The Brief Health Literacy Scale for Adults: Adaptation and Validation of the Health Literacy for School-Aged Children Questionnaire.

The Health Literacy for School-Aged Children (HLSAC) is a brief, generic instrument measuring health literacy among school-aged children. Given its brevity and broad conceptualization of health literacy, the HLSAC is a potentially valuable measuring instrument among adults as well. This validation study aimed to adapt the HLSAC questionnaire to an adult population through assessment of content validity and subsequently determine the structural validity of the adapted instrument, the Brief Health Literacy scale for Adults (B-HLA). The content validity of the HLSAC was assessed through interviews with respondents and experts, and the structural validity of the adapted instrument (B-HLA) was evaluated using Rasch analysis. The content validity assessment (n = 25) gave rise to adjustments in the wording of five items. The B-HLA demonstrated an overall misfit to the Rasch model (n = 290). Items 6 and 8 had the poorest individual fits. We found no signs of local dependency or differential item functioning concerning sex, age, education, and native language. The B-HLA demonstrated unidimensionality and ability to discriminate across health literacy levels (PSI = 0.80). Discarding items 6 or 8 resulted in an overall model fit and individual fit of all items. In conclusion, the B-HLA appears to be a valid and reliable instrument for assessing health literacy among adults.

Participatory System Dynamics Approach Targeting Childhood Health in a Small Danish Community (Children's Cooperation Denmark): Protocol for a Feasibility Study Design.

BACKGROUND: Improving childhood health is complex due to the multifactorial nature and interaction of determinants. Complex problems call for complex intervention thinking, and simple one-size-fits-all solutions do not work to improve childhood health. Early awareness is important, as behavior in childhood often is manifested across adolescence and into adulthood. To facilitate shared understanding of the complex structures and relationships that determine children's health behavior, participatory system approaches in, for example, local communities have shown promising potential. However, such approaches are not used systematically within public health in Denmark, and before being rolled out, they should be tested for their feasibility within this context. OBJECTIVE: This paper describes the study design for Children's Cooperation Denmark (Child-COOP) feasibility study that is aiming to examine the feasibility and acceptability of the participatory system approach and the study procedures for a future scale-up controlled trial. METHODS: The feasibility study is designed as a process evaluation of the intervention with the use of both qualitative and quantitative methods. A local childhood health profile will provide data for childhood health issues, for example, daily physical activity behavior, sleep patterns, anthropometry, mental health, screen use, parental support, and leisure-time activities. Data at system level are collected to assess development in the community, for example, readiness to change, analysis of social networks with stakeholders, rippled effects mapping, and changes in system map. The setting is a small rural town in Denmark, Havndal, with children as the primary target group. Group model building, a participatory system dynamics method, will be used to engage the community, create consensus on the drivers of childhood health, identify local opportunities, and develop context-specific actions. RESULTS: The Child-COOP feasibility study will test the participatory system dynamics approach for intervention and evaluation design and survey objective measures of childhood health behavior and well-being among the ~100 children (6-13 years) attending the local primary school. Community-level data will also be collected. We will assess the contextual factors, implementation of interventions, and mechanisms of impact as part of a process evaluation. Data will be collected at baseline, at 2 years, and 4 years of follow-up. Ethical approval for this study was sought and granted from the Danish Scientific Ethical Committee (1-10-72-283-21). CONCLUSIONS: s: The potential of this participatory system dynamics approach includes opportunities for community engagement and local capacity building to improve children's health and health behavior, and this feasibility study holds the potential to prepare an upscaling of the intervention for effectiveness testing. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43949.

Multimorbidity and health literacy: A population-based survey among 28,627 Danish adults.

AIM: Individuals with multimorbidity often have complex healthcare needs challenging their health literacy skills. This study aimed to investigate the association between the number of physical conditions and health literacy and to examine the difference in health literacy levels between individuals with multimorbidity based on physical conditions and individuals with additional mental disorders. METHODS: Respondents aged 25 years or older from a Danish population-based survey were included (N = 28,627). Multimorbidity was assessed based on 18 self-reported chronic conditions; health literacy was measured using two scales from the Health Literacy Questionnaire focusing on understanding health information and engaging with healthcare providers. Associations were examined using multiple logistic regression analysis. RESULTS: We found a positive association between number of physical conditions and the odds of having difficulties in understanding health information and engaging with healthcare providers. For example, the adjusted odds ratio (OR) of having difficulties in understanding health information was 1.45 (95% confidence interval (CI): 1.09-1.94) for individuals with two physical conditions compared with individuals without multimorbidity. The associations formed a positive exposure-response pattern. Furthermore, respondents with both mental and physical conditions had more than twice the odds of having health literacy difficulties compared to respondents with only physical conditions (adjusted OR 2.53 (95% CI 2.02-3.18) and 2.28 (95% CI 1.92-2.72) for the scales, respectively). CONCLUSIONS: Our results suggest that responding to patients' health literacy needs is crucial for individuals with multimorbidity - especially those with combined mental and physical conditions.

Identifying Health Literacy Responsiveness Improvement Ideas in Danish Health Centers: Initial Testing of the OS! Approach.

BACKGROUND: Health services hold a critical role in mitigating the effect of health literacy challenges. Several tools and approaches have been developed to support health organizations in responding to their target population's health literacy needs. One of these is the OS! approach, which is an adapted and less rigorous version of the Australian Organizational health literacy responsiveness tool (Org-HLR). In this study, we aimed to report on our initial testing of the OS! approach in two Danish health care settings. BRIEF DESCRIPTION: The OS! aim to prompt and support the development of local organizational health literacy improvement ideas. The process consists of three consecutive workshops focusing on reflection, self-evaluation, and prioritization. For each workshop tools are provided to support implementation. IMPLEMENTATION: The OS! approach was tested in two Danish municipal health centers (Tårnby Health Centre and Frederiksberg Health Centre), where both staff members and leaders took part in the processes (N = 62 and N = 84). In Tårnby, the process was closely facilitated by the research team, while local managers was in charge of the implementation in Frederiksberg. RESULTS: In both settings, the process succeeded in identifying a list of relevant prioritized action ideas aimed at improving local health literacy responsiveness. In both instances, leaders were able to integrate some of these ideas in action plans for the organizations nearby future. LESSONS LEARNED: We found the OS! approach effective in its aim to identify health literacy responsiveness improvement ideas and based on our experience also less arduous to implement than the Org-HLR. We also learned that good implementation of the OS! approach depends strongly on careful facilitation including thorough introduction of the concepts of health literacy, openness, and creativity in relation to local adaptions within the overall framework of the approach, and the consolidation of consistent leader support throughout the organization. [HLRP: Health Literacy Research and Practice. 2022;6(3):e232-e238.] Plain Language Summary: This study describes the initial testing of the OS! APPROACH: The OS! approach is based on the Australian methodology "Org-HLR" and use a participatory approach to prompt and support the identification of local health literacy responsiveness improvement ideas in health care organizations. The article provides valuable experiences regarding local development of organizational health literacy in practice.

The Health Literacy in Pregnancy (HeLP) Program Study Protocol: Development of an Antenatal Care Intervention Using the Ophelia Process.

A pregnant woman needs adequate knowledge, motivation, and skills to access, understand, appraise, and apply health information to make decisions related to the health of herself and her unborn baby. These skills are defined as health literacy: an important factor in relation to the woman's ability to engage and navigate antenatal care services. Evidence shows variation in levels of health literacy among pregnant women, but more knowledge is needed about how to respond to different health literacy profiles in antenatal care. This paper describes the development protocol for the HeLP program, which aims to investigate pregnant women's health literacy and co-create health literacy interventions through a broad collaboration between pregnant women, partners, healthcare providers, professionals, and other stakeholders using the Ophelia (Optimising Health Literacy and Access) process. The HeLP program will be provided at two hospitals, which provide maternity care including antenatal care: a tertiary referral hospital (Aarhus University Hospital) and a secondary hospital (the Regional Hospital in Viborg). The Ophelia process includes three process phases with separate objectives, steps, and activities leading to the identification of local strengths, needs and issues, co-design of interventions, and implementation, evaluation, and ongoing improvement. No health literacy intervention using the Ophelia process has yet been developed for antenatal care.

Investigating cow-calf contact in cow-driven systems: behaviour of the dairy cow and calf.

Research is needed on how technology can facilitate cow-calf contact (CCC). This research communication describes the behaviour of dairy cow-calf pairs in two cow-driven CCC-systems differing in cows' access to the calves through computer-controlled access gates (smart gates, SG). Specifically, cow traffic through SG when visiting their calves, allogrooming, suckling and cross-suckling, cows' eating and resting behaviour and finally vocal response to separation were assessed. After 3 d in an individual calving pen, pairs (n = 8) were moved to the CCC compartment with a cow area, a calf creep and a meeting area. During the next 31 d calves could suckle the cows whenever they visited the meeting area (suckling phase). Cows had free (group 1, n = 4 pairs) or restricted access to the calves based on previous activity in the automatic milking system (group 2, n = 4 pairs). SG's controlled cow traffic between the meeting area and the cow area, in which the cows could access resources such as feed, cubicles, and the automatic milking system. Following the suckling phase cow access into the meeting area was gradually decreased over 9 d (separation phase). During the suckling phase, cows paid frequent and short visits to their calves. Pairs spent in total approximately one h/d suckling and allogrooming. However, the duration and frequencies of these events varied among pairs and groups, as did the vocal response to separation. Restricted access - cows performed more (unrewarded) attempts to visit the calves who cross-suckled more. Collectively, free access to the calves may have been more intuitive and welfare friendly. Although a low sample size limits interpretation beyond description and enabling hypothesis formulation for future research, the results indicate that the cow is motivated to visit her calf, albeit through a SG, thus facilitating particular behaviours for which cow-calf pairs are highly motivated.

A CHAT about health literacy - a qualitative feasibility study of the Conversational Health Literacy Assessment Tool (CHAT) in a Danish municipal healthcare centre.

BACKGROUND: Understanding individual health literacy needs is crucial when designing supportive and effective health care. However, tools assessing health literacy in practice are lacking. The Conversational Health Literacy Assessment Tool (CHAT) was recently developed, but its ability to assess health literacy remains unexplored. We aimed to investigate the implementation and adoption of CHAT, its ability to increase awareness of health literacy among healthcare providers, and if CHAT could assess health literacy needs in patients. METHODS: We performed a qualitative feasibility study of CHAT among healthcare providers (nurses, physiotherapists and occupational therapists) who provide rehabilitation services for patients with noncommunicable diseases in a municipal healthcare centre in Denmark. The study used the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance) to structure interview guide and analysis. We collected qualitative data from four small focus groups with healthcare providers (n = 11). The data were analysed using a deductive thematic three-step method for organising and interpreting data. All informants provided written informed consent prior to data collection. RESULTS: CHAT seems to be a feasible and efficient tool for assessing health literacy needs among individuals with different socio-demographic characteristics and with different diagnoses. CHAT was easiest implemented and adopted by healthcare providers, who were already familiarly with the concept of health literacy. The informants emphasised that an introduction to CHAT and health literacy as concept was valuable for the adoption. Some of them felt frustrated that they did not have opportunity and options to meet the health literacy needs identified by CHAT. CONCLUSIONS: CHAT is a promising tool for assessing individual health literacy needs and increasing awareness of health literacy among healthcare providers. For successfully implementation of CHAT, we recommend developing a structured implementation programme, including an introduction to health literacy and an outline of the options for acting upon CHAT results.

Low Health Literacy and Mortality in Individuals with Cardiovascular Disease, Chronic Obstructive Pulmonary Disease, Diabetes, and Mental Illness: A 6-Year Population-Based Follow-Up Study.

BACKGROUND: The objective of the study was to examine the impact of health literacy on mortality in the general population and among individuals with cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), diabetes, and mental illness. METHODS: Data from a large Danish health survey (n = 29,473) from 2013 were linked with national mortality registry data to permit a 6-year follow-up. RESULTS: Individuals reporting difficulties in understanding information about health, had higher risk of dying during follow-up (hazard rate (HR) 1.38 (95% CI 1.11-1.73)) compared with those without difficulties. Higher risk was also observed among people reporting CVD (HR 1.47 (95% CI 1.01-2.14)), diabetes (HR 1.91 (95% CI 1.13-3.22)) and mental illness (HR 2.18 (95% CI 1.25-3.81)), but not for individuals with COPD. Difficulties in actively engaging with healthcare providers was not associated with an increase in the risk of dying in the general population or in any of the four long-term condition groups. CONCLUSIONS: Aspects of health literacy predict a higher risk of dying during a 6-year follow-up period. Our study serves as a reminder to healthcare organizations to consider the health literacy responsiveness of their services in relation to diverse health literacy challenges and needs.

Impact of low health literacy on healthcare utilization in individuals with cardiovascular disease, chronic obstructive pulmonary disease, diabetes and mental disorders. A Danish population-based 4-year follow-up study.

BACKGROUND: Previous research from the USA has shown that low health literacy is associated with higher hospitalization rates and higher rates of emergency service use. However, studies in a European context using more comprehensive health literacy definitions are lacking. The aim was to study the impact of low health literacy on healthcare utilization in a Danish context. METHODS: In this prospective cohort study, baseline survey data from 2013 were derived from a large Danish health and morbidity survey and merged with individual-level longitudinal register data for a 4-year follow-up period. The study included people in the general population (n = 29 473) and subgroups of people with four different chronic conditions: cardiovascular disease (CVD) (n = 2389), chronic obstructive pulmonary disease (COPD) (n = 1214), diabetes (n = 1685) and mental disorders (n = 1577). RESULTS: In the general population, low health literacy predicted slightly more visits to the general practitioner and admissions to hospital and longer hospitalization periods at 4 years of follow-up, whereas low health literacy did not predict planned outpatient visits or emergency room visits. In people with CVD, low health literacy predicted more days with emergency room visits. In people with mental disorders, difficulties in actively engaging with healthcare providers were associated with a higher number of hospital admission days. No significant association between health literacy and healthcare utilization was found for diabetes or COPD. CONCLUSIONS: Even though Denmark has a universal healthcare system the level of health literacy affects healthcare use in the general population and in people with CVD and mental disorders.

Fit for Diversity: A Staff-Driven Organizational Development Process Based on the Organizational Health Literacy Responsiveness Framework.

Working toward equity in health requires attention to local needs. Organizational health literacy responsiveness is defined as the way health information and resources are made available and accessible to people. This case study aims to investigate the feasibility of the the Organizational Health Literacy Responsiveness (Org-HLR) process in developing a health literacy strategy in a Danish municipal rehabilitation unit. The Org-HLR investigates organizational health literacy responsiveness within six domains: (1) leadership and culture; (2) systems, processes, and policies; (3) access to services and programs; (4) community engagement and partnerships; (5) communication practices and standards; and (6) workforce. During three workshops, we applied the appropriate tools to allow staff and management to reflect upon and self-assess local organizational health literacy needs and develop and prioritize ideas for improvement. During the Org-HLR self-assessment, 62 ideas for improvement were identified. After prioritization, the unit produced an action plan with 11 items to develop health literacy responsiveness. The co-creational strategy ensured broad participation, which may increase the likelihood of successful implementation. To become health literacy responsive, organizations need to develop local strategies. This study confirmed the Org-HLR as a feasible approach to identify organizational health literacy needs and to guide organizational health literacy improvements. [HLRP: Health Literacy Research and Practice. 2020;4(1):e79-e83.].

Improving Organizational Health Literacy Responsiveness in Cardiac Rehabilitation Using a Co-Design Methodology: Results from The Heart Skills Study.

For health services, improving organizational health literacy responsiveness is a promising approach to enhance health and counter health inequity. A number of frameworks and tools are available to help organizations boost their health literacy responsiveness. These include the Ophelia (OPtimising HEalth LIteracy and Access) approach centered on local needs assessments, co-design methodologies, and pragmatic intervention testing. Within a municipal cardiac rehabilitation (CR) setting, the Heart Skills Study aimed to: (1) Develop and test an organizational health literacy intervention using an extended version of the Ophelia approach, and (2) evaluate the organizational impact of the application of the Ophelia approach. We found the approach successful in producing feasible organizational quality improvement interventions that responded to local health literacy needs such as enhanced social support and individualized care. Furthermore, applying the Ophelia approach had a substantial organizational impact. The co-design process in the unit helped develop and integrate a new and holistic understanding of CR user needs and vulnerabilities based on health literacy. It also generated motivation and ownership among CR users, staff, and leaders, paving the way for sustainable future implementation. The findings can be used to inform the development and evaluation of sustainable co-designed health literacy initiatives in other settings.

Health Literacy is Associated with Health Behaviors in Students from Vocational Education and Training Schools: A Danish Population-Based Survey.

Health literacy has been identified as an important and changeable intermediary determinant of health equity. Vocational education and training (VET) schools are a relevant setting for health behavior interventions seeking to diminish health inequities because many VET students come from low socio-economic status backgrounds. This study examines VET students' health literacy and its association with health behavior based on a cross-sectional survey among 6119 students from 58 VET schools in Denmark in 2019. Two scales from the Health Literacy Questionnaire was used to assess domains of health literacy. Data were analyzed using Anova and logistic regression. The study population consisted of 43.4% female, and mean age was 24.2 years (range 15.8-64.0). The health literacy domain 'Actively managing my health' mean was 2.51, SD 0.66, and 'Appraisal of health information' mean was 2.37, SD 0.65. For both domains, being female, older age, attending the VET educational program Care-health-pedagogy, and higher self-rated health were associated with higher scale scores. In the adjusted analyses, lower scale scores were associated with less frequent breakfast, daily smoking, high-risk alcohol behavior and moderate-to-low physical activity. Our results show that low health literacy is associated with unhealthy behaviors in this population. Our results support and inform health literacy research and practice in educational institutions and services.

Health Literacy among People in Cardiac Rehabilitation: Associations with Participation and Health-Related Quality of Life in the Heart Skills Study in Denmark.

Health literacy (HL) is a dynamic determinant of health and a promising target of health equity interventions in noncommunicable disease prevention. Among people referred to a cardiac rehabilitation program, we examined the associations between (1) HL and participation in cardiac rehabilitation and (2) HL and health-related quality of life (HRQoL). Using a cross-sectional design, we invited 193 people referred to cardiac rehabilitation in Randers Municipal Rehabilitation Unit, Denmark, to respond to a questionnaire in 2017. Of these, 150 people responded (77.7%). HL was measured using the nine scales of the Health Literacy Questionnaire (HLQ), while HRQoL was measured using the Short Form Health Survey 12 (version 2) (SF-12). The mean age of respondents was 67.0 years; 71.3% of the sample were men. Nonrespondents had significantly lower educational attainment and more often lived alone than respondents. Using multiple regression analyses, we found no significant associations between HL and participation in cardiac rehabilitation. There were significant positive associations between several aspects of HL and physical and mental HRQoL. HL could be a factor of interest in initiatives aimed at improving participation and outcomes of cardiac rehabilitation.

Large diversity in Danish health literacy profiles: perspectives for care of long-term illness and multimorbidity.

BACKGROUND: Health literacy is an important, modifiable, social determinant of health. This study aims to explore health literacy challenges of people with long-term illness or multimorbidity and provide detailed profiles revealing health literacy strengths and weaknesses within a Danish population. METHODS: In this cross-sectional study among Danish individuals (n = 490), health literacy was assessed using the nine-scale Health Literacy Questionnaire (HLQ). Using multiple logistic regression and hierarchical cluster analysis, we estimated the association between HLQ scale scores and the likelihood of long-term illness and multimorbidity, and identified socio-demographic and health characteristics related to profiles of health literacy strengths and weaknesses. RESULTS: An increase in 'actively managing my health' and 'social support for health' decreased the odds of having a long-term illness [odds ratio, OR 0.53 (0.31-0.9); OR 0.43 (0.24-0.74)] and multimorbidity [OR 0.51 (0.26-0.98); OR 0.33 (0.17-0.62)], respectively. Conversely, an increase in 'healthcare provider support' increased the odds of having long-term illness [OR 2.97 (1.78-5.08)] and multimorbidity [OR 2.94 (1.53-5.87)], respectively. Five profiles were identified based on the cluster analysis. Each cluster was characterized by specific health characteristics, e.g. Cluster A by better health status (χ2 = 39.976 (4), P < 0.001) and well-being (χ2 = 28.832 (4), P < 0.001) and Cluster D by poor health status (χ2 = 39.976 (4), P < 0.001) and increased likelihood of long-term illness (χ2 = 18.641 (4), P < 0.001). CONCLUSIONS: The association of health literacy with long-term illness and multimorbidity in combination with the health literacy profiling based on cluster analysis provides a comprehensive needs assessment and a promising starting point for the development of health literacy responsive interventions.

Health literacy is associated with health behaviour and self-reported health: A large population-based study in individuals with cardiovascular disease.

Background Health literacy may constitute a modifiable determinant of health behaviour and affect cardiovascular disease prevention. This study investigates the associations between health literacy and health behaviour as well as health status. Design A cross-sectional study on a population-based sample of people with acute myocardial infarction, angina pectoris or stroke ( N = 3116). Methods Health literacy was assessed using two dimensions from the Health Literacy Questionnaire: 'understanding health information' and 'engaging with healthcare providers'. Health behaviour included physical activity, dietary habits, smoking, alcohol consumption and body mass index. Health status was examined using Short Form Health Survey 12 version 2 (four-week recall) (physical and mental components). We used regression analyses to examine the associations. Results 'Understanding health information' was inversely associated with physical inactivity (odds ratio (OR) 0.48 (0.39;0.59), unhealthy diet (OR 0.64 (0.47;0.88)), underweight (OR 0.43 (0.21;0.89)) and obesity (OR 0.79 (0.63;0.99)). 'Engaging with healthcare providers' was inversely associated with physical inactivity (OR 0.64 (0.53;0.77)), less than healthy diet (OR 0.79 (0.64;0.96)) and daily smoking (OR 0.81 (0.66;1.0)). An increase in 'understanding health information' as well as 'engaging with healthcare providers' was associated with an increase in both physical and mental health status. Conclusions The findings suggest that aspects of health literacy are associated with health status and health behaviour in cardiovascular patients and should be considered in interventions regarding cardiovascular disease prevention.