Health literacy policy, mobilisation and capacity building
At all levels, greater efforts are needed to promote a culture of health literacy in order to foster equitable access to healthcare for all, including people in vulnerable situations. In practice, this means the development of public policy at the local, regional, national and international levels. This also requires cross-sectoral collaboration with other stakeholders (interest groups, coalitions, alliances, networks etc.) and capacity building in health authorities and systems to strengthen the capacity and skills of the workforce.
Health literacy public policy
Health literacy public policy is increasing. Governments across Europe are mobilising forces to increase health literacy in collaboration with non-state stakeholders such as academia, industry, and NGOs. For instance, several European countries have adopted nationwide health literacy actions plans, such as Austria, Norway, Portugal, and the UK (Scotland), which are driving interventions and programmes nation-wide to enhance population health literacy.
Mobilising health literacy communities and ‘champions’
Fostering health literacy communities is a key component in the promotion of health equity. This is because health literacy is highly cross-sectoral and inter-disciplinary. Increased collaboration across sectors and disciplines can enhance the knowledge transfer and outcome of health literacy partnerships and programmes. Formal and informal interest groups, coalitions, alliances, networks, platforms as well as institutes, organisations, and associations help to discuss, assess and strengthen health literacy capacities at various levels in society (some examples below).
To implement health literacy, change-agents are needed to develop and drive impact. These change-agents, often called ‘health literacy champions’, may come from policy, academia, practice or civic society. The presence of advocates for organisational change is critical, however, their impact depends highly on support from leadership. A management structure and culture that supports health literacy innovation and quality improvement is essential for a successful implementation (example far below).
Capacity building in health authorities and systems
Health literacy authorities and systems become more ‘people-centred’ when they integrate health literacy as a cross-cutting, transversal value and strategy in all parts of their work. Resources include The ten attributes of health literate organizations, the Vienna model for health literate hospitals, and the Ophelia Toolkit (below) are examples of how to optimise health literacy in organisations and communities.
Health literacy as a professional skill – increasing the health literacy capacity of the workforce
Health literacy is creating job opportunities and requirements to enhance the workforce with the development of health literacy as a professional skill. Considering the general growth in health literacy research and policymaking, health literacy is becoming a skill and competency demanded by health authorities and systems.
This requires the inclusion of health literacy in the educational curricula of higher education and post-graduate training within a wide range of disciplines. In practice, this means attention to the knowledge, skills, and attitudes of health professionals, especially when dealing with people in vulnerable situations and those with limited levels of health literacy. In this regard, sensitivity towards culturally different people and groups in society is important. The integration of user-experience and testimonials as well as focus on the co-production of health services is also useful to develop.
“Making it easier”, which is Scotland’s second action plan on health literacy developed by the NHS, sets out an action plan for improving health literacy in Scotland 2017-2025. The first plan was titled “Making it easy”. The action plan aims to remove barriers and prevent them being put there in the first place.
Target group:
The action plan is aimed at health providers, patient organisations and decision-makers.
Method:
The action plan focuses on four areas:
share the learning from “Making it Easy” across Scotland;
embed ways to improve health literacy in policy and practice;
develop more health literacy responsive organisations and communities;
design support and services to better meet people’s health literacy levels.
Outcome:
The health literacy action plan helps to improve how to design and deliver services in the future based on supporting people’s needs through shared decision-making.
Added value:
The health literacy action plan sets out the ambition for Scotland to be a health literate society that enables the population to have the confidence, knowledge, understanding and skills to maintain good health.
The development of the National Action Plan on Health Literacy was triggered by results of the first German study on health literacy which showed that more than half of the German population perceive great problems in processing health information. In response, a group of 15 experts from academia, practice and policy worked together to publish the first version in 2018.
Target group:
The Action Plan is aimed at health providers, patient organisations and decision-makers.
Method:
The Plan focuses on four areas of action presenting 15 specific recommendations to strengthen health literacy in Germany following five key principles.
Outcome:
The National Action Plan on Health Literacy was accompanied by an implementation strategy co-designed with relevant stakeholders to enhance the impact.
Added value:
The National Action Plan on Health Literacy has enhanced health literacy on the health agenda in the German policy landscape.
In Portugal, the national action plan on health literacy aims to reach different parts of the population, including, for example, immigrant populations and temporary residents. The national action plan was launched after a survey revealed that up to 40% of the population had difficulties in accessing adequate and reliable information on health care. For young people, health information is often obtained via social media platforms which can be both a challenge and an opportunity to tailor and better direct health literacy towards their lifestyles.
Target group:
The success and development of the Action Plan will depend on the close coordination and work with the following strategic partners: Public, Social and Private Sectors; Ministries, General-Directorates and Inter-ministerial Committees; National Health Plan Health Programmes; other structures belonging to the Ministry of Health Academy, Professional Bodies, Scientific Societies, Private Institutions for Social Solidarity (IPSS), NGOs, Media, Social Media, Digital Media, Civil Society Patient Associations.
Method:
The action plan focuses on four priorities:
adopting healthy lifestyles;
training for proper use;
promoting well-being;
promoting knowledge and research.
Outcome:
The Action Plan facilitates the provision of instruments and tools to health professionals to promote health literacy; campaigns and thematic interventions are carried out for the population that promote health literacy; the network of stakeholders to incorporate and strengthen health Literacy promotion interventions and their impact are increased; and a monitoring committee with the purpose of supporting the prioritisation of actions and measures, and as a resource of excellence for the development of strategic information.
Added value:
Whilst keeping a person-centred approach to interventions, the Action Plan intends to improve the health literacy levels of the Portuguese population continuously and consciously in a sustainable way. Deploying a life cycle approach is in line with other policy initiatives related to “Health Citizenship”, “Equity and Access to Healthcare”, “Quality in Health”, “Healthy Policies” and their respective objectives and goals.
To increase nationwide levels of health literacy by developing necessary cognitive and social skills to access, understand and use health-related information in order to improve their health and maintain good health.
Objectives:
to develop and implement assessment scales which determine the current state of health literacy of the population;
to develop and disseminate accurate, accessible and actionable health information;
to develop and implement software applications related to health, such as in E-NABIZ and MHRS: MHRS is a Central Physician Appointment System; E-NABIZ is a personal health record system which manages personal health information and is used by public and health professionals to view diagnoses and treatments, tests and examination reports, diagnostic imaging records and reports, prescriptions, vaccinations, visits of healthcare services, past and future appointments of patients;
to increase the health literacy of health care workers;
to raise social awareness about disease and risk factors;
to promote healthy lifestyle habits;
to raise public awareness of appropriate uses of health services;
to conduct monitoring and evaluation processes.
Target Group:
The aim is to reach all segments of the public, including children, pregnant women, parents, persons with disabilities and older persons.
Method:
The Action Plan is carried out in cooperation with relevant stakeholders such as universities, TÜİK (Turkish Statistical Institute), TRT (Turkish Radio Television), private TV and radio channels, other ministries and NGOs. Ministries and their regional organisations prepare projects related to health literacy falling within the scope of their duty and responsibilities (e.g. the Ministry of Family and Social Services, in collaboration with the Ministry of Health, carry out health literacy trainings for families). Cooperation is in planning with the following institutions:
TUIK in the implementation of the assessment scales which determine the current state of health literacy of the population;
Universities for the evaluation of results of the abovementioned assessment scales and preparation of scientific publications;
TRT, Private Radio/TV Channels, traditional and new media channels for the preparation of content aimed at increasing health literacy for adults;
Union of Municipalities of Türkiye and relevant NGOs for the organisation and dissemination of activities throughout the country;
The Turkish Green Crescent Society for raising awareness about addiction;
World Health Organisation for studies on addiction and rational drug use.
For the efficacy and continuity of activities within the scope of the Action Plan:
according to the mission, vision and field of work of each institution, a responsible institution is designated among the partner institutions, which is also responsible for submitting a report about the activities every 6 months;
data regarding the activities carried out is input into the online monitoring platform for activities that are under the responsibility of stakeholder institutions;
the General Directorate of Health Promotion of the Ministry of Health monitors the process and preparation of progress reports every six months to ensure efficacy and continuity of the activities in the scope of the Action Plan.
Outcome:
Improvements in and continuity of healthy lifestyle behaviours
Added Value:
Low health literacy is the cause of various negative behaviours and outcomes, such as poor understanding of health-related messages, inappropriate use of drugs, increased hospitalisations resulting from the under-utilisation of preventive health services, and the overuse of emergency services. These situations challenge the efficient use of health services, they also lead to low productivity, increased morbidity and mortality, and an increase in the cost of medical expenses. On this basis, it is predicted that by increasing health literacy levels there will be an increase in general quality of life and a significant decrease in health costs.
Outcome:
According to the “Health Literacy Level and Related Factors Survey of Türkiye (2018)”, in accordance with the Scale of Health Literacy of Türkiye-Türkiye Sağlık Okur Yazarlığı Ölçeği-TSOY-32, the health literacy levels of participants are reported as 30.9% (inadequate) and 38% (problematic-limited). Measuring the level of health literacy of all segments of society at regular intervals provides important guidance for actions and policies to improve health literacy.
The expected outcomes of the Action Plan are as follows:
providing opportunities to access reliable and understandable information for every member of society;
raising awareness among children and their families, by including health literacy as a subject in the basic education curriculum;
positive changes in healthy lifestyle behaviours of individuals;
individuals are involved in the decision-making process for their own treatment and care,
individuals comply with instructions for treatment, helping to reduce errors in drug (medicine) administration and use;
individuals have knowledge and take responsibility for their health and diseases they are faced with;
increasing awareness of society about the fight against substance addiction;
individuals have knowledge about reproductive health, occupational health and safety, health and care of older persons, patient care, environmental health, chronic diseases, such as hypertension, diabetes, asthma, infectious diseases, and comply with disease management programs;
increasing participation in health-promotion practices, such as cancer screening, prevention of risky health behaviours, prevention of home accidents, family education programs;
eliminating the lack of information on preventive health services and using these services effectively;
reducing inappropriate use of emergency services and hospitalisations;
Key health service quality frameworks, including the National Quality and Safety Health Service (NQSHS) Standards and the Royal Australian College of General Practitioner’s Standards for General Practice, require action to address health literacy.
Target group:
A handbook was written for health professionals across Northern NSW for all staff working in health, at all levels.
Method:
Under the accreditation standards, there is an obligation to consumers to provide safe, quality care. This means recognising a consumer’s right to be a partner in their health care. The handbook guides health professionals to enable consumers to make their best health decisions.
Outcomes:
Access to learning material supports the professional development of staff working in healthcare and increases the quality of their work to accommodate the needs of people they serve, in particular people in vulnerable situations.
Added value:
The Handbook is an easy and cost-effective way to upgrade the knowledge, motivation and competency of the health workforce.
In 2012, the Austrian Council of Ministers approved ten comprehensive targets to improve determinants of health in the sense of Health in All Policies. Health target number 3 aimed to enhance health literacy in the population.
Method:
A working group consisting of 30 experts from public administration, social security, research institutions and civic society developed specific sub-targets and indicators including:
to make the health system more health literate through involving stakeholders and those affected (for example, by developing health literate organisations);
to strengthen individual health literacy with consideration for people in vulnerable situations (for example, by collaborating with the education system);
to embed health literacy in the service and production sectors (the economic system).
Outcome:
The national healthcare reform process was an entry point for change towards a more health literate system. The steps included establishing the Austrian Health Literacy Platform as a steering body for health literacy initiatives, participation on European and national health literacy surveys, implementation of interventions focusing on health literacy-sensitive information and communication as well as the development of health literate organisations. Moreover, health literacy is promoted as a professional competency of health providers.
Added value:
Since the agreement of health target 3 on health literacy, health literacy has become part of the mainstream public discourse in Austria and is included in the government’s programme. It is an emerging topic in curricula of health professionals and the health literacy evidence has put in motion multiple new initiatives to improve practice. More can still be achieved with regards to shared decision-making and activities beyond the healthcare sector.
The aim of the strategy is to increase the health literacy of the population in Norway. It is targeted at health and social professionals, decision-makers, and managers as well as patient organisations and other relevant stakeholders. It pursues a cross-sectoral approach, in particular the involvement of the health and educational sector.
Method:
The methods include:
promoting the concept of health literacy in the Norwegian context;
setting- up targeted efforts to improve population health literacy;
highlighting the importance of health literacy among health providers for the patients' engagement in services;
developing health and social services with respect to the health literacy responsiveness of staff;
identifying the state of the art of health literacy in the population;
describing different initiatives that can enhance health literacy in various population groups and showcasing examples of ongoing activities that support health literacy without being labelled as such;
conducting health literacy research;
describing how health authorities will work to improve health literacy in populations and sub-groups of the population.
Outcome:
Health authorities are required to facilitate patients journeys that engage patients in shared and informed decisions, such as asking "what is important to you?". Health literacy is regarded as a precondition for realising patient-centered health services.
Added value:
The strategy on health literacy supports the vision of a patient-centered health system. It implies that patients and users have the knowledge, competencies and opportunities to manage health in the best possible way.
Asian Health Literacy Association was launched in 2013. It hosts the Asian Health Literacy Conferences and supports the development of health literacy in Asia.
Health Literacy Europe was launched in 2010 as a spin-off of the European Health Literacy Project (2009-2012). The network hosts the European Health Literacy Conferences and supports the development of health literacy in a European context.
The Ministry of Health launched the "Alliance for Health Literacy" in 2017 together with the heads of the self-administration of the German health care system. The common goal was to strengthen and further promote health literacy among the population in Germany. The Alliance for Health Literacy includes 14 different organisations.
Francophone health literacy network is the first French-language interdisciplinary network of researchers dedicated to health literacy, including digital health literacy. Its website gathers works carried out in France, Switzerland and Belgium.
UK Health Literacy Network is a multi-disciplinary group. The aim of the network is to advance research, theory, education, and practice on health literacy with special attention to personal, social, economic, and political implications.
Dutch Health Literacy Alliance was created in 2010, as a spin-off of the European Health Literacy Project, to establish a more inclusive society by improving health literacy competencies for health and self-management of the population. The Alliance promotes the health literacy of citizens and supports health professionals in recognising and addressing health literacy issues. The Alliance also promotes clear communication and plain language.
COVID-HL network is an interdisciplinary network established as an open science and research community to foster research in the field of health literacy, health information, and digital health. Since its launch in February 2020, more than 100 researchers from more than 50 countries joined the network, both early career and experienced researchers. Together they explore health literacy in individuals and systems to better understand how the Covid-19 pandemic has changed society, health, and information management.
WHO Action Network on Measuring Health Literacy in Populations and Organizations (M-POHL) was established in 2017 with the purpose of measuring health literacy in Europe at population and organisational levels. The International Coordination Centre is based in Austria. The network oversees the HLS19 European health literacy survey which was conducted in 2019/2020. The initiative is an amplification of the first European Health Literacy Survey from 2011.
Portuguese Health Literacy Society sasa inauguririme ko 2022. Khamela te buhljarel thaj te kerel influence upral impakto kotar e sastimasko dzanlipe ande Portugalo thaj avrijal.
The International Health Literacy Association (IHLA) was inaugurated in 2017. The aim of IHLA is to unite people around the world working to promote health literacy with the purpose of creating health literacy for all and a world where people and societies can act to improve health and quality of life. The backbone of the organisation are the interest groups which develop and implement health literacy within a wide range of topics.
Each Ophelia (OPtimising HEalth LIteracy and Access) project seeks to improve health and equity by increasing the availability and accessibility of health information and services in locally appropriate ways.
Target group:
The Ophelia Approach involves the collaboration of a wide range of community members, community leaders, and workers to develop health literacy interventions that are based on needs identified within a community.
Method:
The method focuses on the development of interventions in local communities. It draws on intervention mapping, quality improvement collaboratives, and realist synthesis. The intervention protocol is outcomes-oriented and focuses on two key questions: 'What are the health literacy strengths and weaknesses of clients of participating sites?', and 'How do sites interpret and respond to these to achieve positive health and equity outcomes for their clients?'.
The first phase is a needs assessment that uses the Health Literacy Questionnaire (HLQ), a multi-dimensional measure of health literacy, to identify common health literacy needs among clients. The second phase involves front-line staff and management within each service organisation in co-creating intervention plans to strategically respond to the identified local needs. The third phase will trial the interventions within each site to determine if the site can improve identified limitations to service access and/or health outcomes.
Outcomes:
Improving health literacy outcomes and responsiveness locally.
The Horowitz Center partnered with the Nebraska Association of Local Health Directors to offer the Health Literacy Champion Toolkit.
Target group:
The Toolkit is for local health department staff to assess health literacy capacity, develop an action plan, and commit to implementing the plan. State health departments and other organisations may also find the toolkit a valuable assessment and planning tool, although some of their organisational functions may differ.
Method:
The Health Literacy Champion Process has 5 steps:
Review the Toolkit background document;
Health Literacy Check-Up: assess health literate policies and procedures in the department;
Health Literacy Action Plan: develop SMART goals and an action plan;
Health Literacy Pledge: commit to implementing the plan;
Action Plan Implementation: implement the plan.
Outcomes:
The Partnership supports health literacy training that aligns with national standards and the development of a database of evidence-based health literacy training resources to aid in program development.
Added value:
The initiative supports the engagement of multiple local health counties in the development of health literacy strategic plans, including discussing county-specific strengths, gaps, and opportunities, accreditation opportunities, education and professional development, guidelines for Maryland to become a health literate state.
The Vienna model has the dual aim of fostering material conditions and creating a work culture inside health care organisations to make it easier for people to use information.
Target group:
The Vienna Health Literate Organisation (V-HLO) self-assessment tool nis a questionnaire for quality managers of health care organisations. Its objective is to determine the strengths and weaknesses of the organisation in terms of health literacy.
Method:
The Vienna Health Literate Organization self-assessment tool focuses on nine standards and 22 sub-standards.
9 standards and the 22 sub-standards of the Vienna Health Literate Organisation
The organisation should:
The organisation:
1. Establish management policy and organisational structures for health literacy
1.1. Understands health literacy as an organisational responsibility
1.2. Ensures quality assurance in the field of health literacy
2. Develop materials and services in participation with relevant stakeholders
2.1. Involves patient representatives in the development of materials and services
2.2. Involves staff in the development of materials and services
3. Quality staff for health-literate communication with patients
3.1. Ensures that staff are trained for health-literate communication in diagnosis, therapy, treatment and care, and discharge preparation
3.2. Ensures that staff are trained for health-literate communication in disease prevention and health promotion
4. Provide a supportive environment – health-literate navigation and access
4.1. Ensures barrier-free contact by internet and telephone
4.2. Provides all information needed for accessing the organisation
4.3. Ensures sufficient orientation support in the entrance area for patients and visitors to easily find their way
4.4. Has an easy-to-follow navigation system and signage
4.5. Ensures that patients and visitors have access to free health information
5. Apply health literacy principles in routine communication with patients
5.1. Face-to-face communication with patients follows health literacy principles
5.2. Written and audio-visual material are designed according to health literacy principles
5.3. The organisation provides resources to guarantee translation support when needed
5.4. Communication in high-risk situations follows health literacy principles
6. Improve the health literacy of patients and their entourage
6.1. Patients (and their entourage) are supported to improve health literacy for disease-related self-management
6.2. Patients (and their entourage) are supported to improve health literacy for healthy lifestyles
7. Improve the health literacy of staff
7.1. Staff are supported to improve the health literacy they need for managing job-related health risks
7.2. Staff are supported to improve health literacy for healthy lifestyles
8. Contribute to health literacy in the region
8.1. Supports health literacy in continuous and integrated care
8.2. Contributes to the development of health literacy in the regional population
9. Share experiences and be a role model
9.1. Support the dissemination and further development of concepts and practice of health-literate healthcare
Outcomes:
The tool is suitable for conducting needs assessment to help hospitals raise awareness and formulate targeted actions to further strengthen their health literacy responsiveness.
Added value:
Strengthening the capacity of hospitals to consider the level of health literacy of the population is needed to improve the quality of care. One way to develop adequate health literacy responsive policy and strategies in hospitals is the use of self-assessment tools to raise awareness, help prioritise action and mobilise stakeholders.
The European health literacy survey is a tool to measure health literacy in populations.
Target group:
The European Health Literacy Survey is currently being used widely across the European region and beyond. It has been translated into multiple languages and has been applied in low, middle-income and high-income countries.
Method:
The questionnaire is available in various versions and can be retrieved from the International Coordination Center for the Action Network on Measuring Population and Organisational Health Literacy (M-POHL).
Outcome:
The Health Literacy Survey helps to benchmark health literacy developments and monitor progress. The analytical insights can inform and qualify health literacy related policy-development, research and practice.
Added value:
Establishing the evidence-base on health literacy is driving action across the European region and beyond. The Action Network involves governmental stakeholders as well as researchers to ensure a strong implementation and impact of the data generated from the health literacy surveys.
Aim and objectives:
Making it Easier. Health Literacy Action Plan - UK (Scotland)