BackgroundHealth literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.MethodsA systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model.ResultsThe review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively.ConclusionsBased upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.

BackgroundSeveral measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations.MethodsBased on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish.ResultsThe development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors.ConclusionsBy illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.

The European Community Health Promotion Indicator Development Model has been developed as the basis for establishing a European set of indicators for monitoring health promotion interventions. This paper offers the model more generally as a common frame of reference for broader public health practice and indicator development. The model builds around the physical, mental and social health of individuals and shows how health develops by interaction between individual and environmental health determinants. It demonstrates that health development can be analysed from a salutogenic and a pathogenic perspective and explains how the differing starting points of different intervention approaches such as health promotion and health care are related to these two perspectives. Finally, a classification system for pathogenic and salutogenic public health outcome indicators is derived from the model and has been applied to the current core list of the European Community Health Indicator system. The model and its application highlight the need for systematic salutogenic indicator development in the field of public health and for strengthening the health promotion perspective in the future.

Data on health literacy (HL) in the population is limited for Asian countries. This study aimed to test the validity of the Mandarin version of the European Health Literacy Survey Questionnaire (HLS-EU-Q) for use in the general public in Taiwan. Multistage stratification random sampling resulted in a sample of 2989 people aged 15 years and above. The HLS-EU-Q was validated by confirmatory factor analysis with excellent model data fit indices. The general HL of the Taiwanese population was 34.4 ± 6.6 on a scale of 50. Multivariate regression analysis showed that higher general HL is significantly associated with the higher ability to pay for medication, higher self-perceived social status, higher frequency of watching health-related TV, and community involvement but associated with younger age. HL is also associated with health status, health behaviors, and health care accessibility and use. The HLS-EU-Q was found to be a useful tool to assess HL and its associated factors in the general population.

The first European comparative survey of population health literacy (HL), HLS-EU, triggered a lot of health policy and health systems responses. In the sense of “What doesn’t get measured doesn’t get done”, data seem important to capture the attention of decision makers and to support evidence-informed policy and practice. This is one of the reasons why the WHO publication “Health Literacy - The Solid Facts” (2013) demands regular internationally comparative surveys of HL. Building up on initiatives by HLS-EU researchers and the German-speaking WHO member states, the Action Network on Measuring Population and Organizational HL (M-POHL) under the umbrella of WHO Europe’s Health Information Initiative (EHII) was founded in 2018 to achieve this aim. M-POHL’s objectives are to support regular measurements of population HL and of organizational HL and to use the results to support evidence-informed policy and practice. A unique feature of M-POHL is that it brings together research and policy: countries typically participate with a research and a policy representative. Experiences so far show that policy representatives in M-POHL find the continuous collaboration with research extremely valuable for maintaining momentum around HL in their respective countries. So far, 24 countries have been involved in M-POHL. M-POHL uses projects to meet its objectives. Its first project will be the next European comparative survey of population HL, abbreviated as “HLS19”. This will build up on HLS-EU by using a standard short form of the survey tool for all participating countries, completing it with optional packages on new topics (digital HL, communication and orientation in health care), and allowing for a few country-specific items. Data collection for HLS19 will start in autumn 2019 and last until March 2020. Based on current expressions of interest, between 10 and 14 countries will participate in the survey. An internationally comparative report will be available in 2021.