Moving Health Literacy Research and Practice towards a Vision of Equity, Precision and Transparency

Legitimizing incapacity: discursive choices in Norwegian sickness certificates

BACKGROUND

In Norway's welfare system, General Practitioners (GPs) issue sickness certificates (SCs) to document patient's inability to work. These documents serve a dual role as medical evidence and as a basis for social welfare decisions. The language used in SCs can shape how non-medical stakeholders perceive a patient's work capacity. This study examines how SC language constructs narratives of work ability, focusing on how it portrays patients' limitations and prospects for recovery.

METHODS

We conducted a qualitative discourse analysis of 155 SCs written by Norwegian GPs for patients under 35 years old with common mental health conditions. We focused on certificates issued around week 39 of the patient's sick leave. Using discourse analysis techniques, we examined linguistic features that convey the patient's work capacity and functional limitations.

RESULTS

SCs predominantly emphasized incapacity and the necessity of work absence through discursive choices such as definitive language, amplified descriptions, and rhetorical strategies reinforcing limitations. Recovery potential was presented with tentative language, reflecting uncertainty in prognosis, while the temporal dimension of treatment was frequently framed as a barrier to returning to work. Additionally, the use of specialized terminology, generalized label, and elliptical constructions placed a significant interpretative burden on non-medical readers. Furthermore, SCs largely lacked explicit recommendations for workplace accommodations or interdisciplinary collaboration, limiting their utility in facilitating structured return-to-work strategies.

CONCLUSIONS

Time constraints, administrative pressures, and the dual roles of GPs as clinicians and bureaucrats shape the entire production of SCs. In turn, these discursive choices often reinforce narratives of incapacity. Enhancing SC relevance through structural modifications and interdisciplinary collaboration, including employer involvement in evaluating workplace accommodations, could improve welfare assessments and support tailored reintegration strategies. Positioning SCs as collaborative tools - rather than standalone assessments - may better align clinical evaluations with workplace realities and foster shared accountability for recovery and return-to-work efforts. SCs seem to place a disproportionate burden on GPs to translate medical conditions into work-related recommendations, often without the support or expertise required for such interdisciplinary evaluations.

Community voices in health literacy: a qualitative exploration into perceptions of a health literacy mediator

Health literacy is a vital asset needed to empower individuals to take control of their health. An individual's health literacy is the ability to find, use and apply health information and services to manage their health. They interact with the health services and members of their community who can offer additional support. Creating the role of a health literacy mediator (HLM) may help to improve health literacy outcomes for all. For this role to be accepted by individuals within a community, the community itself should be involved in the development of the roles and associated responsibilities. The aim of this study was to engage with community members to acquire their perspectives on the potential of this role. Qualitative semi-structured online interviews were used to engage in discussions with local community members. This study implemented a constructivist epistemology with qualitative research design. Data were thematically analysed to identify evolving themes that were important to the HLM role. The analysis identified three main themes that need to be considered when adopting an HLM role: (i) health empowerment of individuals, organizations and communities, (ii) meeting the needs of the community and (iii) addressing the existing barriers in navigating and accessing the healthcare system. Those working in the health promotion space must adopt novel and innovative ways to improve HL on both a local and an international scale. This study concluded that for the role of a HLM to be accepted, it would need to encompass these attributes.

Health Literacy and Health-Related Quality of Life in Beijing Adolescents: A Path Analysis

BACKGROUND

Health literacy is a critical driver of achieving an equitable world for every child and adolescent. Although the relationship between health literacy and health-related quality of life (HRQoL) has been documented, little is known among adolescents. In addition, due to lack of theory-driven empirical research, it remains unknown about the full relationship between health literacy, its antecedents, and HRQoL.

OBJECTIVE

This study aimed to apply Manganello's framework to investigate how health literacy was associated with its antecedents and HRQoL in Beijing secondary students.

METHODS

A cross-sectional study was conducted with 650 students in years 7 to 9 from four secondary schools in Beijing. Based on Manganello's health literacy framework, a self-administered questionnaire was used to collect information on health literacy, its antecedents (i.e., sociodemographics, self-efficacy, social support, school and community environment), and HRQoL. The 8-item Health Literacy Assessment Tool was used to measure health literacy (score range 0-37), and the KIDSCREEN-10 was used to measure HRQoL (score range 10-50). Path analysis was conducted to examine the mediating role of health literacy in the relationship between its antecedents and HRQoL.

KEY RESULTS

Overall, the average score of students' health literacy and HRQoL was 26.37 (±5.89) and 37.49 (±5.78), respectively. Health literacy was positively correlated with HRQoL (r = 0.36, p < .01). In the final path model, health literacy was not associated with HRQoL. However, students' social support, school environment, and community environment were associated with HRQoL. Health literacy was affected by self-efficacy, social support, and school environment (all p < .05).

CONCLUSIONS

A range of intrapersonal, interpersonal, and environmental factors were associated with health literacy and HRQoL. A holistic approach is needed to improve health literacy and HRQoL through multilevel intervention strategies such as increasing personal self-efficacy, promoting social support, and creating positive environments. [HLRP: Health Literacy Research and Practice. 2022;6(4):e300-e309.] Plain Language Summary: We investigated how health literacy was related to its influencing factors and HRQoL among Beijing secondary students in years 7 to 9. Health literacy and HRQoL were independent outcomes affected by a range of social-ecological factors including self-efficacy, social support, and perceptions of school and community environments.

Public Libraries as Supportive Environments for Children's Development of Critical Health Literacy

Critical health literacy enables individuals to use cognitive and social resources for informed action on the wider determinants of health. Promoting critical health literacy early in the life-course may contribute to improved health outcomes in the long term, but children's opportunities to develop critical health literacy are limited and tend to be school-based. This study applies a settings-based approach to analyse the potential of public libraries in England to be supportive environments for children's development of critical health literacy. The study adopted institutional ethnography as a framework to explore the public library as an everyday setting for children. A children's advisory group informed the study design. Thirteen children and 19 public library staff and community stakeholders were interviewed. The study results indicated that the public library was not seen by children, staff, or community stakeholders as a setting for health. Its policies and structure purport to develop health literacy, but the political nature of critical health literacy was seen as outside its remit. A supersetting approach in which children's everyday settings work together is proposed and a conceptual model of the public library role is presented.

A Health Equity Implementation Approach to Child Health Literacy Interventions

Health and behavioural inequalities exist in all populations, including children. As a social determinant of health, health literacy is a crucial driver of equitable health outcomes in children. With the increasing calls for more actions on addressing low health literacy and inequalities, health literacy interventions to improve children's healthy behaviours have emerged as a key strategy to reduce health inequities. However, health literacy interventions face implementation challenges impacting upon potential outcomes, and disparities in the implementation of health literacy interventions also occur. Variation exists in child health literacy intervention target groups, timing, content and formats, and there is a lack of implementation specificity, resulting in a lack of clarity about which intervention strategies are the most effective in improving health literacy, related health behaviours, and associated health outcomes. While actions to facilitate child health intervention implementation exist, to minimise further perpetuation of child health inequities, this perspective calls for a health equity implementation approach to child health literacy interventions.

Comparison of Health Literacy Assessment Tools among Beijing School-Aged Children

Health literacy is a broad and multidimensional construct, making its measurement and conclusions inconsistent. This study aims to compare the patterning of health literacy using different assessment tools and examine their impact on children's developmental outcomes. A cross-sectional study was conducted with 650 students in Years 7-9 from four secondary schools in Beijing. Health literacy was measured by the eight-item health literacy assessment tool (HLAT, score range 0-37), the six-item Newest Vital Sign (NVS, score range 0-6), and the 16-item Health Literacy Survey (HLS, score range 0-16). Based on Manganello's health literacy framework, information on upstream factors (e.g., gender, ethnicity, socioeconomic status) and developmental outcomes (e.g., health-promoting behaviours, health service use, global health status) was collected. Overall, the average scores for health literacy were 26.34 ± 5.89, 3.64 ± 1.64, and 13.72 ± 2.94, respectively, for HLAT, NVS, and HLS. The distribution of health literacy varied by socio-demographics and individual characteristics except for gender, no matter which health literacy assessment tool was used. The magnitude of associations between health literacy, its upstream factors and developmental outcomes was greater when using three-domain instruments (HLAT and HLS) than using single-domain instruments (NVS). The approach to health literacy measurement will influence the conclusion. Using multidimensional assessment tools may better capture a child's health literacy and contribute to the maximum efficiency and effectiveness of school-based health literacy interventions.

Connections and Biases in Health Equity and Culture Research: A Semantic Network Analysis

Health equity is a rather complex issue. Social context and economical disparities, are known to be determining factors. Cultural and educational constrains however, are also important contributors to the establishment and development of health inequities. As an important starting point for a comprehensive discussion, a detailed analysis of the literature corpus is thus desirable: we need to recognize what has been done, under what circumstances, even what possible sources of bias exist in our current discussion on this relevant issue. By finding these trends and biases we will be better equipped to modulate them and find avenues that may lead us to a more integrated view of health inequity, potentially enhancing our capabilities to intervene to ameliorate it. In this study, we characterized at a large scale, the social and cultural determinants most frequently reported in current global research of health inequity and the interrelationships among them in different populations under diverse contexts. We used a data/literature mining approach to the current literature followed by a semantic network analysis of the interrelationships discovered. The analyzed structured corpus consisted in circa 950 articles categorized by means of the Medical Subheadings (MeSH) content-descriptor from 2014 to 2021. Further analyses involved systematic searches in the LILACS and DOAJ databases, as additional sources. The use of data analytics techniques allowed us to find a number of non-trivial connections, pointed out to existing biases and under-represented issues and let us discuss what are the most relevant concepts that are (and are not) being discussed in the context of Health Equity and Culture.

"Now I Feel That I Can Achieve Something": Young Tanzanian Women's Experiences of Empowerment by Participating in Health Promotion Campaigns

The United Nations (UN) emphasizes that health promotion, education, and empowerment of women are all goals that will help to end poverty. In eastern rural Tanzania, young women who dropped out of school now take an active part in health promotion campaigns in schools and villages through the youth program "Innovative and Productive Youth", which is administered by the nongovernmental organization Hatua na Maendeleo (HAMA). The aim of this qualitative study was to explore how some of these young Tanzanian women experience participating in health promotion campaigns. A hermeneutic phenomenology design with focus group interviews was used. The study's participants were nine young women between the ages of 18 and 23 who had participated in the youth program for one year. In addition, the participants were given the opportunity to provide written elaboration in Kiswahili after the interviews. The findings were analyzed from an empowerment perspective and revealed the benefits that the young women had experienced, which were expressed as three themes, i.e., my involvement in the campaigns (a) made me strong and confident, (b) made me become a role model, and (c) made me think that I can achieve something. Involvement in health promotion campaigns seemed to empower the young women by increasing their confidence and providing a feeling of self-efficacy. In addition, their health literacy increased, which appeared to have a ripple effect on their families, peers, and the local community. The findings from this study provide insight into the participants' self-reported short-term effects. Moreover, with this study, it can be argued that by empowering individuals, community transformation can be seen as well.

Measuring and Exploring Children's Health Literacy in The Netherlands: Translation and Adaptation of the HLS-Child-Q15

As health literacy (HL) is hypothesized to develop throughout life, enhancement during childhood will improve HL and health during life. There are few valid, age-appropriate tools to assess children’s HL. The German-language European Health Literacy Survey Questionnaire Adapted for Children (HLS-Child-Q15-DE) is a self-report questionnaire adapted from the adult European Health Literacy Survey Questionnaire. This study aims to translate the HLS-Child-Q15 to Dutch and explore the sample’s HL distribution. The HLS-Child-Q15-DE was translated following WHO guidelines and administered digitally to 209 Dutch schoolchildren (eight-to-eleven-year-olds). Its psychometric properties were assessed and the sample’s HL distribution was explored by demographic characteristics. The HLS-Child-Q15-NL had high internal consistency (α = 0.860) and moderate to strong item-total correlations (mean = 0.499). For 6 of the 15 items, >10% of participants answered “do not know”, indicating comprehension problems. Higher HL scores were observed for ten-to-eleven-year-olds (compared with eight-to-nine-year-olds; p = 0.021) and fourth-grade students (compared with third-grade; p = 0.019). This supports the idea that HL evolves throughout life and the importance of schools in this process. With the HLS-Child-Q15-NL, a Dutch measurement instrument of children’s HL is available, although it needs further tailoring to the target group. More research is needed to decrease comprehension problems and to investigate retest reliability and construct validity.