COVID-19 research response to immediate demands: setting priorities with key stakeholders to enable health services research in NSW, Australia.

PURPOSE: COVID-19 has caused unprecedented disruption to health systems. There is much to be gained by capturing what was learned from changes and adaptations made by health services and systems. The Ministry of Health in New South Wales (NSW), Australia, sought to prioritise health services research (HSR) to address critical issues arising from the COVID-19 pandemic. We tested a priority setting methodology to create priorities for a specific funding opportunity and to extract generalisable lessons. DESIGN/METHODOLOGY/APPROACH: A virtual roundtable meeting of key stakeholders was held in June 2020. We used a modified Nominal Group Technique (NGT) for priority setting, with potential items (n = 35) grouped under headings. Data was analysed through a reflective deliberative process. FINDINGS: We engaged 89 senior policy makers, health service executives, clinicians and researchers in the roundtable. The NGT proved an efficient method with participants reaching consensus on eight priorities. Findings included strong support for learning from the rapid response to COVID-19 and addressing needs of vulnerable populations and the health workforce. Opinions differed about strategic areas investment and where learnings should be via internal evaluation rather than funded research. Three of the eight recommended priorities were included in the funding opportunity. RESEARCH LIMITATIONS/IMPLICATIONS: Coronavirus disease 2019 (COVID-19) required unprecedented change and adaptations within health systems, and rapid, applied health services research can help to create, understand and (where relevant) sustain change beyond the immediate impact of the pandemic. While final decisions may be dependent on a wider range of considerations by government, stakeholder enthusiasm for engagement in priority setting exercises may be dampened if they do not perceive their application in decision-making. PRACTICAL IMPLICATIONS: A modified nominal group technique can be used to set research priorities in constrained conditions by engaging large numbers of stakeholders in rankings and then using an online delivery of a roundtable and to reach consensus on priorities in real time. Recommended priorities for health services research can be readily generated through rapid engagement but does not guarantee their application. SOCIAL IMPLICATIONS: Australia's swift response to COVID-19 pandemic in 2020 was perceived as a relative success due to the rapid public health and policy response and a relatively low number of cases. This response was underpinned by systematic knowledge mobilisation including support for targeted and prioritised health services research to fill knowledge gaps. ORIGINALITY/VALUE: Setting priority processes can provide rich, engaged input to support government funding decisions about HSR. A wide range of dynamic and iterative processes influence decision-making in a rapidly evolving situation in the health system response to COVID-19. It is crucial to consider how major investment decisions will support a value-based healthcare system.

Qualitative Evaluation of a Health Literacy Program for Older Adults Who Live in a Community Dwelling in Brazil.

To address current gaps in health literacy research and practice in low-resource settings, the 'Alfa-Health Program' was designed to improve health literacy in older adults who live in a community dwelling in a socioeconomically disadvantaged community in North-East Brazil. In this longitudinal qualitative study, participants were interviewed before and after participating in the group-based program that was delivered November 2017 to December 2017 in the Primary Care Health Unit. Semi-structured interviews were guided by a previously validated health literacy instrument, translated and adapted for use in Brazil. Data was analyzed using Framework analysis. Of the 21 participants, the majority were age 60 to 69 years with a median of 4-years of school education. Our analysis identified self-reported improvements in health knowledge, behaviors, and skills that matched program content and indicated that participants were supported to manage their health conditions more autonomously. Other themes reflect the distributed nature of health literacy and the potential for group-based health literacy programs to facilitate feelings of social support and cohesion through co-learning. However, age-related deficits in memory and external and structural factors remained important barriers to program participation. This study provides insight into developing health literacy in low-resource settings with older adults, where health literacy is compounded by social determinants and cognitive and sensory changes that contribute to health disparities. Although the targeted Alfa Health Program addresses calls to ensure that priority is proportionate to need by reaching and engaging population groups who are disproportionately affected by low health literacy, further work is needed to adapt the program for people who are unable to read or write. [HLRP: Health Literacy Research and Practice. 2024;8(3):e140-e150.].

PLAIN LANGUAGE SUMMARY: Our team developed a health literacy program for older adults living in Brazil. We explored the impact of the program by interviewing participants before and after the program. Participants reported improvements in health knowledge, behaviors, and skills and reflected on feelings of social support that they received from the program. However, difficulties with memory and challenges getting to the program were important barriers to participation.

The value of health service-based research to health service organisations: a qualitative study with senior health service executives.

BACKGROUND: Research evidence has demonstrably improved health care practices and patient outcomes. However, systemic translation of evidence into practice is far from optimal. The reasons are complex, but often because research is not well aligned with health service priorities. The aim of this study was to explore the experiences and perspectives of senior health service executives on two issues: (1) the alignment between local research activity and the needs and priorities of their health services, and (2) the extent to which research is or can be integrated as part of usual health care practice. METHODS: In this qualitative study, semi-structured interviews were conducted with senior health leaders from four large health service organisations that are members of Sydney Health Partners (SHP), one of Australia's nationally accredited research translation centres committed to accelerating the translation of research findings into evidence-based health care. The interviews were conducted between November 2022 and January 2023, and were either audio-recorded and transcribed verbatim or recorded in the interviewer field notes. A thematic analysis of the interview data was conducted by two researchers, using the framework method to identify common themes. RESULTS: Seventeen health executives were interviewed, including chief executives, directors of medical services, nursing, allied health, research, and others in executive leadership roles. Responses to issue (1) included themes on re-balancing curiosity- and priority-driven research; providing more support for research activity within health organisations; and helping health professionals and researchers discuss researchable priorities. Responses to issue (2) included identification of elements considered essential for embedding research in health care; and the need to break down silos between research and health care, as well as within health organisations. CONCLUSIONS: Health service leaders value research but want more research that aligns with their needs and priorities. Discussions with researchers about those priorities may need some facilitation. Making research a more integrated part of health care will require strong and broad executive leadership, resources and infrastructure, and investing in capacity- and capability-building across health clinicians, managers and executive staff.

Exploring organisational readiness to implement a preventive intervention in Australian general practice for overweight and obese patients: key learnings from the HeLP-GP trial.

BACKGROUND: The HeLP-GP trial aimed to increase the capacity of practice nurses to deliver weight management to overweight and obese patients through an intervention comprising a health check, a lifestyle app and/or telephone coaching. This paper describes implementation through the lens of organisational readiness with emphasis on the role of the practice nurse. METHODS: Routinely collected mixed method research data including practice surveys, field notes, and diaries and process data were mapped against the domains: motivation to implement, general capacity and intervention-specific capacity. RESULTS: Organisational readiness varied considerably, particularly the domain of intervention-specific capacity. Practice nurse turnover negatively impacted the implementation, affecting half of the practices. We observed a general lack of practice-based support for intervention delivery, and varying levels of interest, skill and confidence in delivering the intervention. Nurses struggled to complete the research and intervention tasks in a timely way. Conducting risk assessments and referring to coaching were generally not problematic; however, we noted lower confidence levels with the lifestyle app and instructing patients to use it. CONCLUSIONS: We found a lack of general 'readiness' inherent in the nursing role, particularly related to their capacity to complete intervention tasks and practice-level support to implement the intervention. For nurses in general practice to fulfil their potential in supporting patients to reduce risk and adopt healthier life choices, our study indicates that more could be done to improve their workforce positioning and remuneration, which may, in turn, improve continuity of care, retention and individual motivation.

Development of a novel and more holistic approach for assessing impact in health and medical research: the Research Impact Assessment Framework.

Considered investment in health and medical research (HMR) is critical for fostering a healthcare system that is sustainable, effective, responsive, and innovative. While several tools exist to measure the impact of research, few assess the research environment that nurtures and supports impactful research and the strategic alignment of research with societal needs. This perspective article discusses the limitations of existing assessment tools and presents a novel Research Impact Assessment Framework designed to enable more strategic and targeted investment towards HMR, having the potential for significant public benefit.

Cardiovascular Disease Implementation and Policy Priorities for Australia: Recommendations From an Australian Stakeholder Roundtable.

The Australian Cardiovascular Alliance (ACvA), the Cardiac Society of Australia and New Zealand (CSANZ) and the National Heart Foundation of Australia (NHFA) recently joined forces to bring the cardiovascular and stroke community together to convene and document a national discussion and propose a national CVD Implementation and Policy agenda and action plan. This includes prevention and screening, acute care and secondary prevention.

Interview with inaugural Future Generations Commissioner for Wales, Sophie Howe: embedding a wellbeing approach in government.

In 2016, Wales became the first country in the world to appoint a Future Generations Commissioner - in essence a 'guardian' of the interests of future generations - under its Well-being Future Generations (Wales) Act 2015. The Act puts in place seven long-term wellbeing goals: a prosperous Wales; a resilient Wales; a more equal Wales; a healthier Wales; a Wales of cohesive communities; a Wales of vibrant culture & thriving Welsh language; and a globally responsible Wales. The Act also defines five 'ways of working' or principles that public bodies must demonstrate in decision making: thinking for the long-term, prevention; integration; collaboration; and involvement. The inaugural Commissioner, Sophie Howe, who held the role for seven years, reflects on the challenges and successes of leading transformational change to achieve a whole-of-government focus on wellbeing across policy and practice. In this interview with PHRP Editor-in-Chief Don Nutbeam, she shares some of the key lessons learned during her time in the role, including the need to embed the future generations approach in law, to set holistic, long-term goals - and to avoid blindly following measures and metrics.

Universal health information is essential for universal health coverage.

Universal access to health information is a human right and essential to achieving universal health coverage and the other health-related targets of the sustainable development goals. The COVID-19 pandemic has further highlighted the importance of trustworthy sources of health information that are accessible to all people, easily understood and acted on. WHO has developed Your life, your health: Tips and information for health and wellbeing, as a new digital resource for the general public which makes trustworthy health information understandable, accessible and actionable. It provides basic information on important topics, skills and rights related to health and well-being. For those who want to learn more, in-depth information can be accessed through links to WHO videos, infographics and fact sheets. Towards ensuring access to universal health information, this resource was developed using a structured method to: (1) synthesise evidence-based guidance, prioritising public-oriented content, including related rights and skills; (2) develop messages and graphics to be accessible, understandable and actionable for all people based on health literacy principles; (3) engage with experts and other stakeholders to refine messages and message delivery; (4) build a digital resource and test content to obtain feedback from a range of potential users and (5) adapt and co-develop the resource based on feedback and new evidence going forward. As with all WHO global information resources, Your life, your health can be adapted to different contexts. We invite feedback on how the resource can be used, refined and further co-developed to meet people's health information needs.

In it for the long haul: the complexities of managing overweight in family practice: qualitative thematic analysis from the Health eLiteracy for Prevention in General Practice (HeLP-GP) trial.

BACKGROUND: Australia has one of the highest rates of overweight and obesity in the developed world, and this increasing prevalence and associated chronic disease morbidity reinforces the importance of understanding the attitudes, views, and experiences of patients and health providers towards weight management interventions and programs. The purpose of this study was to investigate patients, family practitioners and family practice nurses' perceptions and views regarding the receipt or delivery of weight management within the context of the HeLP-GP intervention. METHODS: A nested qualitative study design including semi-structured interviews with family practitioners (n = 8), family practice nurses (n = 4), and patients (n = 25) attending family practices in New South Wales (n = 2) and South Australia (n = 2). The patient interviews sought specific feedback about each aspect of the intervention and the provider interviews sought to elicit their understanding and opinions of the strategies underpinning the intervention as well as general perceptions about providing weight management to their patients. Interviews were recorded and transcribed verbatim, and coding and management conducted using NVivo 12 Pro. We analysed the interview data using thematic analysis. RESULTS: Our study identified three key themes: long-term trusting and supportive relationships (being 'in it for the long haul'); initiating conversations and understanding motivations; and ensuring access to multi-modal weight management options that acknowledge differing levels of health literacy. The three themes infer that weight management in family practice with patients who are overweight or obese is challenged by the complexity of the task and the perceived motivation of patients. It needs to be facilitated by positive open communication and programs tailored to patient needs, preferences, and health literacy to be successful. CONCLUSIONS: Providing positive weight management in family practice requires ongoing commitment and an open and trusting therapeutic relationship between providers and patients. Behaviour change can be achieved through timely and considered interactions that target individual preferences, are tailored to health literacy, and are consistent and positive in their messaging. Ongoing support of family practices is required through funding and policy changes and additional avenues for referral and adjunctive interventions are required to provide comprehensive weight management within this setting.

Embedding health literacy research and best practice within a socioeconomically and culturally diverse health service: A narrative case study and revised model of co-creation.

BACKGROUND: Health literacy interventions and research outcomes are not routinely or systematically implemented within healthcare systems. Co-creation with stakeholders is a potential vehicle through which to accelerate and scale up the implementation of innovation from research. METHODS: This narrative case study describes an example of the application of a co-creation approach to improve health literacy in an Australian public health system that provides hospital and community health services to one million people from socioeconomically and culturally diverse backgrounds. We provide a detailed overview of the value co-creation stages and strategies used to build a practical and sustainable working relationship between a University-based academic research group and the local health district focussed on improving health literacy. RESULTS: Insights from our experience over a 5-year period informed the development of a revised model of co-creation. The model incorporates a practical focus on the structural enablers of co-creation, including the development of a Community of Practice, co-created strategic direction and shared management systems. The model also includes a spectrum of partnership modalities (spanning relationship-building, partnering and co-creating), acknowledging the evolving nature of research partnerships and reinforcing the flexibility and commitment required to achieve meaningful co-creation in research. Four key facilitators of health literacy co-creation are identified: (i) local champions, (ii) co-generated resources, (iii) evolving capability and understanding and (iv) increasing trust and partnership synergy. CONCLUSION: Our case study and co-creation model provide insights into mechanisms to create effective and collaborative ways of working in health literacy which may be transferable to other health fields in Australia and beyond. PATIENT AND PUBLIC CONTRIBUTION: Our co-creation approach brought together a community of practice of consumers, healthcare professionals and researchers as equal partners.

Preventing chronic disease in overweight and obese patients with low health literacy using eHealth and teamwork in primary healthcare (HeLP-GP): a cluster randomised controlled trial.

OBJECTIVES: To evaluate a multifaceted intervention on diet, physical activity and health literacy of overweight and obese patients attending primary care. DESIGN: A pragmatic two-arm cluster randomised controlled trial. SETTING: Urban general practices in lower socioeconomic areas in Sydney and Adelaide. PARTICIPANTS: We aimed to recruit 800 patients in each arm. Baseline assessment was completed by 215 patients (120 intervention and 95 control). INTERVENTION: A practice nurse-led preventive health check, a mobile application and telephone coaching. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were measured at baseline, 6 and 12 months, and included patient health and eHealth literacy, weight, waist circumference and blood pressure. Secondary outcomes included changes in diet and physical activity, preventive advice and referral, blood lipids, quality of life and costs. Univariate and multivariate analyses of difference-in-differences (DiD) estimates for each outcome were conducted. RESULTS: At 6 months, the intervention group, compared with the control group, demonstrated a greater increase in Health Literacy Questionnaire domain 8 score (ability to find good health information; mean DiD 0.22; 95% CI 0.01 to 0.44). There were similar differences for domain 9 score (understanding health information well enough to know what to do) among patients below the median at baseline. Differences were reduced and non-statistically significant at 12 months. There was a small improvement in diet scores at 6 months (DiD 0.78 (0.10 to 1.47); p=0.026) but not at 12 months. There were no differences in eHealth literacy, physical activity scores, body mass index, weight, waist circumference or blood pressure. CONCLUSIONS: Targeted recruitment and engagement were challenging in this population. While the intervention was associated with some improvements in health literacy and diet, substantial differences in other outcomes were not observed. More intensive interventions and using codesign strategies to engage the practices earlier may produce a different result. Codesign may also be valuable when targeting lower socioeconomic populations. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN 12617001508369) (http://www.ANZCTR.org.au/ACTRN12617001508369.aspx). TRIAL PROTOCOL: The protocol for this trial has been published (open access; https://bmjopen.bmj.com/content/8/6/e023239).

Addressing the Health Literacy Needs and Experiences of Culturally and Linguistically Diverse Populations in Australia during COVID-19: A Research Embedded Participatory Approach.

Communicating health information quickly and effectively with diverse populations has been essential during the COVID-19 pandemic. However, health communication practices are often top down and poorly designed to rapidly meet diverse health literacy, cultural and contextual needs of the population. This paper describes a research and practice partnership focused on health literacy, multicultural health, and community engagement to address COVID-19 in Australia. The partnership became influential in the local and state-based response to the COVID-19 Delta outbreak in Western and South Western Sydney, an area of high cultural and socioeconomic diversity. Our approach, bringing together academic researchers and frontline health staff working with multicultural populations using a model of co-design and community engagement and action via the "4 M model," has been successful. It supported the Western Sydney community to achieve some of the highest vaccination rates in the world (>90%). There is an ongoing need to engage respectfully and responsively with communities to address specific challenges that they face and tailor communications and supports accordingly for successful pandemic management. Combining co-designed empirical research with community engagement and action ensures needs are robustly identified and can be appropriately addressed to support an effective public health response.

A qualitative study to explore health literacy skills in older people from a disadvantaged community in Brazil.

We aim to describe older peoples' experiences of accessing, understanding, communicating and appraising health information in the context of primary care in a disadvantaged community in North-East Brazil. A qualitative interview study was conducted with 42 older people at two primary healthcare units in the city of Arapiraca, Brazil. Semi-structured interviews were guided by a qualitative health literacy instrument, translated and adapted for use in Brazil. Of the 42 participants, 30 were women and the majority (n = 32) were 60-69 years of age. Qualitative analysis identified that participants had difficulties accessing, understanding and communicating health information, often in the context of chronic disease. Few participants demonstrated an understanding about their specific health concerns, and most had difficulty explaining and interpreting health conditions more generally. Most participants indicated that they did not actively seek health information and this was compounded by physicians who were reported to provide limited information about diagnosis and treatment of health conditions. More than half of the participants reported that they did not understand medical terms included in health information, but most reported that they took no action to clarify understanding. In conclusion, we observed that conventional health literacy skills are very poor in this population of older Brazilians living in a disadvantaged community, with many resigned to not receiving health information or relying on sources other than health professionals. The findings from this study speak to the need for health literacy interventions targeting older adults in Brazil. A two-tiered approach which seeks to reduce the demands and complexities placed upon patients within the healthcare system but also targets interventions toward building the skills and capacities of individuals is likely to be most effective.

Building health literacy system capacity: a framework for health literate systems.

The human and social implications of poor health literacy are substantial and wide-ranging. Health literacy represents the personal competencies and organizational structures, resources and commitment that enable people to access, understand, appraise and use information and services in ways that promote and maintain good health. A large-scale societal improvement of health literacy will require political buy-in and a systematic approach to the development of health literacy capacity at all levels. This article builds the case for enhancing health literacy system capacity and presents a framework with eight action areas to accommodate the structural transformation needed at micro, meso and macro levels, including a health literate workforce, health literate organization, health literacy data governance, people-centred services and environments based on user engagement, health literacy leadership, health literacy investments and financial resources, health literacy-informed technology and innovation, and partnerships and inter-sectoral collaboration. Investment in the health literacy system capacity ensures an imperative and systemic effort and transformation which can be multiplied and sustained over time and is resilient towards external trends and events, rather than relying on organizational and individual behavioural change alone. Nevertheless, challenges still remain, e.g. to specify the economic benefits more in detail, develop and integrate data governance systems and go beyond healthcare to engage in health literacy system capacity within a wider societal context.

Health literacy represents the personal competencies and organizational structures and resources enabling people to access, understand, appraise and use information and services in ways that promote and maintain good health. To meet the needs related to impact of poor health literacy, this article introduces a framework for the development of health literacy system capacity with eight action areas including the development of a health literate workforce, health literate organization, health literacy data governance, people-centred services and environments based on user engagement, health literacy leadership, health literacy investments and financial resources, health literacy-informed technology and innovation, and partnerships and inter-sectoral collaboration. Investment in health literacy system capacity ensures a future-proof effort that can be multiplied and sustained over time, rather than relying on organizational or individual behavioural change alone.

From health education to digital health literacy - building on the past to shape the future.

Health education has continuously evolved and taken several distinctive forms over the decades. The emergence of new concepts such as health promotion and health literacy have helped to shape and refine our understanding of how the purpose, content and methods of health education can adapt with to new public health methods and priorities. Viewing health education through the lens of health literacy has been particularly helpful in differentiating between traditional task-focused health education, and skills-focused health education designed to develop more generic, transferable skills. The advent of digital media has enabled unprecedented access to health information but brought with it new challenges. Managing the volume of available information, and assessing its quality and reliability have become essential digital health literacy skills in the information age. As health educators we need to continue to adapt our practices to these new opportunities and understand the challenges that come with them.

Using Feasibility Data and Codesign to Refine a Group-Based Health Literacy Intervention for New Parents.

Few health literacy interventions exist for new parents. We developed a group-based health literacy program ("Parenting Plus"), which was initially tested in a feasibility study in 2018. In this brief report, we describe how feasibility findings were incorporated into the Parenting Plus program. Using a codesign process with patient partners (feasibility study participants) and health staff to revise the program, version 2 was tested in a single-site pilot using pre- and post-intervention testing. Parents older than age 16 years whose child was between ages 4 and 26 weeks were recruited from nurse home visits in western Sydney, Australia. Interested participants attended the free 4-week health literacy program (four 2-hour sessions) delivered by a trained facilitator. Piloting suggested the revised program is acceptable to new parents, has good retention (93% over the course of 4 weeks), and can improve health literacy skills, including access to reliable health information and services. Our iterative development and codesign approach integrated learnings from various sources to inform the design of an evidence-based health literacy intervention. We now move to an effectiveness implementation hybrid trial to test intervention effectiveness (health literacy skill development) and support translation of research findings into routine practice. [HLRP: Health Literacy Research and Practice. 2021;5(4):e276-e282.].