According to the most widely used definition in Europe, developed by a scientific consortium in preparation for the first European health literacy survey, health literacy (HC) means that “people have the knowledge, motivation and skills to understand information relating to health care, “To find, understand, evaluate and apply disease prevention and health promotion in order to be able to make decisions and actions to improve or maintain one’s own health over the course of life” (Sørensen et al. 2012).

>> The connection between health and health is increasingly proven: people who are more health-competent make everyday decisions that are more health-promoting, for example they exercise more (Pelikan/Ganahl 2017). They use more preventative services and require less acute treatment. As patients, they can communicate their situation better and, conversely, understand medical, therapeutic and nursing recommendations better (Brach et al. 2011). Therefore, they are better able to contribute to their treatment through self-management and also have better clinical outcomes (Berkman et al. 2011). Health economists estimate that 3-5% of the treatment costs can be attributed to inadequate health care (which is also associated, for example, with a higher risk of complications) (Eichler et al. 2009).
We know all of this because GK – in various operationalizations available – is actually measurable and can therefore be related to other measured values. Not least for this reason, GK has become increasingly important in academic, practical and political discourse in recent years.
In the USA, people have been dealing with GK since the 1970s (Simonds 1974) and initially developed a series of instruments with which the GK of patients could be measured in order to be able to tailor communication to their level of competence (cf. Davis et al. 1991; Parker et al. 1995; Weiss et al. 2005; Chew et al. 2004). In addition, connections between education and health issues have also been established in population surveys (Jones 1995; Murray 2005).
The available data also made the political level increasingly aware of the issue. The WHO first prominently discussed GK as one of five sub-topics in 2009 at the Global Health Promotion Conference in Nairobi. In the same year, at a meeting of the United Nations Economic and Social Council (ECOSOC), GK was recognized as an “important factor for ensuring significant health outcomes” (ECOSOC 2009) and the implementation of action plans to promote it was called for. GK was also prominently featured in the program at the WHO's ninth global health promotion conference in Shanghai in 2016 and occupies a central place in the “Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development” (20). There, GK is seen as an important contribution to achieving the United Nations' Sustainable Development Goals (WHO 2016).
Recently, interest in GK in the context of non-communicable diseases has also increased: GK is understood as a central prerequisite for the prevention and effective treatment of these diseases, as for example in the “Montevideo Roadmap 2018-2030 on NCDs as Sustainable Development Priority “ is recorded (WHO 2017).
The OECD has also taken up GK as a topic and published a Fast Track Paper in December 2018, which provides an overview of which OECD member states are already taking up GK in different forms (Moreira 2018).
Since both the measurement of GK and the development of working approaches to its improvement can benefit from international exchange, institutions have also been founded at the global level that pursue this objective, such as the International Health Literacy Association (IHLA)1 or the Global Working Group Health Literacy of the International Union of Health Promotion and Education (IUHPE) (Broeder et al. 2018).
The M-POHL action network, founded in 2018 to measure the health of populations and the organizational health under the auspices of the European Health Information Initiative (EHII) of the WHO-Europe, represents a certain innovation in comparison. Because M-POHL works specifically towards science and politics into an exchange so that the data and knowledge bases that are developed have a good chance of being taken up by politics as a basis for evidence-oriented decisions and measures.

In Europe, GK was only taken up relatively late compared to the USA, in the early 2000s. The starting point for this was the first national population health survey in Switzerland (Wang et al. 2014). This prepared the ground for the GK's first European comparative study funded by the European Commission - the HLS-EU study with initially eight participating countries (HLS-EU Consortium 2012), which ultimately also became the basis for the founding of M-POHL became.

Excursus: The HLS-EU study
An advantage of the HLS-EU study is that it further developed the concept of GK theoretically and takes into account the so-called “relational character” of GK. GK is understood and measured as the interaction of personal skills with the situational demands on these skills. GK is therefore not only a question of personal knowledge and skills, but also depends on what problems people have to overcome with their skills. This means that access to health information, the understanding, evaluation and application of it for one's own decisions and actions also depend on the availability and quality of this information, so that the providers of health information also bear part of the responsibility for the health of the users of this information . According to researchers such as Rudd & Anderson (2006) or Parker (2009), healthcare providers must ensure that healthcare systems are easy to navigate and that information is accessible, understandable, assessable and applicable. Accordingly, the questions in HLS-EU are all formulated according to a specific pattern: “How easy or how difficult is it for you…”.
The measurability of the GK concept and the opportunity it provides for comparison with other countries have certainly contributed to the fact that, as a result of the HLS-EU study, more and more European countries developed an interest in the topic and started their own GK measurements with the help of the HLS-EU instrument carried out at the population level. These states include Albania (Toçi et al. 2014), Belgium (Vandenbosch et al. 2016), Denmark, Germany (Schaeffer et al. 2017), Israel (Levin-Zamir et al. 2016), Italy (Palumbo et al. 2016), Malta (Office of the Commissioner for Mental Health 2014), Portugal (Espanha/Ávila 2016), Switzerland (Bieri et al. 2016), Czech Republic (Kucera et al. 2016), and Hungary (Koltai/Kun 2016).
Although the surveys showed clear differences in the level of GK of the population in the individual states, they also revealed common trends across the participating states. At the time of measurement, between one and two thirds of the adult population in the eight participating countries were affected by GC deficiency. According to the analyses, GK also appears to be clearly related to socio-economic status, education, age and health status. In addition to the European countries, corresponding connections were confirmed for some Asian countries (Duong et al. 2015; Duong et al. 2017; Nakayama et al. 2015) in which the HLS-EU questionnaire was used.
What is particularly important to think about is that, according to the study results, chronically ill and older people in particular - in other words: people who need medical treatment interventions particularly frequently - have below-average health (cf. e.g. Sørensen et al. 2015). Members of these vulnerable groups therefore also have an increased risk of only benefiting suboptimally from the health care system. In keeping with the relational nature of GK, this diagnosis can - and should - be understood to mean that health systems are currently not sufficiently assuming their responsibility to make necessary health-related information easily accessible in an understandable, assessable and action-oriented form.

The availability of data has now led to GK being taken up at the political level in a number of countries and various initiatives have been launched to improve GK, such as national strategies, action plans, health goals, alliances or platforms. A September 2018 report by the WHO-Europe Health Evidence Network with a focus on GC policies identified 46 such approaches at international, national and local levels in a total of 19 countries in the WHO European region (that is 36% of the 53 member states). (Rowlands et al. 2018).
This shows how important data is as an impetus for change. To put it with a phrase from quality management: What is not measured cannot be improved. Against this background, the WHO publication “Health literacy – the solid facts” (Kickbusch et al. 2013) not only compiled the previously known evidence and recommendations for action to improve health, but also called for regular, high-quality, internationally comparable measurements of health a.
In order to implement this demand, a group of researchers and promoters from the GK approached the health ministers of Germany, Austria and Switzerland in 2015 and asked for support in fulfilling this demand at the international level.
This led to the health ministers of the five German-speaking European countries Germany, Liechtenstein, Luxembourg, Austria and Switzerland (the so-called health quintet) deciding to support the researchers' initiative at their annual exchange meeting in 2016. For this purpose, they set up a working group that suggested the quintet establish a WHO action network to broaden the initiative. Exploratory discussions ultimately led to preparations for the establishment of such a network under the auspices of the European Health Information Initiative (EHII) of WHO Europe. During the 67th session of the WHO Regional Committee for Europe in Budapest in September 2017, the delegates of the WHO member states were informed about the plan to establish the network. As a result, a background paper (“concept note”) was drawn up on the goals and working methods of the network (M-POHL 2018a). In February 2018, the founding meeting of M-POHL took place in Vienna with representatives from 19 countries and the “Vienna Statement” (M-POHL 2018b) was adopted. During the 68th session of the WHO Regional Committee in Rome in September 2018, the network had a dedicated technical information session, which contributed to further strengthening the topic in WHO Europe.

M-POHL aims to provide the basis for evidence-based improvement of GC in Europe by providing high-quality, internationally comparable data. The data provision should cover two aspects: data on the GK of the population in the European WHO region and data on the GK-friendliness of health systems and organizations. Recommendations for implementation measures at the political and administrative level should be developed and disseminated based on the study results.
A special feature of M-POHL is the connection between science and administration and politics. Because scientifically proven knowledge usually requires political decisions in order to be socially effective. The countries participating in M-POHL are therefore ideally represented by a duo that represents both areas. This is intended to ensure that the provision of data is linked to the needs of politics and administration and that the recommendations developed by M-POHL are accepted as broadly as possible.
To date, the following countries have been involved in M-POHL: Belgium, Bulgaria, Denmark, Germany, Greece, Great Britain, Ireland, Israel, Italy, Kazakhstan, Luxembourg, Moldova, Netherlands, Norway, Austria, Portugal, Poland, Russian Federation, Slovakia , Slovenia, Spain, Sweden, Switzerland, Czech Republic, Turkey. Austria currently chairs M-POHL.

M-POHL works on its goals in the form of projects. The network's first project is the next European comparative survey on the personal health of the general population in Europe, which operates under the acronym HLS19. At the time this text was written, eleven European countries had declared their intention to participate in the survey. The start is planned for autumn 2019, and an international comparative report should be available in 2021.
The aim of HLS19 is not only to improve the data situation on GK in Europe, but also to pave the way for regular European-comparative surveys on GK. Similar to the WHO's Health Behavior in School-Aged Children Study (HBSC), in which over 40 countries worldwide are already taking part, M-POHL also wants to collect comparative data on GK at regular intervals in the medium and long term in order to stimulate the discourse on the GK both in the participating states and internationally and to put measures to improve the GK on an empirically based footing.
In order to meet the requirement of international comparability and to enable benchmarking between the participating countries, the HLS19 data is collected in all participating countries on the basis of a jointly defined research protocol. The starting point for this is the definition, the multi-dimensional model and the survey instrument of the HLS-EU study (HLS-EU-Consortium 2011; HLS-EU-Consortium 2012; Sørensen et al. 2012).
HLS19 will build on the HLS-EU questionnaire, but will both shorten and supplement it. As in the HLS-EU study, the questionnaire will include questions about GC as well as questions about its determinants and effects. The analyzes will therefore enable statements to be made about the relationships between these levels at an internationally comparative level. In this way, the study will contribute to the further development of the knowledge base in the field of GK.
In addition to a mandatory instrument to be used by all participating states, HLS19 will also include optional data packages. One of them will deal with digital health care, two others with questions of orientation and communication in the health system. In addition, states will also have the opportunity to integrate country-specific questions into the instrument. An attempt is being made to enable a certain degree of comparability with the planned second wave of GK surveys in a number of Asian countries in order to also offer benchmarking beyond Europe.

Tailored information and training offers can make a significant contribution to increasing the health of some population groups. These include, in particular, chronically ill people. However, for capacity reasons alone, improving the health of the high proportion of people who the data show is affected by poor health cannot be achieved through people-oriented measures alone. In order to reach larger groups of people reasonably efficiently and, above all, to enable those with low GK to benefit as best as possible from the health system, interventions are needed to improve the GK-friendliness of health systems and organizations - that is, the way in which they are Health systems and organizations that enable and support the accessibility, understandability, assessability and usability of health information. For example, access to health information can be made easier through public health portals. Navigation in the system can be supported by easily accessible telephone and web-based advice systems. The comprehensibility of information can be supported by using plain language in written products or by taking certain communication rules into account in personal communication. The assessability of the quality of information is supported, for example, by disclosing information sources and potential conflicts of interest and by presenting the possible benefits and possible harms of interventions in a balanced manner. The applicability of information can ultimately be supported by not providing information in a general form, but adapting it to the specific living circumstances of the information recipient.
In order to achieve all of this, it is necessary to systematically reduce barriers and build up supporting resources to make access to health-related information as easy as possible. To support this objective, M-POHL plans to collect data on the organizational GK or “GK-friendliness” of organizations and health systems in the medium term and to enable benchmarks at this level as well. The starting point for this are comprehensive approaches and measurement instruments that were created based on the “Ten attributes of health literate organizations” (Brach et al. 2012), for example the “Vienna Concept of health literate healthcare organizations” (Dietscher/Pelikan 2017), or that “Organizational health literacy responsiveness (Org-HLR) framework” (Trezona et al. 2017).
But the population-oriented HLS19 survey will also make it possible to diagnose the GK-friendliness of health systems to a certain extent. If a European comparison is made to determine how easy or difficult it is for people to find, understand, evaluate and apply certain relevant information, and if systematic differences emerge between the countries involved, this supports the formation of hypotheses about the causes of these differences - such as the quality of control systems or communication in the healthcare system.

All countries in the European WHO region can participate in M-POHL. The prerequisite for participation is a declaration of intent from the respective health ministries and the nomination of representatives - ideally a person from politics/administration and a person from the field of science - who represent the country in M-POHL.
The participating states have the opportunity to become actively involved in the M-POHL projects or even just to participate in an observational manner. The two forms of participation are currently roughly balanced. The costs for each form of participation must be borne by the states themselves. The final number of states that will participate in HLS19 will be determined by summer 2019. <<
Authors:
Mag.a Dr. Christina Dietscher, Austrian Federal Ministry of Labor, Social Affairs, Health and Consumer Protection
Univ.-Prof. em. Dr. phil. Jürgen Pelikan, Julia Bobek, MSc, MA, Mag. Dr. phil. Peter Nowak, Health Austria GmbH