A Delphi study on health literacy competencies for health professionals

Abstract

Background

Health professionals play a key role in promoting health literacy, as they continue to be one of the main points of contact and most trusted source of information for healthcare users on questions and concerns regarding health and disease. To adequately support individuals in dealing with health information and services and to strengthen health literacy, health professionals need a corresponding set of knowledge, skills, and attitudes, hence they need a wide range of health literacy competencies. Despite their crucial role in guiding and supporting patients and their relatives in terms of health-related information and services, in-depth studies on health literacy competencies of health professionals are still scarce. Thus, the aim of this study was to identify and prioritize health literacy competencies of health professionals in German-speaking countries.

Methods

A modified, two-round Delphi study was conducted with 24 experts in the field of health literacy or a relevant field from Switzerland, Austria, and Germany. The experts were asked to evaluate and rate different competencies of health professionals regarding health literacy.

Results

As a result, 14 core competencies have been identified by the experts, including five items referring to the category “knowledge”, seven items to the category “skills” and two items referring to the category “attitude”. The identified competences indicate that health literate health professionals understand health literacy’s importance, employ clear communication techniques, and actively engage patients to ensure comprehension. Furthermore, health literate health professionals recognize cultural barriers, use plain language, and maintain that effective communication is crucial for quality healthcare. Among the 14 core competencies, communication practices were reported to be of particular importance for practice-oriented, professional health literacy skills of health professionals.

Conclusions

The identified set of health literacy competencies provides an essential groundwork for future assessments of competencies concerning professional health literacy among health professionals, their integration into curricula, and further development of tailor-made trainings and education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06539-z.

Background

Health literacy as the knowledge, skills and motivation to deal with health information and services, is an important indirect health determinant and asset for people to make informed decisions and thereby maintain and improve their quality of live and well-being [1, 2]. Grand challenges such as the increasing complexity of healthcare systems, the digitalization of healthcare, demographic developments, environmental changes or pandemics pose dynamic challenges to populations worldwide [3]. These developments in turn have an impact on our health and well-being and impact or transform our (health) behavior and decisions [4]. To proactively approach and assimilate those developments, people, including both individuals, groups and communities, are dependent on sufficient competencies. They need to be able to adequately and proactively deal with health-related complex information and to make sound decisions for their well-being – thereby maintaining or improving their quality of life in social contexts across the life course [5]. In Switzerland, however, almost half of the population (49%) reports dificulties in dealing with health-related information [6], i.e., has low health literacy levels. Difficulties in using information to navigate the healthcare system and in dealing with digital health information are even more common [6]. A comparable study presents similar results for Germany, where more than half of the population (59%) has low health lieracy, in particular groups such as elderly, people with low educational level or social status with migration experience or with long-term health problems [7]. Similar to the Swiss, the majority of Germans report that they have even greater difficulties in dealing with information with regard to orientation and navigation through the system [7]. Also in Austria, people reported similar difficulties, in particular regarding the assessment of different treatment options, the finding of mental health information, and the decision-making processes on disease prevention based on media information [8]. As in Switzerland and Germany, the Austrian Health Literacy Survey found that people with less formal education and financial deprivation were more likely to have lower levels of health literacy [8].

In light of these concerning results, healthcare organizations have great potential to implement health literacy promoting practices and processes to strengthen health literacy of patients, their relatives, as well as of their staff [9, 10]. Hence, strengthening individual and organizational health literacy is an important concern for improving both healthcare services as well as the health and well-being of the population [11–15]. Based on current research, policy approaches on health literacy consider health literacy to be not merely the patients’ responsibility, but rather a shared obligation between health practitioners, professionals and healthcare users [16–18]. Health professionals have emerged as one of the most important and trusted points of contact for information on health and disease issues [19]. According to the Swiss Federal Council’s Health2030 strategy, health professionals should play a central role in the healthcare system. One strategic goal explicitly mentions: “Citizens can make well-informed, responsible and risk-conscious decisions that determine their health as well as the health of their loved ones. In doing so, they are supported by competent health professionals” [20]. How health professionals communicate, convey information, and respond to patients’ questions has an impact both on the success of a treatment itself [21] as well as on how patients and their relatives make sustainable, self-determined and informed decisions [22].

Consequently, health professionals need a specific set of skills, knowledge, and attitudes for interactions with healthcare users, as well as appropriate tools and methods to support their health literacy [20, 23]. In other words, they need a certain set of health literacy competencies. So far, only a few studies have focused on analyzing health literacy competencies of health professionals [23–26]. A systematic literature review identified gaps in health literacy knowledge among both health professionals and their patients [27]. In addition, health professionals often seem to occasionally overestimate health literacy levels of their patients [28, 29]. At the same time, health literacy competencies have long been scarce in curricula for health professions, in the United States (U.S.) and Europe [24, 30]. To address this gap, in the U.S., Coleman and colleagues (2013) conducted a Delphi study to collect a set of competencies and practices of health literacy relevant to health professional education [31]. For the first time, the American study sought to develop a consensus on core competencies and practices of health literacy across health professionals and translate them into a set of measurable competencies for health professionals’ education. In 2017, another research team replicated this landmark study for the European context, with the aim of testing whether the competencies identified in the U.S. were also relevant for health professionals in Europe [24]. The results of their study confirmed that – with some cultural adaptations – the competencies identified and prioritized by the American research group were significant in the European healthcare context as well.

The main aim of the present Delphi study was to identify and prioritize health literacy competencies of health professionals in German-speaking countries in order to inform and build the basis of the recently conducted pilot study on professional health literacy in Switzerland, Austria and Germany [32, 33]. Secondary objectives of this study were to validate the American [31] and the European study [24] specifically for the German-speaking context and to inform the implementation of health literacy competencies into health professionals curricula.

Methods

Expert panel

For this study, 43 experts in the fields of health literacy, healthcare, professional education, and training of health professionals in general or specifically of one of the five included professions (physicians, medical practice assistants, nurses, pharmacists, and physiotherapists) from Austria, Germany and the German-part of Switzerland were invited in 2022 to participate at the study via email. The selection criteria of the experts based on a vast research, publication and teaching experience. Selection started in the authors’ network and was continued according to the snow-ball sampling [34]. Thereby, the number of 43 experts was neither explicitly defined nor intended, but resulted from the process. As in the study of Karuranga et al. (2017), to confirm their expertise in the field of health literacy, they were asked whether their peers would describe them as an expert. The panellists participated voluntarily and could withdraw from the study at any time without giving a reason. A total of 25 experts accepted to participate in the study and 24 experts concluded the full process. Only one person reported that they would not be described by peers as an expert in the field of health literacy. However, since this person was an expert in the development of health professionals curricula, the authors have decided to include them in the study. More detailed information on the socio-demographic characteristics of the experts can be found in Table 1.

Table 1.

Socio-demographic characteristics of the expert panel

Socio-demographic characteristics	Overall (N = 25)	n (%)
Gender
Female	16	64%
Male	7	28%
No response	2	8%
Country of birth
Switzerland	8	32%
Germany	10	40%
Austria	4	16%
Other country	1	4%
No response	2	8%
Country of residence
Switzerland	14	56%
Germany	6	24%
Austria	3	12%
No response	2	8%
Highest level of education completed
Higher vocational training	1	4%
Bachelor	2	8%
Master	5	20%
Doctorate	16	64%
No response	1	4%
Current job
Professor	6	24%
Researcher	6	24%
Clinical practitioner	5	20%
Manager	6	24%
No response	2	8%
Involved in teaching
Yes	24	96%
No	1	4%
Would your peers consider you to have expertise in health literacy?
Yes	24	96%
No	1	4%

Study design

A modified Delphi method with two rounds of questioning was conducted as a study design. In a first step, the list of core competencies identified by the European research group of Karuranga and colleagues [24] was translated into German by a translation agency and subsequently checked and adapted for correctness and comprehensibility by two German native speakers from the research team. In line with the studies of Coleman et al. [31] and Karuranga et al. [24], the translated competencies were divided into three categories: knowledge (K), skills (S), and attitudes (A) (see Table 2). Next to the German translation, some minor changes and cultural adaptions were performed by the authors with focus on the healthcare system in Switzerland. While the present Delphi study aimed to validate the American [31] and European [24] studies for the German-speaking context, a focus on the Swiss context was made because of (1) cultural proximity and (2) the rather similar results of Switzerland, Germany and Austria in recent health literacy surveys [35]. The changes included the following: In the category knowledge, item K5 (K5 in the European study [24]) was culturally adapted referring to the difficulties of the Swiss population with basic literacy skills such as reading and writing and that most education materials require adequate health literacy. Item K6 was newly added and reframed from the ‘difficulties with reading and writing’ into ‘low health literacy’.

Table 2.

Overview research design: modified Delphi method

In the category attitudes, the item S27 (S6 in the European study [24]) on the ability to translate information into scientifically correct and plain language was also culturally adapted with regards to specific terms and wording.

The additional dimension ‘health literacy practices’ used in both the American and the European study was left out due to its strong thematic proximity towards the other three categories. Next to these minor changes in the original item constellation, the authors added additional eight items from the context of organizational health literacy (OHL58 – OHL65), as they considered them relevant and missing in the original American and European lists. These items originated from the Swiss self-assessment tool for organizational health literacy – the Organizational Health Literacy Self-Assessment Tool for Primary Care (OHL Self-AsseT) [12].

The two Delphi rounds were conducted online using two slightly different questionnaires for the first and the second round (Unipark^® survey software) (the interview guide is available as a supplementary file of this paper). 25 experts took part in the first round. In the beginning, the study included 65 items (21 items on knowledge, 25 items on skills, 11 items on attitudes, and 8 items on organizational health literacy). After obtaining the feedback of the expert panel, the output of the first Delphi round included 31 items (12 items on knowledge, 14 items on skills, 2 items on attitudes, and 3 items on organizational health literacy). In the second round, 24 remaining experts participated. The item input comprised 31 items from round 1 and 4 new items (12 items on knowledge, 20 items on skills (including 3 new items and the integration of the 3 OHL items of round 1) and 3 items on attitudes (including 1 new item)). Table 2 illustrates the adaptation of items in the two rounds of the Delphi study.

Decision-making rules

Round 1

In the first round, the health literacy core competencies of health professionals were ranked on a four-point Likert scale according to the two criteria of appropriateness, (i.e., the competencies being appropriate and practicable for health professionals to adopt in their everyday work activities) and importance of the core competence for health professionals in general. The scale for appropriateness ranged from 1 (‘very appropriate’) to 4 (‘not appropriate’) and the scale for importance ranged from 1 (‘very important’) to 4 (‘not important’). The study approach for the first round was in line with the European study [24]. However, the consensus level was set at 90% instead of 70%, and both scales (‘appropriateness’ and ‘importance’) were merged as an index to shorten the list and identify core competencies to fulfil the central study aim. Furthermore, the participating health literacy experts had the opportunity to either add missing competencies or to make comments on the wording of the existing competencies. In addition, in round 1, the panelists’ personal definition or understanding of health literacy of health professionals was asked in an open text field. The participants’ suggestions regarding the terms and formulations, new competencies, or the adaptation of the original formulations were included in the second round of questioning and reassessed by all experts, wherever it seemed useful and appropriate by the study team. In combination with the high cut-off rate of 90%, his procedure meant a reduction to less than half of the items for the second round. In Table 3, these new-, re-formulated and adapted items are each marked with a “ ' ” (e.g., K4’).

Table 3.

Overview health literacy competencies of health professionals in the round 1 and 2

Category Knowledge (K): A health professional should …		Round 1	Round 2
K1	… know what health literacy means.	x	x
K2	… know the basic literacy skill domain (reading, writing, speaking, listening, numeracy) and gives examples of healthcare related demands put on patients for each domain, including difficulties navigating the healthcare systems.	x
K2’a	… know about the importance of basic literacy skills (reading and writing) for health literacy.
K2’b	… know the requirements that are placed on patients and their families in the individual areas in connection with healthcare.
K3	… know the difference between the ability to read, and reading comprehension, and why general reading levels do not ensure patient understanding.
K4	… know which kinds of words, phrases, or concepts may be jargon to patients.	x
K4’	… know which terms and phrases are difficult to understand for patients and their relatives.
K5*	… know that 16% of the Swiss population has basic difficulties with reading and writing, but that most patient education materials are written at a much higher reading level.
K6**	… know that about one in two people in Switzerland has low health literacy, but that most patient education materials require adequate health literacy.
K7	… know that cultural and linguistic differences between patients and health professionals can increase difficulties in mutual understanding.	x	x
K8	… know that adults with low literacy tend to experience shame and hide their lack of skills from healthcare professionals.	x
K9	… know that “you can’t tell who has low health literacy by looking”.
K10	… recognize certain “red flag” behaviors which may suggest patients have low health literacy.	x
K10’	… know certain signs that may indicate low health literacy on the part of the patients or their relatives.		x
K11	… know that tools are available for estimating individuals’ health literacy skills, but that routine screening for low health literacy has not been proven safe or acceptable.
K12	… know that health literacy is context-specific; individuals with high general literacy may have low health literacy.
K13	… know that health literacy may decrease during times of physical or emotional stress.	x
K13’	… know that health literacy / dealing with information is particularly difficult during times of physical or emotional stress.
K14	… know that everyone, regardless of literacy level, benefits from and prefers clear plain language communication.	x
K14’	… know that every person benefits from and prefers easily understandable information and plain language.		x
K15	… know that transition point of “hands-off” in healthcare (e.g., moving from in-patient to out-patient setting) are especially vulnerable to patient communication errors.	x
K16	… know the rationale for, and principles underpinning the need for a universal precautions approach to all health communication interactions.
K17	… know established principles of plain language and clear health communication for oral and written communication.	x
K17’	… know the principles of plain language and clear health communication for oral and written communication.		x
K18	… know that patients learn best when a limited number of new terms or information are presented at the same time.	x
K18’	… know that patients and their relatives learn best when a limited number of new concepts are presented at the same time.
K19	… know examples of the direct relationship between health literacy and
	- knowledge about one’s chronic disease(s) and medications.
	- adherence to medications and treatment plant.
	- receipt of preventive health services.
	- health outcomes or health risks.
K20	… know the rationale for and mechanics of using “teach-back” or “show me” technique to assess patient understanding.	x
K21	… know that community services and resources exist for helping adults improve their general literacy skills.
Partial sum	21	12	6
Category Skills (S): A health professional should …
S22	… have/show the ability to use common familiar lay terms, phrases and concepts, and appropriately define unavoidable jargon, and avoid using acronyms in oral and written communication with patients.	x
S22’	… have the ability to use comprehensible formulations and to apply the principles of plain language in oral and written communication with patients and their relatives.		x
S23	… have/show the ability to recognize, avoid and/or constructively correct the use of medical jargon, as used by others in oral and written communication with patients.
S24	… have/show the ability to follow established principles of easy-to-read formatting and written communication with patients.	x
S24’	… have the ability to follow established principles of easy-to-read formatting and written communication with patients and their relatives.
S25	… have/show the ability to recognize plain language principles in written materials produced by others.	x
S25’	… have the ability to recognize the principles of plain language in written materials produced by others.
S26	… have/show the ability to put information into context by using subject headings in both written and oral communication with patients.
S27	… have/show the ability to translate information from a non-simple language format into a scientifically correct, plain, and easily understood language format.	x
S27’*	… have the ability to translate information from a non-simple language format into a scientifically correct, simple and easily understandable language format.		x
S28	… have/show the ability to speak slowly and clearly with patients.	x
S28’	… have the ability to speak slowly and clearly with patients and their relatives.
S29	… have/show the ability to use verbal and non-verbal active listening techniques when speaking with patients.	x
S29’	… have the ability to use verbal and non-verbal active listening techniques when speaking with patients and their relatives.
S30	… have/show the ability use action-oriented statements to help patients know what they need to do.	x
S30’	… have the ability use action-oriented statements to help patients and their relatives know what they need to do.		x
S31	… have/show the ability to select culturally and socially appropriate and relevant visual aids, to enhance and support oral and written communication with patients.
S32	… have/show the ability to make instructions interactive so that patients are able to engage with, facilitate and recall the information.	x
S32’	… have the ability to make instructions interactive so that patients and their relatives are able to engage with, facilitate and recall the information.
S33	… have/show the ability to elicit the patient’s full set of concerns at the outset of the conversation.	x
S33’	… have the ability to elicit the patient’s full set of concerns at the outset of the conversation.
S34	… have/show the ability to negotiate a mutual agenda at the outset of the encounter.
S35	… have/show the ability to elicit patients’ prior understanding of their health issues in a non-shaming manner (e.g., by asking “what do you already know about high blood pressure?“).	x
S35’	… have the ability to elicit patients’ and their relatives’ prior understanding of their health issues in an appreciating manner.		x
S36	… have/show the ability to non-judgmentally elicit root causes of non-adherent health behaviors or unhealthy lifestyles.
S37	… demonstrate effective use of a “teach back” or “show me” technique for assessing patients’ understanding.	x	x
S37’	… demonstrate effective use of adequate methods for assessing the understanding of patients and their relatives.		x
S38	… have/show the ability to “chunk and check” by giving patients small amounts of information and checking for understanding before moving to new information.
S39	… have/show the ability to effectively ask patients’ questions through a “patient-centerer” approach (e.g., by asking “what questions do you have on the topic?” rather than “do you have any questions?“).	x
S39’	… have the ability to effectively ask questions to patients and their relatives through a “patient-centered” approach.		x
S40	… have/show the ability to orally communicate accurately and effectively in patients’ preferred language, using medical interpreter services.
S41	… have/show the ability to use written communication to support important oral information.
S42	… have/show the ability to emphasize one to three “need-to-know” or “need-to-do” concepts during a given patient encounter.
S43	… have/show the ability to convey numeric information (e.g., risks) using specific approaches and examples, in oral and written communication.
S44	… have/show the ability to write or re-write (“translate”) unambiguous medication instructions (e.g., “take 1 tablet by mouth every morning and evening for high blood pressure” rather than “take 1 tablet by mouth twice daily”).	x
S44’a	… have the ability to write or re-write medication instructions understandably.
S44’b	… have the ability to recommend methods that support proper medication use.
S45	… have/show the ability to use examples or analogies to improve patient’s understanding.	x
S45’	… have the ability to use examples or analogies to improve the understanding of patients and their relatives.
S46	… have the ability to give information that facilitate goal setting concerning health, health behavior and health related activities.
S(i)	… have the ability to discuss the opportunities and risks of digital technologies with patients and their relatives. (the item was added in round 2)
S(ii)	… have the ability to support patients and their relatives in accessing, searching for and using digital information sources. (the item was added in round 2)
S(iii)	… have the ability to support patients and their families in dealing with digital health information. (the item was added in round 2)
Partial sum	25 (+ 3)	14	6
Category Attitudes (A): A health professional should …
A47	… express the attitude that effective communication is essential to the delivery of safe high quality healthcare.	x	x
A48	… express the attitude that all patients are at risk for communication errors and that one cannot tell who is at risk of communication errors simply by looking or through typical healthcare interactions; a universal precautions approach is required with all patients.
A49	… express the attitude that because the “culture” of healthcare includes special knowledge, language, logic, experiences and explanatory models of health and illness, every patient’s encounter can be considered a cross-cultural experience.
A50	… express acceptance of an ethical responsibility to facilitate the two-way exchange of information in “shared decision making” to the degree and at the level desired by the patients and their families.
A51	… acknowledge patients’ autonomous right to both informed consent and “informed refusal” of recommended evaluations or treatments.
A52	… express empathy with patients’ potential sense of shame around low literacy (or health literacy) issues.
A53	… express a non-judgmental, non-shaming, and respectful attitude toward individuals with limited literacy (or health literacy) skills.
A54	… express empathy with the common experience of the healthcare system as a confusing, stressful, frustrating, intimidating and be frightening physical and virtual environment for many patients.
A55	… express the attitude that every patient has the right to understand their healthcare and that it is the healthcare professional’s duty to elicit and ensure patients’ best possible understanding of their healthcare.	x	x
A56	… express the attitude that it is the responsibility of the healthcare sector to address the mismatch between patients’ and healthcare providers’ communication skills and tactics.
A57	… express the attitude that it is a responsibility of all members of the healthcare team to be trained and to be proactive in addressing the communication needs of patients.
A(i)	… express the attitude that digital technologies bring both opportunities and risks. (item was added in round 2)
Partial sum	11 (+ 1)	2	2
Organizational health literacy (OHL): A health professional should …
OHL(S)58	… create circumstances that allow calm communication (e.g., relocate to an appropriate room, closing doors). (item was moved to the category ‘skills’ after round 1)	x
OHL(S)58’	… have the ability to create good conditions for conversation.(item was moved to the category ‘skills’ after round 1)		x
OHL(S)59	… dedicate sufficient time for conversations with patients and their relatives. (item was moved to the category ‘skills’ after round 1)	x
OHL59’	… have the ability to dedicate sufficient time for conversations.
OHL60	… provide assistance for patients and their relatives in completing forms (e.g., in case of referrals, registration, patient decree).
OHL61	… empower patients and their relatives
	a) to access health information (e.g., by referencing good and reliable sources of information, brochures, links, contact person),
	b) to appraise health information (e.g., through explanation, replying to inquiries),
	c) to evaluate health information (e.g., through informing and explaining different options and their advantages and disadvantages),
	d) to apply health information to make informed decisions in regard to their own health (e.g., decisions regarding diagnostic methods and therapies, changes in lifestyle).
OHL(S)62	… offer courses to patients and their relatives about the following topics, or we refer them to other adequate providers: (was moved the category ‘skills’ after round 1)	x
	a) coping with chronic disease (self-management).
	b) lifestyle changes (e.g., nutrition and exercise, health coaching, stop smoking).
	c) use of health information and conversational skills (e.g., how to find trustworthy health information, contributing to a good and informative conversation with a health professional).
OHL63	… provide free-access health information for patients and their relatives.
OHL64	… inform patients of their rights (e.g., right to inspect the patient file, right to information).
OHL65	… support patients in the transition to other service providers (e.g., in making appointments, collecting and filling out documents, by exchanging information between service providers).
Partial sum	8	3	1
Total:		31	15

Legend: K…knowledge, S…skills, A…attitudes, OHL…organizational health literacy, ‘…re-formulated after round 1, *…culturally adapted. **…newly added

Round 2

In the second round, the goal was to obtain a consensus from the experts on the most relevant core competencies related to health literacy of health professionals. The research team received a large amount of feedback from round 1 regarding the somewhat unclear and misleading distinction between the two categories ‘important’ and ‘appropriate’. Thus, the two terms were combined in the second round in the new category of ‘relevance’. The term ‘relevance’ indicated how important these competencies were for all the health professionals mentioned and whether these competencies could be implemented appropriately by health professionals in their everyday work. Accordingly, the panelists had the opportunity to rate each competence dichotomously as ‘relevant’ or ‘not relevant’. Subsequently, the experts were asked to prioritize (i.e., rank) the competencies according to the perceived relevance. This procedure was carried out separately for each of the three categories (knowledge, skills (including OHL), and attitudes) and enabled the study team to exclude items that either (i) did not reach consensus among the expert panel, i.e., items, which were not rated as relevant by at least 70% of the panelists and (ii) were subsequently rated as less important in the ranking (less than 50% of total points for each dimensions) compared to the other competencies (Table 4). The ranking was evaluated in relation to the total sum of points for each of the three categories separately. The total possible score was calculated by multiplying the maximum number of experts (x) by the maximum number of items (y) that could theoretically have been included in the ranking. An example of an equation for the category ‘knowledge’ is therefore: possible total score = x * y = 24 experts * 13 items = 312. Within the categories of knowledge, skills and attitudes, the scores were distributed according to the number of items (i.e., the first place within the category ‘knowledge’ received 13 points, second place 12 points, etc., and the last position received 1 point). If an item was classified as not relevant, it was also not scored and received 0 points respectively. In the end, each item was analyzed to see if it scored at least 50% of the possible total points within its category. In this way, it was also possible to consider items that did not achieve a 70% consensus but were classified as ‘very important’ by some panelists. Thereby, the diverse professional backgrounds of the experts could be taken into consideration. The second round of questioning also included the possibility of giving feedback on the content and formulation of the core competencies in general. In addition, an open text field was used to ask how the experts would operationalize the so-called critical health literacy of health professionals and which aspects were to be considered when operationalizing such critical health literacy. These qualitative data was analyzed with a thematic analysis [36] to identify, analyze and reflect aspects and patterns with the data.

Table 4.

Rules to shorten and prioritize core competencies

Results

Quantitative analysis

The two Delphi rounds included an assessment of the initial list of health literacy competencies for health professionals of 65 items and consensus finding in round 1, and an assessment, consensus finding and prioritization of 37 items in round 2. The two rounds resulted in a condensed list of 14 health literacy core competencies in total in the end, i.e., 6 items on knowledge, 7 items on skills (including 1 item OHL) and 2 items on attitudes. These health literacy core competencies enable health professionals to recognize the level of health literacy of healthcare users, to communicate and support them appropriately in dealing with their health and well-being, and especially in making profound and shared decisions regarding treatment, health and to maintain or improve their quality of life (Table 5).

Table 5.

Core competencies of health literacy of health professionals

K/S/A1	Health literate health professionals …
1-K	… know what health literacy means.
2-K	… know that cultural and linguistic differences between patients and health professionals can increase difficulties in mutual understanding.
3-K	… know certain signs that may indicate low health literacy on the part of the patients or their relatives.
4-K	… know that every person benefits from and prefers easily understandable information and plain language.
5-K	… know the principles of plain language and clear health communication for oral and written communication.
1-S	… have the ability to use comprehensible formulations and to apply the principles of plain language in oral and written communication with patients and their relatives.
2-S	… have the ability to translate information from a non-simple language format into a scientifically correct, simple and easily understandable language format.
3-S	… have the ability to make action-oriented statements to make clear to patients and their relatives what they should do.
4-S	… have the ability to ask patients’ and their relatives’ prior knowledge about their health problems in an appreciative way.
5-S	… use appropriate methods effectively to assess the understanding of the patient and their relatives.
6-S	… have the ability to ask effective questions of patients and their relatives using the “patient-centered approach”.
7-S	… have the ability to create good conditions for discussion.
1-A	… express the attitude that effective communication is essential for ensuring safe and high-quality healthcare.
2-A	… express the attitude that every patient has the right to understand his or her own healthcare and that it is the duty of health workers to obtain and ensure the best possible understanding of patients’ healthcare.

¹ K…knowledge; S…skills; A…attitude

In the first round, 31 items (12 knowledge, 14 skills, 2 attitude, and 3 organizational health literacy items) were rated as important and appropriate and thus were included in the second round. For the second round, four new competencies were included (S(i), S(ii), S(iii), and A(i)) that had been suggested by the experts in round 1. Another four new competencies resulted from a reformulation or a division of one competence into two more detailed competencies (K2 was reformulated into K2’a and K2’b; S44 was reformulated into S44’a and S44’b). These reformulations were as well suggested by the experts, and mainly referred to current developments in relation to the digitalization of healthcare and new technologies. In addition, the three remaining items on organizational health literacy from round 1 (OHL58, OHL59, and OHL62) were moved to the category skills and their formulations were slightly adjusted since the core competencies were mainly targeted for health professionals and not the organizational context. The reformulated or split items were marked with the sign “ ' ” or an additional vowel (e.g., X’a, X’b) to being able to track them back to their original versions.

Qualitative analysis

This study not only included the assessment and prioritization of health professionals’ core competencies of health literacy, but also the possibility to refining the concept of health literacy of health professionals (round 1) and critical health literacy (round 2) via open questions.

In the first round, responses to the question on health professionals’ understanding of health literacy focused on three aspects. First, 12 panelists emphasized that health literacy of health professionals has two dimensions – one related to the health professionals’ own or “private” health information behavior and the other related specifically to the interaction with patients. One panelist commented:

I see two aspects: On the one hand, one’s own health literacy, i.e., how the health professionals themselves interpret and apply information, also for their own health. I think that their own knowledge and understanding of medical backgrounds and correlations is decisive for how health professionals deal with their patients. On the other hand, the awareness of the health professionals of the level and importance of the health literacy of their patients is a second important factor: Do the health professionals put themselves in the patients’ shoes and try to estimate which information reaches the patients and in which form? (Panel member Delphi study).

Second, seven of the experts’ definitions on the concept of health literacy of health professionals were strongly related to common concepts of health literacy. Those common concepts included especially the definitions and conceptualizations of Nutbeam [37] and Sørensen [38]. Third, five expert responses explicitly referred to the social, relational, and communicative aspects of health literacy among health professionals. This focus did not include the answers that were based on existing concepts, but rather highlighted the aspect of communication and interaction.

In the second round, the expert panel was asked how they would operationalize critical health literacy of health professionals and, in doing so, which aspects were specifically to be considered by health professionals. Most answers emphasized that health professionals ought to encourage patients and their relatives towards a “(self-)critical joint interaction” and an “active involvement in decision-making processes”. Furthermore, the experts proposed that patients and their relatives as well as health professionals themselves should be able to critically reflect upon and adequately deal with increasing “uncertainties in knowledge”.

Discussion

The final 14 health literacy core competencies of health professionals identified in the present Delphi study (Table 5) apply to all the five health professions (pharmacists, physicians, medical practice assistants, nurses, and physiotherapists) taken into consideration in this study. Therefore, these 14 health literacy core competencies are also eligible for interprofessional educational approaches. Furthermore, although five health professions were included in the present study, these competencies are also relevant to other health-related professions, such as speech and language therapists [39] and also for social care professionals [40]. While most of the items were rated as important in the first round, their appropriateness in terms of practical applicability for health professionals was not always given. This was partly since some items were not rated important and appropriate for all health professions. In addition, the organizational health literacy-oriented competencies were not always rated as appropriate. One simple reason may have been that they were formulated with organizational structures and processes in mind, rather than the competencies of health professionals. Another reason for these ratings could have been the restricted influence of health professionals on organizational structures, the high workload in the medical setting and the associated lack of personal, financial, and temporal organizational resources – despite the high relevance of structural and processual health literacy support of organizations. This is in line with recent studies which showed that the greatest perceived barriers of health literacy for health professionals were time constraints and a lack of human resources, followed by a lack of organizational resources for implementing health literacy interventions in daily work processes [16, 41]. As suggested by most experts in round 1, the organizational health literacy competencies that reached round 2, were reformulated and recategorized (into skills).

The health literacy knowledge of health professionals

One of the core competencies turned out to be knowing about the importance of health literacy (1-K in Table 5). This is a health literacy competence, which is often mentioned in the literature as the most fundamental and important one [42–46]. The emphasis on the importance of knowing and being aware of health literacy and its benefits is also in line with research on change processes. Research on organizational transformation and change emphasizes that being aware of an issue presents the first step in developing solutions [47]. In addition, the panelists rated the knowledge of cultural and linguistic differences and their consequences in dealing with patients and relatives as an important competence (2-K in Table 5). As an example, the awareness of different culturally-oriented expectations and needs of patients and their relatives, previous experiences with foreign health systems, or other religious and cultural mindsets are some of many specific aspects that health professionals must consider for a health literacy-supportive communication and person-oriented care [48]. In a globalized world, health professionals need the necessary knowledge and skills to face the challenges posed by multiculturalism and to strengthen health literacy among a diverse society, thereby contributing to health equity [49]. Research shows that health professionals reported difficulties when applying well-tried techniques of shared decision-making (e.g., motivational interviewing) in situations with people with certain migration backgrounds, since these patients and their relatives were rather unfamiliar with processes of co-designing health by health professionals and healthcare users [50]. In line with recent research, the experts of the present study also identified the knowledge of how to recognize limited health literacy of patients and their relatives as an important core competence (3-K in Table 5). Despite these fundamental aspects, health professionals still have limited knowledge of health literacy and even tend to overestimate the health literacy of their patients and their families [16, 28, 29]. However, assessing the health literacy of patients and their families is the basis for communicating and acting appropriately in everyday practice and for ensuring the adherence and sustainability of any medical or therapeutic treatment, preventive or health-promoting behavior [51]. In fact, health professionals should be aware of the importance and benefits of simple and clear communication with all individuals, regardless of the level of health literacy of patients and their relatives (4-K in Table 5). Furthermore, health professionals should be aware of how patients can significantly benefit when they know and apply the principles of simple language in interaction with their patients (5-K in Table 5) [52–54]. Accordingly, the items regarding the knowledge of health professionals on health literacy-related aspects were rated as very relevant by the experts and were consequently part of the final set of core competencies for health professionals.

The health literacy attitudes of health professionals

Regarding the dimension ‘attitudes’ and based on the experts’ opinion of the Delphi panel, health professionals should realize that effective communication can enhance the quality of healthcare (1-A in Table 5). This result confirms findings of previous studies [42–46, 55]. Furthermore, the panelists considered it as particularly relevant that health professionals are aware of patients’ rights of understanding health-related information and thus of the importance of communication (2-A in Table 5). Such attitudes may be facilitated and improved through health literacy training for health professionals [43, 56, 57]. Educational interventions may raise health professionals’ awareness on the topic of health literacy in general, enhance the attitude of health literacy promotion as integral part of their profession and job, and encourage the use of clear communication strategies to support patients and their relatives in dealing with health information. Research studies have shown that corresponding positive attitudes of actors towards health literacy are crucial for implementing health literacy in professional and organizational settings [16, 58].

The health literacy skills of health professionals

Health literacy has an important role in patient-centered care. In particular, by strengthening health literacy competencies of health professionals, health professionals can in turn contribute to improving patient understanding, adherence to treatment plans, and ultimately, health-related outcomes [59]. According to the experts participating in this study, one of the core heath literacy skills of health professionals is to be able to communicate health information in a comprehensible manner, both orally and in writing (1-S in Table 5). Furthermore, health professionals must be able to translate complex medical content and jargon into plain and easy-to-understand language (2-S in Table 5) [60, 61], while potential risks of treatment options should be explained in concrete terms rather than abstract numbers or constructs [62]. Shared decision making, for example, can be promoted by discussing the advantages and disadvantages of treatment options in easy-to-understand language, by integrating the contexts, needs and desires of patients, by motivating and enabling patients and their relatives to make decisions together with health professionals and by supporting to weigh the respective consequences of the decision for their lives [63]. Hence, health professionals must have the ability to inquire about prior knowledge in an appreciative manner (4-S in Table 5), not only to assess the level of health literacy [43, 44, 53], but also to determine the needs and wishes of patients and their relatives in a person-centered approach [54]. In doing so, health professionals can effectively assess the understanding of patients and their relatives by using appropriate methods (5-S in Table 5) and by assessing whether their counterpart understood the communicated health information (6-S in Table 5) [50]. Moreover, health professionals should also be able to give clear instructions for action to patients and their relatives so that they can successfully apply those actions and integrate them in their daily lives (3-S). These communication practices provide a fundamental level of involvement and empowerment of patients and their relatives [63]. To be able to enact such communicative skills, adequate conversational conditions and enough time for consultations are, however, required (7-S in Table 5) [55, 64].

Several studies have already identified communication skills as an important aspect of health professional education and curricula [65]. In the present Delphi study, communication practices also emerged as crucial core competences in all three categories of knowledge, skills and attitudes [22, 66]. Another finding of the study is the interwoven nature of the key health literacy competencies of health professionals, i.e., core competencies can be characterized as an interrelated bundle of competencies that complement and build on each other. For example, knowledge regarding the consequences of limited health literacy requires an attitude of being willing to explain rather complex medical terms in plain and easy-to-understand language when communicating with patients and their relatives. Supporting health literacy at a professional level ensures patients and their relatives to be listened to, appreciated, and taken seriously during the treatment process. It encourages and enables them to express their needs and wishes in the sense of shared decision making. In this way, patients, their relatives, and healthcare users in general ultimately feel much more empowered to take responsibility for their own health [67].

The dualistic nature of health professionals’ health literacy

The qualitative results of the present Delphi study include two key findings: First, the results highlight the dualistic nature of health professionals’ health literacy. When asked about the characteristics of health literacy competencies of health professionals, most of the panelists emphasized that in the context of health professions, health literacy is a two-dimensional construct. Based on the understanding of the general health literacy concept, a first dimension of health professionals’ health literacy primarily relates to the health professionals themselves and includes their motivation, knowledge and competencies to find, understand, appraise, and apply health-related information to make sound decisions on health and well-being as an individual. A second dimension of health professionals’ health literacy focusses on their interaction with patients, relatives, clients, and healthcare users. It includes their attitudes, knowledge, and skills to promote, maintain, and support the development and practice of health literacy of others. This dualistic understanding leads to new opportunities and challenges, both in conceptualizing and operationalizing health literacy. According to the experts participating in this study, additional competencies are required when it comes to the second dimension, i.e., to recognizing, supporting the development and strengthening the health literacy of patients and their relatives. Competencies such as patient-oriented communication, assessing the quality of written and audiovisual health information, providing quality-assured health information in plain language, and supporting health literate organizational processes become a bundle of important assets of health literate health professionals. For health professionals in leading functions, these competencies must be complemented by certain knowledge and skills, e.g., to design and promote easily navigable healthcare systems at all levels and competencies to involve target group representatives.

Second, the qualitative results show that most panelists underlined the crucial importance of an interactive communication and of a patient-provider-relationship as a vital element of health professionals’ health literacy. In line with recent studies on essential components of health literacy in practice [16, 21], the qualitative results support the quantitative results of the two Delphi rounds, leading to five explicitly interactive and inter-relational core competencies (4-S, 5-S, 6-S, 7-S, 1-A, Table 5).

During pandemics, infodemics, and increased digitalization, the availability of health information from various platforms and authors has surged, posing challenges in staying current and critically evaluating the information [68–70]. Additionally, healthcare professionals must navigate the complexities of dealing with misinformed and demanding patients [71] and are confronted with the challenges and opportunities offered by the rising of new technologies and AI-based resources, which in turn are requesting further competencies [72]. Thus, health professionals need more than ever to be optimally equipped with health literacy competencies, in their basic training and further education as well as on the job. In addition, the role of health literacy and the competencies needed to face the current social development deserve to be investigated in further research.

Conclusion

In line with the American and European research on health literacy competencies of health professionals, the present study reveals a strong focus on the relevance of communication competencies of health professionals [24, 30]. The awareness on health professionals having a significant influence on patients’ health literacy through their way of communication should therefore always be considered and promoted accordingly. By enacting health literacy competencies, health professionals can also influence treatment pathways and patients’ disease, preventive and health promoting behavior. By tailoring communication to address cultural, linguistic, and literacy diversity, this list of core competencies promotes patient-centered care and equitable health outcomes for practitioners in healthcare. Additionally, they provide a framework for practitioners both in the healthcare and the education sector to identify skill gaps and engage in targeted professional development. For decision-makers, a list of health literacy core competences for health professionals establishes standardized practices that ensure consistent and effective communication across healthcare systems. Such steps of alignment can improve patient outcomes, reduces readmissions, and supports cost-efficiency. Furthermore, these competencies advance health equity by equipping providers to address the needs of underserved populations, fostering more inclusive healthcare delivery.

The strength of the present approach to identifying a short list of core health literacy competencies for health professionals therefore lies in the discussing the very core competences with a diverse panel of experts in the field. Building on these insights, profound frameworks and concepts are to be developed to measure, operationalize, and implement health literacy in education as well as everyday practices of health professionals.

Electronic supplementary material

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Abbreviations

A

Attitudes

K

Knowledge

OHL

Organizational Health Literacy

OHL Self-AsseT

Organizational Health Literacy Self-Assessment Tool for Primary Care

S

Skills

U.S.

United States

Author contributions

SDG and RJ were responsible for the design and the implementation of the Delphi study. ASB interpreted the results and primarily wrote the manuscript. RJ, EA, SDG and ASB reviewed the manuscript and provided guidance in the early stages of the paper process. All authors contributed to the article and approved the submitted version.

Funding

No funding was provided for this research.

Data availability

The interview guide of this Delphi study is available as a supplementary file.

Declarations

Ethics approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki. Ethical review and approval were waived for this study, as it is outside the scope of the Human Research Act and did not require approval by the Swiss Association of Research Ethics Committees (BASEC-Nr. Req-2021-01325). Informed consent was obtained from all the participants via a declaration of understanding and consent to participate directly in the questionnaire, which had to be confirmed in order to be able to participate in the study. Participants have also consented to the dissemination of the anonymized study results.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.