Health literacy is a broad concept that can be used in several contexts and can affect health in many ways. Besides being a determinant of health, health literacy is also a mediating and moderating factor for health (Pelikan et al., 2018).
Some people are more vulnerable to the risk of limited health literacy, and therefore health literacy is also associated with inequity in health (Nutbeam & Lloyd, 2021). For example, limited health literacy is more prevalent among people with lower literacy and educational skills, the chronically ill, the elderly, and various groups of migrants, including refugees (Kickbusch et al., 2013). In the absence of a one-size-fits-all model, it is therefore important to focus on the issue of inequity when working on health literacy in order not to leave anyone behind.
At the international level, the WHO has highlighted health literacy as a significant factor in achieving the Sustainable Development Goal, SDG on health (Goal 3). Health literacy is also a mediating factor in promoting a wide range of other SDGs (WHO Europe, 2021a; WHO, 2016).
Population-based surveys of health literacy in Europe
To know how health-literate a population is, it is relevant to measure and monitor health literacy in surveys. Implemented in 2009–2012, the European Health Literacy Project, HLS-EU produced a survey which provided, for the first time, a status of general health literacy at population level in the European Union, EU. Eight countries across the EU (although none from the Nordic region) participated in the project, in which the European health literacy survey questionnaire, HLS-EU-Q47, was developed and used to collect data on general health literacy. The HLS-EU-Q47 questionnaire operates on four levels of health literacy: inadequate, problematic, sufficient, and excellent. The study showed that almost half of the respondents (47.6 percent) in the total sample had limited (inadequate or problematic) general health literacy, with a prevalence range of 29–62 percent between the countries (Sørensen et al., 2015).
In 2018, the World Health Organization Regional Office for Europe, WHO/Europe, launched the Measuring Population and Organizational Health Literacy Action Network, M-POHL to gauge and generate data on population and organisational health literacy. This was to support evidence-based policy-making, decisions, and interventions. The M-POHL was initiated based on the recommendations of the report Health literacy: The solid facts, published by WHO/Europe and drawing also on the findings of HLS-EU (Gesundheit Österreich GmbH, n.d.a). The Health Literacy Population Survey Project 2019–2021, HLS19, is the first M-POHL project to collect comparative data on population health literacy across member states in the European region of WHO. The survey is intended to be conducted at regular intervals to report comparative trends over time. The HLS19 participants are 17 countries in the European region of WHO, including Denmark and Norway from the Nordic region (Gesundheit Österreich GmbH, n.d.b).
The International Report on the Methodology, Results, and Recommendations of the European Health Literacy Population Survey 2019–2021 (HLS19) of M-POHL shows the participating countries’ results in different types of health literacy they have chosen to study, such as digital health literacy, vaccination health literacy, etc. What all countries have measured is general health literacy, which they surveyed with the help of the HLS19-Q12 instrument, a short form of the HLS-EU-Q47 that was developed and used in the HLS-EU project.
The international report shows that across all participating countries, around 40 percent of respondents have a sufficient level of health literacy, while around 15 percent have an excellent level. On the other hand, about 33 percent have a problematic level of health literacy and 13 percent an inadequate level. In line with the HLS-EU project, when the categorical levels of inadequate and problematic health literacy are combined as limited health literacy, the resulting variation ranges at 25–72 percent between the countries. Compared to the HLS-EU, the variation between countries in this report is even more pronounced, which could be the result of a different methodology and different countries being included in the two studies.
The results from the Danish survey, in the international report, show that 36 percent have a problematic level and 11 percent an inadequate level of health literacy: as a whole, 47 percent of the Danish respondents had a limited level of general health literacy. Similarly, the Norwegian results in the international report show that 38 percent have a problematic level of health literacy, and 8 percent have an inadequate level, resulting in 46 percent having a limited level of general health literacy (The HLS19 Consortium of the WHO Action Network M-POHL, 2021).
Norway has published two national reports based on its own data from the HLS19 survey. These reports give deeper and slightly different insights into the health literacy situation in Norway than is shown in the international report. The report Befolkningens helsekompetanse, part I is based on a representative sample of the Norwegian population (including a total of 6,000 respondents from the age of 16 years). The study operates with three levels of general health literacy as measured by HLS19-Q12-NO. According to the findings, one out of three Norwegian respondents (33 percent) scored at or below level 1, which indicates a limited level of general health literacy (Le et al., 2021a). The report Befolkningens helsekompetanse, part II is built on data from five immigrant groups in Norway – Pakistan, Poland, Somalia, Turkey, and Vietnam (a total of 1733 respondents). Compared to the population’s level of general health literacy, a higher proportion of people with a background in Turkey and Vietnam are at or below level 1 for general health literacy. Somewhat unexpectedly, the study shows that a lower proportion of people with a background in Pakistan, Poland, or Somalia are at the same level. However, there is considerable uncertainty associated with the results of this study, and the findings should be read and interpreted with caution (Le et al., 2021b).
Health literacy in times of Covid-19
The outbreak of the 2019 coronavirus disease, Covid-19, not only started a health pandemic, but also caused an infodemic, a pandemic of misinformation. It spread rapidly through various social media platforms, posing a serious public health problem (Zarocostas, 2020). Correct and important information is mixed up with misinformation and fake news, and much of the information is not communicated in plain and understandable language (Dib et al., 2021; Stern et al., 2021). Understandable and plain information is important if people are to be able to interpret and act on it in an appropriate, health-promoting, and disease-preventing way. It requires health literacy, which is an underestimated problem in the context of Covid-19 (Paakkari & Okan, 2020).
Research indicates that people with limited health literacy to a higher degree than those with higher health literacy find Covid-19 information confusing and difficult to understand (Okan et al., 2021; McCaffery et al., 2020). Furthermore, associations have been found between limited health literacy and poor attitudes towards preventive strategies against Covid-19, less knowledge about Covid-19 symptoms, and preventing behaviours such as physical distancing, handwashing, and wearing a face mask (McCaffery et al., 2020; Okan, et al., 2021; Turhan et al., 2021). Moreover, associations have been found between limited health literacy and higher anxiety and fear regarding Covid-19, and vaccine hesitancy (Turhan et al., 2021; McCaffery et al., 2020).
Health literacy in the context of Covid-19 is important not only for people’s personal health, but also for public health in general and for social justice. People who do not follow restrictions or get vaccinated because of limited health literacy may put both themselves at increased risk of ill-health and risk the health of others. In the fight against Covid-19, everyone in society should take action.
However, it is also important not to stigmatise those with limited health literacy. Instead, the focus should be on the societal level and the importance of increasing organisational responsiveness to health literacy (Trezona et al., 2017). Therefore, the focus should be on making it easier for individuals in the society to access, understand, appraise, and understand information about Covid-19 and other important health issues.