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Int. J. Environ. Res. Public Health 2020, 17, 3010; doi:10.3390/ijerph17093010 www.mdpi.com/journal/ijerph
Editorial
Interdisciplinary Perspectives on Health Literacy
Research around the World: More Important than
Ever in a Time of COVID-19
Tetine Sentell 1,*, Sandra Vamos 2 and Orkan Okan 3
1 Office of Public Health Studies, University of Hawai‘i at Mānoa, Honolulu, HI 96822, USA
2 School of Interdisciplinary Health Programs, Western Michigan University, Kalamazoo, MI 49008, USA;
sandra.vamos@wmich.edu
3 Interdisciplinary Center for Health Literacy Research, Bielefeld University, 33615 Bielefeld, Germany;
orkan.okan@uni-bielefeld.de
* Correspondence: tsentell@hawaii.edu
Received: 1 April 2020; Accepted: 22 April 2020; Published: 26 April 2020
Abstract: As we write our editorial for a health literacy special issue in the midst of the international
COVID-19 crisis, we take this opportunity to highlight the importance of individual, community,
and population health literacy. We are not only in a “pandemic” but also an “infodemic”. Health
literacy is more important than ever in the face of these global health threats, which have impacted
outcomes across the levels of the socio-ecological model (SEM), including individual health
behaviors, family relationships, organizational behavior, state policy-making, national mortality
statistics, and the international economy in the span of weeks. Our special issue sought to pull
together interdisciplinary threads guided by two principles. The first was defining health literacy
as essential skills and situational resources needed for people to find, understand, evaluate,
communicate, and use information and services in a variety of forms across various settings
throughout their life course to promote health and wellbeing. The second was the idea that
enhancing health literacy in populations and systems is critical to achieving health equity. In this
time of public health need across traditional borders, the inter-sectoral and international
perspectives of special issue articles are more urgent than ever. A greater understanding,
appreciation, and application of health literacy can support policy action on multiple levels to
address major public health challenges. Health literacy should be built deliberately as a population-
level resource and community asset. We have summarized the set of articles in this special issue
across the levels of the SEM, hoping their thoughtful considerations and interesting findings will
help to support global health and wellness and inspire future research, policy, and practice in this
global public health emergency and beyond.
Keywords: health literacy; infodemic; education; health education; public health; global; trend;
COVID-19; interdisciplinary; perspectives; equity
1. Introduction
Our international perspectives health literacy special issue of the International Journal of
Environmental Research and Public Health (IJERPH) sought to attract interdisciplinary papers
guided by two principles. The first was defining health literacy as essential skills and situational
resources needed for people to find, understand, evaluate, communicate, and use health information
and services in a variety of forms across various settings throughout their life course to promote
Int. J. Environ. Res. Public Health 2020, 17, 3010 2 of 13
health and wellbeing [1,2]. The second was the idea that enhancing health literacy in populations and
systems is critical to achieving health equity.
As we write this special issue editorial in the midst of the global health threat of COVID-19,
individual, community, and population health literacy are more important than ever [3–7]. Personal
health behaviors, family relationships, organizational actions, state policy, national mortality
statistics, and the international economy have changed in the span of weeks because of decision-
making influenced by, and influencing, health literacy. Critical health literacy and digital health
literacy are urgently needed by both the citizenry and policy makers to synthesize, analyze, and
appraise the vast amount of urgent, complex, and even conflicting information from virologists,
epidemiologists, data modelers, doctors, nurses, health departments, and the media [3,5–7]. Health
literacy capacities allow us to be well-informed about risks, resources, and recommendations and,
ideally, to act in solidarity-based behaviors to achieve public health [3,4,7]. It is increasingly clear that
social responsibility and solidarity may be key outcomes of health literacy, helping to combat
decisions and policies that go against current COVID-19 evidence and best practice public health
guidelines [4]. Similarly, and ever more critical, is the concern for health equity. The most profound
consequences of the decision made in this health crisis are expected to fall hardest on the most
disadvantaged populations [8,9].
We do not live in a vacuum, but rather our individual and collective behaviors and actions are
influenced by changing personal and environmental factors. The socioecological model (SEM) [10],
describes five levels of influence: individual (e.g., knowledge, attitudes, skills), interpersonal (e.g.,
families, friends, co-workers, social networks), organizational (e.g., organizations, social institutions,
workplaces, schools), the larger community (e.g., the relationship between organizations working
together), and public policy (e.g., international, national, state/provincial local laws and regulations).
The need for health literacy skills and considerations across all these levels of influence grows
increasingly acute. The importance of cross-sector and cross-national health literacy conversations in
this time of international crisis are clear, as both the disease and the evidence needed for solutions
have rapidly crossed global borders.
Critical, urgent health information around COVID-19 arrives now every moment from a variety
of sources and perspectives [11–18], from personal messages from a health care provider in scrubs
and a mask somewhere across the globe that have gone viral on Facebook, to local media,
governments, and organizations trying to contextualize the response in a relevant way for their
communities. Sorting through the information deluge to find relevant and reliable information to
inform the decisions of individuals, families, and communities, and, equally importantly, for health
care organizations and governments, is deeply challenging. Adding to complexity to this are
divergent opinions, outright hoaxes, and political posturing. We are not only in a “pandemic” but
also an “infodemic” [19]. This “global epidemic of misinformation—spreading rapidly through social
media platforms and other outlets“ [19] has already had devastating consequences to public health,
wellbeing, and economies across the world. Increasing the possibility for confusion in this global
pandemic, different countries have implemented different mitigation measures. These differences
make finding reliable information even more problematic. Health literacy is even more challenging
when knowledge on the topic is incomplete, changing and context dependent.
Yet, at a time like this, health literacy is required around the world to resist the infodemic and
to allow individuals to trust and act upon reliable information, recommendations, and advice. This
involves people applying a range of skills to make sense of health information and services available
even in rapidly changing situations and contexts [2]. Trusted sources must provide reliable and
timely information that is context relevant, easy to access, easy to understand, easy to take away, and
easy to use.
Numeracy, the ability to use and understand numbers, is also important. As we are blitzed with
news stories involving large, shifting COVID-19 statistics, including actual and projected counts of
confirmed infections and deaths every day, this can become overwhelming. The practice of
translating statistics and restating data into a meaningful context by experts and advocates for public
health action [20,21], also known as “social math”, can support health literacy and numeracy. This
Int. J. Environ. Res. Public Health 2020, 17, 3010 3 of 13
approach involves breaking down the data in terms of time or place, making comparisons with
familiar things, or personalizing/localizing numbers to make them more digestible and meaningful
[20,21]. Infographics and graphs can provide a meaningful way to present data. Social math goes
even further to “tell a story” with the data (often including infographics and visuals) to make the
point.
Officials and experts have been advocating action to “flatten the curve”, a message that has
reached mainstream consciousness. The “flattening the curve” graphics have provided a simple-to-
understand way of visualizing that a slower infection rate means less stress on the health care system.
“Physical distancing” has also been a strong and effective message as a protective measure to slow
the infection rate when implemented early. These are based on complex research, but also provide
clear messages intended for action. One graphic that went viral was from Dr. Singer at the University
of California, San Diego, and art director Gary Warshaw, who depicted the complex math in a simple
way; specifically, that if one person transmits the infection to an average of 2.5 people, and those 2.5
people each transmit to another 2.5 people and so on, that within 30 days 406 people would be
infected [22].
While graphs and infographics can present data, in order to build individual and community
health literacy and numeracy, we must also continue to tell stories to compliment this data for clear
public messaging and to explain risk to those who are not familiar with the language of charts,
statistics, and graphs. Visuals alone may not be enough for many to understand how the world works
now or what should, and can, be different as part of the solution [23]. People may still wonder and
have different interpretations and questions. Figures and statistics need to be part of ongoing
conversations that include meaningful framing [24], local context, and personal stories [25] to build
health literacy. These may require different methods of communication to visualize the spread [26]
or to show the powerful impact of one person’s decision on community risk [27].
We are dependent on each other to protect ourselves, loved ones, and communities from
COVID-19 and to cope with the illness if it arrives. Services and service providers are also critical.
This includes not only primary and emergency health care, but also access to life-sustaining supplies,
food, income payments, and housing. Health and social services resources are continuing and, in
many cases, growing to respond to this emergency, but must remain dynamic in response to the
changing information. Organizations may be stretched too thin delivering actual services to do
comprehensive outreach around availability and changes in scope, timing, or eligibility. Yet access to
these medical, public health, and social services can be a life-or-death matter to individuals, their
neighbors, and communities. Health literacy includes the ability to access and use these services as
needed [2].
In the 2000s, metaphors like silent epidemic [28,29] and silent killer [30] emerged and were used
to figuratively describe the consequences of limited health literacy on individuals and whole
economies. The current COVID-19 crisis could sound the alarm, bringing health literacy to the
forefront of global conversation and revealing it to be a loud pandemic and explicit killer. Limited
health literacy is visibly propelling the spread of COVID-19. For instance, young people defiantly
participating in spring break in Florida in March 2020 in spite of widespread calls for physical
distancing [31], or Italians speaking to “themselves of 10 days before” about how they wished they
had taken calls for precautionary measures more seriously [32]. Higher health literacy, in this case, is
coming at an extraordinarily high price for individuals, communities, and governments, who are
now calling upon others to heed their lessons [31,33].
Practically, the communication surrounding the events of this pandemic in a wide range of
political, health, media, and social channels has shown the importance of Nutbeam’s [34,35]
communicative and critical health literacy concepts as key tools in slowing down and containing the
virus until a treatment and vaccination have been found. The COVID-19 outbreak is health literacy’s
test to demonstrate that the concept is among the most critical personal and environmental
approaches of the 21st century to population health and wellbeing. Only a year ago, Nutbeam [36]
wrote a retrospective entitled “Health Education and Health Promotion Revisited”, highlighting the
paradigm shift in the way in which public health problems are conceptualized and addressing the
Int. J. Environ. Res. Public Health 2020, 17, 3010 4 of 13
move from chronic diseases to new emerging threats such as SARS and Ebola. The concept of health
literacy is adaptable to the challenges of our modern times to support the “voluntary changes in
behavior” in the “new public health” paradigm while always considering the importance of context.
The need for the effective dissemination of reliable information around COVID-19 facts,
precautions, and public health justifications is increasing daily in many communities and across
communities as, at the time of writing, people could still travel to return home across states and
nations. The need for this information to be given consistently in multiple languages and across a
variety of contexts is a major issue for health equity [37] now and in the future. Yet clear language
and universal precautions remain critical, as even many people who are well-educated are panicked,
confused, or thinking that information does not apply to them [38–40]. The ability to even identify
reliable sources can be complicated [41].
A US-based national coalition of medical and health students, called the COVID-19 Health
Literacy Project [42], was recently launched in response to citizen and patient needs for reliable and
easy-to-understand information. The project was started by Pooja Chandrashekar and helps
vulnerable individuals and communities to protect from and cope with COVID-19 by creating and
providing fact sheets and materials in multiple languages. The Lancet [43] has launched their COVID-
19 Resource Centre to provide a platform for disseminating and exchanging up-to-date research
results to support both health workers and researchers in the fight against this novel disease.
Similarly, the New England Journal of Medicine [44] is engaged with research on COVID-19, among
efforts by many others.
Not only are scientific organizations providing key resources, but so are major social media
entities. Instagram and Facebook are providing useful resources to reduce the misinformation around
this critical issue [45], but information and messaging remain complex, inconsistent, and often
confusing to many [3,19]. Many have been turning to Google in this time of emergency, and
coronavirus became the biggest trend in Google search history due to people looking for information
and answers [46]. Consequently, Google launched its separate COVID-19 information site and new
search experience for coronavirus queries [47]. This new site is dedicated to education, prevention,
and locating resources with the intent to provide people with access to information, safety tips, and
search trends related to COVID-19. For example, the top Google trending questions in the US include:
(1) How many cases of coronavirus?; (2) Where to get tested for coronavirus near me?; (3) What is
coronavirus?; (4) When will coronavirus peak in the US?; (5) How to self-isolate in a shared house?
[39]. As the breakout spreads, people want to know how to protect themselves and their families
while preparing for uncertainty. Providing reliable, easy-to-understand information in response to
these basic, urgent queries is critical. Additionally, individuals’, families’, and communities’ health
literacy needs include the awareness and ability to access health information not just about health
system functioning and public health messaging but also how to find information about critical
matters such as food, child care, workplace safety, and unemployment benefits in the swirl of
information that is changing regularly. In the face of a crisis, such as the current COVID-19 pandemic,
we are reminded that investing in education for health literacy across the life course is a global
resource and community asset.
As we write this article, COVID-19 has impacted 192 out of 195 countries; this is information that
can be seen in one of the critical, innovative health communication/data visualization tools that have
emerged in response to this crisis and can support global health literacy: https://ncov2019.live/.
Another COVID-19 dashboard has been provided by the Center for Systems Science and Engineering
(CSSE) at Johns Hopkins University (JHU) [48], which has evolved into a global data and statistics
hub on coronavirus, with many countries having launched similar dashboards to showcase their
national and local data. This global health experience, which is also intensely local and personal, will
provide important information for future studies. Bielefeld University’s Centre for Interdisciplinary
Health Literacy Research is involved in two online surveys on health literacy and COVID-19
information and information behaviour (on adults together with the National Action Plan Health
Literacy initiative and Hertie School of Governance; on university students together with Fulda
Int. J. Environ. Res. Public Health 2020, 17, 3010 5 of 13
University of Applied Sciences [49]) in Germany. Similar surveys are occurring in Vietnam and
Austria.
2. This Special Issue
In this time of crisis, the inter-sectoral, international goals of this special issue are more urgent
than ever. Similarly, the resources, findings, and considerations they bring to us are even more
necessary to help support global health and wellness and to identify lessons, gaps, and
recommendations. Through our call for abstracts, our specific topic goals were the following:
• Research considering cross-country comparisons and/or cross-sector collaborations;
• Research promoting or evaluating a system’s approach to health literacy;
• Research that captures the contemporary discussion on theory, models, definitions, and concept
analyses for different populations and age groups, including insights from other scientific
disciplines;
• Research and practice initiatives on the social function of health literacy, social contexts, social
health literacy, and distributed health literacy;
• Research and practice results that move global, national, or regional policies to action, or the
evaluation of those policies in terms of health promotion and the social determinants of health;
• Research considering capacity building and empowerment for health literacy across professions,
settings, and systems (such as education, health care, workplace, business, and government).
We received a large number of potential submissions, reflecting the growing interest in the field.
Specifically, the final set of articles completing peer-review for this special issue touch upon a number
of areas that have resonance in this time and the future, aligning with many levels of the
socioecological model. We thus present them here across the levels of the socioecological model:
individual (prevention, chronic care); interpersonal (social networks); organizational (health systems,
workplaces, schools), larger community (tailoring for culture and context); and public policy.
Reflecting a growing trend to consider health literacy at levels beyond the individual [50,51], we
note how many of our articles are related to issues beyond individual skill or the patient-provider
relationship (which, of course, remain critical) to focus on organizational health literacy capacity and
solutions or health literacy as experienced in a social context.
3. Individual Level: Prevention and Chronic Care
Reflecting the worldwide epidemiological trends of the growing disease burden, care for chronic
disease was a critical focus, especially cardiovascular disease [52]. Cabellos-García et al. [53] give us
new insights in “Relationship between Determinants of Health, Equity, and Dimensions of Health
Literacy in Patients with Cardiovascular Disease” in the development of suitable strategies to reduce
inequity. In “Health Literacy among People in Cardiac Rehabilitation: Associations with Participation
and Health-Related Quality of Life in the Heart Skills Study in Denmark” by Aaby et al. [54], the
authors help us to understand the associations between health literacy and cardiac rehabilitation
outcomes. Muscat et al. [55] give information on those engaged in a chronic disease prevention
program in “The Impact of the Chronic Disease Self-Management Program on Health Literacy: A
Pre-Post Study Using a Multi-Dimensional Health Literacy Instrument”.
A number of articles also focused on prevention. In “Health Literacy as Communicative
Action—A Qualitative Study among Persons at Risk in the Context of Predictive and Preventive
Medicine”, Harzheim et al. [56] consider the role of predictive and preventive medicine in health
literacy. Rudolf et al. [57] provide objective information that health literacy has a relationship with
physical activity in “Influence of Health Literacy on the Physical Activity of Working Adults: A
Cross-Sectional Analysis of the TRISEARCH Trial”.
4. Interpersonal Level: Social Networks
Health information is spread, digested, and created in communities and social networks. Several
articles help provide insight on these perspectives. Kendir and Breton [58] do so in “Health Literacy:
Int. J. Environ. Res. Public Health 2020, 17, 3010 6 of 13
From a Property of Individuals to One of Communities” as they consider this in more detail. Lorini
et al. [59] consider a specific topic on the influence of health literacy as a distributed resource available
within an individual’s social network in “Health Literacy as a Shared Capacity: Does the Health
Literacy of a Country Influence the Health Disparities among Immigrants?” The article by Amoah
[60], “The Relationship between Functional Health Literacy, Self-Rated Health, and Social Support
between Younger and Older Adults in Ghana”, considers which aspect of social support
(instrumental, informational, and emotional support) is responsible for health literacy by comparing
two groups in an understudied context. In “Considering Health Literacy, Health Decision-Making,
and Health Communication in the Social Networks of Vulnerable New Mothers in Hawai`i”, Sentell
and colleagues [61] consider the importance of health literacy in the decision-making networks of
new mothers, and how to measure this shared capacity using social network analyses. Bessems et al.
[62] created and tested small-group nutrition education intervention for adults with low
socioeconomic status and small incomes in “The Effectiveness of the Good Affordable Food
Intervention for Adults with Low Socioeconomic Status and Small Incomes”.
5. Organizational Level: Health Systems
The growing research topic of organizational health literacy was the level of the social ecological
model with the most articles. These articles include “Improving Organizational Health Literacy
Responsiveness in Cardiac Rehabilitation Using A Co-Design Methodology: Results from The Heart
Skills Study” by Aaby et al. [63], which considers how to improve organizational health literacy
responsiveness in cardiovascular care. Trezona et al. [64] provide a relevant self-assessment tool for
organizational health literacy in “Field-Testing and Refinement of the Organisational Health Literacy
Responsiveness Self-Assessment (Org-HLR) Tool and Process”. Kaper et al. [65] consider the
sustainable changes and longitudinal outcomes of organizational health literacy efforts in
“Implementation and Long-Term Outcomes of Organisational Health Literacy Interventions in
Ireland and The Netherlands: A Longitudinal Mixed-Methods Study”. As in many studies, this
considers two different health contexts and the need to address health inequality. In “A Scoping
Review on How to Make Hospitals Health Literate Healthcare Organizations”, Zanobini et al. [66]
consider the concept of health literacy as a trait of organizations providing health and social services.
6. Organizational Level: Schools, Students, and Adolescents
A number of our studies focused on the young, especially considering the health literacy
capacity of the school setting, the organization in which youth spend much of their time. Health
literacy and many of its determinants are well studied in adults but under researched in children and
adolescents. In “The Online Survey for the Assessment of Generic Health Literacy among
Adolescents in Germany (GeKoJu): Study Protocol” by Loer et al. [67], the authors describe a study
to provide a sound data basis on adolescent health literacy in Germany to support health literacy
goals. Fretian et al. [68] consider the measurement of health literacy in children in “Exploring
Associated Factors of Subjective Health Literacy in School-Aged Children in Germany”. Sukys et al.
[69] similarly consider this issue in the context of an understudied population in “Subjective Health
Literacy among School-Aged Children: First Evidence from Lithuania”. Parents are shown to be key
to health literacy in young people in “How Did Parents View the Impact of the Curriculum-Based
HealthLit4Kids Program Beyond the Classroom?” Nash et al. [70] consider parents’ perspectives on
the HealthLit4Kids program, which aims to build health literacy in a participatory and contextually
relevant way. Klinker et al. [71] find that “Health Literacy is Associated with Health Behaviors in
Students from Vocational Education and Training Schools: A Danish Population-Based Survey”,
supporting an important and changeable intermediary determinant of health equity in a population
where many students come from a low socio-economic status. Dadaczynski et al.’s [72] study “The
Role of School Leaders’ Health Literacy for the Implementation of Health Promoting Schools”
considers the promotion of health literacy as an urgent goal in public health and education and
describes a need for it to be integrated in the school context as a component of the holistic health
promoting school (HPS) approach. In “Potentials of School Nursing for Strengthening the Health
Int. J. Environ. Res. Public Health 2020, 17, 3010 7 of 13
Literacy of Children, Parents and Teachers”, Buhr et al. [73] conducted a pilot study in Germany,
finding promisingly that school nurses may contribute to strengthening health literacy within the
school setting. Rathmann and colleagues [74] consider the organizational health literacy in facilities
for people with disabilities in their pilot mixed-methods study: “Organisational Health Literacy in
Facilities for People with Disabilities: First Results of an Explorative Qualitative and Quantitative
Study”. Domanska et al. [75] provide new evidence around self-reported health literacy in
adolescence in “Development and Psychometric Properties of a Questionnaire Assessing Self-
Reported Generic Health Literacy in Adolescence”.
7. Organizational Level: Workforce in Health Care and Beyond
Considerations of the workforce remain vital to understanding and addressing health literacy
needs. Rowlands and colleagues [76] provide useful guidance in sharing “Evidence-Based
Development of an Intervention to Improve Clinical Health Literacy Practice”. Juvinyà-Canal and
colleagues [77] give us perspectives in “Health Literacy Among Health and Social Care University
Students” to understand better the caregiver pipeline, which can support individual and
organizational health literacy and direct interventions. In “Effectiveness of a Comprehensive Health
Literacy Consultation Skills Training for Undergraduate Medical Students: A Randomized
Controlled Trial”, Kaper et al. [78] provide future doctors with a larger scope of capacities to
strengthen a patient’s autonomy, participation, and self-management abilities. Koduah et al. [79]
consider how sociocultural factors affect the health literacy practices of nurses, especially in low-
income countries, in “’I Sometimes Ask Patients to Consider Spiritual Care’: Health Literacy and
Culture in Mental Health Nursing Practice”. Considering a community not often included in health
literacy, Coman et al. [80] focus on agricultural workers in “Educational Interventions to Improve
Safety and Health Literacy Among Agricultural Workers: A Systematic Review”. This can improve
farmers’ health and quality of life. In their systematic review, “The Agreement between Patients’ and
Healthcare Professionals’ Assessment of Patients’ Health Literacy—A Systematic Review”, Voigt-
Barbarowicz and Levke Brütt [81] investigate the agreement between the patients’ and health care
providers’ assessments of patients’ health literacy. In “Using the Health Literacy Questionnaire
(HLQ) with Providers in the Early Intervention Setting: A Qualitative Validity Testing Study”, Leslie
et al. [82] consider the health literacy of interdisciplinary early intervention providers who are
optimally placed to build the health literacy capacity of caregivers and whose health literacy has not
previously been measured.
8. Community Level: Tailoring by Culture/Topic/Population Needs
Several articles consider the critical importance of tailoring by community, culture, and need,
including several that provide an international comparison. In “Adolescent Health Literacy in Beijing
and Melbourne: A Cross-Cultural Comparison”, Guo and colleagues [83] consider adolescent health
literacy from a cross-cultural perspective. In “Factors that Influence the Former Soviet Union
Immigrants”, Kostareva et al. [84] consider the unique health literacy needs of those from a specific
cultural context in whatever country they arrive. In “Inclusion of People with Intellectual Disabilities
in Health Literacy”, Latteck and Bruland [85] present findings from three different studies on the
health literacy of particular vulnerable groups. Ehmann et al. [86] give information to guide future
work in “The Relationship between Health Literacy, Quality of Life, and Subjective Health: Results
of a Cross-Sectional Study in a Rural Region in Germany”, which will be of particular relevance to a
regional integrated healthcare system. Sykes et al. [87] give insights on health literacy on the topic of
infertility in “Multidimensional eHealth Literacy for Infertility”, considering the concept of eHealth
literacy in individuals and couples in relation to infertility. In “Validation of the Short-Form Health
Literacy Questionnaire (HLS-SF12) and Its Determinants among People Living in Rural Areas in
Vietnam”, Duong et al. [88] validate the use of a comprehensive short-form health literacy (HL)
survey tool (HLS-SF12) in Vietnam. The study by Chakraverty et al. [89], “Gender-Specific Aspects
of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in
Germany”, explores the views of health care professionals on how gender affected their interactions
Int. J. Environ. Res. Public Health 2020, 17, 3010 8 of 13
with migrant patients. In “Dementia Literacy in the Greater Bay Area, China: Identifying the At-Risk
Population and the Preferred Types of Mass Media for Receiving Dementia Information”, Leung and
colleagues [90] consider the mass media preferences for receiving dementia information of
community-dwelling adults in four cities (Hong Kong, Guangzhou, Macau, and Zhuhai) of the
Greater Bay Area of China.
9. Policy Level: Comparing Options Across Countries and the Opportunity for Impactful Change
Hofer-Fischanger et al. [91] give us new insights into active living and health literacy in “Health
Literacy and Active Transport in Austria: Results from a Rural Setting”, providing useful guidance.
In “Making a Case for ‘Education for Health Literacy’: An International Perspective”, Vamos et al.
[92] describe critical perspectives on merging health literacy in the educational sector across contexts
and how to bring policy into practice. Mansfield et al. [93] should provide valuable policy-level
perspectives in “Integrating a Health Literacy Lens into Nutrition Policy in Canada”.
10. International Research Evidence
Perhaps most importantly, this special issue brings together researchers across the globe as well
as across disciplines. We have research from low, middle- and high-income countries. We have
research from Europe (e.g., Lithuania, Germany, Austria, Denmark, Sweden), North America (e.g.,
USA, Canada), and Asia (e.g., Vietnam, Taiwan) along with research from Africa (Ghana), which is
understudied in health literacy. We also consider cross country comparisons—comparing Beijing and
Melbourne in the study by Guo and colleagues [83] and the health literacy of former Soviet Union
immigrants across the globe in the study by Kostareva et al. [84].
The global community of researchers and scientists is working together to build actionable,
meaningful evidence to support shared goals of health and community well-being. Even as we close
borders, we understand that responses and health issues are interconnected across the globe. We
model and learn from decisions in other locations, including about health information and what
works. We hope this set of articles and their wide-ranging lessons and perspectives inspire other
research. Some areas remain underrepresented in health literacy, including the Pacific and many
parts of Africa. Some authors of initial article proposals were unable to complete their papers in these
times of regional crisis (Lebanon) and global stress. In the future, we look forward to seeing more
innovative work concerning the topic of interest to this special issue: cross-country comparisons and
cross-sector collaborations; systems’ approaches to health literacy; new theories, models, definitions,
and concept analyses; innovative research on health literacy in social contexts and health literacy
policies in action; health literacy research considering the capacity-building and empowerment of
health literacy across professions, settings, and systems. These efforts will all help build health
literacy locally, nationally and globally.
Finally, as editors from three countries (U.S., Canada, and Germany) who have worked closely
together for over a year to produce this special issue using virtual tools that would not have been
possible even ten years ago, we can attest to the ability to build knowledge, connections, and
productivity in new information environments. Many of our most treasured colleagues live across
the world. This time may open both new realities but also new pathways for health communication
to build and support health literacy towards better individual and community health.
Author Contributions: All authors have read and agreed to the published version of the manuscript.
Funding: Orkan Okan received funding (01EL1824A) from the Federal Ministry of Education and Research:
Health Literacy in Childhood and Adolescence for this work.
Acknowledgments: We would like to acknowledge our health literacy colleagues, those close to us and scattered
around the globe who have been a source of inspiration and knowledge for many years, especially those who
contributed to this special issue. A special thanks to Irv Rootman who recommended us as co-editors for this
special international health literacy issue. He has helped to advance research, practice, and policy in health
literacy for many years and his mentorship on national and international health literacy initiatives have been
foundational and transformative, and still continue today.
Int. J. Environ. Res. Public Health 2020, 17, 3010 9 of 13
Conflicts of Interest: The authors declare no conflict of interest.
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