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Health Literacy: online discussion

Health Literacy: online discussion.

Welcome to the online discussion on Health Literacy organised by the EBSN EPALE team!The discussion is open to everyone and will take place on this page between Monday, 6th (starting from 10.00 CET) and Tuesday, 7th November 2017. It will be moderated by Helen Casey, UK and the EBSN EPALE team.

Feel free to share your opinion and comment related to:

  • The situation of health literacy in your country
  • How to ensure the health systems more accessible to citizens
  • The role of adult education.

We would also be very interested to read (very) short case studies of health literacy initiatives, including links to documents and web resources that provide more information. It does not matter if these are not in English.

**Please note that comments may be over several pages. Please refresh the page and scroll to the bottom to click through to comments on other pages.**

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Hello all,

NALA looks at health literacy and numeracy in two ways:

1. people understand health information correctly and can make an informed decision and

2. health services communicate clearly and take account of possible health literacy and numeracy needs.

More information is in our factsheet here


In Ireland health literacy is in our Government's Framework for Improved Health and Wellbeing - Healthy Ireland. It has an action to "Address and prioritise health literacy in developing future policy, educational and information interventions."

NALA works with health services to see how they engage with people who have literacy and numeracy needs and helps them to become more health literacy friendly. We have developed health literacy quality standards for phamacies, general practices (doctor surgery) and hosptials. When asked we work with services to:

  • raise awareness of health literacy
  • audit their services
  • deliver workshops and training on general awareness and plain English


Crystal Clear programme

In 2015 Ireland’s first health literacy quality mark was launched by the National Adult Literacy Agency (NALA), Merck Sharp and Dohme (MSD), along with the Irish Pharmacy Union (IPU) and Irish College of General Practitioners (ICGP). The programme was developed to recognise the critical role general practices and pharmacies play in helping patients understand their health issues and the practical steps they can take to improve their health.

It is free to take part in the programme and the quality mark is given for two years. To get the mark, you complete the online audit. The audit asks nine questions under 4 areas:

  • Policies and procedures – 2 questions
  • Communications – 4 questions
  • Staff awareness – 2 questions
  • Evaluating and improving – 1 questions

You must also supply evidence such as photographs of clear signage, examples of clearly written letters and ways that staff communicate effectively with people in a literacy friendly way.

We developed a booklet to support pharmacies and general practices to become more literacy friendly and get the mark.

More information at: 


Supporting health and wellbeing in local communities through ‘Well Now!’

In 2015-6 NALA developed Well Now! – a 10-session course on health and wellbeingfor adults in the community. It was delivered using a partnership model of provision between a local authority, a local education provider and local health service professionals. You can find out more information at and the Well Now! guide has more detail on the course. You can also listen to those involved in this video at  


If anyone would like any more information on these initiatives, please email me at 


Kind regards,

Helen (NALA Policy Officer)


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Not mentioned in this thread so far are the exercise materials om health subjects on, the largest portal in The Netherlands specifically developed for lower educated (young) adults who want to improve skills with regard to language or literacy, numeracy and digital skills. These skills are embedded in subjects as health, work, parenting and money. In 2016 there were 656.693 accounts on this portal!

Individual work at home is free of charge. Organisations that want to work with must buy a license. An initiative strangely enough not funded by the national government!

Here you find the programmes with health subjects:

For instance Begrijp je lichaam (Know your body), De Thuisdokter (Home doctor), Gezond zwanger worden (Become healthy pregnant), Lees en Schrijf! Eten en weten (Read and Write. Eating and knowing) and Praten met je dokter (Talking to your doctor).

Most of these programmaes have additional worksheets, books and User/Teacher manuals.

All the programmes on have a low language level.

Lots of organisations and their students/clients work with For instance libraries in The Netherlands, organisations that employ people with disabolities, regional training centres and lots of other formal and non formal organisations. want to be the medium through which people can develop themselves. 'We always learn'.

The portal is offered by Stichting Experticentrum (Foundation Expertise Center in The Hague.

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Thank you everyone for your contributions to this discussion over the past two days. The moderated period  has now come to an end, but the discussion will remain open. 

I look forward to future discussions here and in the new forum that Graciela has announced. Do please visit the new forum at /en/private/ebsn-forum-health-literacy

Bye for now!

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The piloting of the “Health Development University” was finished in 2015. This project can be a good example for health literacy.

One and a half years ago, the development of a Health Development University concept was completed. Now we strive to test this model of higher education and introduce it over time.

The Health Development University Program is a comprehensive development process aimed at promoting health, living conditions and quality of life of campus citizens (students, teachers, employees). With this program, the university or college can increase its competitiveness, quality and reputation, improve attraction and reduce dropout rates. The Health Development University Program is a system-wide, comprehensive health-oriented organization development process that can affect all of the university's major areas of operation.

The fundamental aim of the University of Health Development is that the commitment to health should pass on the operation of higher education institutions and be emphasized in all their fields.

This thinking is integrated into the institution's structure, processes and organizational culture. It aims at realizing and exploiting the core potential of the institution, which is the result of its nature and situation, alongside promoting health and quality of life. This change is to be achieved in close, open, sincere cooperation with students, workers and the wider community, so that values, goals, processes, results become part of the institutional culture.

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Hi Alexandra, Thanks for the info about this interesting project, integrating health education across a university, ensuring health awareness throughout. I wonder whether the project also has the capacity to pay attention to the literacy levels needed for workers and the wider community to access the health information?

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Dear all,  thank you all for the nice examples! I would like to add, where you can find (In Dutch) some very nice examples of practices as well. One is a project in my home city, Nijmegen, about Health Literacy, there is a project called ‘eHealth4All’ and there is a link to an app called ‘Samen Starten’ which goal is to activate people. You can find information about a project in Zaanstad as well, where professionals learn how to reach several target groups. I hope this is inspiring for you all! Warm greetings!

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In following up various links during this discussion, I've come across several uses of the term health literacy to refer to sharing information about how to be healthy. This is also often called health education

An EPALE blog post last year discussed the definitions and various uses of the term health literacy :/en/blog/what-health-literacy. This discussion defined health literacy  as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions(link is external)."

Information about health education is clearly a key element here, with health literacy describing individuals' capacity to access that information using their literacy, language and numeracy skills. It is about having the literacy skills to access health information.

However there is another use of the term health literacy in circulation, that is to be literate in one's health (to know how to manage your own health), in the same way as we might describe someone as being financially literate (able to manage their money well) or visually literate (able to interpret all kinds of visual images, colours, shapes, textures etc). All of which causes potential confusion for those of us keen to focus on the literacy/communication element within the context of health education and medical treatment.

Do others also experience such confusions?

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Oops I forgot to say that I enjoyed doing the quiz and would recommend it to others. Some ideas there that could potentially translate into teaching material for health numeracy teachers (is this another new term to follow the notion of 'innumeracy' you mentioned earlier?)

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Dear all,

thanks for all the interesting links and comments on health literacy. Just thought to drop a few lines on the health literacy discussion and practices in Finland.

First of all, HL is fully integrated in the Finnish formal education system from 7th-9th grade and in general secondary education it is a separate compulsory subject, i.e. it has a prominent role in the general education and provides the citizens pretty comprehensive understanding of health issues. Over the recent years, more and more attention has been paid to health literacy among the VET sector (including AE in VET). It is also a compulsory module in the basic vocational qualifications and the Finnish National Agency has developed a passport for better occupational work capacity, which outlines the areas of health related to occupational work capacity. The passport is part of the common curricula for basic VET qualifications and it is described in terms of learning outcomes.

Furthermore, many tools have been developed to help monitor e.g. citizens' access to health and well-being services.


For senior citizens some municipalities offer so-called well-being passports from the day they retire. The passport entitles the individuals to participate in the guided swimming gymnastics courses etc. for a nominal price.

Unfortunately, there is very limited number of EN publications on different health literacy initiatives available. However, it appears that it is strongly integrated on all levels of governance in the Finnish society.

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Our discussions to date have not focussed specifically on the numeracy demands of health information. This is an area where our medical colleagues also have high levels of concern. As in the example NALA posted earlier, misunderstandings can end up in a legal process if things go badly wrong!

A recent example from England is :

I'm sure others are also focussing on the numeracy aspects of understanding health information. Do you have any examples to share?

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I am glad that you have raised numeracy in this discussion. It is a good opportunity to highlight the following resource ‘Newest Vital Sign’ available on Belfast Healthy City website. It is a quiz to test your Health numeracy skills, specifically related to nutritional information. The short activity only takes a few moments.


This quiz demonstrates the difficulties that individuals may face on a day-to-day basis if they have to follow a strict diet or are allergic to certain ingredients. Put this into context of an individual who is mathematically illiterate or ‘Innumeracy’ – a termed coined by mathematician John Allen Paulos - the consequences can have a huge impact on our health services.

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Good morning from sunny Helsinki! 

What an interesting discussion you have had here yesterday. Great projects and researches from Europe. Here is one research project form Finland:

Health Information Mastering (HIM), which is part of the Research Community INSPIRES (INStitutions and PractIces of new liteRaciES), focuses on investigating individuals´ information literacy and practices in different contexts, health in particular, to improve the effectiveness of health communication. 

At the initiative of Professor Maija-Leena Huotari, the research group developed a screening tool suitable for measuring the reading skills of health information. Screening is done by a survey in which the examinees evaluate themselves and their own abilities. 

The foci of studies are on tailoring health information and communication, producing patient value, analyzing content of web based weight management services, assessing health information literacy, and mastery of life. The contexts are health promotion and/or obesity prevention interventions, care paths for obese children, and everyday life of young men, adults and aging population. Results of this basic research are being applied in the development of health promoting interventions, health and well-being services and enabling technologies

You can find more information and publications from here.

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Hi Linda, Thanks for the information - it all sounds very interesting. You describe the screening tool that Professor Huotari's team have developed to measure the reading level of health information. When the health information is assessed as having a high reading level, are the team able to engage with the authors of the information to simplify the language level being used?


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Hi there, very interesting to read your comments here.

Earlier this year we produced a new booklet in Ireland called 'Plain English and the law'. The purpose was to show organisations how clear communication can save you time and money - and help you avoid court cases. It presents ‘lessons’ from three Irish legal cases where the interpretation of language was central to the outcome of the court case - one of the the legal case studies referred to a medical/ health related court case.

We have found that it's been really useful way to show the medical profession that plain English and health literacy isn't just a 'nice' thing to consider but can actually help you avoid litigation. Here's the link…



National Adult Literacy Agency

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Graciela talked earlier about the Norwegian expectation for all government institutions for follow Clear Language recommendations and a system of prizes for good example and "fog horn" warnings for foggy information. Does anyone know of other similar examples?

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Hi Helen,


Yes, there are a few examples in Dutch speaking communities in Belgium and The Netherlands that I know off that reward clear language for governmental publications:

  1. the Watblieft prijs ("Come again?"-prize) in Belgium for example rewards officials every year. For example read this article on EPALE /nl/content/wablieftprijs-2015-voor-jan-hautekiet-en-ann-de-craemer 
  2. The Community of Oss (in the South of the Netherlands) has a special Dag van de Klare taal (a clear language day). This governmental organisation has 40 coaches to assist colleagues in writing clearly. More information (in Dutch):…;
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Health literacy in Latvia is closely connected with the general accessibility of health care service and also with the literacy of the nation in general with regard to their health. There is a big reform going on in Latvia with regard to health care system and the discussion connected with the health care system helps promote the general awareness of health care issues. The issues discussed concern not only patients but mostly doctors who care for their patients and for the well-being of the nation. Thus, we can say that at this stage there is an overall interest in health care system and also support for more funding being allocated from the national budget towards health care which currently is being 3.07% of GDP. The target to be reached by the end of the 2020 is 4% of GDP.

One can speak of health literacy not only as self-directed provison and awareness of health care issues but also as of health care system available to everyone and everywhere in need which is where the reform is targeting at.

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Hello Silvija, Great to hear of the developments in Latvia. Do you have any links you could share to the work you have underway?

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In addition to Sivija's comment - link to presentations from the conference "Health Care System - Structural Reforms and Financing Models": and link to the comment and the presentation of the Bank of Latvia:

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The importance of health literacy is also acknowledged by the World Health Organisation (WHO) with a project called "Health Promoting School". Health promoting schools (HPS) promote healthy living to students and local communities trying to educate them on a variety of issues such as a healthy diet, alcohol tobacco use etc.…


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In one of the giving info-meeting  I hear about that The adequate Health literacy level in Turkey is :


According to REALM %58,7

According to NVS    % 28,1


And also survey about 23 cities and 4924 people of Turkey; only one of three have adequate and good health literacy. 1 of Ten people can be said excellent. The rest is have problematic or inadequate Health Literacy knowledge. This results are seem to equal to UK 61% .


I can say of course people need some knowledge about health and can get someway but this may be harmful if it is not under control of some kind of Authority.

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Hi Alper, a question and a request. 1. What is REALM? Can you post a link? Only 1 in 10 people with excellent health literacy (what we all need) is very worrying, but recognisable from teh UK context 2. Can you give some examples of ways in which you think that health literacy knowledge can be harmful?


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Hello David


Rapid Estimate of Adult Literacy in medicine : REALM is some kind of screening instrument. Here is the link for extra information :


For instance a person thinks he has got the ability on health literacy  about he gets the right information (from internet, books or neighbours) and do some (without consulting) wrong things and lose his/her health or get worse in some ways.

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Welcome to this discussion on health literacy. It seems to me that we need to consider both how we can help individuals improve their confidence in engaging with the health system and also what can be done to make health systems more accessible to people. I'm interested to hear your thoughts on this.

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Good morning!

Thank you for pointing out that there are two sides to this coin, Helen. Indeed, when we think of Health Literacy, we focus mostly on increasing the literacy level of adults so that they are more able to take care of their health. But an awful lot could be done to make health information more available. 

In Norway there is a governmental initiative called Klart Språk, Clear Language, which aims at simplifying the language of all governmental texts.

The web site is unfortunately only in Norwegian, but you will be able to get an idea:

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You're right Graciela that health literacy is not just about individuals, it's also about understanding and lowering barriers created by healthcare personnel and systems. In a previous EPALE blog Linda Shohet wrote about the development of Health Literacy polices in Canada in the mid-1990s in which the focus was on plain language/clear verbal communication. This later became a part of the Calgary Charter which called for health-literate systems that 'provide equal, easy, and shame-free access to and delivery of health care and health information'.

It would be good to hear from people who have worked with health professionals and policy makers to produce health-literate systems on any level.

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There have been a range of plain English campaigns and initiatives over the years but so often they are not used by those issuing information about what is often complex health information. What about in Norway, Graciela, what links are there to ensure that writers of health information get the benefit of the Klart Strachan/ Clear Language initiative? Do others have similar examples or interesting initiatives to help clarify health information?

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Helen, all governmental institutions in Norway are expected to follow the recommendations in Clear Language, and a number of tools have been developed to help them do that. It is not "enforced", but there are prizes for the best examples and institutions that publish obscure (foggy) information are publicly allocated a "fog horn" :-).

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