International consensus on school health literacy responsiveness: findings from a modified Delphi process

Abstract

There is a lack of validated tools to assess health literacy responsiveness, defined as the organizational capacity of schools to create accessible and equitable environments that support health literacy development, in school settings internationally. This study, the second phase of a three-part research program, aimed to develop a school-based health literacy assessment tool through a systematic, multi-step development process. Building on a prior scoping review that identified 629 items from existing tools, 210 refined items were presented to 22 international experts via a modified Delphi survey. Experts rated relevance, domain fit, and need for revision. Consensus, derived from qualitative analysis of expert feedback, revealed 47 items as highly important, 119 as potentially relevant, and 44 as unsuitable for schools. Expert feedback informed conceptualization of organizational health literacy in schools. The items reflect practical considerations, cross-national, and multidisciplinary perspectives. Findings highlight strong support for domains such as communication, engagement, and workforce development. The next phase includes pilot testing and validation to support implementation of a tool to promote health literacy among students, teachers, and leaders.

Contribution to Health Promotion.

• International consensus: Established global consensus on school health literacy responsiveness across 11 countries, enhancing transferability to international school health promotion.

• Innovative methodology: Integrated findings from a previously published scoping review and content analysis into a modified Delphi process, advancing evidence-informed tool development to promote health literacy responsiveness within school systems.

• Practical framework: Provided a framework to guide schools in assessing and strengthening their responsiveness to health literacy needs, supporting the design of more health-literate and health-promoting educational environments.

• Equity and inclusivity: Incorporated diverse perspectives from multiple disciplines, regions, and knowledge traditions to promote equity and inclusivity in school health promotion.

Introduction

There is increasing recognition that health prevention, promotion, and protection efforts all rely on health literacy for them to be effective (Palumbo 2021). It has been argued that health literacy development must be considered early in the life course and schools provide an ideal setting (Otten et al. 2023b, Krudewig et al. 2024). Further, health literacy must be conceptualized within a social ecological model (SEM) (McCormack et al. 2017), whereby the individual student is supported to develop their individual health literacy, shaped by the social networks (teachers, peers, and carers) and the environment (school) that surrounds them (Bröder and Carvalho 2019). While low health literacy is associated with poorer health outcomes and inequalities, interventions focusing solely on individual skills have limited impact on reducing disparities (Nutbeam and Lloyd 2021). This emphasizes the need for system-level, responsive approaches, such as fostering health literacy responsiveness (HLR) in schools and broader community settings.

To address the potential for conceptual diffusion within the field, this study is anchored in the “second dimension” of health literacy (Nutbeam 2025), which emphasizes the fundamental role of context in moderating an individual's ability to apply their skills. This shifts the focus from a purely individualistic asset model to the organizational responsiveness of schools. Consistent with the ecological model for health literacy (McCormack et al. 2017), the responsiveness of the school must be optimized to provide students with the best environment for learning and developing their health literacy assets (Bröder and Carvalho 2019, Otten et al. 2026). HLR is “the extent to which organisations recognize and accommodate diverse traditions and health literacy strengths, needs and preferences to create enabling environments that optimize equitable access to and engagement with health information and services, and support for the health and well-being of individuals, families, groups and communities” (Osborne et al. 2022, Box 2). More recently, it has been argued that there is an ethical imperative for schools to contribute to the health literacy development opportunities for children (Otten et al. 2023b).

To date, the Health Promoting Schools (HPS) framework has provided a basis for considering how health literacy can be implemented in schools to focus on the individual, the school environment, and the broader school community (World Health Organization; United Nations Educational Scientific and Cultural Organization 2021). Launched in 1995, the World Health Organization's (WHO) Global School Health Initiative aimed to increase the number of schools that can be truly called “Health Promoting Schools” (World Health Organization 1997). Among other key policies, the Initiative was guided by the Ottawa Charter for Health Promotion. Importantly, the Ottawa Charter recognizes that health promotion goes beyond healthcare. The Charter includes the Action Area “Develop Personal Skills” which include individual health literacy assets such as making informed decisions, managing health, and well-being (World Health Organization 1986, p3). The Charter calls out the role of school, home, work, and community settings in health promotion efforts. Specifically, action is “required through educational, professional, commercial and voluntary bodies, and within the institutions themselves” (World Health Organization 1986). The Ottawa Charter also draws attention to the importance of creating supportive environments, which has relevance to the creation of health literacy responsive school environments which can foster health literacy development.

The HPS framework is a principles-based, normative framework drawing on multiple disciplinary traditions rather than a single, tightly specified theoretical model. Its implementation challenges have been attributed in part to the absence of a clearly articulated theory of change (Darlington et al. 2018), which makes it difficult to understand how broad principles interact with diverse school contexts to produce health outcomes (Langford et al. 2014). While widely adopted, the HPS agenda has had varying levels of global uptake (World Health Organization 2017, Pulimeno et al. 2020). Challenges to implementing HPS arise from a variety of factors, including limited inter-sectoral collaboration, inadequate policy support, insufficient infrastructure and capacity, lack of trained human resources, and insufficient community involvement (Fathi et al. 2014, Langford et al. 2015, Ogasawara et al. 2022, Asadi et al. 2025). Additionally, a lack of awareness and understanding among school staff about their role in health promotion, coupled with competing demands on their time, hinders progress (Cheung et al. 2017, Chrisman et al. 2024). Furthermore, the health and education sectors have historically operated with different priorities and structures, making it difficult to achieve the necessary collaboration (Bundy et al. 2017, Gray et al. 2022). To address these implementation challenges, health literacy is positioned as a core goal within the HPS framework (Okan et al. 2020). However, to move beyond individual skills, HLR is proposed as the specific organizational mechanism to operationalize this vision (Elmer et al. 2021). While HPS provides the overarching strategic vision, a health literacy responsive school functions as the organizational infrastructure that translates generic organizational health literacy (OHL) principles (Brach et al. 2012) into the school context. Accordingly, HLR does not replace HPS but represents the organizational “how-to,” reorienting school environments to ensure that health information and systems are accessible and equitable (Trezona et al. 2017, Chu et al. 2024). While a range of organizational assessment tools have been developed using the HPS framework, these are typically broad in scope and not specifically designed to assess HLR. Although some existing HPS tools include health literacy as a thematic area, they frequently lack the granular indicators needed to identify systemic barriers in information flow and organizational responsiveness. Consequently, there remains a need for a targeted instrument that can systematically capture how schools respond to diverse health literacy needs. The development of a HLR-focused tool therefore complements, rather than duplicates existing HPS assessment approaches, providing actionable, high-resolution insights that operationalize health literacy as a functional and measurable aspect of school environments.

A review by Chu et al. (2024) reported on the limited settings focus and acknowledged that health literacy initiatives must be considered in education and community settings. Aligned with previous research (Trezona et al. 2018, De Gani et al. 2020), Chu et al. (2024) proposed six domains of HLR: (i) communication, (ii) navigation of resources (physical and online, environment), (iii) organizational culture (ethos, leadership), (iv) policies and practice (systems, processes, policies, procedures), (v) involvement and engagement (community, partnerships), and (vi) workforce development (capacity building). Chu et al. (2024) systematically reviewed each domain to ensure there was no overlap in meaning between items and a detailed statement of intent and keywords to describe each domain (and subdomain) were identified to facilitate the systematic and clear creation of items. These outputs informed the development of items for the Delphi study reported here.

While assessment tools or questionnaires are established in healthcare, a critical gap persists in school settings (Elmer et al. 2021, Chu et al. 2024). The dearth of tools in school settings reflects broader challenges in implementing school-based health promotion and health education (Pulimeno et al. 2020), particularly a lack of awareness and understanding regarding how school infrastructure, policies, and processes, the core of OHL, influence students’ learning and application of health-related information (Auld et al. 2020). Historically, schools have emphasized the development of individual health literacy skills rather than creating environments that support and promote them (Yu et al. 2025), such as the design of the health materials, the inclusivity of communication, or the overall school culture (Elmer et al. 2021, Krudewig et al. 2024). Assessing the health literacy environment and its impact remains challenging due to the time and resources required (Yu et al. 2025). Consequently, health literacy researchers have shifted toward adapting the concept of OHL, originally developed for healthcare. For instance, the Australian HealthLit4Kids program found that the community-based tool (e.g. HELLOTas) was not fit for purpose in the school setting (Elmer et al. 2021). Additionally, the Health-Literate Schools (HeLit-School) framework (Okan et al. 2021, Kirchhoff et al. 2022) was developed specifically for the educational sector, providing a more context-sensitive conceptual basis. However, as HeLit-School was primarily established within a specific national context, its applicability across diverse international school systems remains an area for further empirical validation. Despite Nutbeam’s (2025) critique regarding the proliferation of health literacy scales, developing a new tool remains essential to bridge these contextual and cross-cultural gaps. Rather than creating a redundant instrument, this research utilizes the six domains identified by Chu et al. (2024), which synthesize established international HLR-related instruments, including the HeLit-School domains, to ensure the resulting tool is contextually and culturally relevant and addresses the unique pedagogical structures of schools. This systematic item identification is a necessary step to translate HLR into the operational “how-to” that complements the OHL framework through a practical, expert-validated implementation tool.

To date, most reviews that focused on HLR (Rowlands et al. 2019, Zanobini et al. 2020) report on theories and frameworks for implementation, few have focused on the assessment tools in detail. In the context of this study, an assessment tool is defined as a practical organizational checklist that measures how school environments, policies, and practices facilitate health literacy. Prior to the review by Chu et al. (2024), none had sought to produce a finite list of the individual items. In addition, most prior reviews focused exclusively on healthcare organizations, rather than acknowledging that health literacy can exist in many contexts outside of healthcare such as community settings and schools. This is a missed opportunity as schools have the potential to positively impact many stakeholders including teachers, students, parents, and the broader community.

The Delphi method has been applied in scale or assessment development research to systematically gather expert consensus during the stage of assessment design (Sørensen et al. 2013, Lee et al. 2023, Min et al. 2024). Its structured and iterative nature makes it well suited for addressing complex or exploratory issues. Through multiple rounds of anonymous feedback and opinion aggregation, it effectively promotes expert consensus, clarifies concepts, and enhances content validity (Hasson et al. 2000, Shang 2023). In the field of health literacy, particularly in studies related to healthcare systems, professionals, and patients (Tian et al. 2023, Tsai et al. 2024), Delphi is frequently used to gather expert or field specialist opinions on the importance and clarity of proposed items. The process enhances the rigor of instrument development and can ensure its relevance to the target population (Chen et al. 2023, Ravid-Saffir et al. 2023). Overall, the Delphi method enhances the content validity, cultural appropriateness, and practical applicability of scales (Bull et al. 2022, Teig et al. 2023), particularly in multidisciplinary or cross-national contexts.

Therefore, the aim of this Delphi research study was to share the core domains and items from the review carried out by Chu et al. (2024) with international health literacy experts and invite them to provide justifications for the inclusion or exclusion of each domain and item for use in a future health literacy responsive tool for schools.

Materials and methods

Consistent with the tool development methods outlined by Boateng et al. (2018), this study followed a sequential multi-phase process comprising a scoping review, item refinement, and a modified Delphi study. The research question which guided this research was as follows: “Which domains and items (extracted from existing tools) do health literacy experts agree should be included in our health literacy responsive tool for schools?”

Design and ethics

This paper presents the second phase of the tool development process: a modified Delphi study used to determine which domains and items international health literacy experts agreed should be included in the future tool [Health Literacy Responsive Schools Tool (HLRS tool)]. The study was approved by the Social Sciences Human Research Ethics Committee of Tasmania (approval number: H28512). Prior to commencing the online Delphi survey, all participants were provided with an information sheet and signed an electronic informed consent form via REDCap system, issued by the research team. Only participants’ names and email addresses were collected for the purpose of survey administration and communication.

Participants

Experts were identified and purposely recruited from the authors networks via email invitation. A total of 22 experts signed the electronic informed consent form and were included in the panel. For the purpose of this study, a “health literacy expert” was defined as a university academic and researcher with expertise in health literacy, health education, school-based health promotion, health communication, and public health. In addition to their academic appointments, several panel members possessed extensive field experience, having led HPS programs or served as consultants for school-based health initiatives. The invited panel comprised 15 females and 7 males. The experts represented a diverse geographic range, including Australia (n = 6), Norway (n = 3), Iran (n = 3), England (n = 2), Portugal (n = 2), and one each (n = 1) from Canada, Taiwan, Germany, Netherlands, Nigeria, and Ireland. Their responses were submitted between 26 June 2024 and 18 December 2024. Experts were selected based on their experience and diversity in geography, gender, and professional roles, in line with recommendations by Boateng et al. (2018).

Procedure

Item refinement and survey preparation

Building on our previous scoping review (Chu et al. 2024), which identified 629 items from tools such as the Organizational Health Literacy Responsiveness (Org-HLR) self-assessment tool (Trezona et al. 2018) and the Health-Literate Schools (HeLit School) framework (Okan et al. 2021), members of the research team (TC and RK) reviewed and refined the initial 629 items. This process, informed by Elo and Kyngäs (2008), excluded those that were overly specific to non-school contexts, focused solely on individual-level perspectives, or were duplicative or ambiguous (Chu et al. 2024). This ensured the relevance and clarity of the 210 items retained.

Delphi survey implementation

Consistent with e-Delphi methodology (Donohoe et al. 2012), an online Delphi survey was administered via the UTAS REDCap system. To enhance data security and prevent spam, Google reCAPTCHA and a return-code system were employed, allowing participants to resume incomplete surveys securely. A modified Delphi method was adopted in this study; unlike the classical Delphi method, which typically begins with open-ended item generation, the first round was informed by a pre-developed item pool derived from a prior scoping review and content analysis (Chu et al. 2024). This approach ensured that the consensus process was grounded in existing international evidence from the outset, allowing experts to focus on evaluating and refining pre-identified items rather than generating new content (Woodcock et al. 2020, Nasa et al. 2021).

Step 1: Item sorting and questionnaire development

The research team organized the refined items into domains and developed a structured questionnaire. The staged qualitative Delphi process (Sekayi and Kennedy 2017) was delivered via REDCap, allowing focused feedback on each domain.

Step 2: Modified Delphi survey rounds

The modified Delphi survey was conducted in multiple rounds (n = 3), each covering two domains to reduce participant burden. The six domains evaluated were communication, navigation of resources (physical and online, environment), organizational culture (ethos, leadership), policies and practice (systems, processes, policies, procedures), involvement and engagement (community, partnerships), and workforce development (capacity building). In each round, experts were presented with approximately 40 draft tool items. Participants evaluated each item based on its importance, domain fit, and the necessity for revision. Expert responses were retained for each domain they completed, regardless of whether the entire survey was finished. This maximizes the utilization of available expert input, avoided the potential for bias introduced by imputing missing values, and adhere to established modified Delphi protocols that favor analyzing each domain with available data rather than excluding valid responses from partial responders.

Instruments

For each draft tool item, experts provided evaluations based on the following survey questions:

• Survey question 1 (Importance): Response options included Very Important, Slightly Important, Not Important, and Only relevant in some settings or circumstances, with space for comments.

• Survey question 2 (Domain Fit): Response options were Agree or Disagree, with space to explain reasoning.

• Survey question 3 (Revision): Response options were Yes or No, with suggestions for revision encouraged.

Data analysis and item refinement

Responses were analyzed and items were grouped based on consensus levels, following thresholds previously established by Diamond et al. (2014) and Dietrich et al. (2024). The color-coded system was used to indicate decision pathways for item retention, revision, or exclusion, based on the proportion of experts rating each item as “very important.”

• Green category: ≥75% agreement—retained without modification

• Orange category: 50%–74% agreement—considered for revision

• Red category: <50% agreement—excluded

To identify key reasons for inclusion and exclusion of scale items, the comments the experts shared against each red category and orange category item were analyzed using content analysis (Elo and Kyngäs 2008); these are presented in Tables 3 and 4.

Table 3.

Items excluded due to low expert (red group) agreement with content analysis summary.

Reason of exclusion	N	%	Items
Limited relevance	14	31.8	2-2, 2-3, 2-14, 2-16, 2-21, 4-17, 4-23, 4-24, 4-29, 4-36, 5-14, 5-19, 6-25, 6-30
Lack of clarity	12	27.3	1-15, 1-30, 2-23, 2-26, 3-10, 3-11, 3-12, 3-15, 4-18, 5-17, 5-23, 6-29
Ambiguity and limited applicability	7	15.9	1-42, 1-46, 4-13, 4-34, 4-39, 5-20, 5-22
Similar items	4	9.1	1-2, 2-1, 2-8, 4-40
Resource and feasibility constraints	1	2.3	1-6
Outdated or impractical elements	1	2.3	1-33
Contextual and respondent limitations	1	2.3	1-34
Confusing or misleading implications	1	2.3	4-16
Data privacy and conceptual ambiguity	1	2.3	4-22
Limited flexibility in information delivery	1	2.3	5-15
Lack of clarity and practical inconsistencies	1	2.3	5-16

Table 4.

Items requiring further review with overlapping items (Orange group) and justifications for inclusion or exclusion.

Reason of exclusion	N	%	Items
Similar items	39	32	1-12, 1-38, 2-5, 2-6, 2-7, 2-9, 2-12, 2-15, 2-19, 3-3, 3-7, 3-21, 3-22, 3-23, 3-24, 3-25, 3-26, 4-3, 4-4, 4-5, 4-7, 4-33, 4-38, 5-5, 5-8, 5-18, 5-21, 5-24, 6-3, 6-5, 6-9, 6-15, 6-18, 6-21, 6-22, 6-24, 6-26, 6-32, 6-33
Lack of clarity	29	24	1-7, 1-17, 1-23, 1-25, 1-28, 1-32, 1-36, 1-40, 1-43, 1-48, 2-25, 2-28, 2-31, 3-5, 3-13, 3-16, 3-14, 3-18, 3-19, 4-10, 4-19, 4-20, 4-25, 4-26, 4-27, 6-7, 6-11, 6-34
Combine with other items	25	22	1-20, 1-26, 1-41, 2-4, 2-11, 2-13, 2-17, 2-22, 2-27, 3-2, 3-6, 3-9, 3-14, 3-20, 4-6, 4-15, 4-30, 4-41, 4-42, 5-2, 5-11, 5-25, 5-27, 6-20, 6-23
Limited relevance	12	10	1-9, 1-19, 1-44, 1-45, 1-47, 4-12, 4-37, 4-43, 5-3, 5-26, 6-1, 6-19
Resource and feasibility constraints	7	6	1-4, 4-2, 4-28, 4-31, 4-32, 4-44, 6-4
Lack of clarity and resource and feasibility constraints	3	2	1-16, 1-27, 1-39
Need for refinement or reorganization	2	2	1-11, 1-13
Too specific	2	2	1-24, 4-35

Results

A total of 22 experts were included in the modified Delphi panel; the actual participation numbers per round were 14 experts for Domains 1 (D1) and 2 (D2), 13 for Domain 3 (D3), 12 for Domain 4 (D4), and 10 for Domains 5 (D5) and 6 (D6). This corresponds to an overall completion rate of 45% (10 of 22 participants completing all three modified Delphi rounds). Figure 1 outlines the modified Delphi process and indicates the six domains assessed in each round. Based on the results summarized in Table 1, a higher proportion of the green items indicate stronger expert consensus, orange items reflect differing opinions, and red items represent rejection. Three domains showed particularly high consensus including: workforce development (35.29%), which highlights strong agreement on the importance of teacher and staff capacity building; involvement and engagement (29.63%), emphasizing the critical role of partnerships with parents and communities; and communication (27.08%), underscoring that clear organizational support and communication is crucial for developing health literacy in schools. In contrast, domains, such as navigation of resources (16.13%), policies and practice (13.64%), and organizational culture (11.54%), received lower expert consensus.

Figure 1.

A multi-phase framework for establishing the six assessment domains through foundational research and expert consensus. Flow diagram illustrating the progression from Phase 1 (Foundation) to the modified Delphi process, outlining the iterative refinement of the six domains across each round.

Table 1.

Expert consensus on Delphi survey items across six domains.

	Workforce development	Involvement and engagement	Communication	Navigation of resources	Policies and practice	Organizational culture	Total
Green	12	8	13	5	6	3	47
Orange	19	11	27	17	26	19	119
Red	3	8	8	9	12	4	44
Total	34	27	48	31	44	26	210
High Consensus Rate (%)	35.29%	29.63%	27.08%	16.13%	13.64%	11.54%	22.38%

Domain numbering (reflecting original survey order): (1) communication, (2) navigation of resources, (3) organizational culture, (4) policies and practice, (5) involvement and engagement, and (6) workforce development. Item categories: green (high consensus, ≥75%), orange (moderate consensus, 50%–74%), and red (low consensus, <50%). High consensus rate (%): calculated as (green items/total items per domain) × 100. Bold values indicate higher proportions of green items within domains.

As shown in Table 2, the experts’ feedback was carefully analyzed to determine the level of agreement for each item. Items with consensus levels above 75%, classified as the “green” category, were selected for inclusion in the assessment tool with minor or no modifications. For each included item, the table lists the item number, wording, percentage of expert agreement, and a summary of synthesized expert suggestions. Given that only a minority of experts provided open-ended feedback, and their points of view were largely consistent, these comments were consolidated into a concise summary. These summaries primarily provide technical refinements for wording, such as suggestions for simplifying language or splitting complex sentences to improve item's relevance and clarity. Agreement rates in this category ranged from 75% to 100%, demonstrating strong expert consensus on the importance and priority of these items.

Table 2.

Final items included based on expert consensus (≥75% agreement).

Items	Agreement (%)	Synthesized suggestions
D1: Communication
1-1. The school's website is user-friendly and easy to understand even for people with poor digital competencies as well as for people with physical and cognitive disabilities (e.g. use of plain language, adjustable font size, available color choice, simple navigation, read-aloud function).	86%	Consider splitting the sentence for clarity, replacing and simplifying the wording.
1-3. In conversations with our students or caregivers, we ensure the information given is understood (e.g. through conversation techniques such as teach-back).	93%	Example modification: replaced “teach-back” with generic terms to ensure international applicability.
1-5. Easy-to-understand menu information is available (including nutrients) to support healthy choices.	79%	Should reflect school context and age group, focus on healthy diet support, not just menu display or calories.
1-8. Provide a variety of health education materials appropriate to students’ and caregivers’ health literacy levels and needs.	93%	None.
1-10. Our school tailors our written and verbal communication to the specific needs of our target groups (e.g. culture, age, gender, sexuality, cognitive abilities, etc.).	86%	Wording adjustment: Change “target group” to “school community” to ensure it fits the school context.
1-14. Staff within our school utilize various formats to provide health information (e.g. brochures, web based, demonstration, audio).	86%	None.
1-18. Written (printed and/or online) materials follow design guidelines for better understandability (font size, line spacing, color scheme, use of images) (e.g. patient orientation materials, legal materials, informed consent forms, medical history forms, discharge forms and follow-up notifications).	79%	Revise to fit school context and clarify if staff follow established guidelines for clear communication.
1-21. Written and audio-visual materials are revised periodically to ensure best quality and accuracy of information (e.g. based upon current evidence). Materials include a statement of last update and the information source so that the quality of the original information source can be assessed independently.	79%	Split into two items and simplify wording for clarity.
1-22. If math terms (such as mean, average range, rate, or risk) are used, the term is defined in plain language and, if possible, with a helpful example or illustration.	79%	Defining numeracy terms in plain language and providing examples.
1-29. Staff use clear language and avoid jargon and technical terms when communicating with students and caregivers (written and verbal).	86%	None.
1-31. Sensitive conversations take place in rooms/space that support effective communication (e.g. private counseling space, quiet environment).	79%	Ensuring privacy and a supportive environment for sensitive conversations.
1-35. Our school uses appropriate and respectful terminology in all communication (e.g. in relation to cultural groups, gender identity, sexuality).	93%	None.
1-37. We respond to different needs and language requirements of our users (e.g. through mother tongue assistance, visual material and pictograms).	79%	Clarifying the responsible entity and specifying the “school community” or “students” as primary users.
D2: Navigation of resources (physical and online, environment)
2-10. Navigation support for visually impaired staff, students or caregivers is available.	79%	None.
2-18. Our school provides a welcoming and supportive environment for diverse and vulnerable groups (e.g. Aboriginal, CALD, and LGBTIQA + communities).	79%	Broadening examples of diverse groups for better international applicability.
2-20. Our school has clear access and referral pathways in place to healthcare professionals (including allied healthcare professionals).	79%	None.
2-24. All digital services and new media which are available via online portals, app download centers, etc., are technically correct and easy to understand, contain action-oriented information, and are adequate for target groups.	86%	Simplify wording for clearer communication.
2-30. Our phone numbers, addresses, and our website are clear and easy to find in directories (e.g. internet, information brochures).	86%	None.
D3: Culture (ethos, leadership)
3-1. Policy documents, such as the mission statement, goals, and policies, explicitly define health literacy as an organizational priority.	77%	None.
3-4. Promote and enhance health literacy in daily school life.	85%	Revise for improved clarity and readability.
3-8. Strategies to improve health literacy are included in our strategic plan/business/operational plans.	92%	Broaden scope to include curriculum-related terms to better integrate health literacy into education.
D4: Policies and practice (systems, processes, policies, procedures)
4-1. In our strategic documents, health literacy is defined as an organizational responsibility (e.g. in the mission statement, in policies, in business goals).	82%	None.
4-8. Use evidence-based development of health literacy programs.	82%	None.
4-9. Our school's performance indicators include measures of our health literacy practices and activities.	75%	Removing performance-based indicators to ensure suitability for diverse international contexts.
4-11. Our school undertakes quality improvement activities/projects for health literacy.	75%	None.
4-14. The school delivers health education programs containing content that is relevant to staff, students, caregivers, and community needs.	83%	Specify which school actors (e.g. teachers, students, parents) are involved for clarity.
4-21. Our school obtains feedback from staff, students, and caregivers about whether the information they are provided is useful and easy to understand.	83%	Specify which school actors (e.g. teachers, students, parents) are involved for clarity.
D5: Involvement/engagement (community, caregiver, child, families, partnerships)
5-1. We empower our users to access health information (e.g. by referencing good and reliable sources of information, brochures, links, contact person), appraise health information (e.g. through explanation, replying to inquiries), to evaluate health information (e.g. through informing and explaining different options and their advantages and disadvantages), and to apply health information to make informed decisions in regards to their own health (e.g. decisions regarding diagnostic methods and therapies, changes in lifestyle).	80%	Simplify and split for clarity; emphasize access and communication with cultural relevance.
5-4. The school explicitly informs individuals about appropriate self-help organizations and similar support offers.	80%	None.
5-6. Include staff, students, and caregivers in designing and assessing health education materials before implementation.	90%	None.
5-7. Our school supports individuals to be active in and make decisions about their own health and well-being.	90%	None.
5-9. Our school involves individuals and communities in the development and testing of its communication resources to ensure they are audience appropriate and easy to understand.	90%	None.
5-10. Our school involves individuals and the community in evaluation of our services and programs.	80%	None.
5-12. We regularly ask individuals for verbal or written feedback about the quality and effectiveness of our services.	80%	Split into separate items to distinguish service quality from service effectiveness.
5-13. Listen to staff, students, and caregivers needs, concerns, comments, and suggestions.	80%	Add a clear subject (e.g. “we” or “the school”) to improve sentence clarity.
D6: Workforce development (capacity building)
6-2. Staff are offered trainings with regard to use of clear, everyday words and phrases; providing easy-to-understand and easy-to-apply information; active listening, encouraging questions; use of methods and techniques such as chunk-and-check (glossary) or teach-back (glossary); effective risk communication as the basis for informed patient consent on medical treatment; motivational interviewing (glossary); use of written and audio-visual materials to support communication (e.g. decision aids); basic knowledge on designing easy-to-understand print materials; when and how to use an interpreter (à glossary), and how to effectively collaborate with interpreters.	80%	Revise to reflect school context, simplify language, correct typos, and split long sentences for clarity.
6-6. The organization regularly provides trainings on managing occupational health and safety risks.	80%	Replace “organization” with “school” to maintain consistency with school context.
6-8. New staff receive information about health literacy and plain language best practices through orientation presentations and/or written materials.	90%	Evaluate whether the phrase is necessary or can be removed to improve clarity.
6-10. New staff receive information about available resources (such as resource room, library, learning opportunities, online programs, language services) through orientation presentations and/or written materials.	90%	None.
6-12. Orientation and/or training sessions for interpreter staff include information about literacy and health literacy skills of the populations they work with.	80%	None.
6-13. Orientation and/or training sessions for interpreter staff includes information about health literacy insights for best practices.	80%	None.
6-14. Our staff has received training in how to identify, prepare, and simplify materials so that they are written in plain language.	80%	Clarify that training applies to school-distributed health materials and ensure consistency in language use.
6-16. Our staff, including leadership, has received awareness and sensitivity training about literacy and literacy issues.	80%	None.
6-17. We as staff members know the meaning of health literacy (note: see instruction for a definition), how to enhance the health literacy of our users (e.g. provide trustworthy information, simple and easy-to-understand communication, promoting self-management competences), where to find good and reliable information for our users (e.g. about symptoms, diagnostic methods, therapies, guidelines of the health system).	90%	Split into distinct items, revise examples for school or public health context, and clarify whether staff must know the definition of health literacy.
6-27. Our school provides Staff with opportunities to develop knowledge and skills relevant to health literacy.	90%	None.
6-28. The school involves staff representatives in the development and evaluation of staff-oriented communication materials and services.	80%	None.
6-31. Our organization employs a diverse workforce that is representative of the communities it works with (including age, culture, language, gender, sexuality, people with disabilities).	80%	Use “aims to employ” instead of “employs” to reflect realistic implementation feasibility.

Among the items excluded due to low expert agreement (less than 50%), several key reasons emerged based on content analysis. A total of 44 items (100%) were categorized into distinct groups (refer to Table 3). Items classified under “Limited Relevance” accounted for the largest portion. These were followed by items excluded due to “Lack of Clarity” and items categorized as having “Ambiguity and Limited Applicability.” Other reasons can be seen in Table 3. The excluded items cover multiple areas, reflecting different concerns raised by experts, which mainly focused on duplication of project content, inconsistency with practical needs, or the significant administrative burden schools might face during implementation.

Among the items requiring further review due to moderate expert agreement levels (with agreement rating from 50% to 75%), several key themes were identified from the content analysis. A total of 121 items fell into this category (refer to Table 4). The largest group was identified as “Similar Items,” indicating overlap with other content. This was followed by items categorized as having “Lack of Clarity” and items recommended to be “Combined with Other Items” for improved clarity. Other notable categories included “Resource and Feasibility Constraints” and “Limited Relevance” (12 items, 10%), reflecting expert skepticism regarding the scalability of certain items in diverse school contexts.

Discussion

The aim of this Delphi research study was to share the core domains and items from the review carried out by Chu et al. (2024), with international health literacy experts, and invite them to provide justifications for the inclusion or exclusion of each domain and item for use in a future health literacy responsive tool for schools. This modified Delphi approach indicated which domains and items were deemed important to support schools in becoming more health literate. Overall, 22 participants completed a component of the Delphi research study, with a full completion rate of 45% (10 of 22 participants completing all three modified Delphi rounds). A color-coded system was used, with green items (≥75% agreement) spread across all six domains, with higher numbers of items that had high expert agreement being communication, engagement, and workforce development, indicating their importance for health literacy development in schools. This finding aligns with the SEM (McCormack et al. 2017, Dickens et al. 2025) and the HPS framework (Lee et al. 2019, World Health Organization; United Nations Educational Scientific and Cultural Organization 2021), supporting the tool's conceptual validity. Specifically, the tool addresses multiple layers of the SEM by spanning individual workforce development through systemic policy and organizational culture. This multi-level approach resonates with the HPS framework's emphasis on a whole-school environment and community engagement. Previous Australian HL research has also noted the importance of clear communication from schools (Nash et al. 2020a, 2021), staff development (Cruickshank et al. 2023b, Peralta et al. 2025), and engaging key stakeholders such as parents and community members (Nash et al. 2020b, Cruickshank et al. 2025). Beyond Australian research, international research has also reinforced the importance of clear school communication internally (Auld et al. 2020) and externally to the broader school community (Sormunen et al. 2018). Given there appeared to be a greater number of communication items than any other Domain, this implies communication is regarded as an important aspect of health literacy. This finding was also reflected in the study of Nash et al. (2024) exploring the attributes of a health literacy responsive health professional. It could also demonstrate that communication is essential for whole school focus on HLR and development—that without total buy-in across the school (Peralta et al. 2017, Kirchhoff et al. 2025), that health literacy will not be the focus, due to many competing demands (Cruickshank et al. 2023a, Kirchhoff et al. 2025).

The lower consensus for items in the navigation of resources, school culture, and policies, domains may reflect previous research findings (Elmer et al. 2021, Yu et al. 2025) indicating that schools tend to emphasize individual student health literacy development through curriculum, teaching, and learning, rather than factors like school health resource design or overall school culture surrounding health. However, an alternative explanation should also be considered. Given that the modified Delphi panel primarily comprised academics, the lower consensus may partly reflect differing disciplinary perspectives and conceptualizations of health literacy, rather than a definitive indication of school practice.

The exclusion of such items, predominantly because the experts believed they had limited relevance, clarity, and applicability, highlights the importance of developing a school focused tool and the difficulty of adapting a tool designed for a healthcare context. Although several experts had experience working in schools and with schools and teachers, variability in perspectives, particularly between curriculum-focused and systems-oriented approaches, may have contributed to lower consensus in these domains. Further, these findings reflect broader structural and cultural challenges in school settings, where educational agendas such as reading ability, writing skills, numeracy, and cognitive development often take precedence over health and health promotion. This perspective aligns with critiques that health literacy often over-emphasizes individual skills at the expense of structural considerations (The Lancet 2022). While this could risk reproducing individualistic assumptions within the consensus process, our pre-defined theoretical framework ensures that systemic and organizational accountabilities remain central to the final tool. This prioritization was considered as one of the possible reasons why the HPS framework has not been consistently implemented in schools since its inception (World Health Organization 2017, World Health Organization; United Nations Educational Scientific and Cultural Organization [UNESCO] 2020). The HPS framework represents the intersection of curriculum, teaching, and learning; school organization ethos and environment; and partnerships and services (Rowe et al. 2007). However, as experts in our modified Delphi study reached lower consensus on structural domains, these areas may instead represent potential barriers to implementation at the practitioner level, highlighting challenges in accessing and applying these structural resources in practice (Peralta et al. 2022), rather than being of less importance in terms of school-based health literacy promotion. Considering previous research (Cruickshank et al. 2021, Nash et al. 2021) has noted the importance of a whole-of-school approach to facilitate increased prioritization of health in schools, changing school culture could be a key component of meeting the WHO's goal of developing HPS and for developing health literacy responsive schools.

This modified Delphi process generated expert consensus on domains and items considered important for supporting schools in becoming more health literate, based on the perspectives of international health literacy experts. However, research shows that evidence-informed school-based health literacy practices are very difficult to implement at the whole school level (Dadaczynski et al. 2021, Kirchhoff et al. 2022). As this tool develops, it will be important to engage practitioners (e.g. school leaders and teachers) in co-design, including an implementation guideline, a collection of existing materials and programs to strengthen health literacy in the school setting, and ways to utilize the self-assessment tool to measure schools’ OHL (Otten et al. 2023a, Peralta et al. 2025). These tools are intended to guide sustainable school HLR: from baseline inventory to developing and implementing changes and measures and, finally, reviewing the development process. As noted by Kirchhoff et al. (2022) and Krudewig et al. (2024), there is still no strong empirical evidence regarding the practicability and implementation processes of the concept in schools. Thus, detailed information on potential facilitators and barriers to implementation remains lacking.

Strengths and limitations

This study has several strengths. A significant strength is the utilization of up-to-date evidence, informed by a recent scoping review and content analysis, to develop the initial item pool. This ensured that the modified Delphi survey was grounded in established literature and current empirical findings. The modified Delphi process allowed expert-driven item selection from international health literacy and health promotion experts, enhancing the tool's validity. International and multidisciplinary perspectives increased the applicability across contexts. Integrating evidence with practical considerations ensured relevance and feasibility. This multi-level approach resonates with the HPS framework's emphasis on a whole-school environment and community engagement. In addition, the use of a secure survey platform featuring restricted access protocols and encrypted return codes, systematic item reduction, and clear documentation ensured transparency and reproducibility. This study also had a small number of limitations. Some domains, such as communication and workforce development, included more items, while other domains, such as navigation of resources and organizational culture, included fewer, resulting in an imbalance in item coverage across domains, which may have introduced subjectivity prior to the modified Delphi. The online survey allowed anonymous responses but limited open discussion. The three-stage modified Delphi process may have been burdensome for participants, which may have contributed to attrition across rounds. The definition of a health literacy expert was based on the authors’ interpretation, and most participants were academics, which may have favored curriculum-centered perspectives. Accordingly, lower consensus on organizational- and system-level domains may reflect these diverse disciplinary conceptualizations rather than schools’ actual priorities, highlighting the need for further validation with school practitioners and leaders. Experts from low- and middle-income countries were underrepresented, which may limit generalizability. Finally, the Likert scale with a neutral midpoint may have encouraged response avoidance.

Conclusions and future research

These findings led to the identification of a preliminary 47-item pool across 6 domains, indicating that experts agree that these items and domains are the core components of HLR in school settings, with a strong emphasis on teacher skills, professional development, and positive connections with the broader school community. Overall, compared with structural and systemic-level domains (navigation, policies, culture), consensus was stronger for people-centered and practice-oriented domains (communication, engagement, and workforce development). This pattern suggests that interpersonal and school-level strategies are actionable for improving HLR, while system-level change may require further contextual adjustments and long-term investment. While these finding suggest that structural and systemic elements are considered relevant, there is less consensus on how they implement across different school settings. Different education systems, resource availability, and policy support may contribute to the lower consensus in these three areas. Future research may include exploring why there was not high consensus on navigation of resources, organizational culture, and policies and practice. To complete the final stage of Boateng's method of tool development, future research will pilot test and further refine this 47-item version of the HLRS tool with teachers and schools across diverse international contexts.

Author contributions

Teresa Cheng-Chieh Chu (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing—original draft, Writing—review & editing), Shandell Elmer (Conceptualization, Formal analysis, Methodology, Writing—original draft, Writing—review & editing), Vaughan Cruickshank (Formal analysis, Writing—original draft, Writing—review & editing), Louisa R. Peralta (Writing—original draft, Writing—review & editing), Rebecca K. Kelly (Conceptualization, Formal analysis, Writing—review & editing), and Rosie Nash (Conceptualization, Formal analysis, Investigation, Methodology, Writing—original draft, Writing—review & editing)

Conflicts of interest

In accordance with “School Effectiveness and School Improvement” policy and our ethical obligations as researchers, R.N. and S.E. are reporting that they are directors of a health literacy social enterprise health promotion charity (HealthLit4Everyone) that may be affected by the research reported in the enclosed paper. The company provides health literacy services and advice to support health literacy development, including the HealthLit4Kids program. Any revenue raised is used to support the social objectives. No personal income is received by R.N. and S.E. We have disclosed those interests fully to “School Effectiveness and School Improvement” and have in place an approved plan for managing any potential conflicts arising from that involvement. Other authors declare that there is no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The data underlying this article cannot be shared publicly due to the need to maintain the confidentiality and privacy of the participants. The data will be shared on reasonable request to the corresponding authors.