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.

Voltar Strategy to improve health literacy in the population 2019-2023 – Norway

 Aim and objectives:

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. 

 Strategy to improve health literacy in the population 2019-2023 - Norway

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Asian Health Literacy Association

Asian Health Literacy Association was launched in 2013. It hosts the Asian Health Literacy Conferences and supports the development of health literacy in Asia.

 Asian Health Literacy Association

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Health Literacy Europe

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.

 Health Literacy Europe

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German Alliance for Health Literacy

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.

 German Alliance for Health Literacy

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Francophone health literacy network

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. 

 Francophone health literacy network

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UK Health Literacy Network

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.

 UK Health Literacy Network

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Dutch Health Literacy Alliance

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.

 Dutch Health Literacy Alliance

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COVID-HL network

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.

 COVID-HL network

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​ WHO Action Network on Measuring Health Literacy in Populations and Organizations (M-POHL)

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.

  WHO Action Network on Measuring Health Literacy in Populations and Organizations (M-POHL)

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Portuguese Health Literacy Society

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.

 Portuguese Health Literacy Society

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The International Health Literacy Association (IHLA)

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.

 International Health Literacy Association (IHLA)

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Ten Attributes of Health Literate Health Care Organizations – United States

 Aim and objectives:

The Brach model highlights ten attributes of health literate organisations.

 Target group:

The Brach model can be used for strategic planning by health professionals, providers and decision-makers.

 Method:

The model describes ten action areas for health providers and managers to develop and improve to become a health literate organisation: 

  • leadership that makes health literacy integral to its mission, structure, and operations;
  • integration of health literacy into planning, evaluation measures, patient safety, and quality improvement;
  • training of workforce to be health literate and monitor progress;
  • involvement of populations served in the design, implementation, and evaluation of health information and services;
  • meeting the needs of populations with a range of health literacy skills while avoiding stigmatisation;
  • applying health literacy strategies in interpersonal communications and confirm understanding at all points of contact;
  • provision of easy access to health information and services and navigation assistance;
  • designing and distributing print, audio-visual, and social media content that is easy to understand and act upon;
  • addressing health literacy in high-risk situations, including care transitions and communication about medicines;
  • clear communication of what health plans cover and what individuals will have to pay for services.

 Outcome:

The Brach model has been influential in the agenda-setting for structural efforts to improve health literacy.

 Added value:

Applying a strategic approach in the implementation of health literacy strengthens the impact of health literacy across the organisation and beyond.

 Ten Attributes of Health Literate Health Care Organizations

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Ophelia Toolkit – Australia

 Aim and objectives:

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.

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Health Literacy Champion Toolkit – United States

 Aim and objectives:

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. 

 Center for Health Literacy: Health Literacy Champions

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Vienna model for health literate hospitals – Austria

 Aim and objectives:

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.

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Measuring health literacy in populations and organizations (M-POHL) – Europe and beyond

 Aim and objectives:

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.
 

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