Collection

Health Literacy e-collection

Editorial

Marieke Verschuuren¹, Orkan Okan^2,3

^{1 Secretary of the EUPHA Executive Council; 2 Faculty of Educational Science, Bielefeld University; 3 Vice-president of the EUPHA section on Health Promotion}

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Conveying accurate and accessible messages is crucial to promote healthy behaviours, particularly during a crisis such as the COVID-19 pandemic. Therefore, communicating science and health was chosen as one of the themes of the European Public Health Week (EUPHW) 2021¹. One of the related subthemes for the EUPHW is health literacy. Health literacy is linked to literacy and entails people's knowledge, motivation, and competencies to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life². It is an important social determinant of health because it is modifiable on personal and organizational levels, and therefore it is critical to empowerment and overcoming health inequalities³.

Health literacy increasingly is being recognised as an important concept for public health, as illustrated by the fact that the World Health Organization has included health literacy as one of three pillars in the Shanghai Declaration on promoting health in the Sustainable Development Goals (SDGs)⁴. 19 out of 53 WHO Member States in the European Region (36%) have or are developing health literacy policies at national and regional levels⁵; and several large international health literacy studies have recently taken place or are taking place, such as the study coordinated by the M-POHL Action Network on Measuring Population and Organizational Health Literacy⁶, and the study coordinated by the COVID-HL Network on measuring health literacy and digital health literacy in different populations and settings during the COVID-19 pandemic⁷.

The COVID-19 pandemic has underlined the importance of being able to access, understand, critically think and act upon public health information⁸. Self-determination relies upon information, and the COVID-19 related infodemic has complicated people’s abilities to make informed decisions about their health⁹. An infodemic (short for ‘information epidemic’) is characterized by an overabundance of information, including accurate and false information, in digital and physical environments during a disease outbreak¹⁰.

A health-literate society is key to managing infectious disease outbreaks like the COVID-19 pandemic. This e-collection from the European Journal of Public Health provides a timely overview of the evidence base that has been compiled in the journal over the past few years. The e-collection addresses various issues related to health literacy:

levels of health literacy in the population and instruments that can be used to assess these within and across countries;
the relation between health literacy and health status;
the relation between health literacy and healthcare utilization; and
how health literacy interacts with other social determinants of health.

Measuring health literacy levels in the population

Substantial proportions of the population have limited health literacy. An international health literacy survey, which was carried out in eight European countries in 2011, showed that at least 1 in 10 (12%) respondents showed insufficient health literacy and almost 1 in 2 (47%) had limited (insufficient or problematic) health literacy. However, the distribution of levels of limited health literacy differed substantially across countries (29–62%) (Sørensen et al 2015). In South-Eastern European countries, health literacy is an under-explored topic. Toçi et al in Albania therefore assessed the concurrent validity of the European Health Literacy Survey Questionnaire (HLS-EU-Q) and the Test of Functional Health Literacy in Adults (TOFHLA) in a population-based sample of adults, to validate these instruments for the Albanian context. Both instruments exhibited good internal consistency and stability over time as measured by the test–retest procedure. The HLS-EU-Q and TOFHLA instruments therefore could be used in future large-scale studies to explore the concept of health literacy and its correlates in Albania (Toçi et al 2015).

International comparisons of health literacy are challenging and require robust measurement instruments. Paakkari et al examined the cross-national measurement invariance of the instrument Health Literacy for School-aged Children (HLSAC) in four European countries. The attribute of measurement invariance indicates that the instrument performs similarly in different groups or populations. The outcomes indicated that health literacy mean values assessed via the HLSAC instrument can be compared across countries. There were significant mean value differences between countries and age groups (O Paakkari et al 2019). The two international studies described above only include a limited number of countries, and national health literacy levels are known for only some European countries. To overcome this gap, van der Heide et al examined to what extent national health literacy levels can be estimated based on publicly available census data (education, age, working status, gender, income). It was found that prediction models based on such census data can be used for estimating self-assessed and performance-based health literacy on the population level. However, observed health literacy levels or better prediction models are required when one is interested in ranking European countries (van der Heide et al 2016).

Health literacy and health status

The current evidence base indicates that health literacy is an important determinant of health with lower levels of health literacy being associated with poorer health status. In line with this, Paakkari et al found that higher health literacy levels were related to positive health outcomes among 13–15-year-old adolescents in Finland. The study showed that health literacy acts as a mediator between health behaviours and several structural stratifiers (school achievement, educational aspiration, family affluence, and age). The mediating role was clearest in relation to the school-related aspects, meaning that low health literacy places adolescents who have poor school achievement and who do not intend to continue on an academic path are in an unequal position with respect to their health (L Paakkari et al 2019).

Miranda et al found that health literacy is associated with hypertension prevalence in selected ethnic groups in the Netherlands. Dutch and African Surinamese with low health literacy were more likely than those with adequate health literacy to have hypertension, whereas in South-Asian Surinamese this association was not significant. However, no significant associations were found between health literacy and hypertension awareness, treatment and control in any of the ethnic groups. This implies that further research is needed to explore other factors and pathways through which health literacy may impact hypertension outcomes in different ethnic groups (Miranda et al 2019).

Aaby et al explored health literacy challenges of people with long-term illness or multimorbidity in Denmark. They found that having a long-term illness or multimorbidity increased the likelihood of experiencing specific health literacy challenges such as active self-management. Using cluster analysis methods, the authors identified socio-demographic and health characteristics related to profiles of health literacy strengths and weaknesses, showing a strong tendency towards poor health indicators in clusters with poor health literacy profiles. This is concerning since people with poor health have relatively greater need for health literacy competencies (Aaby et al 2020).

In Ireland, Gibney and Doyle looked at the relationship between health literacy and another important determinant of health, namely exercise frequency. They found that an increased odds of exercising almost daily was associated with understanding disease prevention and health promotion information and with accessing and evaluating health promotion information with ease. This implies that public health policy should also consider measures to improve interactive health literacy skills in order to achieve positive behavioural change (Gibney and Doyle 2017).

Health literacy and healthcare utilization

Lower health literacy is associated with poorer health and therefore, it is expected that people with lower levels of health literacy will have higher health services utilization rates. A recent Danish population-based longitudinal study with a 4-year follow-up period performed by Friss et al indeed found that in the general population, difficulties in understanding information about health and in actively engaging with healthcare providers predicted higher odds for being hospitalized and for having longer hospital admission periods. However, these dimensions of health literacy did not predict the number of planned outpatient or emergency room visits and only slightly more visits to the general practitioner. In people with cardiovascular disease, low health literacy predicted more emergency room visits (Friss et al 2020). Again, in Ireland, Jackson et al found that adolescents and young adults with cystic fibrosis who have sufficient levels of health literacy to obtain, understand, appraise and apply health information have better health-related outcomes. Sufficient health literacy was associated with fewer outpatient visits, days hospitalized, days on intravenous antibiotics, days on oral antibiotics and better quality of life (Jackson et al 2020).

Making an informed decision about participation in screening programmes, such as for example for colorectal cancer (CRC), may be challenging for people with lower health literacy. Therefore, van der Heide et al performed a systematic review to explore to what extent the level of a person’s health literacy is related to their informed decision-making concerning CRC screening. The included studies found either no association between health literacy and informed decision-making or evidence that lower health literacy was associated with less knowledge or a less positive attitude toward CRC screening (van der Heide et al 2015). Pancar and Mercan performed a community-based cross-sectional study in Turkey on CRC screening participation rates and found that participation in screenings in general was low, with those with a high health literacy level more likely not to participate. This at first sight counterintuitive outcome may be explained by those with high health literacy having less time to participate in screenings, which is supported by the finding that the likelihood of not participating among the participants working at a paid job was three times higher than that among the non-working participants (Pancar and Mercan 2021).

Health literacy and health inequalities

Several of the studies described above provide insights into the relationship between health literacy and other social determinants of health. For example, Sørensen et al found that low health literacy follows a social gradient, indicating that people with financial deprivation, low social status, low education or old age are more likely to have lower levels of health literacy than people with higher socioeconomic status and those who are younger (Sørensen et al 2015). Toçi et al concluded that in Albania, older age, lower education and lower economic status and higher BMI were significantly associated with lower health literacy scores (Toçi et al 2015). Thus, people with lower socioeconomic status also tend to have lower health literacy, further increasing their risk for poor health. Azzopardi-Muscat and Sørensen focus on digital literacy, which is increasingly relevant because of the progressing digitisation of healthcare services and society at large. They conclude that it is likely that digital technologies will increase health inequities associated with increased age, lower level of educational attainment and lower socio-economic status. They state that programmes to enhance health and digital literacy, and monitoring of access, utilization and impact across all groups in society can help to ensure that digital technologies act to reduce rather than reproduce or exacerbate existent health inequalities (Azzopardi-Muscat and Sørensen 2019).

Conclusion

The evidence presented in this e-collection emphasises the importance of health literacy as a key and modifiable determinant of health and illustrates how poor health literacy is a driver of health inequity. Health literacy is increasingly being recognised as a vital concept for public health and its relevance has been underlined by the current COVID-19 crises. The EUPHW 2021, during which this e-collection will be launched, will provide a platform for further expansion of the evidence base and exchange of knowledge and experiences on this important topic, as will other EUPHA tools and activities, such as the European Journal of Public Health and the European Public Health Conferences.

References

^{1. Monday 17 May: Communicating science and health [Internet]. EUPHA; 2021 [cited 2021 Apr 5]. Available from: https://eupha.org/communicating_science_and_health}

^{2. (HLS-EU) Consortium Health Literacy Project European, Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012 Dec;12(1):80.}

^{3. Nutbeam D, Lloyd JE. Understanding and Responding to Health Literacy as a Social Determinant of Health. Annu Rev Public Health. 2021 Apr 1;42(1):159–73.}

^{4. World Health Organization. Promoting health in the SDGs: report on the 9th Global conference for health promotion, Shanghai, China, 21–24 November 2016: all for health, health for all [Internet]. World Health Organization; 2017 [cited 2021 Apr 5] p. 36 p. Available from: https://apps.who.int/iris/handle/10665/259183?search-result=true&query=WHO%2FNMH%2FPND%2F17.5&scope=&rpp=10&sort_by=score&order=desc}

^{5. Van den Broucke S. EHMA Webinar: Health Systems & Health Literacy in the time of COVID-19 [Internet]. 2020 Apr 23 [cited 2021 Apr 5]. Available from: https://ehma.org/webinar-health-systems-health-literacy-covid-19/}

^{6. M-POHL network. M-POHL [Internet]. [cited 2021 Apr 5]. Available from: https://m-pohl.net/}

^{7. Dadaczynski K, Okan O, Messer M, Leung AYM, Rosário R, Darlington E, et al. Digital Health Literacy and Web-Based Information-Seeking Behaviors of University Students in Germany During the COVID-19 Pandemic: Cross-sectional Survey Study. J Med Internet Res. 2021 Jan 15;23(1):e24097.}

^{8. Okan O, Bollweg TM, Berens E-M, Hurrelmann K, Bauer U, Schaeffer D. Coronavirus-Related Health Literacy: A Cross-Sectional Study in Adults during the COVID-19 Infodemic in Germany. Int J Environ Res Public Health. 2020 Jul 30;17(15):5503.}

^{9. Paakkari L, Okan O. COVID-19: health literacy is an underestimated problem. Lancet Public Health. 2020 May;5(5):e249–50.}

^{10. Eysenbach G. How to Fight an Infodemic: The Four Pillars of Infodemic Management. J Med Internet Res. 2020 Jun 29;22(6):e21820.}