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OBJECTIVE: A case study at the department for heart surgery of an Austrian University Hospital in 2001, examined the outcome of improved communication aimed at empowering patients to be more effective co-producers of recuperation after surgery. METHODS: Evaluated were the effects of a training program for developing communication skills of health professionals (physicians, physiotherapists, and nurses) along with a reorganization of patient information schemes. The clinical outcomes after four types of surgery (bypass, stent, artificial valve insertion and combination of these) were observed in 100 patients without (control group) and 99 with the intervention administered (intervention group). Two objective and two subjective health outcome parameters were selected for analysis: care level adjusted length of stay in hospital, frequency of post-surgery complications, subjective health, subjective satisfaction with care received. Self-administered breathing exercises were measured as an intermediary outcome parameter. RESULTS: In the intervention group length of hospital stay was shorter (by 1 day), incidence of post-surgery tachyarrhythmia was reduced (by 15%), transfer to less intensive care levels was faster and patient ratings for communicative quality of care by doctors and nurses were improved. CONCLUSION: Professional communication aimed at empowering patients to act as co producers can indeed have an effect on clinical outcome. PRACTICE IMPLICATIONS: Staff training and reorganization of communication schemes can be an effective intervention in hospital care. [ABSTRACT FROM AUTHOR]

Health literacy is one of the most critical determinants of health for effectively improving health services and reducing health inequalities. The importance of accurate measurement cannot be overstated. The European 47-item Health Literacy Questionnaire (HLS-EU-Q47) can provide precise measurements of health literacy. Therefore, this study aimed to evaluate the psychometric properties of the European Health Literacy Instrument in Iranian society (HLS-PV-Q47) for its Persian version. This cross-sectional study was conducted using a convenient sampling of 560 people referred to comprehensive healthcare centers. The construct validity was assessed by exploratory (280 people) and confirmatory factor (with 280 people). The internal consistency was calculated using Cronbach's alpha coefficients. Based on the exploratory factor analysis, three factors of healthcare, disease prevention, and health promotion explained 48.9% of the total variance of health literacy. Cronbach's alpha was 0.96 for the whole instrument. The Persian version of the European Health Literacy Instrument (P-HLS-EU-Q47) had good validity and reliability, which can be used in future studies due to its good psychometric properties., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS 19 -Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region., Methods: For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out., Results: The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS 19 -Q12 score with social determinants and selected consequences of HL. The HLS 19 -Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS 19 -Q47 long form., Conclusions: The HLS 19 -Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument.

To manoeuvre a complex and fragmented health care system, people need sufficient navigational health literacy (NAV-HL). The objective of this study was to validate the HLS 19 -NAV measurement scale applied in the European Health Literacy Population Survey 2019-2021 (HLS 19 ). From December 2019 to January 2021, data on NAV-HL was collected in eight European countries. The HLS 19 -NAV was translated into seven languages and successfully applied in and validated for eight countries, where language and survey method differed. The psychometric properties of the scale were assessed using confirmatory factor analysis (CFA) and Rasch modelling. The tested CFA models sufficiently well described the observed correlation structures. In most countries, the NAV-HL data displayed acceptable fit to the unidimensional Rasch partial credit model (PCM). For some countries, some items showed poor data-model fit when tested against the PCM, and some items displayed differential item functioning for selected person factors. The HLS 19 -NAV demonstrated high internal consistency. To ensure content validity, the HLS 19 -NAV was developed based on a conceptual framework. As an estimate of discriminant validity, the Pearson correlations between the NAV-HL and general health literacy (GEN-HL) scales were computed. Concurrent predictive validity was estimated by testing whether the HLS 19 -NAV, like general HL measures, follows a social gradient and whether it forms a predictor of general health status as a health-related outcome of general HL. In some countries, adjustments at the item level may be beneficial.

Background: Sufficient communicative health literacy (COM-HL) is important for patients actively participating in dialogue with physicians, expressing their needs and desires for treatment, and asking clarifying questions. There is a lack of instruments combining communication and HL proficiency. Hence, the aim was to establish an instrument with sufficient psychometric properties for measuring COM-HL., Methods: The HLS 19 -COM-P instrument was developed based on a conceptual framework integrating HL with central communicative tasks. Data were collected using different data collection modes in nine countries from December 2019 to January 2021 ( n = 18,674). Psychometric properties were assessed using Rasch analysis and confirmatory factor analysis. Cronbach's alpha and Person separation index were considered for reliability., Results: The 11-item version (HLS 19 -COM-P-Q11) and its short version of six items (HLS 19 -COM-P-Q6) fit sufficiently the unidimensional partial credit Rasch model, obtained acceptable goodness-of-fit indices and high reliability. Two items tend to under-discriminate. Few items displayed differential item functioning (DIF) across person factors, and there was no consistent pattern in DIF across countries. All items had ordered response categories., Conclusions: The HLS 19 -COM-P instrument was well accepted in nine countries, in different data collection modes, and could be used to measure COM-HL., Competing Interests: The authors declare no conflict of interest.

(1) Background: Health literacy is considered a personal asset, important for meeting health-related challenges of the 21st century. Measures for assisting students' health literacy development and improving health outcomes can be implemented in the school setting. First, this is achieved by providing students with learning opportunities to foster their personal health literacy, thus supporting behavior change. Second, it is achieved by measures at the organizational level promoting social change within the proximal and distal environment and supporting the school in becoming more health-literate. The latter approach is rooted in the concept of organizational health literacy, which comprises a settings-based approach aiming at changing organizational conditions to enhance health literacy of relevant stakeholders. The HeLit-Schools project aims to develop the concept of health-literate schools, describing aspects that need to be addressed for a school to become a health-literate organization. (2) Method: The concept development builds on existing concepts of organizational health literacy and its adaptation to the school setting. (3) Results: The adaptation results in the HeLit-Schools concept describing a health-literate school with eight standards. Each standard depicts an area within the school organization that can be developed for fostering health literacy of school-related persons. (4) Conclusions: The HeLit-Schools concept offers an approach to organizational development for sustainably strengthening health literacy.

The Russian language is the eighth most spoken language in the world. Russian speakers reside in Russia, across the former Soviet Union republics, and comprise one of the largest populations of international migrants. However, little is known about their health literacy (HL) and there is limited research on HL instruments in the Russian language. The purpose of this study was to adapt the Health Literacy Questionnaire (HLS 19 -Q) developed within the Health Literacy Survey 2019-2021 (HLS 19 ) to the Russian language to study HL in Russian-speaking populations in Germany, Israel, Kazakhstan, Russia, and the USA. The HLS 19 -Q was translated either from English or from a national language to Russian in four countries first and then critically reviewed by three Russian-speaking experts for consensus. The HLS 19 protocol and "team approach" method were used for linguistic and cultural adaptation. The most challenging was the adaptation of HLS 19 -Q questions to each country's healthcare system while general HL questions were flexible and adaptable to specific contexts across all countries. This study provides recommendations for the linguistic and cultural adaptation of HLS 19 -Q into different languages and can serve as an example of international collaboration towards this end.

Concerning the determinants of health literacy (HL) mostly socio-demographic or -economic factors have been considered, much less so psychological factors such as self-efficacy. To date, it has mostly been considered to explain the relationship of HL and health outcomes. However, self-efficacy could also be an important determinant for HL. This study therefore examines the effect of self-efficacy on comprehensive HL within the general population in Germany. Data from the German HL Survey (HLS-GER), a cross-sectional, computer-assisted personal interview study among 2000 respondents aged 15+ years in 2014 were used. Self-efficacy was measured using the German version of general self-efficacy short scale (ASKU), comprehensive HL was measured using the German version of the European Health Literacy Survey Questionnaire (HLS-EU-Q47). Correlation and multi-variate linear regression analyses were performed to analyze independent effects of socio-demographic factors-age, gender, social status, educational level and migration background-functional HL and self-efficacy on comprehensive HL. Self-efficacy and comprehensive HL are statistically significantly correlated (Spearman's Rho = 0.405; p < 0.01), respondents with better self-efficacy had better HL scores. Both concepts are significantly associated with most socio-demographic factors and functional HL. Self-efficacy showed the strongest association with HL in the multivariate analyses (model 2: β =0.310, p < 0.001). The effect size of the other predictors decreased, when adding self-efficacy into the equation, but remained statistically significant. Self-efficacy is a rather strong predictor of comprehensive HL. Future research and measures to improve HL should therefore take self-efficacy adequately into account., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Due to their rapid expansion and complexity, it is increasingly difficult for patients to orient themselves in health care systems. Therefore, patients require a high degree of health literacy, or more precisely, navigation health literacy (HL-NAV). The actual extent of HL-NAV of patients and citizens is still largely unknown due to the lack of adequate measurement instruments. Thus, within the new international Health Literacy Population Survey 2019 (HLS 19 ), one aim was to develop a suitable instrument for measuring HL-NAV in the HLS 19 the HL-NAV-HLS19. The item development was conducted by an international working group within the HLS 19 Consortium led by the first and last authors. Methodologically, it is based on a scoping literature review, development of a conceptual framework for HL-NAV, and first item formation, as well as an evaluation by experts, stakeholders, focus groups, pre-test interviews, and continuously feedback from the HLS 19 Consortium. HL-NAV was defined as the ability to access, understand, appraise, and apply information on navigational issues, drawing on ten selected publications and the health literacy definition of the HLS-EU Consortium. Main tasks of HL-NAV at the system, organization, and interaction level were identified, to which first related items were assigned. Based on the feedback from experts, the focus group discussions, and the HLS 19 Consortium, the instrument was slightly revised. Finally, twelve items proved to be feasible in the pre-test. The instrument will be used for the first time in the HLS 19 survey and will provide first data on HL-NAV in general populations for the countries participating in HLS 19 . It is suited for cross-country comparisons and monitoring, as well as for intervention development. However, the instrument should be translated into and validated in further languages and countries for population samples.

This chapter provides an overview of health literacy measurement initiatives with a focus on the European Health Literacy Survey (HLS-EU) - describing where measuring population health literacy started, where it currently is, and providing an outlook to the upcoming European HL survey. In the first part of the chapter, the methodology and the main results of the initial HLS-EU study from 2011 will be introduced. In the second part the worldwide impact of the HLS-EU study will be mapped. Many publications and studies used the HLS-EU instruments in the original or few in an adapted way to measure comprehensive health literacy - in many different settings and in diverse countries. Finally, the chapter ends with an outlook to the M-POHL and HLS19 initiatives of WHO-Europe which are intended to advance HLS-EU as well as the measurement of population and organizational health literacy in a more coordinated, standardized, and institutionalized manner.

Aaron Antonovsky advanced the concept of salutogenesis almost four decades ago (Antonovsky, Health, Stress and Coping. Jossey-Bass, San Francisco, CA, 1979; Unravelling the Mystery of Health. Jossey-Bass, San Francisco, CA, 1987). Salutogenesis posits that life experiences shape the sense of coherence (SOC) that helps to mobilize resources to cope with stressors and manage tension successfully (determining one's movement on the health Ease/Dis-ease continuum). Antonovsky considered the three-dimensional SOC (i.e. comprehensibility, manageability, meaningfulness) as the key answer to his question about the origin of health. The field of health promotion has adopted the concept of salutogenesis as reflected in the international Handbook of Salutogenesis (Mittelmark et al., The Handbook of Salutogenesis. Springer, New York, 2016). However, health promotion mostly builds on the more vague, general salutogenic orientation that implies the need to foster resources and capacities to promote health and wellbeing. To strengthen the knowledge base of salutogenesis, the Global Working Group on Salutogenesis (GWG-Sal) of the International Union of Health Promotion and Education produced the Handbook of Salutogenesis. During the creation of the handbook and the regular meetings of the GWG-Sal, the working group identified four key conceptual issues to be advanced: (i) the overall salutogenic model of health; (ii) the SOC concept; (iii) the design of salutogenic interventions and change processes in complex systems; (iv) the application of salutogenesis beyond health sector. For each of these areas, we first highlight Antonovsky's original contribution and then present suggestions for future development. These ideas will help guide GWG-Sal's work to strengthen salutogenesis as a theory base for health promotion., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The Health Promotion Administration of Taiwan launched an integrative certification initiative in 2016 to streamline a plural system of certifications of health promotion in hospitals. It endeavored to replace original certifications, thereby establishing the proposal of a self-assessment instrument to aid in this integration. This study aimed to verify the robustness of this self-assessment tool by conducting exploratory factor analyses through stratification, reliability tests, content and construct validity tests, and specialist evaluations, which were convened to judge the comprehensibility, applicability, and importance of the standards and measures of this tool. A stratified random sampling of 46 hospitals was performed to confirm the validity of this tool. The tool rendered a floor effect of 0% and a ceiling effect of 13%. A valid factor structure and internal consistency (α ranged from 0.88 to 0.96) in each standard were verified. Hospitals with previous certificates or with 300+ beds achieved high compliance scores. A majority of experts agreed that the sub-standards were comprehensible (≥80%), applicable (≥70%), and important (≥70%). Finally, we conclude that the self-assessment tool is valid and can serve as a reference for other countries with hospitals committed to health promotion in hospital settings.

Background/research Question:: In the health literacy (HL) discourse there is debate about the ways by which HL is impacting health. Three different, logically non-exclusive hypotheses are proposed: (a) HL as a specific, direct, social determinant of health; (b) HL as a mediator between other determinants and health; and (c) HL as a moderator of the effect of other determinants on health. Only few examples of empirically testing the mediator or moderator hypothesis exist. The data of the European Health Literacy Survey allow testing of the three hypotheses comparatively in parallel for functional and comprehensive HL., Methods:: Data collection was based on multistage random samples of about 1000 European Union citizens aged 15 or older with Computer Assisted Personal Interviewing or Paper Assisted Personal Interviewing methodology in 2011 in eight Member States of the EU. Demographic and socio-economic indicators, a comprehensive (European Health Literacy Survey Q47) and a functional (Newest Vital Sign Test) health literacy measure and one self-assessed health variable were surveyed. Correlation analysis, multiple regression analysis and path analysis were performed., Results:: Comprehensive HL (and to a much lesser degree functional HL) is a relevant predictor for self-assessed health. Also, comprehensive HL is only to a limited degree mediating the effects of other determinants on self-assessed health and only for age does HL partly moderate the effect on health. Explained variance and strength of effects vary considerably by national context., Conclusions/implications:: Comprehensive HL is a critical, direct determinant of health. Therefore comprehensive HL has a considerable potential for health promotion to improve population health and tackle the health gap. But comprehensive HL measurement should be standardised in every country to allow for designing adequate measures for the specific situation of the country and also for benchmarking. For better understanding of the causal structure of the impact of HL on health, longitudinal studies will be needed.

Objective: Present and discuss the development and basic structure of a multilevel approach to strengthen patient and family engaged care, "The New Haven Recommendations on partnering with patients, families and citizens to enhance performance and quality in health promoting hospitals and health services"., Methods: A generic literature review was conducted followed by a Delphi procedure to prepare the New Haven Recommendations. From systems theory perspective, three conceptual levels are used to map action areas to enhance patient and family engaged care., Results: The recommendations propose a multilevel approach to enable patient, family, (and citizen representatives') involvement (a) within direct service provision; (b) among hospitals and health services; (c) in planning healthcare delivery systems and policy., Conclusion: The New Haven Recommendations provide a strategic tool and practical recommendations, which can be used for reflection on current practices or generating new ways of thinking about patient and family engaged care. They support the development of patient and family engaged care as core aspect of high quality healthcare, and can contribute to achieving the Ottawa Charter's claim of reorienting health services., Practice Implications: The potential benefit of the multilevel approach is to reorient the basic culture of healthcare towards patient- and health-centered care., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The role of health-related behaviors in the association between age and health literacy has not been well-elucidated. The present cross-sectional study evaluated the interactions between age and health-related behaviors in 942 women in Taiwan between February and October 2013. Women aged 18-78 years were randomly sampled and recruited from the national administrative system. Self-reported health literacy was measured by the European Health Literacy Survey Questionnaire (HLS-EU-Q47) in Mandarin, asking about sociodemographics and essential health-related behaviors (watching health-related television, community involvement). The interviews were conducted confidentially by well-trained interviewers after having participants' consent. In multiple linear regression models adjusted for education attainment, self-perceived social status, ability to pay for medication, and health-related behaviors, health literacy was significantly negatively related to age (unstandardized regression coefficient, B = -0.04; 95% confidence interval [CI] = (-0.07; 0.00); p = .03). The lower health literacy among older women was significantly modified by watching health-related television programs (from "rarely/not-at-all", B = -0.08 (-0.12, -0.04), p < .001 to "often"; B = 0.10 (0.07, 0.12); p < .001) and community involvement (from "rarely/not-at-all", B = -0.06 (-0.10, -0.03); p = .001 to "often", B = 0.06 (0.03, 0.08); p < .001). Specific health behaviors were protective of older women's health literacy and likely their health.

Background: Health literacy is an important health promotion concern and recently children and adolescents have been the focus of increased academic attention. To assess the health literacy of this population, researchers have been focussing on developing instruments to measure their health literacy. Compared to the wider availability of instruments for adults, only a few tools are known for younger age groups. The objective of this study is to systematically review the field of generic child and adolescent health literacy measurement instruments that are currently available., Method: A systematic literature search was undertaken in five databases (PubMed, CINAHL, PsycNET, ERIC, and FIS) on articles published between January 1990 and July 2015, addressing children and adolescents ≤18 years old. Eligible articles were analysed, data was extracted, and synthesised according to review objectives., Results: Fifteen generic health literacy measurement instruments for children and adolescents were identified. All, except two, are self-administered instruments. Seven are objective measures (performance-based tests), seven are subjective measures (self-reporting), and one uses a mixed-method measurement. Most instruments applied a broad and multidimensional understanding of health literacy. The instruments were developed in eight different countries, with most tools originating in the United States (n = 6). Among the instruments, 31 different components related to health literacy were identified. Accordingly, the studies exhibit a variety of implicit or explicit conceptual and operational definitions, and most instruments have been used in schools and other educational contexts. While the youngest age group studied was 7-year-old children within a parent-child study, there is only one instrument specifically designed for primary school children and none for early years., Conclusions: Despite the reported paucity of health literacy research involving children and adolescents, an unexpected number of health literacy measurement studies in children's populations was found. Most instruments tend to measure their own specific understanding of health literacy and not all provide sufficient conceptual information. To advance health literacy instruments, a much more standardised approach is necessary including improved reporting on the development and validation processes. Further research is required to improve health literacy instruments for children and adolescents and to provide knowledge to inform effective interventions.

Background: Health literacy has been increasingly recognized as one of the most important social determinants for health. However, an appropriate and comprehensive assessment tool is not available in many Asian countries. This study validates a comprehensive health literacy survey tool European health literacy questionnaire (HLS-EU-Q47) for the general public in several Asian countries., Methods: A cross-sectional survey based on multistage random sampling in the target countries. A total of 10,024 participants aged ≥15 years were recruited during 2013-2014 in Indonesia, Kazakhstan, Malaysia, Myanmar, Taiwan, and Vietnam. The questionnaire was translated into local languages to measure general health literacy and its three domains. To evaluate the validity of the tool in these countries, data were analyzed by confirmatory factor analysis, internal consistency analysis, and regression analysis., Results: The questionnaire was shown to have good construct validity, satisfactory goodness-of-fit of the data to the hypothetical model in three health literacy domains, high internal consistency (Cronbach's alpha >0.90), satisfactory item-scale convergent validity (item-scale correlation ≥0.40), and no floor/ceiling effects in these countries. General health literacy index score was significantly associated with level of education (P from <0.001 to 0.011) and perceived social status (P from <0.001 to 0.016), with evidence of known-group validity., Conclusions: The HLS-EU-Q47 was a satisfactory and comprehensive health literacy survey tool for use in Asia., (Copyright © 2016 The Authors. Production and hosting by Elsevier B.V. All rights reserved.)

This chapter is concerned with the difference of measuring health literacy of general population for purposes of public health as differentiated from measuring personal health literacy of individuals within health care services. The evolution of concept, measurement and empirical research of health literacy in the last decades is discussed, and the position of measuring comprehensive health literacy in general populations, especially by the European Health Literacy Survey (HLS-EU) study, is defined. Main features of the HLS-EU conceptual and logic model, definition, instruments and study design are described. General results of the HLS-EU study are presented on the distribution of health literacy, its determinants and health related consequences, for the eight involved European countries as well as the total sample. These results principally confirm findings of earlier studies with somewhat different instruments and other kinds of samples, but also demonstrate considerable differences in distributions of health literacy and its relationships with relevant variables among and between the eight countries in a standardized comparative international study. Follow-up studies based on the original HLS-EU study are mapped. In addition, the factors for the relative easy and widespread use of the instrument and research methodology by similar studies in other countries in Europe and Asia are discussed. This chapter closes with an outlook on the challenges of further developments and take-ups.

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., M Ethods: 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., R Esults: 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., (© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association.)

Data on health literacy (HL) in the population is limited for Asian countries. This study aimed to test the validity of the Mandarin version of the European Health Literacy Survey Questionnaire (HLS-EU-Q) for use in the general public in Taiwan. Multistage stratification random sampling resulted in a sample of 2989 people aged 15 years and above. The HLS-EU-Q was validated by confirmatory factor analysis with excellent model data fit indices. The general HL of the Taiwanese population was 34.4 ± 6.6 on a scale of 50. Multivariate regression analysis showed that higher general HL is significantly associated with the higher ability to pay for medication, higher self-perceived social status, higher frequency of watching health-related TV, and community involvement but associated with younger age. HL is also associated with health status, health behaviors, and health care accessibility and use. The HLS-EU-Q was found to be a useful tool to assess HL and its associated factors in the general population., (© 2015 APJPH.)

In late modern "multi-option" and "health" societies, health literacy (HL), understood as a specific competence, is considered necessary to successfully deal with the multitude of health relevant decisions and tasks to be taken every day. The concept has been used in the US, primarily in healthcare, to research the consequences of HL on the outcome of treatment specifically in patients with limited HL. In this context, it became evident that HL has to be understood as a relational or contextual concept. That is, the adequacy of HL does not only depend on personal HL, but equally on the demands organizations put on their users. This understanding of HL opened the road to measure not only individual HL, but also the HL sensitivity of organizations, i.e. organizational HL, and to use targeted measures to improve it. The ten attributes of a health-literate healthcare organization, as defined by the US Institute of Medicine, are a first systematic attempt to use this strategy in healthcare. In the meantime, the strategy has been used in other settings as well. Using experiences from health-promoting hospitals and the quality movement in healthcare, the authors develop this approach further into the comprehensive Vienna concept of the health-literate hospital, which considers all stakeholders and tasks of the hospital which are relevant for HL. A self-assessment tool was developed and tested as a basic instrument for developing a health-literate hospital. By doing so, hospitals are empowered to make a contribution to the promotion of HL as an important societal task.

Organizational capacity building for health promotion (HP) is beneficial to the effective implementation of HP in organizational settings. The World Health Organization (WHO) Health Promoting Hospitals' (HPHs) initiative encourages hospitals to promote the health of their stakeholders by developing organizational capacity. This study analyzes an application case of one hospital of the HPH initiative in Taiwan, characterizes actions aiming at building organizational support to strengthen health gains and identifies facilitators of and barriers to the implementation of the HP in this hospital. Case study methodology was used with a triangulation of various sources; thematic analysis was used to analyze qualitative information. This study found a positive impact of the HPH initiative on the case hospital, such as more support from leadership, a fine-tuned HP mission and strategy, cultivated pro-HP habits of physical activities, a supportive intramural structure, an HP-inclusive system, improved management practices and enhanced staff participation. Transformational and transactional enablers are of equal importance in implementing HPH. However, it was also found that the case hospital encountered more transactional barriers than transformational ones. This hospital was hindered by insufficient support from external environments, leadership with limited autonomy and authority, a preference for ideals over professionalism, insufficient participation by physicians, a lack of manpower and time, a merit system with limited stimulating effect, ineffective management practices in weak central project management, a lack of integration, insufficient communication and an inability to inculcate the staff on the importance of HP, and inadequate staff participation. Several implications for other hospitals are suggested., (© The Author (2014). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Several 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., Methods: Based 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., Results: The 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., Conclusions: By 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.

Health promoting hospitals (HPH) is a concept for hospital development that builds upon the health promotion concept of the WHO Ottawa Charter for health promotion, where the reorientation of health care services is considered as one of five major action areas for an overall health promotion development. The article outlines what such a re-orientation may mean for the main hospital functions. These include: the health promoting hospital setting; health promoting workplaces, the provision of health (related) services, training, education and research; the hospital as an advocate and "change agent" for health promotion in its community/environment; the "healthy" (metaphorically speaking) hospital organisation. Based on the concept, an international network of WHO, Europe has been developing since the late 1980s. The main projects of the international network so far were the first model project "health and hospital" (Vienna, 1989-1996), the European pilot hospital project of HPH (1993-1996), and the development of national/regional HPH networks (ongoing since 1995). It is argued that the further development of the HPH network will have to take into account some major changes that have occurred in the hospital landscape since the start of the network: the quality movement and, as a sub-set of this, the increasing importance of evidence based medicine.