Health literacy in the Nordic region 

There is a growing focus on health literacy in the Nordic countries, partly because the World Health Organization, WHO/Europe, and the EU are increasingly focusing on the issue. As mentioned earlier, Norway has a national strategy on health literacy, and Denmark and Norway have participated in the Health Literacy Population Survey Project 2019–2021 (HLS₁₉) study under the Measuring Population and Organizational Health Literacy Action Network (M-POHL).

Although the Nordic countries, from a national and strategic perspective, have only had a limited specific focus on health literacy in the past, they have previously, too, worked on interventions that can relate to or influence health literacy. Such work includes interventions focusing on health communication, and motivation and empowerment of people. This may well apply to projects based in other organisations and promoters.

The following country profiles for the Nordic region include an introduction to the countries’ general work and focus on health literacy at national and strategic levels. There are also some examples of initiatives and projects that have been launched or implemented with a focus (either exclusively or partly) on immigrant and refugee groups, and on women, with a view to strengthening health literacy at an individual and/or organisational level. 

These examples illustrate actions that can be taken to strengthen the health literacy of migrants and refugees, but it is not an exhaustive list of initiatives and projects. The majority of the examples have been selected either by the countries themselves or from literature on health literacy. 

Health literacy is the English and globally used term, but the Nordic countries have also translated health literacy into their own languages. In Finnish and Swedish, however, there is no consensus on any one translation of the concept of health literacy, and therefore several examples are given under the Finnish and Swedish translations.

Table 1: Health literacy translated into the Nordic languages

(Olander et al., 2020; Le et al., 2021a)

In 2009, the Danish Health Authority published a report on the concept, implications, and possible interventions of health literacy (Health literacy: Begrebet, konsekvenser og mulige interventioner). Based on international knowledge available at the time, the report highlights the concept itself and the consequences of limited health literacy. The report surveys what can be done and how to meet and improve a low level of health literacy and relate existing knowledge to Danish conditions. It also provides an overview of the concept of health literacy, possible health consequences, and available knowledge about interventions and their effect. This serves to prepare a basis for possible work with health literacy in a Danish municipal context (Sundhedsstyrelsen, 2009). Currently, the Danish Health Authority is working on a new publication on the concept of health literacy. The main focus is on health literacy responsiveness and how organisations within the health sector can use this concept to meet the differences in citizens’ health literacy as a means of targeting inequality in health.

In 2019, the Danish Society of Public Health and the Danish Health Literacy Network published the policy brief Health literacy from a structural perspective: A path to equity in health? in collaboration with Danish experts and practitioners. The policy brief includes eight recommendations to improve health literacy in Denmark from a structural perspective. The recommendations aim to prevent limited health literacy and its consequences for Danish citizens by targeting health services at the organisational level. Concrete measures and tools are introduced as a part of the recommendations to support their implementation (Aaby et al., 2019). 

The Danish Health Literacy Network is affiliated with the Danish Society of Public Health and seeks to spread awareness of health literacy in Denmark. The Danish Health Literacy Network is open to all. Currently there are more than 300 members engaged in teaching, research, and practice. Learn more about The Danish Health Literacy Network here.

Denmark is a member of the M-POHL network and participates in the M-POHL HLS₁₉ study.

LIVE is a collaboration initiated in 2020 between Aarhus Municipality and Aarhus University focusing on community responses to ethnic minority challenges on health literacy. 

A major health literacy challenge among ethnic minorities is the barrier to access healthcare created by inadequate abilities to find, understand, seek out, and use the relevant services. The aim of LIVE is to map local barriers affecting access to healthcare services and co-create initiatives to improve the collective local response to dealing with these barriers.

Located in the community of western Aarhus, LIVE has more than 15 local organisations involved in the project. Through group-based modelling, the organisations have mapped central factors and interactions, and have built a model of how they collectively experience local challenges in access to healthcare. Together they have then used the model for improvement ideas to initiate a range of locally owned initiatives based on local needs and local resources. Learn more about LIVE here.

MAMAACT is carried out as a large intervention and research project. It was launched in May 2017 and was completed in March 2021. Out of the 20 maternity wards in Denmark, 19 are MAMAACT members, and the project is estimated to reach 25,000 women.

The aim of the MAMAACT project is to change the social and ethnic inequity in maternal and child health in Denmark by strengthening the dialogue and communication between pregnant women and the midwives. The primary outcome of the project is that the health literacy of non-Western immigrant women will increase to the level that the ethnic Danish women possessed in the beginning of the project. 

Midwives are given a continuing education course in intercultural communication, and health education material such as a pictogram-based information folder, and an app in six languages. The folder and the app explain the most serious signals related to body signs of pregnancy complications, helping the midwives to communicate with the women about how they should respond to these signals. 

In some minority groups in Denmark, the risk of a stillborn child is almost twice as high than in the majority population. By increased and better communication between pregnant women and the midwives, some of these deaths can be avoided. The project will also lead to better health among newborns at birth and reduced infant mortality. Learn more about MAMAACT here.

Adult migrants learning Danish can also learn more about the human body, health, disease, and the Danish healthcare system through Sundhedsdansk, a free online learning platform. The material is developed by Region Zealand, one of the five administrative regions in Denmark, and is designed to be used in an educational context. However, as the material is internet-based, it can be used by anyone who wants to gain knowledge about health and disease and how to communicate with healthcare professionals. The material is intended to support migrants as active residents in Denmark who can act on their own health and the health of their family.

The material provides an opportunity to learn Danish words and concepts that are used in health and healthcare, from what is a health security card to being able to describe one’s own body experiences. The learners are also taught to listen to their bodies, and what symptoms to respond to and seek medical attention for. The learning platform also contains knowledge about risk factors for health, such as smoking and alcohol, and helps navigating the Danish healthcare system.

The material is interactive and the project helps to highlight different aspects of health literacy among migrants, such as communication, interaction, and navigation. Learn more about Sundhedsdansk here.

At present, Finland does not have a national strategy that focuses exclusively on health literacy. However, health literacy is a concept and a subject with a focus on the national agenda. 

To promote the learning of health-related competencies, Finland is the only country in the Nordic region so far to have adopted health literacy as a compulsory part of the national curriculum for basic education (WHO Regional Office for Europe, 2019b). Finland has a history of teaching health issues for more than a hundred years. With the introduction of the most recent Finnish national core curriculum for basic education in 2016, health literacy was adopted as the term covering the teaching objectives and learning criteria for the subject of Health Education in grades 1–9. Having health literacy as a curriculum-based component ensures that all school-aged children are offered the opportunity in an age-appropriate manner to acquire the competencies needed to promote and sustain their health and well-being. Similarly, the law lays out that Health Education teachers must have the required teaching qualifications, that is, such university-level studies in Health Education that clearly approach and focus on health literacy during the teacher training programme (Paakkari & Paakkari, 2019; Utbildningsstyrelsen, 2014).

Finnish pupils are in fact among the best informed school children about health in Europe partly due to the teaching of health literacy in schools through health education (WHO Regional Office for Europe, 2019b). To explore and measure Finnish adolescents’ subjective health literacy, the Health Literacy for School-aged Children instrument was applied as a part of the Finnish study of international Health Behaviour in School-aged Children in 2014. Representative data were collected among 3,833 respondents in 7^th and 9^th grade from 359 schools around Finland. The findings show that one third of the adolescents had a high level of health literacy, around 60 percent had a moderate level of health literacy, and the level of health literacy among some 10 percent of the respondents was low. In general, the health literacy level was lower for boys than for girls, and lower for 7^th graders than for 9^th graders (Paakkari et al., 2018).

Furthermore, the new Finnish national literacy strategy, which came out in 2021, targets people of all ages. The goal is to find models to promote literacy at national, regional, and local levels. Although it does not focus on health literacy explicitly, the strategy does consider health literacy by, for example, discussing the importance of multiple literacy and media literacy (Utbildningsstyrelsen, 2021).

Finland is currently not a member of the M-POHL network and did not participate in the M-POHL HLS₁₉ study.

InfoFinland.fi is a multi-language website providing vital information to people planning to move to Finland and to immigrants already living in Finland. The website also supports authorities with multi-language communications. In addition to Finnish and Swedish, InfoFinland.fi offers users reliable information in ten languages (for example, English, Russian, Somali, Persian, and Arabic) about moving to Finland and regarding work, studying, housing, education, health, family, problem situations, and leisure activities. The language versions are identical in content, and the information is updated continuously. Even though the website offers reliable information in different languages, it seems very heavy in text, and the website also lacks a service of reading the text out loud, which would probably help those to whom the website is aimed. 

InfoFinland.fi is funded by the state and the InfoFinland.fi member municipalities. Learn more about InfoFinland.fi here.

At this point, Iceland does not have any specific policies or strategies focusing solely on health literacy. However, the Directorate of Health in Iceland (DOHI) is interested in the topic and has put health literacy on the agenda in the annual workplan. The aim for 2021–2022 is to develop the work.

DOHI is also preparing a plan to increase health literacy among children and young people. Learning points will be taken from WHO (WHO Europe, 2021b) and the Schools for Health in Europe Network Foundation (Okan et al., 2020). The planning is still at the early stages, but what DOHI aims to do is prepare the data by drawing on the results from the project Health Behaviour in School-aged Children to establish a baseline. The plan is then to work with health promotion in schools to implement health literacy and to develop materials for schools. 

During the Covid-19 pandemic, DOHI has emphasised spreading the message about the epidemic and giving advice about determinants of health not only in Icelandic, but also in English and Polish.

As much as 70 percent of the population in Iceland live in or around Reykjavik. Recently the Municipality of Reykjavik published a public health policy which also includes actions aimed at health literacy.

Iceland is currently not a member of the M-POHL network and did not participate in the M-POHL HLS₁₉ study.

Fjölmenningarsetur is a Multicultural Information Centre that provides information about moving to or living in Iceland, including information about the Icelandic healthcare system. Individuals, associations, companies, and Icelandic authorities can also turn to the centre when they need support, advice, and information regarding immigrant and refugee matters in Iceland.

The Multicultural Information Centre seeks to enable every individual to become an active member of the Icelandic society regardless of their background or where they come from. The role of the centre is to facilitate interrelations between people of different roots and to enhance services to immigrants living in Iceland.

The website of the Multicultural Information Centre can be translated into more than 25 languages, but the pages can become very text-heavy and difficult for people with low literate skills. There is also a lack of images to support the text, and the website does not offer the possibility of having the text read aloud. Learn more about Fjölmenningarsetur here.

Iceland is one of many countries with limited knowledge of health literacy in the population as well as no valid health literacy measurement. A research team with Icelandic researchers in lead conducted a study to translate the short version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) into Icelandic, adapt the version, explore its psychometric properties, and establish preliminary norms. The HLS-EU-Q16 translation model included three steps: 1) translation and backtranslation of HLS-EU-Q16, including the specialists’ review, 2) cognitive interviewing of lay people, and 3) psychometric analysis with survey participants. The study concluded that the Icelandic version of the HLS-EU-Q16 is psychometrically sound, has a reasonably clear factor structure, and is comparable to the original model. This opens for possibilities to study health literacy in Iceland and compare the results internationally. The introduced translation model might furthermore be helpful for other countries where information on health literacy is missing in the absence of validated tools (Gustafsdottir et al., 2020). 

Norway is so far the first and only country in the Nordic region to have a national strategy for health literacy (Strategi for å øke helsekompetensen i befolkningen 2019–2023).

The strategy is a part of the Norwegian Government’s effort to create the patient’s health service (pasientens helsetjeneste), which implies that patients and healthcare users have the knowledge and abilities to take care of their own health in the best possible way. The healthcare sector must involve patients in the decision-making concerning them and their health by asking the question ‘What is important to you?’ Sufficient health literacy is a precondition to realising the patient’s health service (Helse- og omsorgsdepartementet, 2019). 

The overall aim of the strategy is to increase health literacy in the Norwegian population. To do so, different types of measures and instruments can be applied, such as actions aimed directly at the whole or sections of the population, or system-oriented measures that indirectly affect people’s health literacy. For example, in discussing how to increase health literacy, the strategy points out that healthcare professionals must be able to use health communication and health pedagogy in their job with different individuals, and there must be more focus on information from the health and care services in clear language that is easy to understand, appraise, and apply. The strategy is primarily targeted at healthcare professionals, decision-makers, and patient and user organisations (Helse- og omsorgsdepartementet, 2019).

Norway is a member of the M-POHL network and participates in the M-POHL HLS₁₉ study. Norway has published two reports on the results of the Norwegian HLS₁₉ survey: Befolkningens helsekompetanse (part I), based on a representative sample of the Norwegian population, and Befolkningens helsekompetanse (part II), based on data from five immigrant groups in Norway.

Sunn Start was launched in 2017 to improve health literacy among migrants and refugees in Norway. Sunn Start is a free preventive teaching and guidance pack with focus on food and health, mental health, and dental health.

The target group for Sunn Start are newly arrived people in Norway, as well as people who have lived in the country for a long time but have low language skills and/or a low understanding of health information.

The material has been developed by Migration Health in the Health Service, Oslo Municipality, in collaboration with other actors including migrants to better target the material to the key group. 

The Sunn Start material can be used by volunteers who work with migrants, in introduction programmes for newly arrived, employees in the municipality, health personnel, and others. 

Sunn Start helps to improve functional, interactive, and critical health literacy among migrants and refugees, which gives them a healthier everyday life. Learn more about Sunn Start here. 

Zanzu.no was launched in 2019 and is developed by the Norwegian Directorate of Health in collaboration with relevant representatives from other executive agencies, healthcare providers, and NGOs. Zanzu was first created as a joint effort by the Belgian sexual health and rights organisation Sensoa and German Health Authorities, financed by the EU Health Programme and supported by an international expert council including members of the WHO. Currently, in addition to Norway, the site has been adopted in the Netherlands, Belgium, and Germany. 

Zanzu.no is a website with information on sexual and reproductive health and rights, primarily intended for recently arrived immigrants and people with a limited understanding of the Norwegian language. The Norwegian website is available in nine languages, including Farsi, Arabic, and Somali, thus covering the main immigrant groups in Norway. The pages of the website are written in plain language and make use of visual communication. Furthermore, zanzu.no has a text-to-audio function to reach people with language difficulties/illiteracy. The site can both be used directly by the target audience and as a tool to aid communication between health professionals and patients. Learn more about Zanzu.no here.

At present, Sweden does not have a national strategy that focuses exclusively on health literacy. The Public Health Agency of Sweden is interested in the topic but has not yet decided on whether and how the concept of health literacy should be addressed in the agency’s work.

An unpublished report on health literacy serves as a decision basis to the management group at the Public Health Agency regarding the future focus/work on health literacy on a strategic level in Sweden. The report describes different concepts of health literacy and how they are used internationally and nationally from a population and an organisational perspective, but the decision-making process has been stalled by the Covid-19 pandemic.

Sweden has a website on health literacy in Swedish, with national and international information and knowledge on health literacy. The website is run on a voluntary basis by two Swedish health literacy researchers. The website contains, for example, knowledge about measuring health literacy. Many different instruments aimed at measuring health literacy at population level have also been translated into Swedish and into several of the languages spoken by many refugees (for instance, Arabic, Somali, and Dari). The existing instruments are two short forms of the European Health Literacy Questionnaire (HLS-EU-Q16 and HLS- EU-Q6), the Swedish Functional Health Literacy Scale (S-FHL scale), and the Swedish Communicative and Critical Health Literacy Scale (S-C &C HL scale) measuring various dimensions of general health literacy. In addition, there are eHEALS, measuring electronic (also called digital) health literacy. Learn more about the Swedish website on health literacy here. 

Sweden was an observer of the M-POHL network until the end of 2021 but did not participate in the M-POHL HLS₁₉ study.

KomHIT Flykting was carried out in Region Västra Götaland at the Dart Centre for Augmentative and Alternative Communication and Assistive Technology at Sahlgrenska University Hospital. The project ended in 2019, but project material is still available online.

The project was launched to develop support for information and communication in healthcare and dental care between the healthcare professionals and refugees. The material consists of so-called image supports (information sheets, etc.) with norm-critical photos showing different situations in health and dental care. As a supplement to the photos, words explain the situation in both Swedish and a relevant language of the refugee. The material is translated into ten languages and can be used as a supplement to or in combination with an interpreter. 

Combining photos with words limits the risk of misunderstandings. The communication material serves to increase the healthcare professionals’ cultural competences and helps to improve the migrants’ functional, communicative, and critical health literacy. The material is free to use, available online, and is used among different actors and organisations both in Sweden and internationally. Learn more about KomHIT Flykting here.

MILSA is a research-based support platform for migration and health, and hosts various projects. One of these projects, the MILSA educational platform for civic and health communication, aims to increase the capacity for the dissemination of qualitative civic orientation and to implement health communication within the civic orientation programme in Sweden. The project collaborated with universities and experts in various fields, county administrative boards, regions, municipalities, and civil society organisations at both national and international levels and was supported by the European Social Fund and the Swedish Ministry of Health and Social Affairs. 

In 2018–2021, almost 200 cultural mediators working as communicators within civic orientation participated in the education programme which consisted of 22 online modules, supplemented with practical training sessions and on-site meetings. General areas of knowledge included social studies, health, communication, and learning. The education had a strong health literacy perspective, and one module focused on health literacy specifically. In this the participants learned about the concept of health literacy, why it is important, how to promote the health literacy of newly arrived refugees, and how the participants could facilitate the civic orientation of those with limited health literacy (for example, by making civic orientation more health literacy-friendly). On the course agenda were also source criticism and the health literacy-friendly method Teach-back, which aims to improve the quality of the communication and enable the professionals to control that the information they are giving is understood. Evaluations of the project show that most of the participants now work in a more health literacy-friendly manner and promote health literacy in their daily work of civic orientation. Furthermore, health communication is now integrated into civic orientation in more regions in Sweden than before. Learn more about the present MILSA project here. 

In another MILSA project, running until 2023 and also funded by the Swedish Ministry of Health and Social Affairs, cultural mediators are trained as study circle leaders in order to run such circles on mental health for newly arrived refugees. The project thus aims to promote newly arrived refugees’ mental health literacy and mental health. Mental health literacy is a more specific form of health literacy that focuses on knowledge and thoughts about mental illness and how it can be identified, managed, or prevented (Jorm et al., 1997). The concept has four dimensions: 1) understanding how to obtain and maintain positive mental health, 2) understanding mental disorders and their treatments, 3) decreasing stigma related to mental disorders, and 4) enhancing help-seeking efficacy (Kutcher et al., 2016). Evaluations indicate that cultural mediators’ mental literacy has been promoted by participation in this training (Wångdahl & Engström, 2021). Furthermore, the refugees’ mental health literacy tends to increase through participation in a study circle about mental health led by the cultural mediators (Wångdahl, 2021). As the research is ongoing, more reliable and in-depth results will follow in the coming years. Learn more about the present MILSA project here. 

A toolbox for health literacy-friendly organisations has been compiled in a project within the network for health-promoting healthcare in Sweden (HFS-nätverket). The toolbox consists of material that can be used by healthcare organisations wanting to work actively to make it easier for people to access, understand, evaluate, and use information and services related to healthcare and health. The material is intended to provide a basis for increasing the understanding and awareness of issues related to health literacy and health literacy-friendly organisations, and to offer practical tools that can be used in the meeting with patients in daily activities. Examples include a checklist for health literacy-friendly organisations, leaflets about the Teach-back communication method and how to promote questions from patients, and infographics about health literacy and source criticism. Learn more about the Toolbox for health-literate organisations here.