Using co-design to develop the Adolescent Health Literacy Questionnaire for adolescents in Ireland.

Health literacy measurement studies are important for the success of health promotion efforts targeting adolescents. However, the majority of health literacy measurement tools were originally developed for adult populations and may not be reflective of health literacy in the context of adolescence. The present study sought to co-design a health literacy questionnaire and vignettes for adolescents in Ireland aged 12-18 years. This article describes the qualitative phase of the study. In 2019-2021, eight adolescents from the Irish Heart Foundation's Youth Advisory Panel participated in two concept mapping workshops during which they defined healthy living. Results of the thematic analysis indicated that adolescents defined 'healthy living' as a life that was balanced, prioritizing mental health and sleep. According to their definition, healthy living was comprised of six main constructs, namely, knowledge; sources of quality health information; facilitators and barriers; influence of others; self-efficacy, self-management and resilience; and citizenship and communication. These constructs were used to develop vignettes and items for the Adolescent Health Literacy Questionnaire (AHLQ). These were tested on a sample of 80 adolescents to check whether the respondents understood the items and vignettes as intended. Results of the nine cognitive interviews indicated that the adolescents understood the content of the 10 vignettes and 41 items. While the vignettes and AHLQ were developed with Irish adolescents, the approaches taken can be generalized to adolescents living in other countries. This will allow for the development of tailored and relevant solutions for health literacy development and health promotion for this sub-population.

Understanding needs and expectations to start effective communities of practice.

BACKGROUND: Communities of practice (CoPs) are frequently used in health settings to enhance knowledge and support action around public health issues. Yet, most are ineffective and often at risk of not delivering on this promise. To prevent loss of time and resources by organisations, facilitators, and members, this paper argues for a reliable assessment of the needs of people who intend to join and to set realistic expectations to assure effective communities of practice. This research proposes a valid and reliable needs assessment and analysis tool for starting communities of practice, by presenting the results of using such a tool. METHODS: Inception needs assessments were developed, tested and administered to 246 respondents entering five communities of practice that focused on one of three public health issues: health literacy, mental health literacy and trauma-informed care. One community of practice had a global audience, four were based in Australia. Data from the needs assessments were analysed qualitatively and supplemented with descriptive statistics. Results were used to develop an analysis tool to support future communities of practice. RESULTS: The short-term expectations of respondents included seeking to increase their knowledge and getting to know other members of the community of practice. Long-term expectations shifted towards undertaking action, collaborating and improving health outcomes. While respondents learning expectations included a wide range of topics, they articulated very specific knowledge they expected to share with others. There were high expectations of receiving practical support from the facilitator and a strong preference for meetings with synchronous interaction. Most respondents who planned to join focused initially on the direct and individual benefits and participation they expected from others, whereas they indicated limited intention to actively contribute to the learning needs of other community members. Respondents appeared to need to take time to build self-confidence and trust, and frequently applied a wait-and-see attitude. CONCLUSIONS: The findings of this study suggest that an inception needs assessment allows members to express their needs and expectations, which directly informs the direction and structure of a community of practice, gives voice to members, and supports facilitators in managing expectations.

Examining the nexus between medical education and complexity: a systematic review to inform practice and research.

BACKGROUND: Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research. METHODS: A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education. RESULTS: Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems. DISCUSSION: There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research. CONCLUSION: This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Codesign and community outreach to create COVID-19 safe communities: A Karen community case study.

During the COVID-19 pandemic, government directives for health and community services focused on building capacity for COVID-19 safe behaviors. During 2020-2021, there was mounting pressure to increase vaccination numbers to boost population-wide immunity, thereby enabling the lessening of pandemic response restrictions. The Australian population, in general, faced communication hurdles in understanding COVID-19, government directives and policies, and health initiatives. This was particularly challenging given the rapid changes in disease behaviors and community response requirements. This community case study documents local experience in delivering information about COVID-19 safety and vaccination to a former refugee community (the Karen community) in regional Victoria. Community outreach and codesign approaches established closer engagement between the Karen community and Bendigo Community Health Services (BCHS). This case study is explored through semi-structured interviews conducted face-to-face and via videoconferencing with key Karen community leaders, Karen community members, vaccination clinic volunteers, and BCHS staff and bicultural workers. A hybrid approach that employed community outreach and codesign approaches in tandem built trust and closer ties between the Karen community and BCHS, leading to increased understanding and compliance with COVID-19 safe messages and vaccination uptake. Community-led innovations included codesign of COVID-19 fact sheets and videos in the Karen language, involvement of "local champions," assisting Karen businesses with COVID-19 safe plans, and creation of a COVID-19 information hotline. The latter was facilitated by BCHS bicultural staff. These innovations supported the delivery of vaccination clinics at the local Karen Temple. Embedding multi-level, tailored, and responsive public health approaches is particularly important in complex settings where there are disproportionately high levels of community disadvantage, as occurred during the COVID-19 pandemic.

Application of the optimizing health literacy and access (Ophelia) process in partnership with a refugee community in Australia: Study protocol.

Refugees experience health inequities resulting from multiple barriers and difficulties in accessing and engaging with services. A health literacy development approach can be used to understand health literacy strengths, needs, and preferences to build equitable access to services and information. This protocol details an adaptation of the Ophelia (Optimizing Health Literacy and Access) process to ensure authentic engagement of all stakeholders to generate culturally appropriate, needed, wanted and implementable multisectoral solutions among a former refugee community in Melbourne, Australia. The Health Literacy Questionnaire (HLQ), widely applied around the world in different population groups, including refugees, is usually the quantitative needs assessment tool of the Ophelia process. This protocol outlines an approach tailored to the context, literacy, and health literacy needs of former refugees. This project will engage a refugee settlement agency and a former refugee community (Karen people origin from Myanmar also formerly knowns as Burma) in codesign from inception. A needs assessment will identify health literacy strengths, needs, and preferences, basic demographic data and service engagement of the Karen community. This community will be engaged and interviewed using a semi-structured interview based on the Conversational Health Literacy and Assessment Tool (CHAT) will cover supportive professional and personal relationships, health behaviors, access to health information, use of health services, and health promotion barriers and support. Using the needs assessment data, vignettes portraying typical individuals from this community will be developed. Stakeholders will be invited to participate in ideas generation and prioritization workshops for in-depth discussion on what works well and not well for the community. Contextually and culturally appropriate and meaningful action ideas will be co-designed to respond to identified health literacy strengths, needs, and preferences of the community. This protocol will develop and test new and improved methods that are likely to be useful for community-based organizations and health services to systematically understand and improve communication, services and outcomes among disadvantaged groups, particularly migrants and refugees.

Health literacy development is central to the prevention and control of non-communicable diseases.

The WHO's report Health literacy development for the prevention and control of non-communicable diseases (NCDs) delivers practical what-to-do how-to-do guidance for health literacy development to build, at scale, contextually-relevant public health actions to reduce inequity and the burden of NCDs on individuals, health systems and economies. The key premise for health literacy development is that people's health awareness and behaviours are linked to lifelong experiences and social practices, which may be multilayered, hidden and beyond their control. Meaningful community engagement, local ownership and locally driven actions are needed to identify health literacy strengths, challenges and preferences to build locally fit-for-purpose and implementable actions. Health literacy development needs to underpin local and national policy, laws and regulations to create enabling environments that reduce community exposures to NCD risk factors. Deficit approaches and siloed health system and policy responses need to be avoided, focusing instead on integrating community-based solutions through co-design, cognisant of people's daily experiences and social practices.

Distributive health literacy and medication management: A longitudinal qualitative study with Bhutanese former refugees in Tasmania.

ISSUE ADDRESSED: Tasmania, Australia is home to a population of Bhutanese former refugees who have resettled since 2007. Their refugee journey and disrupted education opportunities have resulted in gaps in literacy in their primary language (Nepali), and many suffer one or more chronic conditions (ongoing communicable or noncommunicable diseases (NCDs)). This research explored how this community perceives chronic conditions and managed their medication using the concept of distributed health literacy. METHODS: A longitudinal qualitative method was used whereby 15 former refugees and their carers were interviewed 3-4 times over 9 months. Data were thematically analysed using a hybrid approach of inductive and deductive coding and theme development. RESULTS: Four themes related to distributed health literacy were identified. These were "barriers to medication literacy and adherence," "support people as health literacy mediators," "understandings of chronic disease" and "strengthening distributed health literacy." Participants described managing relatively low levels of knowledge about their chronic conditions and medications by appointing support people who acted as health literacy mediators. This resulted in interactions with health professionals, information gathering and medication use being enacted collectively between family members. Carers felt responsible for supporting others who were new to the Australian health system to learn new skills in addition to assisting with tasks such as informal interpreting. SO WHAT?: Interventions to improve the health literacy of former refugees should focus on collective critical health literacy action rather than just the functional health literacy of individuals. Health literacy mediators are a vital form of support for former refugees managing chronic conditions, so must be included in education and support programs.

Training physiotherapists to be responsive to their clients' health literacy needs.

OBJECTIVE: To evaluate health literacy learning modules designed specifically for physiotherapists in private practice. METHODS: Mixed-method design was used, evaluating pre-post physiotherapist health literacy knowledge and competencies using questionnaires and semi-structured interviews. One rural and one metropolitan private physiotherapy practice were recruited. PARTICIPANTS: Clients, physiotherapists, and other clinic staff. The OPHELIA (Optimizing Health Literacy and Access) process was applied to identify the health literacy needs of clients; co-design interventions; and implement and evaluate the interventions. The health literacy learning modules were co-designed with the physiotherapists and included one 3-h face-to-face workshop, followed by two 1-h videoconference workshops. Health literacy knowledge (rated 1-5 for 10 items, max score 50) and skills (rated 1-5 for 5 items, max score 25) were assessed before and after the workshops. Data were analyzed by paired t-test. Interviews were recorded, transcribed, and thematically analyzed. RESULTS: Health literacy knowledge of 19 health professionals improved after the workshop by 63% (pre 26.0 (7.5), post 41.0 (2.7), p < .001). Health literacy skills improved by 65% (pre 4.2 (3.3), post 21.8 (2.3), p < .001). We identified three themes from interview data: 1) 'the multi-faceted nature of health literacy requires multiple strategies'; 2) 'changing practice to promote understanding'; and 3) 'reflection on roles of multidisciplinary private practice.' PRACTICE IMPLICATIONS: Improvements in health literacy knowledge and skills are possible through post-graduate professional development. CONCLUSION: Workshops changed physiotherapists' understanding of their role in promoting health literacy.

Are communities of practice a way to support health literacy: a study protocol for a realist review.

INTRODUCTION: Communities of practice are used for knowledge sharing and learning in health settings. However, more needs to be known to understand how they work, if they work different in different settings and what outcomes they might generate. Of particular interest is their potential role in health literacy development. METHODS AND ANALYSIS: This realist review will be undertaken in seven stages, aiming to develop a framework to show how the various contexts of communities of practice in health settings trigger mechanisms that lead to improved health literacy outcomes. The first stage of a realist review is considered important as it clarifies the scope of the review, yet it is rarely elaborated in detail. This paper describes this first stage in detail and shows how scoping techniques can support drafting an initial framework which can guide the rest of the review. After the initial scoping review, the subsequent stages follow an iterative and recurring process (until saturation is reached) that includes searching and appraising evidence, extracting and organising results, and analysing and summarising. The review will then generate conclusions and recommendations for stakeholders seeking to use communities of practice for their health literacy challenges. Findings of the scoping review are presented in this paper as part of the methods description to show the relevance of conducting a scoping review prior to a realist review. ETHICS AND DISSEMINATION: Ethical review is not required for this review. Experts and stakeholders will be involved in the process after the first stage to increase the quality of the process and to ensure practical relevance and uptake. This review focuses on communities of practice and health literacy, yet findings will likely be relevant for other health settings. Findings will be disseminated through stakeholders, publications, presentations and formal and informal reports.

School-Based Health Literacy Programs for Children (2-16 Years): An International Review.

BACKGROUND: Health literacy impacts children's health and educational attainment. Therefore, determining the most appropriate pedagogical design is critical. The long-term health benefits of health literacy for each child's life course further justify this imperative. School-based health literacy programs are of interest internationally. METHODS: We brainstormed the search terms and established inclusion/exclusion criteria for this systematic review. We searched 2 databases (CINAHL, ERIC) following PRISMA guidelines. Three authors screened and sorted the findings. RESULTS: We identified 21 relevant studies from 629 retrieved. Few (6/21) studies were situated in the primary school setting. CONCLUSIONS: This review found a variety of project designs, evaluation methods, and conceptual models. Descriptive analysis of the final 21 papers highlighted the importance of multicomponent design (whole-of-school and curriculum), cross-curricula integration, professional development for teachers, age of children, role of parents, and role of community. The results of this analysis may inform primary school program design in the future. Schools provide a logical setting for health literacy development. Despite the evidence that adolescence is too late, few studies have been situated in primary schools. Teachers lack confidence to teach health and need ongoing professional development. Parent, child, and community voices are essential for sustained engagement and program success.

Attributes and generic competencies required of doctors: findings from a participatory concept mapping study.

BACKGROUND: Medical education should ensure graduates are equipped for practice in modern health-care systems. Practicing effectively in complex health-care systems requires contemporary attributes and competencies, complementing core clinical competencies. These need to be made overt and opportunities to develop and practice them provided. This study explicates these attributes and generic competencies using Group Concept Mapping, aiming to inform pre-vocational medical education curriculum development. METHODS: Group Concept Mapping is a mixed methods consensus building methodology whereby ideas are generated using qualitative techniques, sorted and grouped using hierarchical cluster analysis, and rated to provide further quantitative confirmation of value. Health service providers from varied disciplines (including medicine, nursing, allied health), health profession educators, health managers, and service users contributed to the conceptual model's development. They responded to the prompt 'An attribute or non-clinical competency required of doctors for effective practice in modern health-care systems is...' and grouped the synthesized responses according to similarity. Data were subjected to hierarchical cluster analysis. Junior doctors rated competencies according to importance to their practice and preparedness at graduation. RESULTS: Sixty-seven contributors generated 338 responses which were synthesised into 60 statements. Hierarchical cluster analysis resulted in a conceptual map of seven clusters representing: value-led professionalism; attributes for self-awareness and reflective practice; cognitive capability; active engagement; communication to build and manage relationships; patient-centredness and advocacy; and systems awareness, thinking and contribution. Logic model transformation identified three overarching meta-competencies: leadership and systems thinking; learning and cognitive processes; and interpersonal capability. Ratings indicated that junior doctors believe system-related competencies are less important than other competencies, and they feel less prepared to carry them out. CONCLUSION: The domains that have been identified highlight the competencies necessary for effective practice for those who work within and use health-care systems. Three overarching domains relate to leadership in systems, learning, and interpersonal competencies. The model is a useful adjunct to broader competencies frameworks because of the focus on generic competencies that are crucial in modern complex adaptive health-care systems. Explicating these will allow future investigation into those that are currently well achieved, and those which are lacking, in differing contexts.

Engaging "hard-to-reach" men in health promotion using the OPHELIA principles: Participants' perspectives.

ISSUE ADDRESSED: Men in the Northern Suburbs of Launceston, Tasmania, experience substantially poorer health outcomes and socio-economic disadvantage than most Australians. They are often described as "hard-to-reach," meaning difficult to engage in research, health promotion, policy and planning. This paper summarises the OPHELIA process to combine health literacy profiling with engagement of local men in health promotion, and their experience of the process and outcomes. METHODS: Interviews were conducted to explore the experiences of middle-aged men with the OPHELIA process and subsequent interventions. RESULTS: Local data and health literacy profiling revealed experiences of isolation, lack of trust in the system, medication non-adherence, mental illness and chronic pain, which formed the basis for generation of ideas to improve their well-being and understanding of health. Tailored interventions were implemented, including suicide prevention, "Numeracy for Life" and "Healthy Sheds" courses. Interviews with six participants revealed that the process contributed to a sense of worth, social support and ability to break "old habits." CONCLUSIONS: Prioritising the lived experience of "hard-to-reach" men through the OPHELIA process resulted in co-design of interventions that were valued by participants. SO WHAT?: Health literacy profiling and genuine community engagement can empower vulnerable, under-represented communities to co-design, and engage in, health promotion.

HealthLit4Kids: Supporting schools to be health literacy responsive organisations.

ISSUE ADDRESSED: To reduce inequity, services and community organisations must respond to the health literacy needs and strengths of each individual accessing their services. As a social determinant, health literacy is compounded by interactions between the service provider, the individual, and their wider community. Schools provide a critical nexus between the teacher (as service provider), the student (as learner) and their family (carers and wider community) to support the development of children's health literacy. METHODS: Five Tasmanian primary schools (84 teachers) completed an assessment of their school in relation to the domains of a health literate organisation using the HeLLOTas! (HEalth Literacy Learning Organisations Tasmania) Self-Assessment Checklist, before and after taking part in the HealthLit4Kids program. RESULTS: While the differences between pre- and post-intervention ratings were not large, they moved in a positive direction for all six domains. There was a significant main effect of time, F (1, 4) = 83.9, P < .001, ƞ2  = 0.99, showing that overall ratings increased from before to after the intervention. Teacher-recommended actions across all schools were grouped for insight into their interpretation and application of the tool in the school context. CONCLUSION: Using the HeLLOTas! Self-Assessment Checklist served a dual purpose. Teachers developed a shared understanding of the characteristics of a health-literate organisation to produce a schoolwide action plan. Simultaneously, we gained valuable insights into the processes required to support the development of organisational health literacy in schools, and we share ten propositions applicable to other schools locally, nationally and internationally. SO WHAT?: To the best of our knowledge, this is the first time that a school's health literacy responsiveness has been measured. Our key propositions will support future efforts by policy makers, researchers and school principals.

Piloting an interprofessional chronic pain management program: Perspectives of health students and community clients.

Interprofessional learning (IPL) is vital for developing work-ready graduates of tertiary health professions and enhancing outcomes of patients with chronic pain. Twenty-two students from six health professions participated in or co-facilitated components of a 6-week group chronic pain management program. Twelve community clients with chronic pain and one family member participated. The program was piloted through the University of Tasmania Exercise Physiology Clinic and consisted of an initial assessment, weekly 1-hour group education sessions, and a 1-hour individualized, supervised exercise session. The program was evaluated using a constructivist approach via an investigator developed survey. Seven students and nine clients responded. A conventional content analysis was undertaken. Three categories were identified from students: Importance of IPL, Understanding Chronic Pain, and Improvement Suggestions. Three categories were identified from clients including Beneficial Aspects, Positive Peer Support, and Positive Pain Outcomes. Results indicate the program was beneficial for student learning and improved pain outcomes for participants. The model demonstrates value to student IPL and the potential to flexibly offer a real-world learning experience across many health professions, whilst addressing some of the common challenges associated with implementing IPL within curricula. The outcomes offer ways to explore sustainable implementation of the program long term.

Development and validity testing of the Adolescent Health Literacy Questionnaire (AHLQ): Protocol for a mixed methods study within the Irish school setting.

INTRODUCTION: Health literacy research has focused predominantly on the adult population, and much less is understood about this concept from an adolescent perspective. The tools currently available to measure adolescent health literacy have been adapted from adult versions. This limits their applicability to young people because of the developmental characteristics that impact on adolescents' behaviour, including impulse control and judgement skills. This protocol describes the intended development and validity testing of a questionnaire to measure health literacy in adolescents. METHODS AND ANALYSIS: This protocol describes this mixed methods study that has three phases: the first phase will involve grounded research with adolescents using qualitative group interviews, co-design and concept mapping workshops to understand what health and healthy behaviours mean to adolescents and to explore their health literacy needs and the potential domains for the questionnaire. The draft health literacy domains identified will be presented to the youth advisory panel, and the questionnaire will be altered based on their feedback. Cognitive pretesting of the questionnaire items will also be conducted. Phase 2 will involve piloting the questionnaire to a two-stage random sample of young people in five urban and rural schools in Ireland. Test-retest reliability will be conducted using Pearson correlation coefficient. Confirmatory factor analysis will also be conducted to analyse the psychometric properties of the questionnaire. Phase 3 will involve the questionnaire being rolled out to a nationally representative sample of adolescents (n=6052) in Ireland to assess their levels of health literacy. ETHICS AND DISSEMINATION: Ethical approval to conduct this study has been granted from the University College Dublin Human Research Ethics Committee - Sciences (LS-20-08). Informed assent from adolescents and informed consent from parents/guardians will be sought. The findings of this research will be disseminated at national and international conferences, as well as through publication in peer-reviewed journals.

Fostering Health Literacy Responsiveness in a Remote Primary Health Care Setting: A Pilot Study.

Primary healthcare organisations have an important role in addressing health literacy as this is a barrier to accessing and utilising health care. Until recently, no organisational development tool operationalising health literacy in an Australian context existed. This research evaluated the efficacy of the Organisational Health Literacy Responsiveness (Org-HLR) tool and associated assessment process in a primary healthcare organisation in the Pilbara region of Western Australia. This study utilised a sequential explanatory mixed methods research design incorporating the collection and analysis of data in two phases: (1) Pre- and post-survey data and; (2) seven semi-structured interviews. Survey results showed that participants' confidence in core health literacy concepts improved from baseline following the intervention. Analysis of the interview data revealed participants' initial understanding of health literacy was limited, and this impeded organisational responsiveness to health literacy needs. Participants reported the workshop and tool content were relevant to their organisation; they valued involving members from all parts of the organisation and having an external facilitator to ensure the impartiality of the process. External barriers to improving their internal organisational health literacy responsiveness were identified, with participants acknowledging the management style and culture of open communication within the organisation as enablers of change. Participants identified actionable changes to improve their organisational health literacy responsiveness using the process of organisational assessment and change.

How Did Parents View the Impact of the Curriculum-Based HealthLit4Kids Program Beyond the Classroom?

The HealthLit4Kids program aims to build health literacy in a participatory and contextually relevant way. Whole-of-school and curriculum strategies aim to empower and build capacity to make informed health choices amongst students, teachers, parents, and their local community. The aim of this study was to evaluate the HealthLit4Kids program from the perspective of parents, using a Self-Determination Theory framework. This is one component within a larger evaluation of the program. Parents at four Australian primary schools were interviewed post-program. Qualitative data collected through parent interviews were analyzed thematically to identify themes, and coding checks were completed by experienced qualitative researchers. The three key themes identified were student engagement, behaviour change, and parent engagement. Findings also indicated that parents placed a high value on effective communication from schools and raised a range of health areas such as food and nutrition, physical activity, and mental health with the interviewer. Parent opinions of the HealthLit4Kids program were positive, with many reporting a perceived increase in their children's ability to understand, communicate and act on health-related knowledge at home. The HealthLit4Kids program requires further research to determine its viability as an optimal pedagogical strategy for the health literacy development of primary school-aged children.

Health Literacy Studies Conducted in Australia: A Scoping Review.

Health literacy (HL) is an essential component of various literacies mentioned in the field of health and education, including cultural, technological, media and scientific literacies. It is important for motivating higher consumer engagement. We aimed to review previous studies of HL in Australia to inform future studies, extend current knowledge and further enhance HL. Using search strings, a systematic search of four databases (i.e., MEDLINE; Embase; CINAHL and Eric) was carried out. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) based search strategy led to identification of a total of N = 9696 records, that were further screened for inclusion in the review. The review findings were categorized into three major themes: (1) HL and health numeracy; (2) contrast of: knowledge deficiency, knowledge gained, problems of current health care system and (3) HL measurement methods and its domains. The findings from this scoping review show a dearth of measurement tools with sound psychometric properties for assessing HL. The findings also reveal low levels of HL in consumers which is in turn affecting health-related behaviors, utilization of health services and navigation of the health system. More recent developments have tried to integrate vital aspects, including introduction of applications to increase HL and exploring HL in Aboriginal communities.

HealthLit4Kids study protocol; crossing boundaries for positive health literacy outcomes.

BACKGROUND: Health attitudes and behaviours formed during childhood greatly influence adult health patterns. This paper describes the research and development protocol for a school-based health literacy program. The program, entitled HealthLit4Kids, provides teachers with the resources and supports them to explore the concept of health literacy within their school community, through classroom activities and family and community engagement. METHODS: HealthLit4Kids is a sequential mixed methods design involving convenience sampling and pre and post intervention measures from multiple sources. Data sources include individual teacher health literacy knowledge, skills and experience; health literacy responsiveness of the school environment (HeLLO Tas); focus groups (parents and teachers); teacher reflections; workshop data and evaluations; and children's health literacy artefacts and descriptions. The HealthLit4Kids protocol draws explicitly on the eight Ophelia principles: outcomes focused, equity driven, co-designed, needs-diagnostic, driven by local wisdom, sustainable, responsive, systematically applied. By influencing on two levels: (1) whole school community; and (2) individual classroom, the HealthLit4Kids program ensures a holistic approach to health literacy, raised awareness of its importance and provides a deeper exploration of health literacy in the school environment. The school-wide health literacy assessment and resultant action plan generates the annual health literacy targets for each participating school. DISCUSSION: Health promotion cannot be meaningfully achieved in isolation from health literacy. Whilst health promotion activities are common in the school environment, health literacy is not a familiar concept. HealthLit4Kids recognizes that a one-size fits all approach seldom works to address health literacy. Long-term health outcomes are reliant on embedded, locally owned and co-designed programs which respond to local health and health literacy needs.

Perceived Barriers to Managing Medications and Solutions to Barriers Suggested by Bhutanese Former Refugees and Service Providers.

INTRODUCTION: The purpose of this study was to explore perceived barriers to managing medications and potential solutions to such barriers among Bhutanese former refugees and service providers in Tasmania, Australia. METHOD: Thirty Bhutanese former refugees and service providers recruited through community health programs participated in a community-based participatory research design. Data were elicited through a structured focus group process and analyzed using content analysis. RESULTS: Perceived barriers to managing medications included language barriers, low health literacy, and culturally unresponsive interactions with services. Themes identifying potential solutions to barriers referred to the functional health literacy of individuals (providing reassurance, checking understanding, and involving support networks) and creating supportive health care environments (consistent service providers, culturally responsive care, assistance navigating services, using trained interpreters). DISCUSSION: Creating environments conducive to interactive and critical health literacy about medications is as important for culturally congruent care as supporting the functional health literacy of individuals.