The Italian Health Literacy Project: Insights from the assessment of health literacy skills in Italy

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The Italian Health Literacy Project: Insights from the assessment of health literacy skills in Italy Rocco Palumbo a,∗ , Carmela Annarumma a , Paola Adinolfi a , Marco Musella b , Gabriella Piscopo a a b

Department of Management & Innovation Systems, University of Salerno, Via Giovanni Paolo II, nr. 132, Fisciano, Salerno 84084, Italy Italian Health Literacy Project (HLP-IT), Italy

a r t i c l e

i n f o

Article history: Received 23 November 2015 Received in revised form 27 July 2016 Accepted 14 August 2016 Keywords: Health literacy Health-related competencies Patient empowerment Patient involvement Access to care

a b s t r a c t Inadequate health literacy, namely the problematic individual’s ability to navigate the health care system, has been depicted as a silent epidemic affecting a large part of the world population. Inadequate health literacy has been variously found to be a predictor of patient disengagement, inappropriateness of care, increased health care costs, and higher mortality rates. However, to date the evidence on the prevalence of limited health literacy is heterogeneous; moreover, studies dealing with this topic show a pronounced geographical concentration. To contribute in filling these gaps, this paper investigates health literacy skills in Italy. Drawing on the European Health Literacy Survey (HLS-EU), a tool to measure self-perceived levels of health literacy was administered to a representative sample of Italian citizens. A stepwise regression analysis allowed to shed light on the determinants and consequences of limited health literacy. Findings suggested that inadequate health literacy is a prevailing problem in Italy, even though it has been overlooked by both policy makers and health care practitioners. Financial deprivation was found to be a significant predictor of inadequate health literacy. Low health literate patients reported higher hospitalization rates and greater use of health services. As compared with the European Countries, Italy showed some peculiarities in terms of health literacy levels and socio-demographic determinants of health literacy, which provide with intriguing insights for policy making. © 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction The health literacy concept dates back to early 70s, when it was introduced by Simonds [1] as a crucial social policy issue involving the improvement of the individual’s ability to navigate the health care service system. Health literacy could be understood as a multifaceted construct, which is composed of the functional (i.e. literacy and

∗ Corresponding author. Fax: +39 089963505. E-mail addresses: [email protected], [email protected] (R. Palumbo).

numeracy), interactive (i.e. ability to establish co-creating partnerships with health care providers), and critical (i.e. ability to discriminate between health services available) skills, which are needed to grasp health-related issues and to deal with them properly [2]. Scholars depicted inadequate health literacy as a silent epidemic [3], which is affecting the functioning of health care systems all over the world. In fact, poor health literacy has been variously found to be a predictor of: medication nonadherence [4], inappropriate access to care [5,6], increased health care costs [7], higher mortality rates [8], and inequity [9,10]. From this point of view, inadequate health literacy may predict a misuse of health resources;

http://dx.doi.org/10.1016/j.healthpol.2016.08.007 0168-8510/© 2016 Elsevier Ireland Ltd. All rights reserved.

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besides, it may compromise the ability of health care systems to meet equity targets in providing health services [11]. To the authors’ knowledge, the evidence on the prevalence of limited health literacy is heterogeneous, relying on a wide array of measurement tools. In addition, studies aimed at assessing health literacy skills show an uneven geographical distribution [12], mainly concerning the United States of America. A research project entitled “European Health Literacy Survey” (HLS-EU) was launched in 2011, with the purpose of measuring health literacy levels across 8 European Countries: Austria, Bulgaria, Germany, Greece, Ireland, Netherlands, Poland, and Spain [13]. A report summarizing the main findings of this research project showed that about 47% of respondents reported limited health literacy skills. This study is aimed at expanding the HLS-EU survey, by assessing the levels of health literacy in Italy. Health literacy has been rarely contemplated as a strategic priority to improve the functioning of the Italian National Health Service. Moreover, health care settings in Italy are usually designed assuming limitless health literacy skills by the side of patients [14]. In light of the consequences which could be attached to inadequate health literacy, the prevalence of limited health-related skills in the Italian population could be stressed as a social alarm. Indeed, limited health literacy is able to impair the functioning of the health care system. From this point of view, it is important to assess the levels of health literacy in Italy, in order to ensure the sustainability of the health care service system. The following research questions inspired this paper: R.Q. 1: What are the estimated levels of health literacy in Italy? R.Q. 2: Is there any distinguishing attribute which characterize the Italian population as compared with its European counterparts in terms of health literacy skills? R.Q. 3: What policy insights could be drawn from the assessment of health literacy in Italy? For the purpose of this study, health literacy was understood as the complex set of individual knowledge, motivation and competences which is needed to access, understand, appraise, and apply health information [15]. As anticipated, this set of skills is crucial to make judgments and take decisions in everyday life concerning health care, disease prevention, and health promotion. In line with this conceptualization, it was assumed that health literate patients are able to collect, process, understand, and use health-related information properly, as well as to make wise choices in the fields of health protection and promotion. Alternatively, low levels of health literacy were considered to engender the misuse of health resources available and the inappropriate access to care [16], which was conceived as the degree of fit between the patients’ abilities and the health care system requirements [17]. The paper is organized as follows. Section 2 depicts the research design and the methods which were used to assess health literacy skills. The findings of the research are described in Section 3, which points out the distribution of the Italian population by health literacy levels. Besides, some insights on the correlates and socio-demographic

determinants of limited health literacy are presented. Section 4 discusses the findings of the research, comparing them with the results of the HLS-EU survey. Discussion paves the way for several policy implications, which are included in the concluding section of the paper. 2. Research design and methodology Drawing on the conceptual model and the measurement tools suggested by the HLS-EU consortium [13], a survey tailored to the Italian health care system was devised and administered to a random representative sample of Italian citizens. The survey consisted of 86 items and required about 30 min to be filled. The items of the survey were organized according to the following layout: • 47 items were intended at measuring the self-rated health literacy skills of respondents. Particular attention was paid to the individual self-experienced ability to obtain, understand, process, and apply health-related information, considering both functional, interactive, and critical competencies; • 7 items were aimed at assessing the individual literacy and numeracy skills through an objective tool to measure functional health literacy, called “Newest Vital Signs” (NVS) [18]. The NVS scores were used to check the validity of self-reported health literacy skills; • 16 items examined the main social determinants of health literacy, including: gender, age, education, employment, and self-assessed social status; • Lastly, 16 items provided information about every-day life styles and self-reported use of health services. As suggested by the scientific literature [19], the original version of the questionnaire was first translated from English into Italian by two independent professional translators. The two drafts of the translated survey were compared to identify and resolve disagreements. The translators agreed on a joint draft of the Italian survey, which was back-translated into English by two native English speakers to verify its consistency. The draft of the survey was accepted by the members of the research team and it was tested on a convenient sample of 30 people, who were asked to fill the questionnaire and to disclose their perceived meaning of each item. The results of the pilot test paved the way for several minor revisions, which were agreed by all the members of the research team. The revised draft of the survey was tested again on 30 people. The results of the second test were satisfactory. The 47 items of the survey measuring self-assessed health literacy skills were formulated as direct questions. The respondents were asked to rate their ability to deal with health-related issues on a 4 points rating scale, where “1” indicated high difficulty and “4” implied high proficiency. The decision of respondents to not answer the question was coded as “5”. Socio-demographic variables were formulated either as open questions or as closed questions linked to 10 points Likert scales. Lastly, questions concerning health services utilization and everyday lifestyles were assessed through closed questions, including either 3 or 5 options.

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To improve the comparability of the Italian survey with the European data, the questionnaire was administered to a random sample of 1.000 Italian citizens, the same number of people involved in each of the European Countries participating in the HLS-EU project. The sample was built applying the Eurobarometer standards in methodology and sampling procedures [20]. People aged 18 years and older were included in the sample. Data were collected face to face from 100 sampling points, using the Paper And Pencil Interviewing (PAPI) method. Following the HLS-EU study, 8 indices were constructed according to a formative model [21]. Each index represented a specific dimension of individual health literacy skills. Going more into details, the 47 items of the survey assessing self-perceived health literacy were aggregated in a general health literacy index (General HL), which provided a synthetic measure of health literacy levels. 3 specific indices were built by categorizing these 47 items in three groups, concerning: (1) health care-related health literacy (HC-HL); (2) disease prevention-related health literacy (DP-HL); and (3) health promotion-related health literacy (HP-HL). Similarly, 4 indices covering the different stages of information processing – that is to say obtain (OI-Index), understand (UI-Index), process (PI-Index), and apply (AI-Index) health information – were arranged. To achieve a better comparison with the European data [10], the 8 indices were standardized on a scale from a minimum of 0 (lowest level of health literacy) to a maximum of 50 (best level of health literacy), using the formula: Index = [(IndexMean − 1) × (50/3)] The internal consistency of the 8 indices was assessed through the Cronbach’s alpha coefficients. Both General HL and HC-HL showed excellent internal consistency (˛ ≥ 0.9). Alternatively, DP-HL, HP-HL, OI-Index, and PIIndex disclosed good internal consistency (0.9 > ˛ ≥ 0.8), while UI-Index and AI-Index revealed only acceptable internal consistency (0.8 > ˛ ≥ 0.7). In sum, all the indices used for the purpose of this study were found to be reliable measures of self-reported health literacy skills. In line with the European study [10], three different thresholds were established to sort the respondents in 4 groups, which reflected their health literacy abilities. Group 1 (“inadequate health literacy”) included people who scored between 0–25, group 2 (“problematic health literacy”) people who scored between 25.01–33, group 3 (“sufficient health literacy”) people who scored between 33.01–42, and group 4 (“excellent health literacy”) people who scored between 42.01–50. Both group 1 and group 2 were assumed to include the respondents who lived with limited health literacy skills. Table 1 depicts the characteristics of the sample. 517 out of 1.000 people were female. The respondents were fairly distributed in terms of age groups: 460 of them were aged between 18–45 and 540 were aged between 46–88. As well, all the education levels were contemplated in the sample: 31.3% of the respondents expressed either per-primary, primary, or lower secondary education, 45.1% reported secondary education levels, while 22.8% stated tertiary education. Most of the respondents lived together

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Table 1 The characteristics of the sample (n = 1000). Variable

Total No.

%

Gender Male Female

483 517

48.3 51.7

Age group 18–25 26–39 40–54 55–64 65–74 75+

77 271 274 165 140 73

7.7 27.1 27.4 16.5 14 7.3

Education Pre-primary Primary Lower secondary Upper secondary Post-secondary First stage of tertiary Second stage of tertiary Don’t know

6 120 187 273 178 90 138 8

0.6 12 18.7 27.3 17.8 9 13.8 0.8

Household living situation Single and living alone Shared household In a serious relationship, but not living together Don’t know/do not answer

247 693 42 18

24.7 69.3 4.2 1.8

Status of employment Unpaid work, traineeship and/or apprenticeship Full time Part time Unemployed Student Retired Permanently disabled Military or community services Full-time homemaker Inactive Other

121 261 128 80 61 188 18 7 90 19 28

12.1 26.1 12.8 8 6.1 18.8 1.8 0.7 9 1.9 2.8

with a partner, while about 1 out of 3 of the respondents stated to live alone. About 40% of the respondents had either a full-time or a part-time job; about 25% were either unemployed, students, or trainees. 1 out of 5 respondents was retired. About 10% were full-time home makers. 3. Findings The average levels of self-reported health literacy were similar for all the indices, with limited standard deviations. Average values ranged from a score of 30.5 ( = 8.4) for the processing information index to a score of 33.5 ( = 7.7) for the understanding information index. The general health literacy index showed a mean value of 31.6 ( = 7.15), suggesting that Italy performed worse as compared with its European counterparts, which exhibited an average general health literacy score of 33.8 ( = 8). As suggested by the distribution of the Italian sample in the 4 groups concerning health literacy skills, more than half of the population was found to live with limited health literacy. In fact, 17.3% of the sample was included in the “inadequate health literacy” group. In other words, 1 out of

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6 respondents stated to encounter major hurdles when dealing with health-related issues. The group “problematic health literacy” involved about 37% of the sample. That is to say, 1 out of 3 respondents self-experienced impaired ability to obtain, understand, process, and use health information. These findings were echoed by the NVS scores. Indeed, more than 40% of the respondents were found to exhibit high likelihood of limited functional health literacy. In addition, 16% of the sample expressed a significant probability of poor functional health literacy skills. Only about 4 out of 10 respondents were found to live with adequate literacy and numeracy skills to deal with health-related issues. The indices measuring self-perceived health literacy skills were correlated with the Italian version of the NVS in order to confirm their validity. All the indices exhibited a small, but statistically significant (0.01 level, 2-tailed) correlation with the NVS, ranging from a minimum of 0.196 (PI-Index) to a maximum of 0.328 (UI-Index). As expected, the general health literacy index showed one of the highest levels of correlation with the NVS (0.278). Interesting insights could be drawn from the analysis of the correlations between the general health literacy levels and the main demographic and social predictors of health literacy suggested by the scientific literature [26], including: gender, age, education, employment, financial deprivation, and self-assessed social status. As shown in Table 2, gender was positively – but without statistical significance – correlated with health literacy levels ( = 0.054), suggesting that women were more proficient than men in handling health related information. As expected, a small negative and statistically significant (0.01 level, 2-tailed) correlation between age and health literacy skills was found ( = −0.123): people aged 65 and more were consistent in achieving lower scores in all the indices as compared with their younger counterparts. Moreover, a positive and significant correlation between education levels and health literacy was found ( = 0.217), confirming that higher levels of education were associated with an enhanced ability to deal with health-related issues. A significant and slightly negative correlation between status of employment and self-reported health literacy skills was identified ( = −0.100). Full-time and part-time workers, trainees, and students showed higher levels of health literacy as compared with unemployed people. What is even more interesting is that full-time homemakers, retired, inactive, and people suffering from disabilities, who are generally in need of the highest amount of health care, exhibited the lowest health literacy levels, thus pointing out that work inactivity was associated with worse ability to perform basic tasks in the health care environment. Financial deprivation ( = −0.396) and self-assessed social status ( = 0.241) were found to perform as the most important correlates of limited health literacy. In fact, the findings of the survey suggested that people suffering from financial deprivation were more likely to state impaired ability to obtain, understand, process, and apply healthrelated information. In a similar way, respondents who declared to belong to the lower social classes of the population were likely to express worse health literacy skills as

compared with those who stated to belong to medium and high social classes. Socio-demographic correlates of health literacy were tested within a stepwise regression model, which identified the general health literacy index as the dependent variable (Adjusted R2 = 0.156). The results of the regression model suggested that financial deprivation (ˇ = −0.312), age (ˇ = −0.85), self-assessed social status (ˇ = 0.83), and education (ˇ = 0.77) performed as statistically significant (p < 0.05) predictor variables of health literacy skills. These findings seemed to confirm the insights provided by the correlation analysis, suggesting that elderly, less educated, and needy people met greater difficulties in navigating the health care service system. Similar results were achieved when using the NVS score as the dependent variable of the stepwise regression model (Adjusted R2 = 0.144). In this case, education (ˇ = 0.250), financial deprivation (ˇ = −0.184), and age (ˇ = −0.088) were found to be significant (p < 0.01) predictors of functional health literacy. Table 3 depicts the relationship between the general health literacy scores of the respondents, their selfreported health status, and their use of health services. A small negative and statistically significant correlation was found between general health literacy and self-perceived health status ( = −0.249), emphasizing that poor health literacy skills were consistently associated with lower selfperceived health status. A small positive and significant correlation was also found between general health literacy and both long-term conditions ( = 0.144) and limitations in daily life ( = 0.170). People who lived with one or more chronic conditions and who faced either strong or modest limitations in daily life were likely to report lower health literacy abilities. General health literacy was negatively and significantly (0.01 level, 2-tailed) associated with increased use of hospital services ( = −0.332) and emergency services ( = −0.290). These findings were confirmed also after controlling for self-perceived health status, long-term conditions, and limitations in daily life. In addition, limited health literacy was associated with a greater number of primary care visits ( = −0.158). From this point of view, it could be argued that limited health literacy paved the way for increased risks of misuse of health resources available, involving higher use of emergency and hospital services irrespective of self-assessed health conditions. The results of a stepwise regression analysis aimed at examining the determinants of health services’ use seemed to confirm this intuition. In fact, health literacy was found to perform as the most important predictor of both hospital services’ use (ˇ = −0.284; p < 0.01; Adjusted R2 = 0.181) and emergency services’ use (ˇ = −0.205; p < 0.01; Adjusted R2 = 0.151). Interestingly, health literacy was able to predict neither access to primary care nor access to specialist care. On the one hand, self-assessed health status was found to perform as the main predicting variable of access to primary care (ˇ = 0.290; p < 0.01; Adjusted R2 = 0.201). On the other hand, only long term conditions were found to predict the access to specialist care (ˇ = −0.135; p < 0.01; Adjusted R2 = 0.158). Last but not least, adequate health literacy was found to be significantly related with healthy life-styles. Peo-

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Table 2 Spearman’s Rho correlations between General HL and demographic and social determinants of HL.

General HL Gender Age Education (ISCED) Main status of employment Financial deprivation Self-assessed social status **

General HL

Gender

Age

1.000 0.054 −0.123** 0.217** −0.100** −0.396** 0.241**

1.000 −0.062 0.023 0.108** −0.012 −0.022

1.000 −0.306** 0.333** 0.044 −0.084**

Education (ISCED)

Main status of employment

Financial deprivation

Self-assessed social status

1.000 −0.311** −0.353** 0.378**

1.000 0.261** −0.133**

1.000 −0.408**

1.000

Correlation is significant at the 0.01 level (2-tailed).

Table 3 Spearman’s Rho correlations between General HL, health status variables, and health service use.

General HL Self-perceived health status Long-term illness Limitations in daily life

General HL Emergency service Doctor visits Hospital services Other health care professionals **

General HL

Self-perceived health status

Long-term illness

Limitations in daily life

1.000 −0.249** 0.144** 0.170**

1.000 −0.470** −0.451**

1.000 0.663**

1.000

General HL

Emergency service

Doctor visits

Hospital services

Other health care professionals

1.000 −0.290** −0.158** −0.332** −0.042

1.000 0.235** 0.463** 0.197**

1.000 0.421** 0.349**

1.000 0.181**

1.000

Correlation is significant at the 0.01 level (2-tailed).

ple living with excellent or sufficient health literacy skills were less likely to smoke as well as to consume alcohol as compared with their poor health literate counterparts. Alternatively, low health literate respondents stated to be less willing to perform physical activities and to control their weight. In fact, lower health literate patients were more likely to report either overweight or obesity as measured by the Body-Mass Index (BMI). 4. Discussion The findings of this research suggested that limited health literacy is a serious problem in Italy. However, it gained the attention of scholars and practitioners only in the last few years [22]. The European Health Literacy Project [13] pointed out that little less than half of the European population self-experienced limited health literacy skills. Besides, among the poor health literate European population, more than 1 out of 4 people showed an inadequate ability to collect, process, understand, and use health-related information, being unable to navigate the health care system. As shown in Fig. 1, the Italian sample performed worse in the general health literacy index as compared with most of its European counterparts. On the one hand, 13% of the European population showed inadequate health literacy skills, while 35.4% revealed problematic health literacy. On the other hand, 17.3% of the Italian population was found to exhibit inadequate health literacy skills. When also those who revealed problematic health literacy skills were contemplated (37.3%), more than half of the Italian population (54.6%) showed limited health literacy. Drawing on these data, Italy reported the high-

est number of people living with limited health literacy in Europe, after Bulgaria (62.1%), Spain (58.3%), and Austria (56.4%). In addition, Italy revealed the highest levels of inadequate health literacy (17.3%) in Europe, after Bulgaria (26.9%) and Austria (18.2%). To the authors’ knowledge, scholars are not consistent in discussing the determinants of inadequate health literacy [23]. The findings of this study pointed out that some demographic and social variables significantly affected the levels of health literacy in Italy. The role played by gender was unclear, echoing the inconsistent findings discussed by the scientific literature [24]. Alternatively, education seemed to perform as an important predictor of health literacy [25]. In fact, higher levels of education were associated with increased ability to access and understand health information, paving the way for an appropriate use of health resources [26]. Even though the relationship between education and health literacy was positive and significant, it turned out to be relatively weak. In light of these findings, it could be pointed out that, in addition to general education, the attendance at specific courses in the fields of health prevention and health promotion are crucial to improve the individual health literacy skills [27]. As suggested by Williams et al. [28], it was found that age and health literacy were negatively related. Actually, people aged 65 and more consistently showed lower health literacy scores as compared with their younger counterparts. It could be assumed that cognitive limitations – including impairment of immediate recall of health information and inadequate numeracy – performed as relevant factors involving limited health literacy [29]. In light of these results, health policy makers should pay particular

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Fig. 1. Comparison of European Countries per general health literacy levels.

attention to the specific information needs of the elderly, who should be identified as individuals at special risk of limited health literacy. From this standpoint, tailored health communication policies should be addressed to them. The findings of this study also revealed that the employment status performed as an important correlate of health literacy skills, with people having a full-time or a part-time job performing better as compared with unemployed or retired. Dealing with this issue, several scholars claimed that occupation in terms of employment status was likely to negatively affect the ability of the patients to access and use health care facilities [30], mainly due to time constraints. However, this study emphasized that the participation in the workforce contributed in enhancing the individual ability to obtain, process, and understand health information, thus paving the way for a greater ability to navigate the health care system. Both full-time and parttime workers showed higher average health literacy scores as compared with unemployed, retired, and work inactive. Interestingly, students and people in military or community services showed the highest average health literacy scores. Alternatively, permanently disabled respondents – that is to say those with greater health needs – exhibited the lower health literacy levels. The growing attention paid to health literacy is widely associated with a strong concern for equity issues [31]. This paper contributes in advancing the scientific knowledge about this topic, by pointing out that both financial

deprivation and self-assessed social status were significant and relatively strong predictors of health literacy skills. In line with what has been found in the European sample [32], people suffering from financial deprivation were likely to achieve poor scores in both the general health literacy index and the 7 sub-indices. In addition, the lower the self-assessed social status of respondents, the worse their performance in terms of health literacy skills. Drawing on these findings, health policy makers should encourage targeted interventions aimed at promoting the health literacy skills of disadvantaged people, with the purpose of enhancing their ability to navigate the health care service system properly. The relationship between health literacy levels and demographic and social variables should be read in light of the effects produced by limited health literacy on the proper use of health services. Several scholars argued that inadequate health literacy paves the way for misuse of health resources available, which in turn produces spiraling health care costs [33]. Nonetheless, the relationship between health literacy, the proper use of health resources, and health care costs is still not clear. This study highlighted that poor health literate people were more likely to use both hospital services and emergency services as compared with their health literate counterparts, apart from their self-assessed health conditions. The greater rates of hospitalization of individuals with problematic health literacy skills could be understood as a

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signal of their impaired ability to navigate the health care system. Limited health literacy was also found to be associated with unhealthy behaviors. In particular, people living with either problematic or limited health literacy skills were more likely to be frequent smoker. Besides, the consumption of alcoholic beverages was consistently higher for those who revealed poorer health literacy skills. Lastly, low health literate people were found to be less willing to perform physical activities and to control their weight. The results of this study should be examined in light of its main limitation. In fact, the indices used to assess the individual ability to deal with health-related issues involved a self-reported appraisal of health literacy skills. As a consequence, they did not include objective items to measure the processing abilities of the respondents. From this point of view, the findings could have been biased by subjective self-ratings. Notwithstanding, the validity of this paper was supported by the statistically significant and positive correlation between the self-reported assessment of health literacy and the NVS, one of the most used objective tools for measuring functional health literacy. In addition, the measurement tool used for the purpose of this study paved the way for more insightful findings as compared with traditional objective scales to assess individual health literacy levels, including the Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (ToFHLA), and the Single Item Literacy Screeners (SILS). Actually, this survey allowed to contemplate interactive and critical skills of respondents beyond functional ones, which are widely overlooked in traditional assessments of health literacy. Further developments should be aimed at exploring in-depth the relationship between health literacy and its demographic and social determinants. Among others, particular attention should be paid to the role played by financial deprivation in predicting the individual’s inability to navigate the health care system. As well, the effects of specific health education initiatives in bridging the gap between education and health should be better examined. Lastly, the consequences of health literacy on the appropriate access to care and on health care costs deserve strong attention, with the eventual purpose of improving health outcomes and enhancing the sustainability of the health care service system. 5. Conclusions and policy implications Inadequate health literacy has been found to be prevailing in the Italian sample. More than half of the respondents self-experienced limited ability to obtain, understand, process, and use health information. Moreover, the results of the survey suggested that inadequate health literacy paved the way for improper access to care and misuse of health resources available. In consideration of the increased health care costs which are associated with inadequate health literacy, the sustainability of the health care service system is at stake. From this point of view, the prevalence of limited health literacy in Italy should be reasonably deemed as a social alarm. In spite of the growing attention paid by the scientific literature to it, health literacy is still not conceived as

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a priority in health policy making. From this standpoint, the findings of this paper contributes in raising the policy makers’ awareness of health literacy-related issues, inciting further developments aimed at discussing the effects of inadequate health literacy on health outcomes and health care costs. Patient empowerment and patient engagement have been generally identified as imperative approaches to enhance the appropriate access to care and to improve the sustainability of the health care system. However, the role played by health literacy – a requisite to patient empowerment – has been neglected. To fill the gap between education and health, policy makers should pay greater attention to the process of users’ enablement, which is strictly related to the individual health-related competencies. The enhancement of individual health literacy is crucial to make people more able and willing to participate in the protection and the promotion of their health status. Since limited health literacy is prevailing among less educated people, elderly, and disadvantaged population, tailored initiatives to promote self-care skills of marginalized people should be included in both health policies and health care practices. Policy makers are still far from realizing that the health care system itself contributes in impairing the patients’ ability to navigate the health care environment. In fact, health care settings are usually designed assuming limitless health literacy skills by the side of patients. As a consequence, health care organizations are unable to identify and meet the information needs of low health literate people. Besides, an environment which presumes the ability of patients to deal with health-related issues is expected to produce disengagement. As shown by the scientific literature [34], patients living with limited health literacy are likely to conceal their impaired understanding of health information, in order to escape the stigma which is associated with inadequate health literacy. Beyond promoting individual health literacy, policy makers should encourage health care organizations to help patients in navigating the health care service system. A more friendly and comfortable health care environment would contribute in preventing the unwillingness of patients to disclose their poor understanding of health information, allowing the establishment of a co-creating partnership between the patients and the health care professionals. Ultimately, it could be maintained that enhanced health literacy paves the way for both patient empowerment and patient engagement, which are crucial requirements to enhance the functioning of health care organizations. In light of these considerations, health literacy should be understood as a strategic priority inspiring the future shapes of the health care system.

Acknowledgements This study was partly financed by MSD Italia, which supported data collection. We wish to acknowledge helpful translators, who contributed in devising the assessment tools used in this paper.

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Please cite this article in press as: Palumbo R, et al. The Italian Health Literacy Project: Insights from the assessment of health literacy skills in Italy. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.08.007