maryland specifically. We present four organizational health literacy projects - two from oral health and two from COVID-19 vaccination - that used or were influenced by Dr. Rudd's the Health Literacy Environment of Hospitals and Health Centers. In the oral health projects, we describe the organizational assessments we conducted, the assessment results, and the actions organizations took in response. In a Frederick, Maryland, COVID-19 project, we worked with multiple organizations in a single city to train them in the organizational assessment process, and we report the activities and results of this training. In the Baltimore, Maryland COVID-19 project, we provided general information about organizational health literacy and trained key health professionals in local organizations. Our results confirm that Dr. Rudd's tools work mainly as intended because they help organizations or third-party evaluators identify health literacy barriers and create health literacy insights. Also, we observed that organizational health literacy tools can support organizations' interest in equity goals and increase their willingness to spend time on health literacy projects. Translating knowledge and skills to actions can require more time than organizations can commit or be more difficult than they can handle. In our projects, the four most positive examples were driven by a collaboration between our team and a change champion who had the power to institute new ideas and actions. While it can take time and money to gain traction, our Maryland work shows that organizational assessments are accessible, practical and tangible. We conclude that Dr. Rudd's influence extends beyond specific tools and is reflected in the field's acceptance of organizational and professional responsibility for health literacy as an equity and justice issue. [HLRP: Health Literacy Research and Practice. 2024;8(3):e151-e158.].