Anna Aaby

Health literacy challenges are associated with greater risk and adverse outcomes of long-term conditions such as diabetes mellitus and contribute to persistent health inequalities. In response, increasing attention has been given to Organisational Health Literacy (OHL), which addresses how healthcare organisations can make health information and services more accessible and easier to navigate for users (def: people receiving care, treatment, education or health-related support from the organisation) with diverse health literacy needs. Despite the increased focus on the organisational perspective, most previous interventions have focused on individual health literacy. Thus, there is limited systematic evidence on organisational interventions designed to improve OHL and which mechanisms and contextual factors support and facilitate change. The aim of this paper is to describe the protocol for the implementation and evaluation of an OHL intervention (OHL-Act) across primary care and hospital settings caring for individuals with long-term conditions. The primary objective for the future project will be to evaluate whether the implementation of OHL-Act is associated with improvements in OHL across diverse healthcare organisations providing care and support for people living with long-term conditions. The OHL-Act comprises three workshops designed to strengthen OHL through facilitated reflections among staff and managers, a structured self-assessment of the organisation and identification and prioritisation of improvement ideas in a local action plan. The OHL-Act will be implemented in 8–10 Danish outpatient clinics and municipal units providing care and preventive services for people living with long-term conditions such as diabetes. A mixed-methods evaluation (2026–2029) will use the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework combined with the Practical, Robust Implementation and Sustainability Model (PRISM) to examine implementation processes, mechanisms of change and contextual factors. Data will be collected from surveys, organisational self-assessments, and implementation logs, as well as qualitative interview data. The study will generate insights into the implementation and effectiveness of the OHL-Act across healthcare settings and thereby give a deeper understanding of how OHL can be embedded in routine care and provide evidence of the development of more health literacy responsive and equitable healthcare systems.

Background: Organisational health literacy (OHL) is increasingly recognised as a system-level strategy to address health literacy-related inequities in healthcare, yet evaluation of practical OHL tools and frameworks remain limited. This study aimed to examine the implementation experiences of the Danish OS! to inform refinements, and to examine the feasibility of the refined version, renamed OHL-Act, in practice. Methods: A two-phase study guided by the RE-AIM framework was conducted. Phase 1 comprised a formative evaluation of OS! based on interviews from previous applications, informing refinement. Phase 2 involved feasibility testing of OHL-Act in a specialised diabetes centre. Results: Across implementing organisations, OS! was experienced as a practical approach supporting reflection and the generation of OHL improvement ideas, while also revealing barriers. These insights informed refinements, including clearer language, more structured facilitation guidance, and explicit prompts addressing health literacy challenges and high-risk situations. Feasibility findings indicated that OHL-Act could be delivered as intended and was perceived as acceptable, relevant, and useful in supporting reflection and the generation of OHL improvement ideas. Conclusions: OHL-Act represents a structured, co-creational approach to support OHL work. Further research is needed to examine how generated improvement ideas translate into sustained action and their potential implications for equity.

Objective. To estimate proportions of contacts to the general practitioner (GP) among people with specific and nonspecific lung cancer symptoms, respectively, in the Danish general population and to analyse the associations between health literacy and these contacts based on smoking status. Methods. A total of 67,280 randomly selected individuals aged ≥40 years were invited to a survey concerning symptoms and healthcare seeking. This study included lung cancer symptoms, GP contacts, smoking status, four aspects of health literacy, and socioeconomics. Descriptive statistics and multivariable logistic regression models were applied. Results. Of 22,055 respondents, 23% reported at least one specific lung cancer symptom, while 47% reported at least one nonspecific symptom. GP contacts ranged from 30% (tiredness) to 60% (shortness of breath). Individuals who currently smoke had lower odds of GP contacts. The health literacy aspect “Feeling understood and supported” increased the likelihood of GP contact, while “Having sufficient information” decreased the likelihood. Smoking status did not modify these associations. Conclusion. Efforts targeting individuals at risk of postponing healthcare seeking with lung cancer symptoms are needed. This study highlights aspects of health literacy that may be addressed in interventions increasing both individuals and community‐based health literacy responsiveness and enhanced chances of timely healthcare seeking.

Background: Improving childhood health is complex due to the multifactorial nature and interaction of determinants. Complex problems call for complex intervention thinking, and simple one-size-fits-all solutions do not work to improve childhood health. Early awareness is important, as behavior in childhood often is manifested across adolescence and into adulthood. To facilitate shared understanding of the complex structures and relationships that determine children’s health behavior, participatory system approaches in, for example, local communities have shown promising potential. However, such approaches are not used systematically within public health in Denmark, and before being rolled out, they should be tested for their feasibility within this context. Objective: This paper describes the study design for Children’s Cooperation Denmark (Child-COOP) feasibility study that is aiming to examine the feasibility and acceptability of the participatory system approach and the study procedures for a future scale-up controlled trial. Methods: The feasibility study is designed as a process evaluation of the intervention with the use of both qualitative and quantitative methods. A local childhood health profile will provide data for childhood health issues, for example, daily physical activity behavior, sleep patterns, anthropometry, mental health, screen use, parental support, and leisure-time activities. Data at system level are collected to assess development in the community, for example, readiness to change, analysis of social networks with stakeholders, rippled effects mapping, and changes in system map. The setting is a small rural town in Denmark, Havndal, with children as the primary target group. Group model building, a participatory system dynamics method, will be used to engage the community, create consensus on the drivers of childhood health, identify local opportunities, and develop context-specific actions. Results: The Child-COOP feasibility study will test the participatory system dynamics approach for intervention and evaluation design and survey objective measures of childhood health behavior and well-being among the ~100 children (6-13 years) attending the local primary school. Community-level data will also be collected. We will assess the contextual factors, implementation of interventions, and mechanisms of impact as part of a process evaluation. Data will be collected at baseline, at 2 years, and 4 years of follow-up. Ethical approval for this study was sought and granted from the Danish Scientific Ethical Committee (1-10-72-283-21). Conclusions: s: The potential of this participatory system dynamics approach includes opportunities for community engagement and local capacity building to improve children’s health and health behavior, and this feasibility study holds the potential to prepare an upscaling of the intervention for effectiveness testing. International Registered Report Identifier (IRRID): DERR1-10.2196/43949

BACKGROUND Improving childhood health is complex due to the multifactorial nature and interaction of determinants. Complex problems call for complex intervention thinking, and simple one-size-fits-all solutions do not work to improve childhood health. Early awareness is important, as behavior in childhood often is manifested across adolescence and into adulthood. To facilitate shared understanding of the complex structures and relationships that determine children’s health behavior, participatory system approaches in, for example, local communities have shown promising potential. However, such approaches are not used systematically within public health in Denmark, and before being rolled out, they should be tested for their feasibility within this context. OBJECTIVE This paper describes the study design for Children’s Cooperation Denmark (Child-COOP) feasibility study that is aiming to examine the feasibility and acceptability of the participatory system approach and the study procedures for a future scale-up controlled trial. METHODS The feasibility study is designed as a process evaluation of the intervention with the use of both qualitative and quantitative methods. A local childhood health profile will provide data for childhood health issues, for example, daily physical activity behavior, sleep patterns, anthropometry, mental health, screen use, parental support, and leisure-time activities. Data at system level are collected to assess development in the community, for example, readiness to change, analysis of social networks with stakeholders, rippled effects mapping, and changes in system map. The setting is a small rural town in Denmark, Havndal, with children as the primary target group. Group model building, a participatory system dynamics method, will be used to engage the community, create consensus on the drivers of childhood health, identify local opportunities, and develop context-specific actions. RESULTS The Child-COOP feasibility study will test the participatory system dynamics approach for intervention and evaluation design and survey objective measures of childhood health behavior and well-being among the ~100 children (6-13 years) attending the local primary school. Community-level data will also be collected. We will assess the contextual factors, implementation of interventions, and mechanisms of impact as part of a process evaluation. Data will be collected at baseline, at 2 years, and 4 years of follow-up. Ethical approval for this study was sought and granted from the Danish Scientific Ethical Committee (1-10-72-283-21). CONCLUSIONS s: The potential of this participatory system dynamics approach includes opportunities for community engagement and local capacity building to improve children’s health and health behavior, and this feasibility study holds the potential to prepare an upscaling of the intervention for effectiveness testing. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/43949

Background: Health services hold a critical role in mitigating the effect of health literacy challenges. Several tools and approaches have been developed to support health organizations in responding to their target population's health literacy needs. One of these is the OS! approach, which is an adapted and less rigorous version of the Australian Organizational health literacy responsiveness tool (Org-HLR). In this study, we aimed to report on our initial testing of the OS! approach in two Danish health care settings. Brief description: The OS! aim to prompt and support the development of local organizational health literacy improvement ideas. The process consists of three consecutive workshops focusing on reflection, self-evaluation, and prioritization. For each workshop tools are provided to support implementation. Implementation: The OS! approach was tested in two Danish municipal health centers (Tårnby Health Centre and Frederiksberg Health Centre), where both staff members and leaders took part in the processes ( N = 62 and N = 84). In Tårnby, the process was closely facilitated by the research team, while local managers was in charge of the implementation in Frederiksberg. Results: In both settings, the process succeeded in identifying a list of relevant prioritized action ideas aimed at improving local health literacy responsiveness. In both instances, leaders were able to integrate some of these ideas in action plans for the organizations nearby future. Lessons learned: We found the OS! approach effective in its aim to identify health literacy responsiveness improvement ideas and based on our experience also less arduous to implement than the Org-HLR. We also learned that good implementation of the OS! approach depends strongly on careful facilitation including thorough introduction of the concepts of health literacy, openness, and creativity in relation to local adaptions within the overall framework of the approach, and the consolidation of consistent leader support throughout the organization. [ HLRP: Health Literacy Research and Practice . 2022;6(3):e232–e238. ] Plain Language Summary: This study describes the initial testing of the OS! approach. The OS! approach is based on the Australian methodology “Org-HLR” and use a participatory approach to prompt and support the identification of local health literacy responsiveness improvement ideas in health care organizations. The article provides valuable experiences regarding local development of organizational health literacy in practice.

A pregnant woman needs adequate knowledge, motivation, and skills to access, understand, appraise, and apply health information to make decisions related to the health of herself and her unborn baby. These skills are defined as health literacy: an important factor in relation to the woman’s ability to engage and navigate antenatal care services. Evidence shows variation in levels of health literacy among pregnant women, but more knowledge is needed about how to respond to different health literacy profiles in antenatal care. This paper describes the development protocol for the HeLP program, which aims to investigate pregnant women’s health literacy and co-create health literacy interventions through a broad collaboration between pregnant women, partners, healthcare providers, professionals, and other stakeholders using the Ophelia (Optimising Health Literacy and Access) process. The HeLP program will be provided at two hospitals, which provide maternity care including antenatal care: a tertiary referral hospital (Aarhus University Hospital) and a secondary hospital (the Regional Hospital in Viborg). The Ophelia process includes three process phases with separate objectives, steps, and activities leading to the identification of local strengths, needs and issues, co-design of interventions, and implementation, evaluation, and ongoing improvement. No health literacy intervention using the Ophelia process has yet been developed for antenatal care.

Individuals with multimorbidity often have complex healthcare needs challenging their health literacy skills. This study aimed to investigate the association between the number of physical conditions and health literacy and to examine the difference in health literacy levels between individuals with multimorbidity based on physical conditions and individuals with additional mental disorders. Respondents aged 25 years or older from a Danish population-based survey were included (N = 28,627). Multimorbidity was assessed based on 18 self-reported chronic conditions; health literacy was measured using two scales from the Health Literacy Questionnaire focusing on understanding health information and engaging with healthcare providers. Associations were examined using multiple logistic regression analysis. We found a positive association between number of physical conditions and the odds of having difficulties in understanding health information and engaging with healthcare providers. For example, the adjusted odds ratio (OR) of having difficulties in understanding health information was 1.45 (95% confidence interval (CI): 1.09–1.94) for individuals with two physical conditions compared with individuals without multimorbidity. The associations formed a positive exposure–response pattern. Furthermore, respondents with both mental and physical conditions had more than twice the odds of having health literacy difficulties compared to respondents with only physical conditions (adjusted OR 2.53 (95% CI 2.02–3.18) and 2.28 (95% CI 1.92–2.72) for the scales, respectively). Our results suggest that responding to patients’ health literacy needs is crucial for individuals with multimorbidity – especially those with combined mental and physical conditions.

Background: The objective of the study was to examine the impact of health literacy on mortality in the general population and among individuals with cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), diabetes, and mental illness. Methods: Data from a large Danish health survey (n = 29,473) from 2013 were linked with national mortality registry data to permit a 6-year follow-up. Results: Individuals reporting difficulties in understanding information about health, had higher risk of dying during follow-up (hazard rate (HR) 1.38 (95% CI 1.11–1.73)) compared with those without difficulties. Higher risk was also observed among people reporting CVD (HR 1.47 (95% CI 1.01–2.14)), diabetes (HR 1.91 (95% CI 1.13–3.22)) and mental illness (HR 2.18 (95% CI 1.25–3.81)), but not for individuals with COPD. Difficulties in actively engaging with healthcare providers was not associated with an increase in the risk of dying in the general population or in any of the four long-term condition groups. Conclusions: Aspects of health literacy predict a higher risk of dying during a 6-year follow-up period. Our study serves as a reminder to healthcare organizations to consider the health literacy responsiveness of their services in relation to diverse health literacy challenges and needs.