Stephan Van den Broucke

Health literacy and public health: A systematic review and integration of definitions and models

BackgroundHealth literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.MethodsA systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model.ResultsThe review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively.ConclusionsBased upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.

Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU)

Background: Health literacy concerns the capacities of people to meet the complex demands of health in modern society. In spite of the growing attention for the concept among European health policymakers, researchers and practitioners, information about the status of health literacy in Europe remains scarce. This article presents selected findings from the first European comparative survey on health literacy in populations. Methods: The European health literacy survey (HLS-EU) was conducted in eight countries: Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland and Spain (n = 1000 per country, n = 8000 total sample). Data collection was based on Eurobarometer standards and the implementation of the HLS-EU-Q (questionnaire) in computer-assisted or paper-assisted personal interviews. Results: The HLS-EU-Q constructed four levels of health literacy: insufficient, problematic, sufficient and excellent. At least 1 in 10 (12%) respondents showed insufficient health literacy and almost 1 in 2 (47%) had limited (insufficient or problematic) health literacy. However, the distribution of levels differed substantially across countries (29–62%). Subgroups within the population, defined by financial deprivation, low social status, low education or old age, had higher proportions of people with limited health literacy, suggesting the presence of a social gradient which was also confirmed by raw bivariate correlations and a multivariate linear regression model. Discussion: Limited health literacy represents an important challenge for health policies and practices across Europe, but to a different degree for different countries. The social gradient in health literacy must be taken into account when developing public health strategies to improve health equity in Europe.

Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q)

BackgroundSeveral measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations.MethodsBased on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish.ResultsThe development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors.ConclusionsBy illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.

Factors associated with prevalence and severity of caries experience in preschool children.

OBJECTIVES The aim of the present study was to examine the prevalence and severity of caries experience in the primary dentition of preschool children and to assess the association of disease distribution with oral hygiene levels, reported oral health behaviours and socio-demographic factors. METHODS Study samples comprised 1250 3-year-old and 1283 5-year-old pre-school children from four distinct geographical areas in Flanders. Information on oral hygiene and dietary habits, oral health behaviours and socio-demographic variables was collected using questionnaires completed by the parents. Clinical examinations were performed using standardized criteria. Caries experience was recorded at the level of cavitation (d(3) level). Simple as well as multivariable logistic regression analyses were performed in order to identify factors associated with prevalence and severity of caries experience. RESULTS Visible plaque was present in 31% of 3-year-olds and 37% of 5-year-olds. In 3-year-olds, 7% presented with caries experience while this was the case in 31% of 5-year-olds. Multivariable logistic regression revealed significant associations, in 3-year-olds, of caries experience with presence of dental plaque (OR = 7.93; 95% CI: 2.56-24.55) and reported consumption of sugared drinks at night (OR = 7.96; 95% CI: 1.57-40.51). In 5-year-olds, significant associations were seen with age (OR = 7.79; 95% CI: 2.38-25.43), gender (OR = 0.37 with 95% CI: 0.19-0.71 for girls), presence of visible dental plaque (OR = 3.36; 95% CI: 1.64-6.89) and reported habit of having sugar-containing drinks in between meals (OR = 2.60 with 95% CI: 1.16-5.84 and OR = 3.18 with 95% CI: 1.39-7.28, respectively for 1x/day and > 1x/day versus not every day). In 5-year-olds with caries experience (30.8% of total sample), the severity of disease was further analysed (d(3)mft between 1 and 4 versus d(3)mft 5 or higher). Multivariable analyses showed a significant association with gender [girls more likely to have higher disease levels; OR = 4.67 (95% CI: 1.65-13.21)] and with presence of plaque (OR = 3.91 with 95% CI: 1.23-12.42). CONCLUSIONS Presence of visible plaque accumulation and reported consumption of sugared drinks were associated with prevalence of caries experience in Flemish preschool children. Severity of disease was associated with gender and with presence of plaque. Results underline the importance of plaque control and diet management from very young age on.

Strengthening the capacity for health promotion in South Africa through international collaboration

Background. This paper describes a project to strengthen the capacity for health promotion in two Provinces in South Africa. The project draws on the key health promotion capacity dimensions of partnership and networking, infrastructure, problem-solving capacity, and knowledge transfer. The project was carried out in a partnership between the Provinces, the Ministry of Health of South Africa, the government of Flanders, Belgium, and the World Health Organization (WHO). Objectives. The project aimed to: (i) integrate health promotion into national, Provincial and district level health policy plans (ii) strengthen the health promotion capacity in the two Provinces; and (iii) support the development of tools to monitor and evaluate health promotion interventions. Method. Starting from a situation analysis and identification of priority health issues and existing actions in each Province, capacity-building workshops were organized for senior participants from various sectors. Community-based health promotion interventions were then planned and implemented in both Provinces. Outcomes. A systematic evaluation of the project involving an internal audit of project activities and results based on document analysis, site visits, focus groups and interviews with key persons demonstrated that stakeholders in both Provinces saw an increase of capacity in terms of networking, knowledge transfer, problem solving, and to a lesser extent infrastructure. Health promotion had been well integrated in the Provincial health plans, and roll-out processes with local stakeholders had started after the conclusion of the project. The development of tools for monitoring and evaluation of health promotion was less well achieved. Lessons learnt. The project illustrates how capacities to deliver health promotion interventions in a developing country can be enhanced through international collaboration. The conceptual model of capacity building that served as a basis for the project provided a useful framework to plan, identify and assess the key components of health promotion capacity in an African context.

Toward European consensus tools for reviewing the evidence and enhancing the quality of health promotion practice

Les notions de donnees probantes et de qualite prennent de l’importance dans la promotion de la sante. Alors qu’on attend de plus en plus des specialistes de la promotion de la sante qu’ils demontrent et qu’ils ameliorent la qualite de leurs actions, ceux-ci ne devraient pas se contenter d’adopter les concepts existants et les outils fournis par la medecine fondee sur les preuves et par l’assurance qualite telle qu’elle est appliquee dans la pratique medicale, et cela en raison de la nature complexe, dynamique et multisectorielle de la promotion de la sante. Afin de montrer si la promotion de la sante est efficace, quelles interventions marchent le mieux, et sous quelles conditions elles peuvent etre mises en oeuvre, le cadre actuel de la pratique basee sur les donnees probantes et sur la qualite a besoin d’etre elargi. Il est necessaire de developper et de s’accorder sur des criteres d’efficacite qui respectent la nature contextuelle, multidimensionnelle, emancipatrice et ethique de la promotion de la sante. De plus, un ecart important subsiste entre la recherche et la pratique, dans le sens ou l’etat actuel des connaissances sur les methodes efficaces de promotion de la sante pour differents themes et lieux de vie est meconnu des professionnels, et donc pas toujours applique. Pour faire face a ces questions, les chercheurs et les praticiens de la promotion de la sante peuvent utiliser des protocoles et des directives pour examiner et analyser les donnees probantes et ameliorer la qualite des interventions. A cet egard, de nombreux protocoles existent qui aident a analyser les informations recueillies sur l’efficacite de la promotion de la sante. Certains d’entre eux sont applicables a des questions multiples et dans divers lieux de vie, tandis que d’autres sont plus specifiquement thematiques et contextuels. De meme, de nombreuses directives ont ete mises a disposition pour ameliorer la qualite des interventions de promotion de la sante, et des outils ont ete developpes pour evaluer leur qualite. Le projet europeen GEP, « Getting Evidence into Practice » (Mettre en pratique les donnees probantes) part des directives et des outils existants pour faire avancer tout ce qui touche aux preuves d’efficacite et a la qualite. Outre le fait de presenter un etat des lieux des donnees probantes de la promotion de la sante et de les rendre plus accessibles aux praticiens, ce projet a pour but de creer un consensus entre specialistes europeens de la promotion de la sante sur le contenu et la forme a donner aux directives et aux outils d’analyse de la litterature, des documents et de la pratique pertinents pour la promotion de la sante, et d’utiliser les donnees probantes dans la pratique. Ce projet puise dans l’experience acquise dans plus de 25 pays quant a la ‘mise en pratique des donnees probantes’. Il s’agit de renforcer l’utilisation d’une large base de donnees probantes, en analysant et etablissant des criteres d’efficacite de la promotion de la sante fondee sur les preuves, et en en soutenant l’application par les praticiens. Pour mettre en commun cette experience, un consortium a ete forme qui regroupe des agences et des instituts de promotion de la sante de presque tous les Etats membres de l’Union Europeenne.

Type 2 diabetes self-management education programs in high and low mortality developing countries a systematic review

Purpose Although self-management education is a key factor in the care for diabetes patients, its implementation in developing countries is not well documented. This systematic review considers the published literature on diabetes self-management education in high and low mortality developing countries. The aim is to provide a state of the art of current practices and assess program outcomes, cultural sensitivity, and accessibility to low literate patients. Methods The Cochrane Library, PubMed, MEDLINE, PsycInfo, and PsycArticles databases were searched for peer-reviewed articles on type 2 diabetes published in English between 2009 and 2013. The World Bank and WHO burden of disease criteria were applied to distinguish between developing countries with high and low mortality. Information was extracted using a validated checklist. Results Three reviews and 23 primary studies were identified, 18 of which were from low mortality developing countries. Studies from high mortality countries were mostly quasi-experimental, those from low mortality countries experimental. Interventions were generally effective on behavior change and patients’ glycemic control in the short term (≤9 months). While 57% of the studies mentioned cultural tailoring of interventions, only 17% reported on training of providers, and 39% were designed to be accessible for people with low literacy. Conclusions The limited studies available suggest that diabetes self-management education programs in developing countries are effective in the short term but must be tailored to conform to the cultural aspects of the target population.

Public health and health promotion capacity at national and regional level: a review of conceptual frameworks.

The concept of capacity building for public health has gained much attention during the last decade. National as well as international organizations increasingly focus their efforts on capacity building to improve performance in the health sector. During the past two decades, a variety of conceptual frameworks have been developed which describe relevant dimensions for public health capacity. Notably, these frameworks differ in design and conceptualization. This paper therefore reviews the existing conceptual frameworks and integrates them into one framework, which contains the most relevant dimensions for public health capacity at the country- or regional level. A comprehensive literature search was performed to identify frameworks addressing public health capacity building at the national or regional level. We content-analysed these frameworks to identify the core dimensions of public health capacity. The dimensions were subsequently synthesized into a set of thematic areas to construct a conceptual framework which describes the most relevant dimensions for capacities at the national- or regional level. The systematic review resulted in the identification of seven core domains for public health capacity: resources, organizational structures, workforce, partnerships, leadership and governance, knowledge development and country specific context. Accordingly, these dimensions were used to construct a framework, which describes these core domains more in detail. Our research shows that although there is no generally agreedupon model of public health capacity, a number of key domains for public health and health promotion capacity are consistently recurring in existing frameworks, regardless of their geographical location or thematic area. As only little work on the core concepts of public health capacities has yet taken place, this study adds value to the discourse by identifying these consistencies across existing frameworks and by synthesising them into a new framework. The framework proposed in this paper can act as a theoretical guide for academic researchers and institutions to set up their own public health capacity assessment. Significance for public health As the concept of public health capacities is increasingly debated across countries and national/ international organizations, there is no consensus on the main dimensions of public health capacity. This paper therefore provides a rigorous review of currently existing frameworks, which describe public health capacities at the national or regional level. The main objective is to highlight commonalities among these frameworks, and propose a country-level framework which integrates all reoccurring dimensions. Such a comparison can yield vital information on those dimensions for public health capacities, which are common across all frameworks, and hence could be considered indispensable, irrespective of their context or geographic origin. As such, this review and the subsequent presentation of a conceptual framework is targeted at academic researchers and policy makers, who are interested in setting up a capacity mapping process and who are looking for concepts and frameworks on which they can base their work.

Assessment of implementation fidelity in diabetes self-management education programs: A systematic review

OBJECTIVE As diabetes requires extensive self-care, self-management education is widely recommended to enhance the effectiveness and reduce the costs of treatment. While a variety of diabetes self-management (DSM) programs are available, the conditions for their effective implementation are not well documented. This paper reviews the literature on implementation fidelity (IF), the degree to which programs are delivered as intended, as a factor influencing the effectiveness of diabetes education. METHODS Medical, psychological and educational research databases were searched to identify published studies on diabetes education describing the implementation process. Studies detailing the intervention adherence/fidelity/integrity were included to assess the way key elements of IF were addressed. RESULTS From an initial 418 abstracts, 20 published papers were retained for an in-depth analysis focusing on the components of IF. Intervention content was mainly assessed through observation, whereas intervention dose was more often assessed through self-report measures. Only one study addressed the relationship between IF and intervention effectiveness. CONCLUSION Despite the importance of IF to achieve program outcomes, IF of DSM programs remains largely under-investigated. PRACTICE IMPLICATIONS The results of this review suggest that reports on DSM education should systematically describe how the program was implemented. The impact of IF on program outcomes needs further investigation.

Construction and validation of a marital intimacy questionnaire

The degree of intimacy experienced in ones marital relationship significantly contributes to a persons physical, emotional, and psychological well-being. This contribution is attested by the growing number of research findings linking the failure to develop an intimate relationship with a partner to a variety of problems, including loneliness (Derlega & Margulis, 1982), marital dissatisfaction (Schaefer & Olson, 1981; Waring, McElrath, Mitchell, & Derry, 1981), physical illness (Reis, Wheeler, Kernis, Spiegel, & Nezlek, 1985), depression (Hickie et al., 1990; Waring & Patton, 1984), psychosomatic illness (Waring, 1983), and sexual abuse (Marshall, 1989). In view of these findings, it is not surprising to see that intimacy is increasingly recognized as a key characteristic of marital relationships, of which the importance is reflected in a large body of literature (for a review, see Van den Broucke, Vandereycken, & Veommen, in press). According to recent conceptualizations, marital intimacy may be regarded either as a process (i.e., a characteristic way of relating of two partners that develops over time), or as a state (i.e., a relatively stable structural quality of a relationship that emerges from this process; Acitelli & Duck, 1987). In the latter sense, it refers to a multidimensional construct, which may include such diverse aspects as reciprocal understanding, affection, self-validation, support, and commitment (Chelune, Robison, & Kommor, 1984; Reis & Shaver, 1988; Sternberg, 1988). Several of these aspects are contained in existing measures of marital intimacy. Examples of such instruments are the Personal Assessment of Intimacy in Relationships (PAIR; Schaefer & Olson, 1981), which provides information about the expected and perceived degree of marital intimacy in five areas (emotional, social, sexual, intellectual, and recreational); the Waring Intimacy Questionnaire (WIQ; Waring & Reddon, 1983), which measures eight components of intimacy (affection, expressiveness, compatibility, cohesion, sexuality, conflict resolution, autonomy, and identity); and the Intimate Bond Measure (IBM; Wilhelm & Parker, 1988), which assesses two dimensions of intimacy (care and control). All of these instruments have been empirically validated and their psychometric properties are well established. An important disadvantage, however, is that they are not based on a theoretical model of marital intimacy. As a result, it is not clear exactly what they measure. Although they all claim to assess marital intimacy, it is obvious that they are not tapping into the same dimensions, which raises concerns about their construct validity. Moreover, in want of a sound theoretical basis, the term intimacy is used in these questionnaires to indicate a heterogeneous mixture of variables, referring to both experiential aspects (e.g., cohesion or sexual fulfillment) and behavioral ones (e.g., expressing thoughts or resolving conflicts), and making no distinction between relational characteristics (e.g., compatibility), individual capabilities (e.g., expressing feelings), or qualities of the relationship between a couple and its social environment (e.g., autonomy towards ones parents). Thirdly, and perhaps most importantly, some of the dimensions assessed by the above instruments could be viewed as possible manifestations or outcomes of marital intimacy rather than as actual subdimensions of the construct. Sexuality, for example, has been found to correlate only moderately with marital intimacy (Patton & Waring, 1985). By including this aspect in an operational definition of intimacy, the latter, in fact, becomes a synonym for marital quality in general and does not add any new meaning to it. A THEORETICAL MODEL OF MARITAL INTIMACY A possible way to address the above shortcomings is to integrate theory formulation and test construction into a construct validation approach (Wiggins, 1973). …