Governments around the world have adopted national policies and programs to improve health literacy. This paper examines progress in the development of evidence to support these policies from interventions to improve health literacy among community populations. Our review found only a limited number of studies (n=7) that met the criteria for inclusion, with many more influenced by the concept of health literacy but not using it in the design and evaluation. Those included were diverse in setting, population and intended outcomes. All included educational strategies to develop functional health literacy, and a majority designed to improve interactive or critical health literacy skills. Several papers were excluded because they described a protocol for an intervention, but not results, indicating that our review may be early in a cycle of activity in community intervention research. The review methodology may not have captured all relevant studies, but it provides a clear message that the academic interest and attractive rhetoric surrounding health literacy needs to be tested more systematically through intervention experimentation in a wide range of populations using valid and reliable measurement tools. The distinctive influence of the concept of health literacy on the purpose and methodologies of health education and communication is not reflected in many reported interventions at present. Evidence to support the implementation of national policies and programs, and the intervention tools required by community practitioners are not emerging as quickly as needed. This should be addressed as a matter of priority by research funding agencies.

Issue addressed Complex health promotion programs, which can have multilevels of implementation and multi‐components with nonlinear causal pathways, present many evaluation challenges. Traditional evaluation methods often fail to account for the complexity inherent in assessing these programs. In real‐world settings, evaluations of complex programs are often beset by additional constraints of limited budgets and short timeframes. Determining whether a complex program is successful and how a program worked requires evaluators of complex programs to adopt a level of pragmatism. Methods This paper describes a pragmatic evaluation approach used to evaluate the Get Healthy at Work workplace health promotion program, implemented in New South Wales, Australia. Using the program as a case study, we describe some key principles for applying a pragmatic evaluation approach and use these principles to develop an appropriate evaluation strategy. Results The evaluation includes multiple research methods to assess program outputs and implementation; and identify emergent program impacts, within constrained resources. The evaluation was guided by epistemological flexibility, methodological comprehensiveness and operational practicality. Conclusion Health promotion programs, such as state‐wide obesity prevention programs, require appropriate evaluation methods which address their inherent complexity amidst the real‐world evaluation constraints, and focuses on the essential evaluation needs. So what The main complex program evaluation principles are applicable to other multilevel health promotion programs, challenged by methodological and practical or political constraints.

BackgroundNon-communicable chronic diseases in Australia contribute to approximately 85% of the total burden of disease; this proportion is greater for Aboriginal communities. The Get Healthy Service (GHS) is effective at reducing lifestyle-based chronic disease risk factors among adults and was enhanced to facilitate accessibility and ensure Aboriginal cultural appropriateness. The purpose of this study is to detail how formative research with Aboriginal communities was applied to guide the development and refinement of the GHS and referral pathways; and to assess the reach and impact of the GHS (and the Aboriginal specific program) on the lifestyle risk factors of Aboriginal participants.MethodsFormative research included interviews with Aboriginal participants, leaders and community members, healthcare professionals and service providers to examine acceptability of the GHS; and contributed to the redesign of the GHS Aboriginal program. A quantitative analysis employing a pre-post evaluation design examined anthropometric measures, physical activity and fruit and vegetable consumption of Aboriginal participants using descriptive and chi square analyses, t-tests and Wilcoxon signed-rank tests.ResultsWhilst feedback from the formative research was positive, Aboriginal people identified areas for service enhancement, including improving program content, delivery and service promotion as well as ensuring culturally appropriate referral pathways. Once these changes were implemented, the proportion of Aboriginal participants increased significantly (3.2 to 6.4%). There were significant improvements across a number of risk factors assessed after six months (average weight loss: 3.3 kg and waist circumference reduction: 6.2 cm) for Aboriginal participants completing the program.ConclusionsWorking in partnership with Aboriginal people, Elders, communities and peak bodies to enhance the GHS for Aboriginal people resulted in an enhanced culturally acceptable and tailored program which significantly reduced chronic disease risk factors for Aboriginal participants. Mainstream telephone based services can be modified and enhanced to meet the needs of Aboriginal communities through a process of consultation, community engagement, partnership and governance.

BackgroundHealth insurers worldwide implement financial incentive schemes to encourage health-related behaviours, including to facilitate weight loss. The maintenance of weight loss is a public health challenge, and as non-communicable diseases become more prevalent with increasing age, mid-older adults could benefit from programs which motivate weight loss maintenance. However, little is understood about their perceptions of using financial incentives to maintain weight loss.MethodsWe used mixed methods to explore the attitudes and views of participants who had completed an Australian weight loss and lifestyle modification program offered to overweight and obese health insurance members with weight-related chronic diseases, about the acceptability and usefulness of different types of financial incentives to support weight loss maintenance. An online survey was completed by 130 respondents (mean age = 64 years); and a further 28 participants (mean age = 65 years) attended six focus groups.ResultsBoth independent samples of participants supported a formalised maintenance program. Online survey respondents reported that non-cash (85.2%) and cash (77%) incentives would be potentially motivating; but only 40.5% reported that deposit contracts would motivate weight loss maintenance. Results of in-depth discussions found overall low support for any type of financial incentive, but particularly deposit contracts and lotteries. Some participants expressed that improved health was of more value than a monetary incentive and that they felt personally responsible for their own health, which was at odds with the idea of financial incentives. Others suggested ongoing program and peer support as potentially useful for weight loss maintenance.ConclusionsIf financial incentives are considered for mid-older Australian adults in the health insurance setting, program planners will need to balance the discordance between participant beliefs about the individual responsibility for health and their desire for external supports to motivate and sustain weight loss maintenance.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5136-z) contains supplementary material, which is available to authorized users.

Goal setting for weight management and increasing physical activity in the overweight and obese population, undertaken in a telephone-based coaching program, can be effective.

• Statewide implementation of the Live Life Well @ School (LLW@S) program in New South Wales, Australia, has enhanced health promotion initiatives in the school setting over time • LLW@S monitoring data demonstrate high reach to schools with disadvantaged populations, in remote areas and with a high proportion of Aboriginal students • A dedicated implementation workforce has been continually funded since 2011, allowing local health promotion staff to target schools and tailor LLW@S strategies to the local context, to support achievement of the desirable practices

Facebook is used as part of public health communication efforts but little evidence is available on why people engage with health-related Facebook pages and what content appeals to them. This study aimed to investigate user perceptions of and experience with the Make Healthy Normal (MHN) Facebook page, part of a government campaign to address overweight and obesity in adults in New South Wales, Australia. This sequential mixed methods study comprised an online survey (n = 591) and six focus groups (n = 33) of Facebook users, including both fans (i.e., users who have "liked" the MHN page) and nonfans. We analyzed the online survey descriptively and employed inductive thematic analysis for the focus groups, integrating the two data sources at the stage of interpretation. Our results show that MHN and similar health pages are in demand but that there are a number of contextual and content-related factors that are critical in determining user engagement and over which page administrators have varying levels of influence. Contextual factors, including the drivers for user engagement and Facebook user practices, can be leveraged or managed to influence user engagement but they cannot be controlled. On the contrary, content factors, like the nature of posts, post presentation, and post subject, can be directly influenced by page administrators. Policymakers and practitioners can use these findings to inform the design and operation of their own Facebook pages and should look to conduct and disseminate robust evaluation of their pages to improve user satisfaction and engagement.

Issue addressed This study examines how sedentary behaviour (too much sitting) was covered as a health issue by Australian newspapers and how physical activity was framed within this newspaper coverage. Methods Articles featuring sedentary behaviour published in Australian newspapers between 2000 and 2012 were analysed for content and framing. Main outcome measures were volume, number and content of newspaper articles; framing and types of sedentary behaviour; responsibility for the problem of and solutions to high levels of sedentary behaviour; and physical activity mentions and how it was framed within sedentary behaviour coverage. Results Out of 48 articles, prolonged sitting was framed as bad for health (52%) and specifically as health compromising for office workers (25%). Adults who sat a lot were framed as 'easy targets' for ill health (21% of headlines led with 'sitting ducks' or 'sitting targets'). Prolonged sitting was framed as an issue of individual responsibility (>90%) with less mention of environmental and sociocultural contributors. Thirty-six of 48 articles mentioned physical activity; 39% stated that being physically active does not matter if a person sits for prolonged periods of time or that the benefits of physical activity are undone by too much sitting. Conclusions News coverage should reflect the full socio-ecological model of sedentary behaviour and continually reinforce the independent and well-established benefits of health-enhancing physical activity alongside the need to limit prolonged sitting. So what? It is important that the entire 'move more, sit less, every day!' message is communicated by news media.