2. Educational Paradigms
2.1. No Education Without Health
2.2. No Health Without Education
2.3. No Education and Health Without Health Literacy
3.1. Policy in Canada
3.2. Policy in the United States
3.3. Policy in Germany
4. Gaps and Tensions
4.1. Health Literacy Definitions
- Health literacy means different things to different people. This makes measuring (or even talking about) the concept, process, and outcome challenging.
- Policy means different things to different people. There is policy, public policy, health policy, and health literacy policy. There does not seem to be a consensus on health literacy policy. While we use the aforementioned definition for policy in the paper, and do think policies in the broader definition are relevant to momentum and conversations around topics (in this case health literacy), many of the health literacy policies are non-mandatory and non-binding. Instead, they are promoted and recommended. These can be powerful and influential (e.g., WHO Shanghai declaration as a good example), but may not actually be prioritized or implemented in given competing priorities and funding constraints in practice if they are not mandatory.
4.3. Theory to Mandated Practice
- States adapt from national models with their own interpretation, which can lead to idiosyncratic models and fragmented outcomes.
- No funding attached.
- Mandating does not mean implementation will occur.
- Even if mandated, human capacity requirements (e.g., trained staff, improved education) are often lacking to ensure operationalization and sustainability.
- Competing priorities in education system.
- Oversight around implementation is often minimal.
4.4. Evaluation and Cost Effectiveness
- Follow up is often not done. No evaluations. No evidence reviews.
- Evidence is about literacy or health education, but not “health literacy”.
- Action plans exist, but is there evidence to back these “recommendations”.
4.5. Health vs. Education
- Fragmented training of teachers in the US and Canada, coupled with the decentralized system make it difficult to ensure a quality national education-related effort even if there is a policy manifest.
- Whole school and healthy school approaches and premises may be preached in countries, but in reality, the health and education link is not fully operationalized. Health and education sectors are not coordinating as well as they could due to system goals.
5. Strategic Directions and Opportunities
5.1. Canadian Pockets of Practice
5.2. Future for Education for Health Literacy
Conflicts of Interest
|Non-Profit Organization||The Indigenous Story Studio (formerly the Healthy Aboriginal Network) is a non-profit organization based in British Columbia whose purpose is to create entertaining knowledge translation tools for youth (pre-teens to early 20 s) on health and social issues using modalities such as comic books, graphic novels, film/video, animation and augmented reality, all of which take into consideration providing youth with information that they can understand and that appeals to them. For more information visit: https://istorystudio.com/about-us/|
|University Course||In 2013, Vamos developed and currently teaches the first Canadian core undergraduate health literacy course titled Health Literacy and Systems Navigation in the School of Public Health & Social Policy at the University of Victoria in British Columbia . Aligned with the aforementioned Canada’s milestone reports that promote ‘education for health literacy’ focusing on higher education, this innovative course provides future allied-health professionals the opportunity to explore practices, tools, and policies guiding health literacy efforts for diverse people across settings and the life-course. It was recently adapted and used as a blueprint for a proposed introductory online European health literacy course for two German universities .|
|Provincial Network||The BC Health Literacy Network is a unique network of networks of people and organizations representing various sectors working together (e.g., education, health care, library, seniors, government) committed to the advancement of health literacy. Since its establishment in 2011, Rootman continues to lead the steering committee meeting monthly to pursue goals articulated in a provincial strategy  and to help organize educational activities related to the goals. Example activities include: a two-day summer school; community of practice meetings; webinars; and workshops to raise awareness and build capacity of the BC networks to deliver health literacy programs over the life-course.|
|Provincial Organization||The Council of Senior Citizens Organization (COSCO) of British Columbia  is an umbrella organization made up of seniors’ organizations and individual associate members representing about 80,000 seniors. A grant from the former Canadian Council on Learning led to the development of a series of workshops related to health literacy using a “training of trainers” model. Currently, on request, they offer workshops on 43 different issues and topics of particular interest to seniors at no cost, delivered mostly by seniors trained to do so using “plain language” principles. For more information visit: http://www.coscobc.org/index.php/cosco-workshops|
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|K-12 System Structure||Federal system; academic year runs Fall—Summer (e.g., October–August)||Provincial/territorial system with provinces (10) and territories (3) having autonomy; academic year runs Fall—Spring (e.g., September–June)||Federal system with strong role for local governments; academic year (Fall—Spring (e.g., August–June)|
|K-12 School Governance||Mostly controlled by the 16 Länder (states)||Most guidelines set at the province and territory level.||Mostly in control of local school boards.|
|Higher Education System Structure||Federal academic education framework available, but due to the national higher education act, the sixteen state governments have the responsibility for design, content and aims of their universities. However, to certain degree the state and federal government(s) collaborate.||Provincial/territorial system is responsible for education and regulate standards; no federal accreditation; academic year split into 3 semesters [Fall (end of Aug/start of Sept to December), Spring (January to April), Summer (April/May to July/August)]||Federal and state systems responsible. Accreditation involves non-governmental entities as well as federal and state government agencies. Accreditation’s quality assurance function is one of the three main elements of oversight governing the Higher Education Act’s (HEA’s) federal student aid programs.|
|Higher Education Governance||Internal with university president, team of administrative leaders (provost, chancellor, faculty senate, deans, department chairs)||Internal with university president, team of administrative leaders (provost, chancellor, faculty senate, deans, department chairs)||Internal with university president, team of administrative leaders (provost, chancellor, faculty senate, deans, department chairs)|
|Testing||Secondary schools in Germany are divided among several tiers. Cumulative test to leave school.||Similar to US, almost all provinces conduct standardized tests from junior kindergarten into high school (e.g., reading, writing, math, science), but these vary by province.||Since 2002, there is a requirement for testing of all students in middle grades and sometimes in high school. These tests are standardized by state. Only basic skills test required to complete school.|
|Teacher Training||Standards for teacher education are centralized within each state with some coordination across states.||Standards for teacher education Teaching is selective in Canada.||Teacher training is decentralized, state requirements vary widely, and oversight can be lax.|
|Teacher Pay||Most teachers are civil servants and are paid well (relative to their US counterparts).||Teachers are paid well (relative to their US counterparts).||Teachers are paid poorly.|
|Curriculum Consistency||Curriculum recommendations and frameworks available provided by the Kultusministerkonferenz (KMK) but, due to the federated system the states modify those based on their needs and policies.||Much consistency across schools and districts in curriculum and teaching methods.||Little consistency in training, curriculum, or methods.|
|Federal Government Focus||Health equity and health inequalities in several policies and the health promotion law.||A strong common commitment to equity across provinces/territories||Compensatory education for students from low-income backgrounds and special education for students with disabilities.|
|Equity||In general whole-of-society, but families, special needs (“inclusion”) and Immigrant and refugee communities are a focus for equity efforts. (idealistic; implementation of equity action is not secured)||Focus on at risk youth, migrant, and indigenous populations. Canada has many immigrant families, but is one of the few countries where migrant children achieve at a level similar to their non-migrant counterparts.||Focus on racial/ethnic minorities and urban inequities. While the federal government’s role has focused on ensuring equity for disadvantaged populations, deep inequities by race/ethnicity remain.|
|Groups of Focus for Equity||Migrants, students with disability and special needs (“inclusion”), to a certain degree all students are supposed to benefit from equity action in schools. (idealistic; implementation of equity action is not secured; Germany has a multi-track school system in place starting with secondary school and which might contribute to inequities and inequalities by its very structure as at the end of primary school pupils are being distinguished by their marks, which determine which school they can attend within this multi-track system.)||Canada has many immigrant families, but is one of the few countries where migrant children achieve academic outcomes at a level similar to their non-migrant counterparts.||Compensatory education for students from low-income backgrounds and special education for students with disabilities.|
|How Health Literacy is Addressed||No formal, national health literacy standards available. Guidelines exists (e.g., Digital education standards; Life-skills in the school health promotion strategy)||No formal, national health literacy standards available. Guidelines exists (e.g., School Health Guidelines, Sexual Health Education Guidelines)||National Health Education Standards: Achieving Health Literacy; Achieving Excellence (NHES, 1995; 2007)|
|Whole School Approach||No mandatory whole-school approach, but a modified Health Promoting School approach is in some regions in place, where participation of schools is not mandatory. Health literacy is not yet part of this.||No mandatory whole-school approach, but many provinces have a website for their own Healthy Schools approach with resources. Provinces vary with their framework used. Extent to which health literacy is a part of this varies across provinces.||Whole School, Whole Community, Whole Child approach promoted nationally; extent to which this is utilized varies across states. Health literacy is embedded in this.|
|Pisa Score Science *||509||496||528|
|Pisa Score Reading||509||497||527|
|Pisa Score Math||506||470||516|
|Pisa Share of Top Performers in At Least One Subject Science, Reading and Mathematics||19.2||13.3||22.7|
|Pisa Share of Low Achievers in All Three Subjects (Below Level 2)||9.8||13.6||5.9|
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