The level of Health Literacy among students of Bergamo: observational study 
10.54103/dn/20570
BACKGROUND: Recent studies have highlighted how Health Literacy (HL) represents one of the fundamental determinants of health for people's well-being. Despite this concept being widely approved by the scientific community, research trends focus on outcomes such as misinformation and HL deficiencies in individuals with mental health issues, chronic diseases, drug use and abuse, rather than evaluating its actual level in the population. Therefore, a broader and more generalized analysis is needed to support the European community in assessing HL levels in the population, in order to demonstrate how increasing HL can improve both individuals' health and the healthcare system.
AIM: To measure HL competences in a sample of fifth-year students attending high schools, aged between 17 and 19 years old.
METHODS: This descriptive monocentric study was conducted between September 15th and 30th, 2021, and used the HLS Q-16 questionnaire (European Health Literacy Survey Questionnaire) validated by Lorini et al. (2019) to assess the level of HL.
RESULTS: The results are consistent with those obtained by Lorini et al. (2019) and indicate that more than half of the sample has problematic or inadequate HL levels.
CONCLUSION: It is essential to continue research in this unexplored area in Italy and to objectively and demonstrably analyze potential corrections that can remedy the lack of HL in citizens.​
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Dissertation Nursing
 Infermieri
Il livello di Health Literacy negli studenti Bergamaschi: uno studio osservazionale
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2024-02-01
2023-07-11
2024-01-31
2024-02-01
DN
Giulia Barcella
2024/02/01
10.54103/dn/20570
SC Anestesia e Rianimazione 2_Terapia Intensiva Neurochirurgia ASST Papa Giovanni XXIII, Bergamo
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McCleary-Jones, Voncella PhD, RN, BC, CNE. Una revisione sistematica della letteratura sull'alfabetizzazione sanitaria nell'educazione infermieristica. Nurse Educator 41(2): p 93-97, 2016.
Il livello di Health Literacy negli studenti Bergamaschi: uno studio osservazionale
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           ISSN: 2785-7263                                                                                               DOI: 10.54103/dn/20570




         The level of Health Literacy among high school
          students of Bergamo: an observational study
                1
Luca Ongis       , Giulia Barcella2
1 S.C.   Endocrine Diseases 1 and Diabetology, ASST Papa Giovanni XXIII, Bergamo, Italy
2   S.C. Anaesthesia and Resuscitation 2 - Neurosurgery Intensive Care Unit, ASST Papa Giovanni XXIII, Bergamo, Italy



Findings:                                           ABSTRACT
More than half of the sample has                    BACKGROUND: Recent studies have highlighted how Health Literacy
problematic or inadequate H.L. levels. he           (H.L.) represents one of the fundamental determinants of health for people's
acquisition of H.L. skills requires specific        well-being. Despite this concept being widely approved by the scientific
training to enable health professionals to          community, research trends focus on outcomes such as misinformation and
adopt       appropriate     communication           H.L. deficiencies in individuals with mental health issues, chronic diseases,
strategies.                                         drug use and abuse, rather than evaluating its actual level in the population.
                                                    Therefore, a broader and more generalized analysis is needed to support the
                                                    European community in assessing H.L. levels in the population, in order to
                                                    demonstrate how increasing H.L. can improve both individuals' health and
                                                    the healthcare system.

                                                    AIM: To measure H.L. competencies in a sample of fifth-year students
                                                    attending high schools, aged between 17 and 19 years old.

                                                    METHODS: This descriptive monocentric study was conducted between
                                                    September 15th and 30th, 2021, carried out on a sample of 434 students, and
                                                    used the HLS Q-16 questionnaire (European Health Literacy Survey
                                                    Questionnaire) to assess the level of H.L.

                                                    RESULTS: The results are consistent with those present in the literature
                                                    and indicate that more than half of the sample has problematic or inadequate
                                                    H.L. levels.

                                                    CONCLUSION: It is essential to continue research in this unexplored area
                                                    in Italy and to objectively and demonstrably analyze potential corrections that
                                                    can remedy the lack of H.L. in citizens.




                                   KEYWORDS: Health Literacy, Students, Survey, Nurses, Nursing Care


          Corresponding author:                                            21                                   Submission received: 11/07/2023
          Luca Ongis: ongisluca@gmail.com                                                                End of Peer Review process: 04/10/2023
          ASST Papa Giovanni XXIII, Piazza OMS,                                                                           Accepted: 04/10/2023
          124127, Bergamo (BG), ITALY
                                                                                      This work is licensed under a Creative Commons
           ISSN: 2785-7263                                                                                            DOI: 10.54103/dn/20570




    Il livello di Health Literacy negli studenti Bergamaschi
         delle scuole superiori: uno studio osservazionale
               1
Luca Ognis      , Giulia Barcella2
1   SC Malattie Endocrine 1 e Diabetologia ASST Papa Giovanni XXIII, Bergamo
2   SC Anestesia e Rianimazione 2_Terapia Intensiva Neurochirurgia ASST Papa Giovanni XXIII, Bergamo



Riscontri:                                          ABSTRACT
Più della metà del campione presenta livelli di     INTRODUZIONE: Recenti studi hanno evidenziato come l’Health Literacy
HL problematici o inadeguati. L’acquisizione        (HL) rappresenti uno dei determinanti della salute fondamentali per il
di competenze in materia di HL necessita di
una formazione specifica che permetta ai
                                                    benessere delle persone. Nonostante questo concetto sia ampiamente
professionisti della salute di adottare strategie   approvato dalla comunità scientifica, il trend di ricerca verte su outcomes quali
comunicative appropriate.                           disinformazione e carenza di HL nel soggetto con problematiche legate alla
                                                    dimensione della salute mentale, delle malattie croniche, utilizzo e abuso di
                                                    droghe, piuttosto che valutarne l’effettivo livello nella popolazione. È quindi
                                                    necessaria un’analisi più ampia e generalizzata, che appoggi la comunità
                                                    Europea nella valutazione dei livelli di HL nella popolazione, così da
                                                    dimostrare quanto un suo incremento, permetta un miglioramento sia della
                                                    salute degli individui, che del Sistema Sanitario.

                                                    OBIETTIVI: Misurare le competenze di HL in un campione di studenti delle
                                                    classi quinte frequentanti istituti superiori, con un’età compresa tra i 17 ed i 19
                                                    anni.

                                                    MATERIALI E METODI: Questo studio monocentrico, descrittivo, si è
                                                    svolto nel periodo tra il 15 ed il 30 settembre 2021, su un campione di 434
                                                    studenti, ed ha utilizzato il questionario HLS Q-16 (European Health Literacy
                                                    Survey Questionnaire), per valutare il livello di HL.

                                                    RISULTATI: I risultati sono in accordo con quanto presente in letteratura e
                                                    consentono di affermare che più della metà del campione, risulta avere un
                                                    livello di HL problematico o inadeguato.

                                                    CONCLUSIONI: Risulta fondamentale continuare la ricerca in questo
                                                    ambito fortemente inesplorato sul territorio italiano ed analizzare in modo
                                                    oggettivo e dimostrabile, dei potenziali correttivi che possano rimediare alla
                                                    carenza di HL nel cittadino



                    KEYWORDS: Alfabetizzazione Sanitaria, Studenti, Indagine, Infermieri, Assistenza Infermieristica


          Corresponding author:                                         22                                   Submission received: 11/07/2023
          Luca Ongis: ongisluca@gmail.com                                                             End of Peer Review process: 04/10/2023
          ASST Papa Giovanni XXIII, Piazza OMS,                                                                        Accepted: 04/10/2023
          124127, Bergamo (BG), ITALY
                                                                                   This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                 DOI: 10.54103/dn/20570




BACKGROUND                                                      From the several publications in the literature, it is
"Health literacy is correlated with the concept of              evident that nurse involvement, being the encounter
literacy and refers to the necessary knowledge,                 between citizens and the healthcare system, is
motivation, and competencies that allow people to               fundamental when researching this factor.
access, understand, evaluate, and use information
about health, with the goal of expressing opinions
and making daily life decisions in with regards to
                                                                Aim:
healthcare, sickness prevention, and promoting
health and to maintain or improve ones' life quality"           The primary endpoint of this study is to determine
(1).                                                            H.L. levels in a specific population sample through a
                                                                survey validated in the literature for the attribution of
Despite studies and research of the last decade
                                                                an objective level of H.L. The identified sample is
describing Health Literacy (H.L.) as one of the
                                                                made of senior (last year) students in high schools in
fundamental predictors of people's well-being and
                                                                the city of Bergamo, who participated voluntarily. The
health, research interest has been focused on specific
                                                                descriptive monocentric study was inspired by the
populations with outcomes of specific pathologies,
                                                                literature. It measured H.L. levels among participants
such as the ones from mental health, chronic diseases,
                                                                through the subministered survey HLS Q-16
prevention and information about sexually
                                                                (European Health Literacy Survey Questionnaire)
transmissible diseases, drug use, and abuse, analyzing
                                                                validated by Lorini (4), which was built of 16
their correlations at a scarce level of H.L. In the past
                                                                questions.
years, no researcher has focused on a broader and
nonspecific analysis. It would be reasonable to
support the European community in the evaluation of
H.L. levels among the population to show that its               METHODS
increase could allow for an improvement both of                 The study design is observational, descriptive, and
individuals' health and of the healthcare system. The           monocentric. An initial literature review was carried
concept of H.L. is often difficult to grasp in its              out, followed by sampling and survey methods ideal
entirety, as it is interconnected to multiple dimensions        for the target and goals of this study. Subsequently,
that led several authors to give it diverse definitions,        after identifying the proposed survey, the sub-
as shown in the literature review by De Caro et al. (2),        ministration methods were chosen, as well as the data
where 28 definitions are pinpointed between 1998                gathering period (from September 15th, 2021, to
and 2014. In that regard, five thematic areas                   September 30th, 2021).
representing the multidimensional construct of H.L.
have been defined (Figure 1).

H.L. should, therefore, be considered as a citizen
empowerment tool, a means for health promotion,
surpassing the limits of the educational context (3).
Although the growing interest in health has led to an
increase in the number of studies and research about
this topic, the concentration of publications about a
topic more generic than H.L. is not homogeneous.

      Corresponding author:                                23                                 Submission received: 11/07/2023
      Luca Ongis: ongisluca@gmail.com                                                  End of Peer Review process: 04/10/2023
      ASST Papa Giovanni XXIII, Piazza OMS,                                                             Accepted: 04/10/2023
      124127, Bergamo (BG), ITALY
                                                                    This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                                                     DOI: 10.54103/dn/20570




                                                                                                                 SERVICES
                                      GOALS OF
                                      HEALTH
         User Traits                                                                                     AND INFORMATION                            Healthcare system
                               (promote and maintain good health,                                      (Information, services, basic health
                                make appropriate health decisions)                                     information, health information in
                                                                                                               RESOURCES
                                                                                                         written, spoken or digital form,
         Family and                                                                                            electronic sources                    Ethical aspects
         Community                                                          Time
                                                                     (During the course of life)
                                                                                                                                                         Equity
           Society
                                      ACTIONS                                                                  SKILLS,                                   Costs
                                                                                                              ABILITIES
      Educational System         (to gain access, to obtain, to
                                           interpret)                                                  (Skills, ability, capacity, knowledge,
                                                                                                         analysis, higher level cognitive               Type of
                                                                                                                         ability)
      Media and Business                                                                                                                             communication


    Labour and Economic                                                                                                                               Interventions
           System          Figure 1: dimensional areas related to Health Literacy and connection to its context (2)                                    Outcomes


Data collection     instruments
      Political System                                                                    Strengths of the HLS-EU-Q16 survey:

To facilitate the use of the survey to the selected                                                     automatic fill-in tools;
target, a website was designed to instruct participants                                                 measure       interactions,     comprehension,
through a tutorial video, where the student was                                                          information research, application/function,
directed to a specific post, with the survey link,                                                       decision process/critical thought, evaluation,
reproduced according to its validation, on the                                                           responsibility, trust, and internet surfing
platform Google® Moduli; the time frame planned                                                          navigation ability.
for data collection was from September 15th to                                                          the Pearson correlation index with the HLS-
September 30th, 2021. To avoid inopportune answers                                                       EU-Q47 (5) is very high;
or fill-in errors, an access password was made
                                                                                                        the scores are strongly correlated to high
available     for    students     through       written
                                                                                                         indexes in the NVS test;
communication, sent exclusively to the participants,
                                                                                                        in the survey validation, participants showed
together with an illustrated communication for the
                                                                                                         a small percentage of answers "I don't know/
students' parents, and approved by the single
                                                                                                         refuse to answer," which are aspects proving
participants. The survey is made of first standardized
                                                                                                         acceptance and comprehension of the
part with questions on anagraphic and demographic
                                                                                                         proposed items;
data, such as age, gender, nationality, and attending
school; the second part hosts the HSU-EU-Q16 (4),                                                       the survey is validated in the Italian language;
consisting of 16 items and the possibility to choose a                                                   hence, it is easy to use for the sample.
Likert scale answers ranging from "Very difficult" to
"Very easy."                                                                              Weakness of the HLS-EU-Q16 survey:

Once the data collection period finished, the data                                        Differently from the E.U. research (6), the items
was collected and cataloged with Microsoft Excel                                          concerning mental health (numbers 8 and 13) in
worksheets and discussed with descriptive statistics.                                     Lorini's study show a higher percentage of "I do not
                                                                                          know" answers (14,3% vs. 5,6% for items 8, 6,3% vs.
                                                                                          3,9% for item 13). As suggested by other Authors
                                                                                          (7), this displays a lack of sensitivity of the tool,
      Corresponding author:                                                      24                                            Submission received: 11/07/2023
      Luca Ongis: ongisluca@gmail.com                                                                                   End of Peer Review process: 04/10/2023
      ASST Papa Giovanni XXIII, Piazza OMS,                                                                                              Accepted: 04/10/2023
      124127, Bergamo (BG), ITALY
                                                                                                   This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                DOI: 10.54103/dn/20570




which ought to be calibrated based on the country                  INSTITUTIONS INVOLVED
                                                                                                        N. OF
                                                                                                                     N. COMPLETED
                                                              N°                                      DECLARED
and the area in which it is proposed. Keeping this in                   IN THE STUDY
                                                                                                      STUDENTS
                                                                                                                    QUESTIONNAIRES

mind, the high percentage of "I do not know"                         TECHNICAL INSTITUTE -
                                                               1     CHEMISTRY, MATERIALS                  293            15
answers for mental health problems highlights                        AND BIOTECHNOLOGY

critical issues that might be attributed on the one            2   LINGUISTIC HIGH SCHOOL                  275           162

hand to the lack of the respondents' experience with           3
                                                                   TECHNICAL AGRICULTURAL
                                                                          INSTITUTE
                                                                                                           187            5

mental health problems and on the other hand, with                  PROFESSIONAL INSTITUTE
                                                               4     FOR TRADE - TOURISM -                 170            4
prejudice and denial surrounding these issues.                        HOTEL MANAGEMENT
                                                                    INDUSTRIAL TECHNICAL
                                                               5    INSTITUTE FOR FASHION                  177            39
                                                                        AND GRAPHICS
Ethical aspects                                                6
                                                                   COMMERCIAL AND TOURIST
                                                                     TECHNICAL INSTITUTE
                                                                                                           187            4

                                                                     HUMANITIES AND MUSIC
                                                               7                                           241            6
The research attained to the constraints imposed by                     HIGH SCHOOL
                                                                   SCIENTIFIC HIGH SCHOOL -
D.lgs. 196/03 "Code in matter of protection of                 8
                                                                    LINGUISTIC - HUMANITIES
                                                                                                           204           146

personal data" and kept maximum confidentiality                             TOTAL                          1734          434

concerning data, information, and knowledge                                     NON-PARTICIPATING DELTAS                 1300

acquired in the data collection process. The collected                                          % PARTICIPANTS           25%

data is used in an anonymous and confidential form,                      Table 1: List of the partecipating high schools
exclusively for statistics and research. It is not
intended to give any value judgment to the policies in
force in the institutes examined nor to the personal          RESULTS
thoughts of the students who kindly contributed to
the study.                                                    At the end of the data collection period (September 15th to
                                                              30th, 2021), the data collection of the official website was
                                                              interrupted in order not to exclude eventual accidental data
Statistical validity
                                                              compilations. All the participants were considered valid
In other studies related to the evaluation of H.L.            thanks to the first question of verification and exclusion:
conducted on the population, a total homogenous               "Are you a senior (last year) high school student?".
standard of a thousand candidates have been                   An Excel worksheet was made for the elaboration of the
examined and casually selected. For this study, the           responses that allowed the development of the following
potential research population communicated by the             conclusions:
regional school office was 18 schools in the city of
Bergamo, with a total of 3600 students. The                       434 students answered the survey in a complete way
institutes that confirmed their participation in this              (25% of the total available sample).
study were 8 (44,45%) for a total of 1734 senior high             Students belonged to 16 different nationalities.
school students (communicated by the school                        Specifically, 406 students were of Italian origin (96%),
                                                                   and 15 were of other nationalities (4%).
directors), of which 434 participated (25%) (Table 1).
                                                                  94,5% of the students were aged between 17 and 19,
                                                                   while the remaining percentage was divided between
                                                                   20 and 21 years old respondents.
                                                                  63,6% of the students were female, and 33,9% were
                                                                   male. The remaining part chose not to specify the
                                                                   answer.

      Corresponding author:                              25                                  Submission received: 11/07/2023
      Luca Ongis: ongisluca@gmail.com                                                 End of Peer Review process: 04/10/2023
      ASST Papa Giovanni XXIII, Piazza OMS,                                                            Accepted: 04/10/2023
      124127, Bergamo (BG), ITALY
                                                                   This work is licensed under a Creative Commons
        ISSN: 2785-7263                                                                                                DOI: 10.54103/dn/20570




The scores obtained by the students were calculated as
predicted by Lorini (4). To generate the score, the items
were dichotomized into two categories with two different                                                           ITEMS
scores, "easy" ("quite" and "very" easy = 1) and "difficult"                                                                  Distribution
                                                                                                               Acquired
("quite" and "very" difficult = 0). In Lorini's study (4), "I                                   Question
                                                                                                                Score
                                                                                                                                % among
do not know/refuse to answer" has been recorded as a                                                                          434 students
missing value. The scores on the scale were calculated as a                                          1             282              64,98%
sum of the scores of each item and ranged from 0 to 16.                                              2             340              78,34%
Considering the scores of the HLS-EUQ16 survey, three                                                3             341              78,57%
different levels of health literacy have been defined:                                               4             398              91,71%
inadequate health literacy (0- 8), problematic health literacy                                       5             136              31,34%
(9-12), and adequate health literacy (13-16).                                                        6             241              55,53%
                                                                                                     7             395              91,01%
The scores obtained by individual students broken
                                                                                                     8             137              31,57%
down for each question were also identified so that a
                                                                                                     9             344              79,26%
value was assigned for each item (Table 2).
                                                                                                    10             266              61,29%

Next, the score results for each individual student                                                 11             141              32,49%

was calculated, allowing the corresponding H.L.                                                     12             144              33,18%

bands to be allocated and assigned according to the                                                 13             277              63,82%
                                                                                                    14             308              70,97%
bands identified by Lorini et al. and the G-HL index
                                                                                                    15             248              57,14%
explained          below            (Table        3).
                                                                                                    16             277              63,82%
                                                                                             Table 2: Survey with single scores per item



                                                                                                    Distribution % among 434
                               LEVELS OF HEALTH LITERACY              N. SINGLE RESULTS
                                                                                                             students
                       0-8       Inadequate health literacy                  131                              30,18%
                      09-dic     Problematic health literacy                 205                              47,24%
                      13-16       Adequate health literacy                    98                              22,58%
                                                                          N. SINGLE                Distribution % among
                     RANGES OF GENERAL HEALTH LITERACY INDEX Gele
                                                                          RESULTS                       434 students
                      0-25       Inadequate health literacy                  153                              35,25%
                     25,1-33     Problematic health literacy                 202                              46,54%
                     33,1-42      Sufficient health literacy                  70                              16,13%
                     42,1-50      Excellent health literacy                    9                               2,07%
                                 Table 3: Distribution of questionnaire scores according to Lorini (4) and

                                 identification of the generic band of the G-HL index according to Gele (8)




       Corresponding author:                                        26                                       Submission received: 11/07/2023
       Luca Ongis: ongisluca@gmail.com                                                                End of Peer Review process: 04/10/2023
       ASST Papa Giovanni XXIII, Piazza OMS,                                                                           Accepted: 04/10/2023
       124127, Bergamo (BG), ITALY
                                                                                   This work is licensed under a Creative Commons
           ISSN: 2785-7263                                                                                                 DOI: 10.54103/dn/20570




Similarly to the score of the survey HLSEU-Q47, it                                average per each, thus, will range between 1 and 4,
is possible to point out a general index of H.L.                                  and consequently (mean value-1) will range between
general (index G-HL, table 3) recommended in the                                  0 and 3. If the average (mean) is 0, then the G-HL
analysis of the results on large samples (8), calculated                          Index assumes a value equal to 0; if the average
as follows: firstly, the scores of the Likert scale have                          (mean) is 4, then the G-HL Index assumes a value
to be redistributed where the answer was "I do not                                equal to 50. Subsequently, four different levels of
know" 0 points, "Very easy" 1 point, "Quite                                       health literacy have been defined in HLS-EUQ47:
difficult" 2 points, "Quite easy" 3 points, "Very easy"                           adequate health literacy (0-25), problematic health
4 points; the formula is: Index G-HL = ((mean value                               literacy (25,1-33), sufficient health literacy (33,1-43),
-1) *50) / 3 where "mean value" is the average of the                             and excellent (42,1-50) (see table 3).
scores of the single answer of each participant. The



DISCUSSION
Confronting results on a worldwide scale
  AUTHOR                  AGE           COUNTRY          TOOL                                                RISULTATI
                                                                             Greater difficulty on items 12-8-11 (online). 55.2% of the sample had H.L.
 Lorini et al. (4)    40-60 yo (mean)     Italy        HLS-EU-Q16
                                                                                                             problems.
                                                                        Poor HL among males and younger students, but without identifying a specific age
 Klinker et al. (9)   15-26 yo (mean)    Denmark         HLQ-Q47
                                                                                     group (questionnaire not designed for this purpose).
                                                     Chinese Citizens
 Wang et al. (10)     19-21 yo (mean)     China            H.L.         The level of health knowledge among Chinese school students is extremely low
                                                      Questionnaire     (1.4% of students have adequate health knowledge).
                                                                              The H.L. level was lower than that reported in the literature, but without
 Rababah et al.
                      19-21 yo (mean)    Jordan          HLQ-Q47            identifying a specific age group (the questionnaire was not prepared for this
     (11)
                                                                                                               purpose).
                                                                           Results not classified as the type of study involved the creation of a new age-
   Harper (12)        20-24 yo (mean)    America         NAMLE
                                                                                                      specific assessment method
                                                                               Results not classified as the type of study involved the validation of the
  Gazibara (13)       15-18 yo (mean)     Serbia         eHEALS
                                                                                                questionnaire in the Serbian language
                                                                         No classification of results, only inferences between individual questions without
   Elsborg (14)       20-24 yo (mean)    Denmark         HLQ-Q47
                                                                               identifying a H.L. band (questionnaire not designed for this purpose).
   Pelikan (5)           25-80 yo        Europe        HLS-EU-Q47                                    Results reported in Figure 2
                                              Table 4: Results of similar studies in the rest of the world




         Corresponding author:                                            27                                      Submission received: 11/07/2023
         Luca Ongis: ongisluca@gmail.com                                                                   End of Peer Review process: 04/10/2023
         ASST Papa Giovanni XXIII, Piazza OMS,                                                                              Accepted: 04/10/2023
         124127, Bergamo (BG), ITALY
                                                                                        This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                           DOI: 10.54103/dn/20570




                                    Figure 2: Graphical summary of the results of Pelikan et al. (5)

As can be interpreted from table 4 and figure 2, the                    Lorini et al. (4), although the sample was utterly
results obtained in this study are similar to the ones in               different. It was not possible to estimate ulterior
the rest of the world, specifically, compared to the                    comparisons related to similar age ranges and to the
study carried out in Italy, more difficulties are seen                  target in other studies, as the methods and evaluations
with regards to item 12-8-11 (in line) and the 55,2%                    adopted were different from the ones of this study.
of the sample with a problematic H.L.; in Denmark                       However, we may affirm that as of today, a
health literacy is scarce among males and younger                       measurement tool for the H.L. index dedicated to the
students, but without identifying a specific age range,                 "young adults" category has not been developed, and
as that was not the survey's goal; the other study, also                it seems evident how each measurement tool needs to
carried out in Denmark, did not highlight findings,                     be adequate to its territorial context. Concerning the
but rather the inference between the single questions,                  results of the European study on H.L. level (6), which
thus without identifying a specific H.L. range; in                      used survey HLS-EU-Q47 from which Lorini et al.
China, the knowledge level on health among students                     (4) used the questions of survey HLS-EU-Q16, we
is extremely low (only 1,4% of the students had an                      found how many European countries have similar
adequate knowledge level about health); in Jordan the                   high percentages of problematic H.L., as the one
level of H.L. appeared to be lower than the level                       found among our sample of students. These
reported in the literature, but without accounting for                  comparisons underline the evidence that society
a specific age range; the study in the U.S. did not                     needs to remedy this serious issue of public health.
classify the results according to a H.L. level as the
typology of study was aiming at creating a new                          Limitations and weaknesses of this study
evaluation method specific for age, and accordingly in
                                                                         The results are based on limited HL-related
the study in Serbia. Concerning the European study,
                                                                          literature, especially in relation to the sample type
figure 2 shows that problematic and inadequate H.L.
                                                                          and the type of general collected data.
is equal to, if not higher than, the sufficient H.L. Our
results are mainly in line with the ones found by

      Corresponding author:                                       28                                    Submission received: 11/07/2023
      Luca Ongis: ongisluca@gmail.com                                                            End of Peer Review process: 04/10/2023
      ASST Papa Giovanni XXIII, Piazza OMS,                                                                       Accepted: 04/10/2023
      124127, Bergamo (BG), ITALY
                                                                              This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                 DOI: 10.54103/dn/20570




 The students’ sample does not guarantee a strong              who appear to be a competent figure proactive in this
  statistical power, as it is not representative of the         type of activities, also in the educational field. In the
  entire student population (selection bias).                   past 20 years, many approaches and tools have been
 The typology of the study design limits the ability           developed to strengthen H.L. in different
  to conclude a causal inference.                               environments and for different population groups,
 Our results are not representative of all types of            but the interventions need to be developed in several
  curricula of students in Bergamo.                             settings: health professionals urge the educational
                                                                sector to improve the literacy abilities of people, but
 This study is based on self-reported data.
                                                                the healthcare sector itself needs to act in order to
 The sampling method is not probability-based: the
                                                                remove barriers of access to information, to service
  participants involved are exclusively senior high
                                                                and treatments (7).
  school students in the city of Bergamo.
                                                                Albeit limited, the available research based on testing
                                                                efficiency suggests a clear necessity to invest in H.L.
CONCLUSIONS                                                     as early as possible, starting from childhood and
                                                                adolescence (16). Schools ought to assume a
Thanks to the literature and the results of this study,         fundamental role and include health instruction and
we can affirm that our sample, representing citizens            formation programs managed by nurses, who are
and "future adults," is at risk of negative outcomes            currently only sporadically involved in the initiative of
for health, which:                                              the individuals. Schools, which reach out to almost all
                                                                children of school age, offer an ideal environment to
       increased risk for high mortality (15);
                                                                work on H.L. through the realization of long-term
       increased health expenses, lower participation          H.L. programs, such as in Finland (17), in the U.S.
        in health promotion and disease detection,              (18-19) and in Australia (20), guaranteeing more
        and adoption of risky behavior leading as a             sustainable and profitable educational interventions
        consequence to work accidents, ineffective              (21). Occasions to promote health in schools and
        management of chronic diseases, scarce                  health-education activities have an important impact
        adherence      to therapeutic       indications,        on the levels of H.L. In Lithuania, it has been
        increased hospitalization, increased morbidity          observed that students who took part in interventions
        and mortality (7);                                      for health promotions at school and health-
       limited H.L., associated with social                    educational activities (especially the ones focused on
        dimensions that might reinforce ulteriorly              bullying) displayed a better H.L. compared to
        existing inequalities (7);                              students who did not partake (22).
Equal access to provisions and healthcare services              Implications for nursing practices
alone is not sufficient to obtain equality in health,
measured in terms of life quality and life expectancy;          The relationship between H.L. and nursing practices
citizen education is therefore key ingredient and is            has yet to be widely investigated/examined/analysed
indispensable to reach such equality, as well as                (2). The attention of nurses for H.L. is limited: 53%
activation strategies with the goal of increasing H.L.          of nurses do not consider it a priority aspect as
levels in the population, from all parties involved in          compared to clinical-assistance necessities (23) both
the socio-health sphere, with a specific eye on nurses,         due to a not full understanding of its outcomes on

       Corresponding author:                               29                                 Submission received: 11/07/2023
       Luca Ongis: ongisluca@gmail.com                                                 End of Peer Review process: 04/10/2023
       ASST Papa Giovanni XXIII, Piazza OMS,                                                            Accepted: 04/10/2023
       124127, Bergamo (BG), ITALY
                                                                    This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                DOI: 10.54103/dn/20570




individual health, both due to a lack of evaluation of            Florence and its surroundings. Ann Ist Superiore
the topic (2). The interaction between the settings,              della Sanità, Vol. 55 - No. 1, pp.10 - 18. 2019.
people, and professionals is essential for the
development of policies and programs that tackle the           5. Pelikan JM, Röthlin F, Ganahl K, 2014.
issues of H.L. and its evaluation (7), and it is a                Measuring comprehensive health literacy in
necessity to create specific programs for training and            general populations: validation of instrument,
awareness about this topic (25). The acquisition of               indices and scales of the HLS-EU study. 6th
competencies on the subject of H.L. requires training             Annual Health Literacy Research Conference.
focused on the development of abilities that allow                Bethesda, Maryland: Hyatt Regency.
health professionals employed in healthcare education
to identify correctly the level of H.L. in a person in         6. HLS-EU Consortium: comparative report of
order to adopt different communication strategies                 Health Literacy in eight E.U. member states. The
appropriate for making the assistance relationship                European Health Literacy Survey HLS-EU. 2012
effective (7).
                                                               7. Kickbusch I., Pelikan J., Apfel F. and Tsouros A.
                                                                  Health Literacy: the solid facts. World Health
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      Corresponding author:                               30                                 Submission received: 11/07/2023
      Luca Ongis: ongisluca@gmail.com                                                 End of Peer Review process: 04/10/2023
      ASST Papa Giovanni XXIII, Piazza OMS,                                                            Accepted: 04/10/2023
      124127, Bergamo (BG), ITALY
                                                                   This work is licensed under a Creative Commons
       ISSN: 2785-7263                                                                                DOI: 10.54103/dn/20570




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      Corresponding author:                                31                                Submission received: 11/07/2023
      Luca Ongis: ongisluca@gmail.com                                                 End of Peer Review process: 04/10/2023
      ASST Papa Giovanni XXIII, Piazza OMS,                                                            Accepted: 04/10/2023
      124127, Bergamo (BG), ITALY
                                                                   This work is licensed under a Creative Commons
