Health literacy improves lives and reduces health inequities. Building up people’s competencies and knowledge regarding health can empower them and boost their resilience, helping them in managing their health and wellbeing in complex healthcare systems. Promoting health literacy can boost the health of future generations and allow healthcare professionals and their organisations to better engage with people in a patient-centric way. Not only is it a key determinant of health, health literacy can create “herd immunity” against misinformation and disinformation, challenges which are growing since the covid-19 pandemic.

This report by the Economist Intelligence Unit explores recent evidence in the field of health literacy, with a focus on its impact, challenges, solutions and opportunities. The following set of priorities can be drawn based on findings from the research to engage people, healthcare professionals, providers and policy makers:

Definitions and overarching policy

• As healthcare systems grow in complexity and public health challenges such as covid-19 emerge, health literacy is becoming a more necessary asset. A multidimensional concept, health literacy can be defined as the competencies for accessing, understanding, appraising and acting on information for the benefit of health. The value of health literacy has been examined by the academic literature across a wide range of dimensions. For example, at the personal level, health literacy allows people to make better decisions regarding their own self care and health, resulting for example in timely and effective use of health care and prevention services. Similarly, it allows for a successful management of chronic diseases, including better treatment. These actions can translate into better health outcomes and appropriate utilisation of health services. At the collective level, health literacy can support the efficiency of health services, which may result in reduced health system pressures. Good health literacy is likely to result in more effective individual behaviours conducive to improved public health, a key tool to help address global challenges, such as covid-19 today. 
• Even though there are limitations in measuring and comparing the status of health literacy among populations, survey-based studies have shown that deficiencies exist even in highly developed countries. For example, across eight European countries, nearly one in two of the respondents showed inadequate or problematic health literacy in 2012. Low health literacy has been associated with low levels of formal education, low income, and in people who are older or are less fluent in local languages (for example, migrants). Furthermore, people living with intellectual disabilities might be heavily impacted by health literacy limitations, but anyone can face health literacy challenges during particular points in their life. This study also identified that culture and traditions also influence notions of health literacy. For example, in certain low and middle income countries health learning and decisionmaking is a shared experience involving families and communities (to a greater extent than in the West). 
• In an EIU snapshot analysis of health literacy initiatives across seven countries from different regions of the world, Australia and the US stand out with consistent policy efforts to improve health literacy further. These countries have produced dedicated strategies and resources that continue to influence policy today. Following behind are England and France, where even though no dedicated policies are observed, health literacy (as a distinct concept) features within government-funded healthcare programmes and resources. A nascent status of the field is observed in India, Mexico and South Africa, where no dedicated policy was observed but health literacy is indirectly addressed through health promotion programmes. Outside of this group, Austria’s health literacy project stands out with the creation of a dedicated body driving and coordinating health literacy efforts.

                                                                     EIU snapshot analysis of health literacy policy and initiatives in seven countries

Health literacy and the healthcare sector

• Health literacy requires combined action from individuals, healthcare providers and healthcare systems. Encouragingly, policies and initiatives are emerging from the healthcare sector. The US is training healthcare professionals in health literacy, where federal agencies have produced a rich variety of resources for continuing education (such as online training). Initiatives are also taking place in Australia at the state level, while health literacy is gaining prominence in medical schools. In England, most of the effort focuses on making online resources available to healthcare professionals. Numerous techniques to improve health literacy between healthcare professionals and patients are available, some of the most commonly discussed are “teach back” and “plain language”. 
• Integrating health literacy measures into the accreditation of healthcare providers is a promising policy tool to boost health literacy principles at a healthcare system level. Among seven countries examined by the EIU, Australia showed the strongest regulatory framework. Multiple health literacy dimensions are incorporated within the National Safety and Quality Health Service Standards, a system of mandatory implementation across hospitals. England features standards for health information, while efforts in the US have focused on producing guidance documents. Pharmacists also play an important role in communicating health information and their role within healthcare networks should be strengthened.
• Personal self-care and health can be advanced if people can easily access gateways into health information and health services. The EIU examined how national health system portals are enabling health literacy. Australia’s HealthDirect and England’s NHS online resources feature accessible formats, interactivity, actionable health information and a route to contact healthcare services. Across India, Mexico and South Africa, digital platforms are also emerging. This study finds that there are numerous ways in which developing countries can improve engagement with health information even with limited resources. Examples include the use of visuals aids for health information or fostering better communication protocols between patients and healthcare professionals. The covid-19 emergency has also accelerated the adoption of online channels, such as online pharmacies. With increased choice for patients, health literacy becomes a more needed asset.
• Australia, England and the US showed the most progress in adopting shared decision making approaches with patients. India, Mexico and South Africa evidenced limited policy support for these approaches and implementation deficiencies. Adoption of these approaches should consider cultural differences too. For example, in low and middle income settings there are different attitudes towards the doctor patient-relationship and the role that should be played by families in decisions. Taiwan is an example of advanced patient-centred health approaches, helped by health system incentives and structures that promote patient empowerment and health literacy, as well as by a strong democratic culture.  

Health literacy and education

• Developing health literacy early in life could bring lifelong lessons and benefits, making schools an appropriate environment to introduce health literacy programmes. Australia, England and France have introduced robust health education programmes in national curricula. In the US, the work has focused on development of guidelines and reference standards. Mexico has also recently made efforts to prioritise health education. In India and South Africa, health literacy is mostly promoted through specific health promotion campaigns. Policymakers need to see health literacy education as a long haul investment in people’s health and there are different approaches, such as teaching it in an integrated or standalone way.
• Health literacy education should be lifelong, targeting vulnerable adults too. Adult health education appears to be somewhat neglected in the seven countries examined, with good examples of leadership stemming from middle-income countries. Mexico’s largest social security scheme carries out a health promotion and health education programme (“PrevenIMSS”) that entails outreach activities from the primary care level and provides a range of information and education tools. In India, community activists are the cornerstone of health promotion and health education efforts, such as in the “ASHA” programme, or the “mitras” (friends) who support people in accessing health services. Australia has developed significant health education initiatives targeting First Nations people. Limited initiatives, however, were observed targeting immigrants in high-income countries such as France, the US and the UK. This report also notes how the communitybased programme “Village Health Volunteers”, supporting health literacy, is helping in the covid-19 response in Thailand. 

Health literacy and digital technology

• Digital technologies are already transforming health literacy. The internet, social media and apps are widely used sources of health information. Meanwhile, emerging technologies are likely to have a further impact on people’s engagement with health information. For example: the role of artificial intelligence in powering chatbots with personalised solutions; the use of voice technologies facilitating our interactions with technology; wearables which capture personalised data and produce timely health data. As patients deal with increasingly complex health information in digital formats, individuals will need to be ready to constantly update their skills and engage in continuous learning. Technology creators, on the other hand, should ensure patients’ needs and concerns guide design processes.
• Technology also brings challenges. These include: access and connectivity gaps (which pose the risk of leaving some people behind), the quantity and quality of health information, the amplification of fringe messages, as well as safety and privacy concerns. Misinformation and disinformation have intensified in the context of the covid-19 pandemic. Combating this complex problem will require action from individuals (in developing critical analysis), technology businesses (in accountability and limiting the spread of misinformation on platforms), governments (in setting standards and control), as well as global collaboration.
• Australia, France, England and the US have clear frameworks for regulating health apps. Usually, regulation is only required for apps with a clear medical purpose. Among this group the UK is perhaps the most advanced country in that it features regulatory frameworks addressing a more extensive group of apps. The NHS, for example, produced a framework to evaluate health apps, including those that serve only information and education purposes. This is a step in the right direction as it favours trust (by both healthcare professionals and patients) and wider adoption. Regulators should continue to keep up with the rapid pace of innovation in digital health, balancing quality and safety priorities on one hand, with supporting an environment for continued improvement and innovation, on the other. 
• Lastly, this study examined how countries are creating communication guidelines to foster better health communication in their healthcare landscapes. Australia, England, France and the US have guided content creators in producing clear and accessible health information in print, digital and graphic formats. There was limited visibility of such initiatives in South Africa and India at a national scale. In Mexico no comparable guides for online content were observed but some resources are created to support health promotion by federal health institutions. For example, educational and communication materials for health promotion and healthy lifestyles are widely available.