Health Literacy and Public Health: what now?

Even if health literacy has been considered, in the beginning, as an individual-level construct, public health literacy has recently gained more and more importance, and it takes into account the complex social, ecologic, and systemic forces affecting health and well-being. Is it so possible to measure HL in its different dimensions? How can we measure it at an individual, community, organizational level? T he HL measurement tools can explore many different settings, and in the future they will be a key instrument for healthcare organizations to shift to a real citizen-centered vision.

health, and more health for all.
T he measure of HL is in fact strictly linked to the opportunity to ensure the appropriate answer to healthcare needs for all the people and to improve equity in access to care.
T he HL measurement tools can explore two main different settings: the personal HL of each individual, and the organizational HL of the healthcare system and its structures (table 1). While in the first case the focus is on the patient (or the citizen) accessing the healthcare system to find the best answer for his/her needs, in the second circumstance the focus is on the citizen as part of a community: in this case, the assessment is on the structural and managerial aspects adopted to plan interventions for health promotion, disease prevention, and healthcare as developed by the organizations. It regards all the community with the aim to avoid inequalities in access to care.
T hese two main categories could be better described in different levels as in the following Adapted from [1] .
T he assessment of the health literacy level can be done by means of specific instruments that have been developed in the last twenty-five years [2] [3] : they differ for the aim of the measurement (screening or deeper measurement), for the object (they use different definitions of health literacy and focus on one or more abilities), for the characteristics of the individuals (patients or population) and for the procedures used to evaluate their validity (i.e., face, content and concurrent validity compared to other instruments) [4] .
T he blooming of the productions of measurement tools is, on one hand an opportunity that gives more choices to researchers and operators for exploring specific issues, on the other hand it restricts the comparison between studies and populations because of the lack of a gold standard [5] , which does not exist yet.
On a healthcare level, all the services must be appropriate and targeted to the HL level of the population. In order to do so, it is mandatory that the upper and middle management includes health literacy in the organizational policies and that all the healthcare workers are well informed about its role as a determinant of health. Specifically, if the people's or patients' HL level is not known, it is fundamental to apply some universal precautions to guarantee that all the persons will be able to understand the messages (prescriptions, services, professionals in charge, pathways) and will be well oriented in the healthcare environment [6] . T his last feature is nowadays particularly important, considering the changes in the health systems on a national and regional levels and the growing complexity of services and places of healthcare, often far from the patients' residences and too hard to be comprised by themselves: see, for instance, the enormous increase in imaging and laboratory diagnostic services.
Among the universal precautions, interventions to improve written and oral communication have been carried on, like teach-back method or brown bag medication review techniques, and the use of easily understood written material, with few words and many images [6] .
At a managerial level (which corresponds to the third and fourth voices in table 1), a healthcare organization can be defined health literate if it is easily accessible for the population and if all the processes of distribution of services are patient-centered.
Specifically, according to the Institute of Medicine [7] , a healthcare organization must respond to ten attributes to be defined as "health literate". A Health Literate Health Care Organization 1. Has leadership that makes health literacy integral to its mission, structure, and operations.
2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement.
3. Prepares the workforce to be health literate and monitors progress. 7. Provides easy access to health information and services and navigation assistance.
8. Designs and distributes print, audiovisual, and social media content that is easy to Furthermore, considering a bigger perspective on the health system, professionals must take into consideration that also the caregivers could have low health literacy levels; the studies done to evaluate this aspect highlight that half of the caregivers, both informal (that is, a familial, a parent or a friend) and formal (i.e., a paid person hired to take care of the patient) have inadequate health literacy levels [8] . Interventions to improve the health literacy level of caregivers must be encouraged, mainly for those patients with a low level of health literacy, for previous life experiences or intervening cognitive impairment. According to this prespective, OPtimising HEalth LIterAcy (Ophelia) is a community-based project started in Victoria that aims to identify and answer to health literacy needs of the population, acting both on an individual and on an organizational level [10] . T his approach, guided by eight principles (table 2) T he project has been adopted in nine services, comprising primary and homecare assistance as well as ICUs, creating the fit-for-purpose interventions, with the aim to improve organizational processes and staff knowledge and competencies, to involve the community and to obtain better health outcomes and equity among users. needs to be explored in its assumptions. T he examples coming from the Anglo-Saxon Countries and the interventions made to assess and improve the health literacy levels demonstrate that the scientific world should consider this discipline as a key to improve the health of each single person and of communities, and they should push -but not only -healthcare organizations to shift to a real citizen-centered vision, never fully embraced until now in spite of the many promises pronounced both by politicians and healthcare professionals and managers.