Consider the following examples:

►   The Covid-19 pandemic prompted the largest vaccination campaign in human history. Among the many challenges faced by individuals was the assessment of risk vs benefit of vaccination (arguably requiring a deep conceptual comprehension of statistical data, such as percentage, probability, predictive models, and different scenarios). In this regard, health literacy can help people to perceive, understand and assess associated risks.

►   Eating a healthy diet contributes to a healthy life, including lower risks of cardiovascular disease. Diet is strongly dependant on the cultural and geographical dimensions of people and groups in society. In this regard, health literacy contributes to the skills, sensibilities and empathy needed towards different people and groups in order to be more effective in encouraging changes in their daily diets.

Individuals need:

·         to seek and find health information from different sources;

·         to compare, synthesise and appraise health information from different sources;

·         to reflect on the usefulness and applicability of information from one’s personal perspective.

Systems have the responsibility to offer:

·         information in a manner that secures information access to people with differing needs, such as those with learning disabilities or hearing and seeing impairments;

·         easily available health information in all relevant languages, through different channels and in different formats;

·         information that is easy to understand, culturally sensitive and empathetic, by using different communication strategies;

·         updated and valid health information from trusted sources;

·         information that is relevant and adaptable to the daily lives of individuals with differing needs.

Good practice

Teaching digital education and literacy via cross-cutting themes addressed across various subjects – Germany

Aim and objectives: Based on the German education sector’s strategy, all schools should prepare pupils for digital transformation. On the state level, digital education and digital literacy strategies translates into the media literacy competence framework and curriculum.

Target group: School pupils

Method: Digital education and digital literacy serve as cross-cutting themes that should be addressed across subjects from grades 1-13. Along with learning using digital tools, communicating in digital spaces, data protection and ethics, pupils are taught to develop a critical stance, and to seek, compare and analyse information from various sources.

Outcome: Using health as a subject within a competence framework and curriculum makes it possible to address health literacy and at the same time saves resources.

Added value: Education in schools reaches all school-aged children. Health literacy as part of the school curricula, including media and digital literacy, is a promising strategy to support all young people in acquiring the knowledge and skills needed to access valid health information, relevant for their health and wellbeing.

Good practice

Teaching health literacy as a mandatory school subject – Finland

Aim and objectives: Health literacy, including critical thinking, is taught through an independent and mandatory school subject called “health education”.

Target group: Pupils in primary and secondary schools.

Method: In grades 1–6, health education is taught as an independent component in a cluster of subjects called ‘environmental studies’. In grades 7–9, and general upper secondary school, health education is a stand-alone subject. Already in lower grades, pupils are taught to assess information and to select valid information sources. Then in higher grades they are taught to assess information using several criteria. Later, they are also taught about the reliability of information as well as differences between lay information and scientific information. Health-related competencies, as well as media literacy and digital skills, are taught via crosscutting themes running through all school subjects.

Outcome: The curriculum improves the ability of children and adolescents to access valid health information.

Added value: Teaching health literacy as a mandatory subject has the potential to reduce health literacy disparities within schools.

Good practice

Health literacy for caregivers of older persons with different levels of dependency – Italy

Aim and objectives: Nowadays, many older persons with different levels of physical and/or mental challenges are assisted at home. They need help for a considerable part of their daily living, which is usually provided by a family member or by a person employed to do so.  In both cases, the health literacy for the caregiver is of crucial importance in guaranteeing older persons access to appropriate information and care, which includes the administration of medication, preparing and eating food, help with personal hygiene, and support when accessing and navigating the health system (e.g. programming visits with health professionals, physical examinations, etc.).

Many family and paid caregivers do not have the requisite levels of health literacy (cognitive, social abilities) to access, understand, and act upon the information needed to take care of dependent older persons.

Method:

►   measuring caregivers’ health literacy levels in different settings, including at home and in contacts with the health system;

►   assessing caregivers’ health literacy levels in relation to the level of complexity of care needed to assist older persons;

►   targeting training for health care professionals assisting older persons with disabilities, to help them assess the health literacy levels needed for caregivers during different phases of the care pathway for older persons;

►   reviewing the health literacy skills and competencies for caregivers to advise and train them accordingly.

Outcome: Being able to assess the health literacy skills and competencies needed for caregivers helps to decide whether a given caregiver has the capability to take care of older persons with comorbidities and/or a high level of care complexity. This assessment plays a key role in reflecting and reviewing the relationships between healthcare professionals to ensure continuity in the care offered, so that the family remains supported.

Added value: The health literacy for caregivers helps to provide appropriate continuous care - formal, managerial and relational care - for older persons with different levels of dependency.

Good practice

Health literacy for children to promote healthy lifestyles – Romania

Obesity is one of the most serious public health challenges. Obesity, as well as associated diseases, are largely preventable if acted upon from childhood. Preventing childhood obesity is therefore a priority.

Aim and objectives: The “Granny's Health Bag. Healthy traditions for healthy children” initiative was launched in Iasi (Romania) in 2012. It is a community-based program to encourage healthy behaviours via the promotion of cultural traditions, this includes campaigns in kindergartens and schools to encourage healthy behaviours in children and original educational resources based on scientific evidence.

The main learning tool is the “Health Bag”. Children learn about the elements of a healthy lifestyle helped by a magic bag, namely “Granny’s Health Bag”. Illustrated with folk tale characters (the goat, the three kids, the bad wolf, etc.); children learn to recognise what is good and what is bad for their health.

Method:

►   training courses for teachers to teach the 2020-2021 optional course "Granny’s Health Bag";

►   information campaigns - for example, the campaign “Body rhythms: traditions and health”, in which 20,000 children from Iași County participated;

►   workshops for children, parents and teachers;

►   introducing in schools the optional discipline of healthy lifestyle training which, in September 2020, led to the enrolment of 4,000 children aged between 5 and 10 years;

►   development of teaching materials for the training of healthy behaviours in children;

►   the conference "Prevention of childhood obesity", which is organised annually in Iasi, was last held in June 2021, and focused on "Childhood obesity during Covid-19 - the evolution of family habits". The conference took place online and had speakers from 10 countries.

Added value / Outcome:

The initiative targets children from 3-11 years and their families and has benefitted 100,000 children. In 2021, the prevalence of childhood obesity has decreased from 11% to 7% in the city of Iași.

There has been considerable international recognition of the initiative, notably:

►   it is part of the international networks for the prevention of obesity among children – EPODE (Ensemble Prévenons l'Obésité Des Enfants) International Network and Youth Health Community;

►   at the Global Obesity Forum (New York, 2012), it was awarded the first prize for the best childhood obesity prevention activity;

►    it was awarded by the European Community with the first prize – the 2020 EU Health Award- category Healthy Lifestyle Cities for the best initiative at the level of community (Iași city) to promote healthy lifestyles.

Individuals need:

·         information about one’s rights as patients, including available and options for health care, and be able to demand appropriate care;

·         relevant information about one’s health condition;

·         to be able to identify and interpret the symptoms of various diseases;

·         to know when and where to seek help;

·         to be able to think through the consequences of one’s actions on others (e.g., how to seek health care in relation to communicable diseases).

Systems have a responsibility to:

·         promote cultural sensitivity and understanding of care, to use intercultural mediators if needed to adapt health services to the cultural characteristics of migrants and others in similar situations, offering options for various types of care;

·         make available easy access information on various options for care, in all relevant languages;

·         develop coherent and simple health system environments for people to navigate;

·         involve people in developing user- and health literacy friendly systems.

Tools

Health literacy and patient journeys

Aim and objectives: The focus on health literate organisations highlights the need for them to facilitate a coherent and smooth journey for users of the health system. Patient journey mapping (see example below) is a way to visualise and obtain an overview of patient experience during their entire care journey.

Method: A patient journey map (also known as health system customer journey map) is an outline of all the touchpoints a patient goes through in their care journey in a health system facility. This includes all the touchpoints pre-, during, and post-visit.

Outcome: This method provides insights into patient experiences during their care journey in a health system facility and the patient flow in general to create strategies to improve the quality of care, increase efficiency, and improve patient satisfaction.

Added value: Patient journey mapping is an increasingly valuable tool for health organisations and companies of all types and sizes, for many applications. The benefits include highlighting the obstacles patients face in accessing care; define how to deliver a better patient experience during treatment; and identify ways to support patients after treatment ends.

Figure: Example of health system customer journey map

Good practice

Facilitating Syrian refugee access to medical services – Türkiye

Türkiye hosts millions of refugees whose access to health care is hindered by cultural and linguistic barriers. Reinforcing the trust of migrants in health systems and health professionals is a key component in facilitating their access to health systems.

Aim and objectives: The objective of the joint Türkiye, EU and WHO initiative is to familiarise Syrian refugees with the Turkish health care system so that they may practice medicine in Türkiye and provide health services directly to Syrian refugees. In doing so, the initiative fosters the integration of Syrian refugees in Turkish society and empowers them to serve the community. The initiative also helps to alleviate the burden on the Turkish health system.

Target group:  The initiative targets Syrian health care workers who form part of the 3.7 million Syrian migrants displaced in Türkiye. In particular, the initiative is designed for doctors, nurses, midwives and other medical specialists.

Method: Syrian health care workers are identified and undergo theoretical and practical training in one of the seven training centres established across the country (Ankara, Gazantiep, Sanliurfa, Izmir and Mersin), under the supervision of Turkish medical professionals.  There, they undertake an adaptation course designed by the WHO country office in Türkiye. During the Covid-19 pandemic, training was dispensed digitally through a specifically developed distance learning platform. The course contents include modules on mental health, non-communicable diseases, early childhood development, psychosocial support training in disasters, medical record systems, and occupational health and safety. The centres also train translators to serve as cultural mediators in medical facilities. Eventually, Syrian health professionals receive authorisation to work in the Turkish health system.

Outcome:  Thousands of health professionals have undergone the program since it began. Teaching materials have been developed as part of the program that have also been used to train Turkish professionals on mental health.

Added value: The employment of Syrian health professionals in Türkiye is instrumental in suppressing language and cultural barriers in access to health care. Their empowerment and integration in Türkiye provide an occupational opportunity for refugees and a chance to gain additional knowledge. This improved the cultural sensitivity of the health system and has helped to build resilience at the local level. More generally, it has improved the health literacy of Syrian refugees.

Good practice

MILSA: A Support Platform for Migration and Health – Sweden

Aim and objectives: Receiving information about the society in which you are living in and gaining knowledge of how to take care of your health is a key component for successful integration in society. This is the guiding principle for civic and health communicators working all over Sweden.

MILSA is a knowledge-based support platform for migration and health which is devoted to producing and supporting methodological development conducive to a health-promoting and inclusive reception of newly arrived migrants in Swedish society. 

The MILSA educational platform is a national initiative for civic and health communicators with a focus on education, exchange of experiences and networking. The project is supported by the European Social Fund and the Ministry of Health and Social Affairs of Sweden. The project collaborates with universities and experts in various fields, county administrative boards, regions, municipalities, and civil society organisations at both national and international levels.

The research within MILSA is oriented towards the integration system and needs of newly arrived migrants, and it is carried out by way of broad collaboration between different universities and multi-level agencies that work with newly arrived migrants. The work is based on a broad approach to health, including themes such as societal participation and empowerment, mental health and well-being, housing issues, economic stress, confidence, and trust. 

Target group: Approximately 200 communicators provide civic orientation and health communication in different languages throughout the country. MILSA’s educational programme covers 22 essential topics concerning different aspects of life and takes approximately 18 months to complete.

Teachers from several universities, together with experts, have been responsible for shaping the content of the education which is carried out mostly at a distance, supplemented with practical training sessions and physical meetings.

Method: In addition to providing a unified education for civic and health communicators, MILSA is producing textbooks on civic and health communication and a manual of methods for communicators. The textbooks are based on the national civic orientation regulation and aim at providing a deeper understanding of the subject areas. The manual of methods is to provide practical hands-on support for the communicators in the classrooms. For example, it deals with how to create a safe environment in the classroom, how to ensure that the participants receive and understand the information that is communicated, how to approach and discuss sensitive topics and what are the limitations of the communicator´s role.

Outcome: The MILSA educational platform creates a framework for networking, collaboration and exchange of experiences between communicators and other professionals working on migration, health and integration.

Added value: The work in the MILSA educational platform is built on civic orientation of unique potential for newly arrived migrants and opportunities for integration, employment and health.

Good practice

Health care professionals working in nursing homes – Italy

Aim and objectives: Health care professionals working in nursing homes, in direct contact with fragile and dependent older persons, are essential for access to appropriate care for those with comorbidities and insufficient family support. Staff working in these settings have specific roles and responsibilities in guaranteeing the best quality of life for these older persons. Measuring the health literacy skills and competencies of these health care professionals is a necessary first step in understanding how and when to build targeted health literacy programs for them.

Method:

►   by promoting the concept of health literacy in nursing homes;

►   by promoting also specific efforts and programs devoted to the development of the health literacy of health professionals in nursing homes;

►   by involving the directors and personnel of nursing homes in health literacy programs;

►   by developing an ‘organisational health literacy’ approach within nursing homes.

Outcome: Nursing homes - via the education of their directors and staff - adopt an ‘organisational health literacy’ approach as a principle of management, aimed at guaranteeing the best access to appropriate care for older persons, especially those who are fragile and dependent.

As a secondary objective, the development of health literacy skills for these health care professionals also helps them at home with their own families.

Added value: The health literacy skills and competencies of staff and professionals in nursing homes, in the framework of an ‘organisational health literacy’ approach, supports the right care pathways for older persons in institutionalised settings. This provides health care professionals with an opportunity to apply health literacy skills and competencies in their everyday working lives.

Good practice

Literacy Audit for Healthcare Settings – Ireland

Aim and objectives: This audit, prepared by the National Adult Literacy Agency, seeks to make the Irish health service literacy friendly where both the skills of individuals and the literacy demands of the health service are analysed. It envisions a health service where literacy is not a barrier to treatment. It works to support the health service in every context: promotion, protection, prevention, access to care and maintenance.

Target group: The responsibility for making health activities less burdensome and services more accessible rests with those providing the services. Organisations have a responsibility to make their environment easy to access and navigate. While literacy skills are often viewed as the responsibility of the individual, it is important to examine the skills of health professionals as well.

Method: The health literacy audit promotes an understanding of how literacy friendly a health setting is. This audit helps to identify possible barriers for adults with literacy difficulties. Healthcare workers need a way to measure how literacy friendly their writing material, websites and general communication are to the public. The audit is designed to help analyse and record how patients and service users might encounter difficulties in accessing health services and in understanding health and administrative messages, and pinpoint areas that can be improved.

Outcome: Each organisation can devise its own specific literacy plan based on the results of the audit. The summary sheet is helpful as a record of what work is needed.

Added value: The audit tool helps to inform and qualify the work of health service organisations to become health literacy friendly. The approach can be tailored to suit local needs.

Individuals need:

·         to be informed that they have the right to communication, in a manner that is appropriate to one’s capacity for understanding;

·         knowledge about their health condition and relevant concepts to be able to understand what health professionals are saying, and what is communicated in printed materials;

·         an ability to communicate clearly (also on online) and to seek clarifications;

·         an ability to assess the appropriateness of care and the applicability of instructions from a personal perspective, to apply the instructions and decisions in practice, in daily life.

Systems have the responsibility to:

·         adapt transparent and open ways of communicating, also on uncertainties related to health risks;

·         create spaces for communication that consider the special communication needs and cultural background of patients, providing professional translators or consider using cultural mediators if needed;

·         develop the availability of digital eHealth sites and services for people with different communication needs, and to complement face-to-face appointments;

·         avoid medical jargon and difficult words (shared language) in their communications;

·         offer training for health professionals about various ways of communicating with patients with or without complex communication needs and their caregivers, and to communicate in digital environments in a way that supports shared decision-making.

Good practice

Informing patients diagnosed with an illness (Cancer Plan) – France

Aim and objectives: The system to inform patients diagnosed with an illness was a measure introduced in the early 2000s, as part of the first cancer plan. The aim of this system (which responds to a request made by patients in the context of general meetings with them) is to provide patients (and their families) with better conditions when being informed of the diagnosis of their disease and the proposed treatment. This system encourages adherence to the proposed treatment and the strategies for adapting to the disease. It is based on the provision of clear and appropriate information that respects patients and their wishes, leading to real support.

Target group: All cancer patients are targeted by the system, starting from the initial diagnosis of a histologically confirmed cancer to relapse of the disease.

Method: The system is centred on the hospital and is composed of four phases:

►   informing a patient of the diagnosis and proposed treatment of an illness;

►   accompanying the patient, identify his/her needs;

►   referral/access to support care (notably in the event of preserving fertility);

►   coordination between the town of residence and the hospital.

Various documents are provided to the patient to help him/her navigate the health system, such as the possibilities for personalised care and its pathway, which sets out the stages of treatment, the corresponding timetable, and information on supportive care as well as a list of useful contacts.

The system is based on multidisciplinary care, primarily involving doctors and paramedical staff. The National Cancer Institute has published recommendations and guidelines to help health establishments and professionals set up the system. The professionals concerned (both hospital and private practitioners) receive ad hoc continuing education.

The system has evolved with successive cancer plans, taking into account the diversification of care (increasing the role of so-called "town" medicine) and the situations of certain groups, such as children and people with intellectual disabilities.

Outcome: The system to inform patients diagnosed with an illness is implemented in all health establishments authorised to provide cancer treatment. Its organisation is described in the National Cancer Institute's guidelines and is identical throughout the country. The implementation of the system is one of the transversal quality conditions that all establishments concerned with cancer treatment must apply.

Added value: The added value of the system lies in the provision of clear and appropriate information that respects patients and their wishes, leading to real multidisciplinary support. The fact that it has been developed throughout the country, in accordance with a reference system, is a major asset.

Good practice

Improving literacy in the use of prescription medication – Türkiye

The establishment of the “Unit of Patient Education for Medicine Use” is an example of a local health literacy project in Şanlıurfa Training and Research Hospital, which is located in the province of Ş.Urfa in the southeastern Anatolian region of Türkiye.

Aim and objectives: To ensure correct drug use and effective treatment results for hospital in-patients who are prescribed medication.

Target group: All patients, including children (and their parents) undergoing treatment.

Method: After being examined, a physician may prescribe medication which must be followed by the patient. Patients are therefore directed to the “Unit of Patient Education for Medicine Use” where nurses work under the supervision of a pharmacist. The Unit, which is located in the centre of the hospital for easy access, teaches patients how to use their medicines. Patients with chronic illnesses are incentivised to visit the Unit because they may be issued with a ‘medication report’ by a specialist physician which allows for medicines to be prescribed by a family doctor, thereby helping to reduce the number of hospital visits.

Outcome:

►   improved patient health outcomes;

►   reduced possible side effects due to incorrect drug use;

►   reduced emergency service admissions, hospitalisations and repeated applications.

Added value: The correct use of medication reduces health costs and improves patient outcomes.

Good practice

Professional interpreting in health for liberal doctors (all specialties) and liberal midwives in the North-East territory - France

Aim and objectives: the lack of knowledge of the French language by patients during medical consultations is an obstacle to quality care. Promoting understanding during exchanges between health professionals and patients thus allows:

►   improving access to prevention, screening and medical care;

►   the reduction of irrelevant, unnecessary and costly examinations;

►   the reinforcement of the person's autonomy and the respect of his or her rights (information, confidentiality, free and informed consent).

The aim is therefore to give health professionals the opportunity to use health interpreting services.

Target group: All non-native speakers in the North-East region are concerned, as well as all private doctors and midwives who may be consulted by them.

Method: Private practitioners and midwives in the North-East region can request telephone (and/or face-to-face) interpreting services from a service provider chosen and financed by the Agence Régionale de Santé via a call for tenders. To do so, they must first register for the scheme, which offers 185 languages. Professionals are provided with a user guide, which invites them to prepare consultations in advance and in writing, in order to optimise the interpreter's contribution. This interpreting service is free of charge for both the professional and the patient. Interpreters are bound by professional secrecy.

Outcome: An interpreter who speaks the patient's language is available within 5 minutes of the request by the health professional, even without a scheduled appointment.

Added value: As mentioned above, access to professional health interpreting helps to promote quality access to care for non-native speakers and thus their integration into the health system. Telephone interpreting also helps to reduce territorial disparities in access to this service.

Tools

“Communicate For All: a guide to accessible communication” – France

Aim and objectives: “Communicate for all: a guide to accessible communication” is a guide developed by a French health agency (Santé Publique France) based on the concept of literacy.

Target group: The guide is intended for all actors involved in designing and sharing information accessible to all, regardless of their audiences and literacy skills: general population, migrants, people in illiteracy situations, older persons, people with disabilities. This reference framework has, among other actors, been designated for health and medico-social facilities and services, to help these organisations become pro-literacy organisations. It is of relevance to health professionals and health promotion professionals.

Method: This guide is a very practical tool, illustrated with many examples, as an aid to conceive written, oral, digital, pictorial communication, whatever the patient’s level of health literacy. The guide also identifies pitfalls to avoid and share good practices.

Outcome: The guide meets the needs of actors, depending on whether they want to design printed documents, design and/or use images, design web sites or other digital media, design oral communication. It also proposes ways to better consider differences in literacy skills within an organisation.

Added value: The guide has been designed in such a way that the actors who consult it are guided, accompanied step by step in the design of their communication, with the ultimate objective of being understood by all.

Tools

Health Literacy Tool Shed – United States

Aim and objectives: The Health Literacy Tool Shed is hosted by Boston University. It is an online database of more than 200 health literacy measures. The site contains information about measures, including their psychometric properties, based on a review of peer-reviewed literature.

Target group: It is a database for researchers, decision-makers, and health providers. It helps them identify the most relevant measurements to use in health literacy research, needs assessments, evaluations, etc.

Method: It is an open-source database, freely available to all users.

Outcome: It enhances the opportunities for choosing the most relevant tool for a certain research purpose.

Added value: The Health Literacy Tool Shed makes it possible to gain access to cutting-edge measurement tools. Previously, the review of such tools was published in scientific journals. The Health Literacy Tool Shed democratised accessibility to these measurements and accelerated the speed of knowledge-sharing and use of appropriate measurement tools.

Tools

Ask me 3: Good Questions for Your Good Health® – United States

Aim and objectives: Ask Me 3® is an educational program developed by the Institute for Healthcare Improvement that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.

Target group: Designed by health literacy experts, Ask Me 3® is a quick, effective tool designed to improve health communications between patients, families, and health providers and help patients become more active members of their health care team.

Method: Ask Me 3® promotes three simple but essential questions that patients should ask their providers in every health care interaction and providers should always encourage their patients to understand the answers to:

►   what is my main problem?

►   what do I need to do?

►   why is it important for me to do this?

Outcome: Ask Me 3® is simple to use, inexpensive to implement and facilitates simple communication.

Added value: Active participation empowers patients and makes the conversation easier for the health provider. Questions prompted by patients give health providers clues to the level of understanding, acceptance, and insight of the condition which in turn may guide the health professional to deliver timely and appropriate information.

Tools

Quick Start Guide to Teach-Back – United States

Aim and objectives: Teach-Back is an activity in which learners teach each other what they have learned, for instance, by using verbal explanations, demonstrations, and skits.

Target group: According to the US Agency for Healthcare Research and Quality, Teach-back is a technique for health care providers to ensure that they have explained medical information clearly so that patients and their families understand what is communicated to them. This intervention includes several materials to support adoption.

Method: The method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health and to confirm that things have been explained in a manner that patients understand. Teach-back can be applied whenever explaining important and complex concepts to patients about their health care, such as a new diagnosis, medication, home care instructions, treatment plans, behavioural change recommendations, the use of new devices, treatment options and follow-up instructions.

Outcome: The resources needed for Teach-back are modest. Health providers can implement Teach-back as part of their regular duties. The time of implementation using this practice is minimal in the short run and can save much time in the long run.

Added value: Using Teach-back systematically will help remove barriers and challenges to improve communication and processes.

Tools

Toolkit for Making Written Material Clear and Effective – United States

Aim and objectives: Most text-based health information continues to be too hard for most adults to read. While plain language is only one of many broad-based solutions needed to address limited health literacy, the benefits to everyone call for increased use by health organisations.

Target group: Given that clinical research communications can be very technical and complex, using plain language can help clearly explain information so that the target audience has a better chance of understanding. The target group can be patients, caregivers, other actors in the health eco-system involved in solving health challenges.

Method: Plain language helps the reader to:

►   find what they need;

►   understand what they find;

►   use what they find to meet their needs.

Outcome: Applying plain-language principles facilitates relevant health information for the audience, keeping it simple, making sure its readable, and making it timely and actionable.

Added value: Plain language supports access to information, equity, and participation in society. It also improves efficiency and builds brand trust.

Tools

Mapping linguistic landscapes

Aim and objectives: Mapping linguistic landscapes is used to gain insights in how people navigate health systems and to improve health system environments.

Target group: It is a tool for health providers, managers, and decision-makers to enhance service design and user journeys.

Method: Using linguistic landscape analysis as a diagnostic, relevant questions may include:

►   how many and what languages occur on signs in a specific public space?

►   are the signs monolingual, bilingual, multilingual and in what ways, i.e. what combinations of languages occur?

►   are different languages used for different contents and in different domains?

►   in what forms do signs occur (notice boards, traffic signs, billboards, shop windows, posters, flags, banners, graffiti, menus, T-shirts, Facebook, Twitter, Instagram, Blogs, Websites)?

►     what about the language in terms of normativity: orthography, handwriting conventions, lexicon, syntax, literacy level?

A next step would include a more in-depth analysis and interpretation of the signs. Looking at deeper layers of meaning connected to the signs that can explain what they refer to in addition to their referential meaning is also called the indexicality. Examples include to study the past (e.g., the conditions of production), the future (e.g., the conditions for uptake), and the present (e.g., at the specific placement of the sign among other signs).

Tools

Open-Source tools for Data Visualisation

Aim and objectives: Data visualisation, such as the use of infographics and graphs, has become a meaningful way to present medical data that impacts decision-making on a collective and individual level to enhance health literacy.

Target group: Applying visual elements and plain language help bring an individual with limited health literacy and numeracy skills to an outcome that equates to better health behaviours and practices.

Method: Data visualisation involves breaking down the data points in terms of time, place, and elements of which people are familiar with, or personalising/localising numbers to make them more digestible and meaningful. Data dashboards may be effective visualisation tools for tracking and visualising data from multiple sources (e.g., tables, pie charts and stacked bar charts, line graphs and area graphs, histograms, scatter plots, heat maps and tree maps). It might also be combined with infographics, including icons and minor text to show a visual narrative.

Outcome: Storytelling with data through simple graphs, comparative charts and representational icons often helps to make the implicit explicit to enhance individual and population health.

Added value: Data visualisation can improve understanding and analyses, as well as enabling better and faster decision making.

Individuals need:

·         relevant information about their health conditions and available options for care;

·         information about their right to be heard and to participate in making decisions that influence their health and health care;

·         to identify and describe their expectations, preferences, wishes and needs;

·         to reflect on information from their personal perspective and to assess what fits with their own lives (opportunities, preferences);

·         to ask for clarifications when necessary;

·         to participate in making care plans, to discuss alternative options and to make joint decisions.

Systems have the responsibility to:

·         provide sufficient amounts of information for patients, in needed formats;

·         facilitate patient’s reflective thinking and question-making;

·         value patients (their knowledge, experiences etc.);

·         distribute power, creating mutual understanding and trust, respect patients’ views, expectations and values, by using, if needed, intercultural health mediators;

·         be aware of patient diversity and their unique needs.

Good practice

Integration of patients’ and health care professionals’ different domains of knowledge for shared decision making in treatment discussion – Finland

Aim and objectives: Integrating the knowledge pools of professionals’ medical knowledge and patients’ experiential knowledge when negotiating treatment in health care encounters.

The domains of knowledge or “knowledge pools” into which patients and health care professionals are entitled to have access to are asymmetric: professionals have access to medical information, whereas patients have access to information concerning their own experiences and life world, such as their symptoms, their preferences and values.

Target group: Health care professionals.

Method:

►   inquiring about the patient’s perspective, such as expectations concerning treatment and its integration in the treatment suggestion;

►   presenting options rather than just one possible alternative;

►   if needed, recommending a specific option by drawing upon the patient’s disclosed perspective and explaining why this option is recommended.

Outcome: Patients can match the suggested treatment to their possible expected treatment solutions and to understand the grounds for treatment recommendation.

Added value: Expected improvements in patient experience of possibilities to influence their own treatment and better adherence to treatment.

Good practice

Shared decision-making tools and guidelines – UK

Aim and objectives: Shared decision-making is a joint process in which a healthcare professional works together with a person to reach a decision about care. It involves choosing tests and treatments based both on evidence and on the person's individual preferences, beliefs and values.

Target group: The key audiences for decision aids of the National Institute for Care and Excellence (NICE) are people facing those decisions (and their carers, guardians and relatives as appropriate) and the practitioners involved in their care. Secondary audiences are organisations commissioning or providing care (which may include decision aids in policies and pathways), and voluntary and community sector organisations (which may promote them to the people with whom they work).

Method: Preference-sensitive decision points are points where the person’s values and preferences are particularly important. They occur when either:

►   There are two or more options for investigation, treatment or care that deliver similar outcomes but:

-       they have different types of harms and benefits which people may value differently, or

-       the likelihood of the harms or benefits may differ, or

-       the practicalities of the options are different (for example, the choice is between medicine and surgery, or the requirements for monitoring differ), or

-       people may consider the overall risks of harms for any of the options outweigh the overall benefits compared with no treatment.

or

►   The choice between an investigation, treatment or care option and the option of 'no treatment' is finely balanced.

The NICE decision aids are developed for various treatments and care options which helps to:

►   summarise the best available evidence relating to the effectiveness, safety and practical factors relating to the treatment or care options, and

►   present that information in a way that is easy for people facing the decision (and their carers, as appropriate) to understand, with support from their health or care practitioner, so that they can weigh up the options pros, cons and trade-offs.

Outcome: Decision-making aids allow people to discuss and share information. This makes sure people have a good understanding of the benefits, harms and possible outcomes of different options. Shared decision-making empowers people to make decisions about the treatment and care that is right for them at that time, including choosing to continue with their current treatment or choosing no treatment at all.

Added value: Shared decision-making tools allow people the opportunity to choose to what degree they want to engage in decision making. Although, at times, some people prefer not to take an active role in making decisions with their healthcare professionals.

Tools

Health Literacy Pathway Model – United States

Aim and objectives: The Health Literacy Pathway Model describes how health literacy develops along a trajectory that enables individuals supported by others, to seek, engage with and act on health information to manage their health and become actively involved in health system consultations and informed decision-making.

Target group: Patients with a long-term condition can develop health literacy skills over time and put their skills into practice in becoming more active in health system consultations.

Method: The method entails development of knowledge, health literacy skills and practices, health literacy actions, abilities in seeking options and informed and shared decision-making opportunities.

Outcome: Applying the health literacy pathway in practice, helps to identify the motivations and barriers to developing and practising health literacy skills while also taking into account the characteristics of the individuals as well as the health professionals.

Added value: Developing the health literacy pathway supports people to become more involved in health system processes, including informed and shared decision-making.

Figure : The supported health literacy pathway[12].

Covid-19

In Europe, before the Covid-19 pandemic, nearly 40 % of people lacked the basic digital skills needed to access digital spaces and services[14]. Such a divide increases vulnerability in reaching timely and appropriate health care. It also increases exposure to various unfavourable health indicators, such as depression and loneliness. During the Covid-19 pandemic, this vulnerability increased, especially among older persons, resulting in inequities in vaccine access across countries.

The Covid-19 pandemic demonstrated the importance of being able to access digital platforms on an equal basis. Digital technologies, such as mobile phones, made it possible to organise rapid contact tracing, symptom checking, advice seeking and receiving online health care (e.g., tele-medicine, online prescriptions), and to advance public communication and education. With billions of people in self-isolation, digital environments enabled access to valid and updated information, including self-care guidelines and health-care services. They provided a vital means for people to connect with each other while minimising their exposure to infectious disease.

Digital access for older persons

During the Covid-19 pandemic, many older adults used traditional media, such as television and newspapers, as sources of information about the virus and protective measures. These were accessible to nearly everyone, whereas electronic information was accessible to less than half. It is important to secure access to appropriate offline information along with the access to online information.

Those with limited levels of education, who live alone or lack social support or have impaired cognitive functioning are often more challenged when accessing digital spaces. Significantly older persons (i.e. persons over the age of 85) are less likely to use digital devices and to access digital information.

Mediation for Roma - Latvia

The Covid-19 pandemic significantly increased the challenges facing Roma parents and children alike, and communication and dialogue between Roma families and municipality institutions.

In March 2020, the Ministry of Culture updated its Guidelines for Roma mediators to provide Roma mediation services at the municipal level. The Guidelines include the provision of regular information to Roma families on prevention measures regarding the Covid-19 virus. In February 2021, additional financial support for Roma mediation services was provided to cope with the constraints and precautionary measures related to the Covid-19 pandemic.

Access to online learning for Roma children - Greece

Following a ministerial decision to suspend all school services during periods of lockdown, it was decided to support Roma students attending primary and secondary education. In cooperation with the Ministry of Education and Religious Affairs, equal access and distance learning for Roma students was ensured by offering them a 200 euros voucher to purchase equipment (tablet, laptop, desktop). Τhe voucher was awarded based on low family income (up to 6,000 euros) and social criteria which resulted in support given to 325,000 families with 560,000 dependent children and young people aged 4 to 24 years.

Individuals need:

·         general digital skills to use devices and applications;

·         knowledge on available digital health system services (sites and applications), and relevant health concepts, to find appropriate information in (online medical) records;

·         skills to find, navigate and use relevant digital health system sites and services;

·         skills to interpret and critically appraise the results of various health apps;

·         (online) communication skills with health personnel in eHealth.

Systems have the responsibility to:

·         develop secure easily accessible internet access for all people (incl. homeless people, etc.);

·         offer support to use information technologies;

·         develop digital health communications and health system services (sites and applications) that are easy to use and adaptable for individuals with different needs;

·         develop health system providers competencies in using online health services;

·         develop health system providers’ competencies that are sensitive to the different needs of individuals who are using digital technologies and services, for example digital health service-related mediators who help communities as well as people in vulnerable situations.

Good practice

eHealth portal – Denmark

Aim and objectives: There is an urgent need to break down industry silos and increase collaboration to drive progress towards a patient-centric and cost-effective model. Denmark has been at the forefront of many IT initiatives within health services. The majority of these initiatives are based on a common infrastructure. The Danish National eHealth Portal, known as sundhed.dk ("sundhed" means "health") helps to promote the optimisation of the Danish healthcare sector. 

Target group: Sundhed.dk is a public, Internet-based portal that collects and distributes healthcare information among citizens and healthcare professionals.

All Danish citizens have access to Sundhed.dk, enabling patients to communicate, and patients and their families to get an overview of correct and updated healthcare information, making the services appear close-by, open and familiar. Every citizen has his/her own personal page (available upon identification), which reflects the specific situation of this particular person.

Method: Sundhed.dk is a partnership established between all public health authorities in Denmark. The platform builds on a role-based and personalised, customizable portal environment. The portal provides information to a large range of user groups: physicians, GPs, pharmacists, dentists, chronically sick, frequent users, occasional users, etc. Every user group has its own special requirements with regard to the information it needs and how it is presented. To handle all these user groups, almost 100 different applications are needed and updated every three months. 

Outcome: Sundhed.dk has transformed the Danish health service from consisting of information islands of independent, individual solutions and databases, each with its own limited group of users, into a structure that is based on the joint use of standard solutions and sharing of data. In helping every user who logs on to the portal via personal identification, the portal has been built in such a way that it adapts the presentation to its user needs, integrating the several channels of technological information into one. 

Added value: The portals range of information and services has proved that it is possible to work across sector borders and specialist fields to present the user with a single point of entry that provides a general view and guides the user to the relevant information and the relevant services. Thus, Sundhed.dk integrates systems that are specific to the Danish health service but other regional or national health services, or completely different sectors or industries, will be able to obtain similar benefits by making use of the experience gained from sundhed.dk of building transparency and sharing information and systems.

Good practice

My Health Space: making patients real players in the management of their health data – France

Aim and objectives: The aim is to make a single digital portal available to all persons affiliated to the social security system. The portal is fed input directly by health professionals thanks to a system of interoperability with the software they use. My Health Space enables users to better monitor and manage their health. The overall objective is to improve medical care by centralising documents (avoiding loss and omission), improving coordination between health professionals (authorised to access patients' care history), and raising digital awareness among all users (via an ad hoc support system).

Target group: My Health Space is aimed at all people affiliated to the social security system, and all they need is a carte vitale to benefit from it. This represents a target of more than 60 million users, for whom the creation of an account is automatic, with the possibility of opposition left to the user.

Method: My Health Space is the result of a dialogue between the Ministry of Health, the Assurance Maladie, health professionals, software publishers, patient associations and users of the health system.

My Health Space is built around four main components: 1) a shared medical file supplied by healthcare professionals and the patient; 2) a secure messaging system for confidential exchanges with healthcare professionals; 3) a diary listing medical appointments; and 4) a catalogue of services referencing several applications. Access to the documents contained in My Health Space is entirely at the patient's discretion, and the patient can choose to hide a document or "block" a health professional, if necessary.

Following the roll out of My Health Space in February 2022, a support strategy for all users has been put in place, with a focus on those who are furthest from the digital environment (awareness-raising and training of digital mediation players, funding of posts dedicated to the digital mediation strategy in the regions).

Numerous partnerships have been formed with associations and companies, and training has been provided to all administrative assistance offices.

Outcome: The deployment of My Health Space is progressive. All French people have been notified of the creation of their account with a six-week withdrawal period. The automatic creations will be completed in July 2022. My Health Space is already used by many French people, and the software used by health professionals is currently being made compatible with their product by sector (pharmacies, medical laboratories, radiology, etc.).

Added value: My Health Space is a unique tool, used by all the players in the healthcare chain but which remains in the hands of the patient. It has been co-constructed with citizens (setting up of a citizen committee), health professionals, software publishers and users of the health system, who also benefit from support in learning how to use it. This is the first time that a State digital product has been proposed in conjunction with a digital inclusion strategy. Finally, the tool meets high ethical and legal requirements.

Good practice

Digital health system – Estonia

Aim and objectives: Estonia’s health service has been digital for 12 years. More than 99% of the data generated by hospitals and doctors is digitised.

Target group: Citizens can access their own medical records via a super-secure online portal and choose who gets to look at those records.

Method: Many health services happen online — from video consultations to e-prescriptions. Services are intersectoral, also including notifications of death. For example, once a death is registered online, notifications are automatically sent to that person’s workplace, the tax office, and the population registry.

Outcome: The system is highly transparent and health professionals can communicate easily with patients. Moreover, patients are empowered to ‘lock’ and ‘unlock’ their own data thereby deciding who has access to their data. Moreover, being highly people-centred, citizens are also involved in key decisions about the system.

Added value: Trustworthiness is built into the system’s design. Every time someone accesses a patient’s information, it is logged. No one can check the medical records just for curiosity. The system is designed to integrate citizen science to inform and qualify digital services.

Tools

European Ethical Principles For Digital Health – European Union

In January 2022, the European Union set out a framework for digital health. Approved by the eHealth Network, composed of EU Member State representatives responsible for digital health, and proposed by the French Presidency of the Council of the European Union, 16 European principles for ethics in digital health were established to improve mutual understanding and to facilitate discussions on the future European regulation on the European health data space. They directly address the EU citizen and incorporate four ethical dimensions: “placing digital health within a framework of humanist values”, “enabling people to manage their own health data digitally”, “developing inclusive digital health”, and “implementing eco-friendly digital health”.

Base Digital Health on humanistic values

1.         Digital Health complements and optimises face-to-face healthcare

2.         Individuals are informed about the benefits and limits of Digital Health

3.         Individuals are informed about the functioning of Digital Health services and can easily customise interactions with them

4.         When artificial intelligence is used, all reasonable efforts are made to make it explainable and without discriminatory bias

Enable individuals to manage their Digital Health and data

5.         Individuals are actively involved in shaping the European and national frameworks of Digital Health and data

6.         Individuals can easily and reliably retrieve their health data in a commonly used format

7.         Individuals can easily get information on how their health data have been or may be accessed and for which purpose

8.         Individuals can easily and reliably grant access to their health data and exercise their rights, including objection when applicable

Make Digital Health inclusive

9.         Digital Health services are accessible by all, including by people with disabilities or low levels of literacy

10.      Digital Health services are intuitive and easy to use

11.      Individuals have access to Digital Health training

12.      Digital Health services include support through human communication when needed

Implement eco-responsible Digital Health

13.      Environmental impacts of Digital Health are identified and measured

14.      Digital Health services are developed in compliance with eco-design best practices

15.      Re-use and recycling of Digital Health equipment is ensured

16.           Digital Health stakeholders are committed to reducing their ecological footprint

Good practice

Health literacy as a national health goal – Austria

Aim and objectives: 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.

Good practice

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.

Good practice

Improving health literacy – Portugal

Aim and objectives: 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.

Good practice

Health literacy Action Plan 2022-2026 – Türkiye

Aim: 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;

►    reducing health expenditures.

Good practice

Making it Easier. Health Literacy Action Plan – UK (Scotland)

Aim and objectives: “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.

Good practice

National Action Plan on Health Literacy – Germany

Aim and objectives: 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.

Tools

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.

Outcome: 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.

                     Tools

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.

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.

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

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.

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.

Portuguese Health Literacy Society was inaugurated in 2022. It seeks to develop and influence the impact of health literacy in Portugal and beyond.

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.

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.

Tools

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.

Tools

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 is 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 Organisation self-assessment tool focuses on nine standards and 22 sub-standards.

Outcome: 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.

Tools

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.

Outcome: Improving health literacy outcomes and responsiveness locally.

Tools

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-based 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.

Good practice

Health Literacy Handbook – Australia

Aim and objectives: Key health service quality frameworks, including the National Quality and Safety Health Service Standards (NQSHS) 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.

Outcome: 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.