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Fundamental Resources Related to Health Literacy.

International Report on the Methodology, Results, and Recommendations of the European Health Literacy Population Survey 2019-2021 (HLS19) of M-POHL

The HLS19 Consortium of the WHO Action Network M-POHL published the International Report on the Methodology, Results, and Recommendations of the European Health Literacy Population Survey 2019-2021 (HLS19) of M-POHL, in 2021, the publisher of the report was Austrian National Public Health Institute, Vienna. Owner, editor and the publisher was the HLS19 Consortium of the WHO Action Network M-POHL.

This report contributes to the implementation of the 2030 Agenda for Sustainable Development, in particular to the Sustainable Development Goal (SDG) 3 “good health and well-being”, and the Sustainable Development Goal (SDG) 10 “social inequity”.

Here is a brief summary of the report you could download the whole report as pdf file from the link.

Background

In Europe, there is a growing interest in assessing adult population health literacy (HL) concerning public health, disease prevention, and health promotion to inform health policies. This builds on a tradition from the US, focusing on patients. The European Health Literacy Survey (HLS-EU, 2009-2012) affirmed HL’s relevance for health in eight EU countries, and subsequent studies in more European and Asian countries echoed these findings. These studies revealed that a significant portion of the general population has limited HL, with a social gradient and adverse effects on healthy lifestyles, self-reported health, and healthcare utilization. Following WHO’s recommendations in “Health Literacy: The solid facts” (2013), WHO/Europe initiated the Action Network on Measuring Population and Organizational Health Literacy (M-POHL) involving 28 countries. The Health Literacy Survey 2019 (HLS19) was conducted in 17 countries in the WHO European Region. HLS19 explored General HL, as well as specific HLs like Navigational HL, Communicative HL with physicians, Digital HL, and Vaccination HL, using newly developed and validated instruments. Additionally, HLS19 analyzed HL’s role as a mediator for health costs.

Methods

The HLS19 employed a cross-sectional multi-center survey study design, targeting permanent residents aged 18 and above in private households across 17 participating countries. The study included 42,445 interviews, with national sample sizes ranging from 865 to 5,660 respondents. Countries utilized multi-stage random sampling or quota sampling, often stratifying samples by gender, age group, population density, and geographical areas. Data collection occurred through personal, telephone, or web-based interviews, spanning from November 2019 to June 2021.

To assess General HL, the HLS19-Q12, a shortened version of the original HLS-EU-Q47 instrument, was validated and used across the 17 countries. Simultaneously, new instruments for Navigational HL, Communicative HL with physicians, Digital HL, and Vaccination HL were developed and validated, involving 7 to 13 volunteering countries. Explicit definitions for these specific HLs were aligned with the HLS-EU definition for comprehensive, general HL, and items were selected or constructed accordingly. Relevant correlates of HL were also measured. The HLS19 instruments were translated into national languages by 16 countries and into migrant languages by some. HL scores were calculated by combining “easy” and “very easy” categories, standardized from 0 to 100, with higher scores indicating higher HL levels. For General HL, four categorical levels were established (excellent, sufficient, problematic, inadequate).

Recommendations Based on HLS19 Results

Regarding General HL:

Investment in Longitudinal Studies:
- Health policy should allocate resources for longitudinal studies to regularly measure and monitor population HL.
Systematic Implementation of Interventions:
- Health policy should systematically implement interventions to enhance HL, with a specific focus on reducing the health gap among at-risk groups.
Comprehensive Approach to Health Information:
- Interventions should address all four aspects of processing health-related information (accessing, understanding, appraising, and applying) within healthcare, disease prevention, and health promotion.
Prioritization of Difficult Tasks:
- Interventions targeting specific, concrete HL tasks should prioritize those perceived as more challenging by the population.
Improving Mass Media Health Information:
- Efforts should be made to enhance the quality of health information provided through mass media channels.
Prioritizing Mental Health Interventions:
- Interventions to improve HL in the context of mental health should be prioritized, supported by dedicated research.

These recommendations aim to guide health policies and interventions, emphasizing the importance of addressing diverse aspects of HL, targeting at-risk populations, and focusing on specific challenging tasks and mental health domains.

Recommendations Regarding Specific HLs:

Navigational HL:

Systemic and Organizational Interventions:
- Health policy should devise strategies to enhance Navigational HL, focusing on systemic and organizational interventions to create more health-literate, user-friendly, and navigable health systems.

Communicative HL: 2. Priority on Professional-Patient Communication:

High priority should be given to interventions improving communication between health professionals, particularly physicians, and patients. Support should be provided to enhance person-centered communication skills among health professionals.

Digital HL: 3. Enhanced Digital Information Accessibility:

Efforts should concentrate on increasing the accessibility of easily understandable, high-quality, trustworthy, assessable, and applicable health information through digital sources.

Vaccination HL: 4. Top Priority for Vaccination HL Improvement:

Improving Vaccination HL should be prioritized, focusing on enhancing trustworthiness and communication of vaccination information.

Regarding Research on HL:

Regular Measurement Across Countries:
- Health policy should support the regular measurement of HL in the adult population across as many countries as possible.
Planning for Future Measurement:
- The next wave of HL measurement is recommended for data collection in 2024.
Focused Research and Tool Enhancement:
- In preparation for the next wave, specific research funding is needed to conduct in-depth analyses, revise tools for measuring HL, and explore relevant correlates.
Detailed Analyses and Publications for Specific HLs:
- More detailed analyses and publications on the HLS19 data are required, along with continued research and development for improvements in later applications.
Exploration of Additional Health Literacies:
- Additional specific health literacies and relevant topics related to General HL should be reviewed, selected, and researched for inclusion in the next wave of HL measurement.
Costs and Economics of HL:
- Further detailed analyses are needed to understand the costs and economics associated with HL.
Dissemination Through Scientific Publications:
- Results from HLS19 should be disseminated more widely through peer-reviewed scientific publications to ensure broader accessibility and utilization.

Measuring Comprehensive, General Health Literacy in the General Adult Population: The Development and Validation of the HLS -Q12 Instrument in Seventeen Countries

This is a scientific paper published in International Journal of Environmental Research and Public Health in November 2022. Here is the abstract of the paper.

You could download the full article in the link.

Background: To enhance health literacy (HL) through national and international public health policies, there is a need for a comprehensive instrument to measure population HL. This study introduces the HLS-Q12, a concise tool developed from the HLS-EU-Q47, applied and validated across 17 countries in the WHO European Region.

Methods: Factorial validity and dimensionality were assessed using Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM). Discriminant validity was evaluated through correlation analysis, while linear regression analysis tested concurrent predictive validity.

Results: Cronbach alpha coefficients exceed 0.7, indicating strong internal consistency. Single-factor CFAs demonstrate good model fit, though certain items exhibit differential item functioning in specific country datasets. Regression analyses reveal HLS-Q12 scores’ association with social determinants and selected HL consequences. The HLS-Q12 score exhibits a high correlation (r ≥ 0.897) with the HLS-Q47 long form.

Conclusions: The HLS-Q12, grounded in a comprehensive HL understanding, exhibits satisfactory psychometric and validity characteristics across diverse languages, country contexts, and data collection methods. It proves suitable for measuring HL in general, national, adult populations, while highlighting areas for potential instrument enhancement.

Health Literacy: More Important Than Ever in the COVID-19 Pandemic

Here is the summary of the editorial letter from the Turkish Journal of Health Literacy, published in December 2020. The letter is emphasizing the important of health literacy in COVID-19 pandemic. The article could be downloaded from the link.

This editorial letter reflects on the unprecedented challenges posed by the COVID-19 pandemic and emphasizes the significance of health literacy during these extraordinary times. The editorial introduces a special edition of the Turkish Journal of Health Literacy, dedicated to exploring national and international perspectives on health literacy.

The COVID-19 pandemic has profoundly impacted societies globally, leading to significant health, economic, and social consequences. Public health measures have been implemented worldwide to curb the spread of the virus, and the editorial highlights the social effects of the pandemic, including fear, panic, mental health problems, and economic issues.

The letter underscores the critical role of health literacy in navigating the challenges posed by the pandemic. It emphasizes that limited health literacy is akin to a silent epidemic and stresses the importance of addressing health literacy in public health initiatives. The editorial notes that health literacy is a social determinant of health, affecting individuals across various education and income levels.

Studies have shown that higher health literacy is associated with better health knowledge, improved health status, reduced health inequalities, and overall better well-being. The letter underscores that high health literacy empowers individuals to make informed decisions, contributing to effective interventions and reducing fear and panic during an epidemic.

The editorial asserts that health literacy has become even more critical in today’s information-rich world and calls for increased attention and debate on this often-overlooked issue. It emphasizes that improving health literacy is an effective strategy for health promotion, disease prevention, and rapid interventions required during situations like the ongoing pandemic.

In conclusion, the letter advocates for health literacy to be viewed as a crucial element of social responsibility and resilience. It stresses the importance of an interdisciplinary approach to improving health literacy, especially during the ongoing pandemic, and encourages its use as a vital tool for both consumers and providers of health information.

The Relationship Between Health Literacy Level and Media Used as a Source of Health-Related Information

This article was published in Vol 5, No 2 of Health Literacy Research and Practice in 2021. The article emphases the importance of the source of health-related information in promotion of health literacy. Here is the summary of the article.

You could reach the article from the linked file.

Background:

Previous research in Turkey has not comprehensively examined national health literacy levels and associated factors using a culturally adapted scale. This study aimed to assess health literacy levels in Turkey and explore the relationship between health literacy, socioeconomic factors, and various sources of health-related information.

Methods:

Conducted as a cross-sectional, nationally representative study with a computer-assisted personal interview approach, the research included 6,228 households (with a 70.9% response rate). Health literacy was measured using the Turkey Health Literacy Scale. Additionally, sources of health-related information, such as newspapers, television, internet, and smartphones, were incorporated into the regression model for health literacy.

Key Results:

Approximately 7 out of 10 participants demonstrated limited health literacy, with 30.9% categorized as inadequate and 38% as problematic. Inadequate and problematic health literacy frequencies were higher in disease prevention and promotion domains compared to health care domains. The internet (48.6%) emerged as the most frequently used medium for health-related information, followed by television (33%). Controlled models revealed associations between higher health literacy scores and elevated education and income levels. Significant impacts on the general health literacy index were observed for television, internet, newspapers, and smartphones as sources of health-related information.

Conclusions:

Health literacy in Turkey mirrors social inequalities, with the study underscoring the relevance of socioeconomic variables and health information sources to health literacy levels. The findings emphasize the need to enhance health information sources to improve overall health literacy in the country.

Turkish Version of Health Literacy Surveys; Validity and Reliability

The report of validity and reliability of health literacy surveys was published in 2016 by Turkish Health Ministry. This book is in Turkish, but here is the long summary of the content of the book.

The whole book-report could be reached from the link.

The proposal for collaboration on developing a scale for assessing health literacy was brought to the Department of Public Health at Adnan Menderes University Faculty of Medicine by the General Directorate of Health Promotion of the Ministry of Health of the Republic of Turkey in September 2013. Following the decision to collaborate, a meeting was arranged to discuss the topic and gather research proposals. The initial meeting took place on October 28, 2013, during the 16th National Public Health Congress.

During this meeting, it was decided to use “The European Health Literacy Survey (HLS-EU)” framework developed in the HLS-EU Consortium (2012) as the conceptual framework for the new scale. Building on the HLS-EU study, it was agreed to develop two scales: one with declarative questions based on a Likert scale and another with scenario-based questions involving different types of applications.

The HLS-EU study developed questions using a matrix based on the conceptual framework, evaluating health literacy through twelve components, categorized into three dimensions (“Treatment and Service Dimension,” “Disease Prevention Dimension,” and “Health Promotion Dimension”) and four processes (“Understanding Information,” “Applying Information,” “Evaluating Information,” and “Using/Implementing Information”). The functions of these components were assessed for ease or difficulty levels.

To develop these scales, it was decided to form an expert panel, and through email correspondence, the idea of conducting a workshop with the participation of experts from various disciplines for both types of scales emerged. In preparation for the workshop, English-Turkish and Turkish-English translations of the HLS-EU Scale were commissioned from experts, and the translated scale was presented to workshop participants. Translation methods included translation-back translation (Brislin, 1980) for linguistic validity, using group translation (language validity), and expert opinions.

The Health Literacy Scale Development Workshop was held on December 19-20, 2013, in Ankara. Over the two days, 17 experts from diverse disciplines, divided into two groups, worked on developing two types of scales. On the second day, both scales were presented to the entire group for feedback. As a result of this workshop, item suggestions were made for the Health Literacy Likert Scale, and a Health Literacy Scenario Scale consisting of four scenarios was developed.

Following the workshop, it was decided that assessing how the items of ASOY-TR (adaptation of the European Health Literacy Survey to Turkish) worked in the field would be beneficial before developing a new scale. Consequently, the ASOY-TR study was conducted, and its results are presented in the second part of the report.

After this study, it was observed that the scale generally measured health literacy; however, difficulties arose in separately defining the dimensions of “treatment and service,” “disease prevention,” and “health promotion.” Therefore, for the new Likert scale, a change was made in the conceptual framework, and it was decided to combine the “disease prevention” and “health promotion” dimensions for the specific context of our country. In line with this goal, a 32-item Likert scale was developed using the suggested items from the workshop.

The developed Health Literacy Likert Scale was presented to 15 experts, 13 of whom provided evaluations and opinions. Explanations in expert feedback, statistical evaluations, opinions from an expert consultant on the scale, and experiences gained from the ASOY-TR study were taken into account by the research team in finalizing the scale. The resulting scale was named “Turkey Health Literacy Scale-32 (TSOY-32)”.

During the Health Literacy Scale Development Workshop held on December 19-20, 2013, the developed Scenario Scale was preserved as is, but due to expert opinions suggesting the development of a different evaluation method for the same scenarios, it became prominent.

Scenarios were developed that assess the three dimensions of health in the conceptual framework of the European Health Literacy Scale (“treatment-service,” “disease prevention,” and “health promotion”) in terms of accessing, understanding, and decision-making/applying processes. Therefore, each scenario contains a specific question for each dimension, and an additional knowledge question related to each scenario was added. As a result, each scenario consisted of four questions. In this form, it was named the “Health Literacy Scenario Scale (HLSS)”.

International Handbook of Health Literacy

The book called International Handbook of Health Literacy, Research, practice and policy across the lifespan is published in 2019 and edited by Orkan Okan, Ullrich Bauer, Diane Levin-Zamir, Paulo Pinheiro and Kristine Sørensen.

The book consists of 45 chapters, covering 4 parts; Research into health literacy: an overview of recent developments, Programmes and interventions to promote health literacy, Policy programmes to promote health literacy and Future dialogue and new perspectives.

The digital PDF version of this title is available Open Access and distributed under the terms of the Creative Commons Attribution-Noncommercial 4.0 license. Hence you can download the pdf here.

Here is the summary of the introduction of the book, before you start reading it.

The “International Handbook of Health Literacy” delves into the dynamic landscape of health literacy, a subject that has garnered increasing attention across diverse disciplines. The surge in interest is propelled by the recognized potential of health literacy to elucidate and address variations in health outcomes among individuals and communities. The handbook encapsulates the evolution of health literacy, reflecting empirical insights, societal transformations, and paradigm shifts in healthcare dynamics, both globally and locally.

The narrative unfolds against the backdrop of significant historical milestones, highlighting key empirical findings such as those emanating from the European Health Literacy Project. The societal canvas is painted with the advent of digital technologies, which has not only intensified the availability of health information in various forms but also posed challenges related to accessibility and comprehension. Terms like ‘shared decision-making’ and ‘patient empowerment’ indicate a paradigm shift in the doctor-patient relationship, echoing broader societal changes where individuals are increasingly viewed as informed consumers making choices about their health and information.

The handbook recognizes the multidisciplinary nature of health literacy, bridging health-related databases with education, library and information sciences, nursing, pharmacy, communication, and sociology databases. The multidimensional character of health literacy is underscored, encompassing cognitive, social, and cultural dimensions. It emphasizes that health literacy is a lifelong endeavor, evolving from birth to death, thus necessitating a life course perspective.

A historical lens reveals the evolution of health literacy from a narrow focus on functional skills to a broader, interdisciplinary construct. The narrative captures the transition from a healthcare-centric perspective, primarily concerned with functional skills like reading and numeracy, to a public health approach that incorporates cognitive, social, and cultural components. The public health lens views health literacy as integral to health promotion and advocates a social justice approach, considering wider determinants of health.

In addressing health literacy, the handbook goes beyond an individual-centric focus to acknowledge the contextual dimensions. The attention shifts to collective health literacy and distributed health literacy, recognizing the influence of social, cultural, economic, and political contexts. The handbook makes a compelling case for adopting a systems perspective, emphasizing the need for a comprehensive, collaborative approach that spans individuals, professionals, organizations, and policymakers.

Comprising 45 chapters divided into four thematic parts, the handbook serves as a comprehensive repository of knowledge. It addresses various populations across different settings, employing diverse concepts, methodologies, and interventions to enhance health literacy. The handbook also fosters interdisciplinary connections, linking health literacy with education, sociology, health promotion, social epidemiology, public health, healthcare, medicine, nursing, and pharmacy.

The acknowledgment section pays tribute to the collaborative efforts of 100 authors from 19 countries, recognizing their substantial contributions. Special thanks are extended to those who supported the formatting process. The handbook’s availability as Open Access is attributed to the German Federal Ministry of Education and Research, marking a significant contribution to the field. In essence, the “International Handbook of Health Literacy” stands as a pioneering work, offering a global perspective, practical insights, and a roadmap for future research, practice, and policy in the health literacy domain.

Health Literacy, The Solid Facts

The book was published by WHO Europe Office in 2013 and edited by Ilona Kickbusch, Jürgen M. Pelikan, Franklin Apfel and Agis D. Tsouros. You could download the book from as pdf from the link.

The book titled “Health Literacy, the Solid Facts,” published by WHO, addresses the pressing health decision-making paradox in 21st-century knowledge societies. Despite the increasing challenges individuals face in making healthy choices and navigating complex health environments, they often lack the preparation and support needed for these tasks. Modern societies, marked by active promotion of unhealthy lifestyles and intricate health care systems, coupled with educational systems falling short in equipping individuals with essential health-related skills, contribute to this paradox.

The introduction highlights a health literacy crisis observed in Europe and beyond, as evidenced by the European Health Literacy Survey, revealing that nearly half of adults in tested European countries lack adequate health literacy skills, adversely impacting their health. Weak health literacy is linked to less healthy choices, riskier behavior, poorer health outcomes, reduced self-management, and increased hospitalization, exerting a significant burden on human and financial resources in the health system.

The publication aims to catalyze policy action to address the health literacy crisis. It advocates for a broader, relational concept of health literacy, considering both individual competency and the complexities of contextual influences. Part A emphasizes the necessity of policy action, framing inadequate health literacy as a key determinant of health, a prevalent problem, a resource drain, and a developmental obstacle.

Part B delves into actionable strategies across various settings and sectors to enhance health literacy. It presents evidence supporting interventions that empower individuals to make informed health decisions in diverse contexts—home, community, workplace, healthcare system, educational system, marketplace, and media.

Part C focuses on the development of policies to bolster health literacy at global, regional, national, and local levels. Each chapter identifies a critical issue, provides evidence of its significance, and proposes evidence-informed interventions along with useful sources for further exploration. The book aspires to be a comprehensive guide fostering a deeper understanding of health literacy and advocating for policies and actions to address this critical aspect of public health.

The Level of Health Literacy in the World and Turkey and Affecting Factors

This article is from the Turkish Health Literacy Journal, published in June 2020. The language of the article is Turkish.

The article can be downloaded as pdf.

History of Health Literacy

The emergence and evolution of health literacy as a significant interdisciplinary field of study over the past 40 years. Initially developed in Western countries, health literacy has gained global importance, influencing research, educational programs, and policy-making worldwide. Organizations like the WHO and UNESCO, along with many governments, have integrated health literacy into their agendas. The historical development of health literacy, exploring its roots in various disciplines and the factors influencing its growth.

The four main origins of health literacy: school health education, adult education, healthcare research, and public health. It begins by tracing the historical development of health literacy, starting from the 1974 Saranac Lake conference in New York to the 2016 WHO Shanghai Conference. These events marked significant milestones in recognizing and addressing health literacy in different specialized fields.

Focusing on school health education, the term “health literacy” was first used in 1973 during a conference in Saranac Lake, New York. Scott K. Simonds emphasized the importance of health education, advocating for its integration into education systems, the healthcare sector, and media channels. Health literacy was defined as an outcome of health education, focusing on acquiring health knowledge and skills. Despite its early introduction, health literacy did not gain much traction in school curriculums until later years.

In the U.S., health literacy remained a largely theoretical concept in school education until the 1990s. The curriculum was eventually updated to include health literacy, but implementation varied widely across states. In contrast, Australian educators consistently emphasized the role of schools in promoting health literacy, adopting a public health approach. Finland also demonstrated success in integrating health literacy into its education system, emphasizing a multidimensional framework.

The health literacy has become an essential aspect of school health education, its incorporation into curriculums and practice is still uneven. The importance of including health literacy in school education is recognized, but more work is needed to develop effective classroom practices and evidence-based approaches.

History and Future Directions for Health Literacy

Despite shared features, the four primary origins of health literacy—school health education, adult education, healthcare research, and public health—offer diverse perspectives and approaches to the concept.

A commonality among these roots is the perception of health literacy as a result of health education, emphasizing the interplay between individual responsibility and environmental factors, including social and cultural aspects. The early agendas in the 1970s and 1980s incorporated social policy elements like citizenship, just health systems, participation, and empowerment. Today, health literacy initiatives are seen in both top-down and bottom-up strategies across these disciplines. The growing trend of incorporating health literacy into national policies is matched by grassroots efforts in education and healthcare.

In the U.S., adult education and healthcare merged in the 1990s, combining educational methods and extensive research. However, school health education has largely remained separate from these fields. Public health, while sharing some aspects with healthcare, primarily focuses on a health promotion approach that extends beyond medical services to include everyday life and social determinants of health.

A notable aspect is the emphasis on developing socially responsible citizens and critical thinkers, a common goal in both school health education and public health. In healthcare, health literacy still largely centers on medical service use and patient-provider interactions, while public health and school education focus more on broader health promotion goals.

The differences and commonalities in the conceptualization of health literacy across these fields. The healthcare approach has been primarily driven by U.S.-based organizations, focusing on the health literacy of professionals and organizations. In contrast, public health has contributed a broader notion of health literacy, emphasizing everyday life settings, determinants, and critical judgment of information.

Despite these varied approaches, there is a need for a unified understanding of health literacy that can adapt to different populations, settings, health aspects, and conceptual needs. Looking ahead, the chapter suggests that the future of health literacy will benefit from an integrated approach that combines elements of healthcare and public health, fostering lifelong learning for health from early education through to adult and continuing education.

Public Health and Health Literacy

In the realm of public health, the evolution of health literacy is deeply entwined with the health promotion movement. This movement gained momentum with the WHO’s Ottawa Charter in 1986, particularly in Europe. However, the concept’s foundations were laid earlier with the 1974 Lalonde report in Canada, which introduced ‘health promotion’ to a wider audience. The term ‘health promotion’ itself dates back to the 1940s, but the Lalonde report is credited with significantly advancing the concept, emphasizing a public health framework that goes beyond biomedical aspects to include environmental, lifestyle, and social determinants of health.

The Ottawa Charter, while focusing on developing personal skills as a part of health promotion, did not explicitly mention health literacy. This changed in the 1990s when Australian public health goals began intertwining health literacy with education, influenced by the WHO’s health-promoting schools approach. The WHO’s Jakarta Conference further expanded on this, incorporating health literacy as a key component of personal skills development. Health literacy was then defined more broadly than just relating to healthcare, emphasizing cognitive and social skills for maintaining good health.

The public health approach to health literacy, as opposed to the narrow healthcare perspective, emphasizes its role beyond functional literacy. It’s seen as a set of social practices enabling practical abilities in everyday life. This broader view includes functional, interactive, and critical health literacy, linking to Paulo Freire’s ideas of empowering education. Health literacy is thus considered a vital skill for the 21st century, essential for participation in society and for addressing health determinants.

Significant steps were taken to strengthen health literacy in public health policies, particularly in the context of increasing disease burden and the importance of disease prevention. The role of culture in influencing health literacy was also recognized, especially in the context of migrant and refugee populations.

The first major health literacy survey conducted in Europe acted as a catalyst for global research, practice, and policy in this field. The WHO’s subsequent reports and policy briefs have emphasized the need to integrate health literacy into various sectors, particularly education. The Shanghai Declaration on health promotion further prioritized health literacy as a key goal. Despite these advancements, there remains a disparity in health literacy efforts globally, with significant work in Europe, North America, and Australasia, but limited progress in regions like Africa, the Middle East, India, South America, Russia, and some European countries.

Current Understanding of Health Literacy for Children and Adolescents

Health literacy in children and adolescents is a complex and varied concept, with over 100 general definitions and at least 12 specific to this age group. Commonly, health literacy is seen as an individual attribute, focusing on how young people access, comprehend, evaluate, and use health information for decision-making and behavior. The emphasis is often on cognitive skills like reading and critical thinking, but affective attributes (e.g., self-efficacy, motivation) and operational skills (e.g., communication, healthcare navigation) are also included.

Health literacy is conceptualized as both a personal and societal asset, useful for one’s own health and that of others. It’s seen as a tool for personal empowerment, with outcomes linked to healthy behaviors and overall wellbeing. The idea of a rational, actively choosing individual is central in these concepts, though this perspective sometimes overlooks the complexity of factors influencing behavior and change, such as cultural and social support factors.

In child and adolescent health literacy, the role of environmental and social contexts is crucial. These contexts include family and peer influence, school and community settings, and broader social and cultural environments. Some models explore these contexts through sociological perspectives, acknowledging the interplay of these factors with health literacy.

There’s also recognition of the ‘collective’ nature of health literacy in this age group, involving adults, peers, and institutions. However, there’s a gap in recognizing children and adolescents’ unique perspectives on health, their informational needs, and their participation in health decision-making. To address this, the 5D model was proposed, focusing on differential aspects like epidemiology, demographics, development, dependency, and democracy in health literacy.

There’s a vast array of health literacies (e.g., oral, mental, diabetes) for children and adolescents, leading to a high degree of differentiation within the concept. This diversity poses challenges for measuring health literacy and implementing it in practice and policy.

From a developmental perspective, health literacy is often tied to cognitive abilities, with stage models outlining expected skills at different ages. However, these models can be overly normative and don’t account for individual-environment interactions or cultural differences. For instance, the increasing proficiency of children in computer skills challenges the idea that age is a reliable indicator of ability. Thus, while developmental aspects are important for understanding how health literacy evolves in children and adolescents, a one-size-fits-all approach is limited and does not fully encompass the diverse experiences and environments of young individuals.

Measuring and screening Health Literacy

Health literacy in children and adolescents is a multifaceted concept with over 100 general definitions and numerous models specific to this age group. It is primarily viewed as an individual attribute, involving the ability to access, understand, evaluate, and use health information for decision-making and behavior. The focus is typically on cognitive skills such as reading and critical thinking, along with affective attributes like self-efficacy and operational skills including communication and healthcare navigation.

Health literacy is seen as both a personal and societal asset, contributing to personal empowerment, healthy behaviors, and overall well-being. However, this individual-centric view often overlooks the role of broader cultural and social influences on behavior and decision-making.

In the context of children and adolescents, the importance of environmental and social contexts, such as family, peers, school, and community settings, is emphasized. There is recognition of the collective nature of health literacy in this age group, but there’s a notable gap in acknowledging their unique health perspectives and needs. The 5D model addresses this by focusing on differential aspects like epidemiology, demographics, and developmental processes.

The diversity of health literacies poses challenges for measurement and implementation in practice and policy. Developmental aspects are crucial for understanding the evolution of health literacy in young people, but existing stage models are often too normative and fail to account for individual and environmental interactions.

In terms of measurement tools, the most frequently mentioned or cited ones include TOFHLA, REALM, NVS, eHEALS, HLS-EU, and HLQ. These tools vary significantly in size and the underlying definition of health literacy they are based on. Many of these tools, however, focus on health literacy as an individual-level factor, potentially overlooking the broader system dynamics.

The majority of these tools are self-reported, while older tools like TOFHLA, REALM, and NVS attempt a more objective measurement. It is important for users of these tools to consider their validation and reliability for the specific population being assessed.

An interesting development in the field is the trend towards privatization, affecting the accessibility of these tools. Many, but not all, are freely available, which is a crucial consideration for those with limited resources.

The limitations of these tools often reflect a narrow focus, aligning with older definitions of health literacy that emphasize individual abilities rather than acknowledging systemic barriers. There’s a need in the field to balance understanding individual health literacy without reinforcing the deficit model that has historically dominated the field.

HLS-EU-Q47 as a Cognitive Interview

Cognitive interviews, a technique used in social sciences for qualitative pre-testing of questionnaire items, help evaluate response errors based on theoretical models of the question-answering process. This method, conceptualized by Tourangeau in 1984, involves understanding the question, retrieving relevant information, estimating, and responding.

For the HLS-EU-Q47, a health literacy questionnaire for adolescents, a purposive sample of 20 adolescents aged 14-17 was selected using a snowballing technique. Interviews conducted between December 2015 and March 2016 focused on 15 out of 47 items identified as challenging from previous tests. These interviews, lasting between 55 to 110 minutes, were semi-structured, recorded, and partially transcribed.

The interview techniques included ‘verbal probing’ and ‘retrospective think-aloud’ to determine if items were understood as intended and if adolescents had relevant experiences in health-related situations. Analysis of transcripts and notes used Tourangeau’s cognitive model, with a framework approach for categorizing qualitative data. Reliability was ensured by having two researchers independently categorize and code a portion of the data.

Three dominant themes emerged:

Comprehensibility of Items: Not all items were well understood. For instance, some adolescents didn’t understand the term ‘second opinion’ or the concept of ‘political changes’ affecting health. This indicated a difficulty in understanding specific terms or complex issues requiring higher abstraction.
Motifs for Choosing a Response Option: When an item or term was unclear, some adolescents chose ‘very difficult’ rather than not responding, suggesting that their responses reflected their understanding of the item rather than the actual difficulty of the assessed competence.
Experiences with Specific Health-Related Situations: Many adolescents lacked experience with the health-related situations described in the questionnaire. For example, some assumed they would understand medication leaflets without having read them, and others couldn’t envision how community activities could impact health and wellbeing. This suggests that adolescents might overestimate their health literacy in unfamiliar situations.

Overall, the study on HLS-EU-Q47 revealed challenges in questionnaire comprehension and response biases among adolescents, highlighting the importance of considering the respondents’ understanding and experience when assessing health literacy.

Development of HLS-EU Survey

The HLS-EU project, supported by the Executive Agency for Health and Consumers of the EU, aimed to develop a tool for measuring health literacy in Europe and establish a network for health literacy. This involved creating a comprehensive model and definition of health literacy, conducting a survey, and analyzing the data to understand health literacy’s determinants and consequences.

Development of the HLS-EU Concept and Definition:

A literature review led to a consensus definition and model of health literacy.
Health literacy was defined broadly, encompassing people’s abilities to access, understand, appraise, and apply health information across healthcare, disease prevention, and health promotion.
This definition integrated aspects of clinical, medical, patient, and public health literacy, emphasizing the role of health literacy in everyday life settings.

Operationalizing Health Literacy for the HLS-EU Survey:

The survey aimed to be comprehensive in content and types of competencies.
A matrix focusing on three domains of health and four cognitive information-processing competencies was used.
The instrument consisted of 47 items, each representing a specific task within the matrix.
Questions were based on perceived difficulty, using a four-point Likert scale.

Data Collection and Analysis:

Data was collected through interviews, taking about 10 minutes for the HLS-EU-Q47 section.
The survey involved about 1,000 participants from each participating EU country.
Analysis allowed for examining single items and aggregated indices.
Health literacy levels were defined to facilitate understanding and comparison across countries.

Main Results:

Almost half of the survey participants had limited health literacy, with considerable variation across countries.
Health literacy was associated with various socio-demographic factors, health behaviors, health status, and healthcare usage.
The survey highlighted a social gradient in health literacy, with disparities based on education, financial status, and other social determinants.

In summary, the HLS-EU project successfully developed a comprehensive tool for measuring health literacy in Europe, providing valuable insights into the state of health literacy across various EU countries. This tool and the resulting data have implications for policy, practice, and research, helping to tailor interventions and improve health literacy among different populations.

O1-OER PLATFORM

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Fundamental Resources Related to Health Literacy.

Assess Your Own Health Literacy Level.

You can measure your level of health literacy. You can find out if you fill out the HLS19-Q12 questionnaire, which is a validated scale in Europe.

Questionnaires and Checklists on Health Literacy and Health Communication

Resources Developed Within the Scope of the Project.

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