Health Literacy Studies Conducted in Australia: A Scoping Review

Health literacy (HL) is an essential component of various literacies mentioned in the field of health and education, including cultural, technological, media and scientific literacies. It is important for motivating higher consumer engagement. We aimed to review previous studies of HL in Australia to inform future studies, extend current knowledge and further enhance HL. Using search strings, a systematic search of four databases (i.e., MEDLINE; Embase; CINAHL and Eric) was carried out. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) based search strategy led to identification of a total of N = 9696 records, that were further screened for inclusion in the review. The review findings were categorized into three major themes: (1) HL and health numeracy; (2) contrast of: knowledge deficiency, knowledge gained, problems of current health care system and (3) HL measurement methods and its domains. The findings from this scoping review show a dearth of measurement tools with sound psychometric properties for assessing HL. The findings also reveal low levels of HL in consumers which is in turn affecting health-related behaviors, utilization of health services and navigation of the health system. More recent developments have tried to integrate vital aspects, including introduction of applications to increase HL and exploring HL in Aboriginal communities.


Introduction
According to the World Health Organization, health literacy (HL) is the key determinant of the health and wellbeing of an individual [1,2]. It is one component of various literacies mentioned in the insufficient general literacy in order to deal with daily life activities and work [36]. Almost half of the adult populations in developed countries such as the US, New Zealand and Canada have inadequate HL skills [38][39][40][41][42].
Even though there is increasing prevalence of chronic diseases, the levels of HL continue to be low in the United States and Canada [11,43,44]. Indeed, there is a gap in our current understanding of HL and its relationship to chronic diseases [10,45] but it is definite that people with low HL have worsened health outcomes [46]. The overall estimates revealed that there are 1.5 to 3 times greater chances of worsened health outcomes among individuals with low HL [47]. The low levels of HL are linked with greater utilization of services of health, less information among consumers, and worsened health outcomes [22]. The underlying access and equity issues can be exacerbated, for disadvantaged or vulnerable groups in Australia, due to low HL [48]. The Australian Bureau of Statistics revealed that according to Ethnic Communities' Council of Victoria, compared to 43% of individuals born in Australia, only 33% of the individuals born outside Australia have sufficient or higher HL [49].
The HL of a patient has a strong influence on the extent of a patients' medication adherence [50][51][52][53][54] and associated health care utilization [55,56]. HL is a known predictor of medication adherence [50,57,58]. Patients with low HL had been shown to experience a higher rate of medication errors and incorrect interpretation of medication label warnings [59][60][61]. The patients with low HL levels are difficult to counsel because they cannot comprehend the benefits and risks of medications adherence on health outcomes [62,63].
In Australia, the provision of safe and quality healthcare have been impacted by poor sources of health information, low HL across the population, and rising demands from a complex health system [30,64]. For example, a research study in Australia showed diminished cognition, depression and insufficient HL as the main risk factors for patients on warfarin therapy [65]. The rising costs linked with low HL have been examined in a systematic review and extra costs have been seen to correspond to almost 3-5% of aggregate health care expenditure [66].
The process for reviewing, and collecting and synthesizing evidence from previous health information research varies [67]. For instance, scoping reviews are gaining popularity to review health information research [68,69]. The reviews vary on three main dimensions. The first dimension is the aim of a review, its theoretical and ideological premises, and its logics of aggregation and synthesis of data. The second dimension consists of structure, quantity, as well as mapping and synthesis of the research and the data connections between the data. The third and an important dimension is the profundity and the extent of 'work done' in exploring a research issue [70]. A scoping review was chosen for this task of reviewing the research about health literacy in Australia. A scoping review enables the initial assessment of potential size and scope of available research literature. It also helps in recognizing the nature and extensiveness of research evidence [67,68,70]. In this present study, the scoping review helped to identify the boundaries of HL within the context HL related work undertaken in Australia. Contrary to narrative or literature reviews, scoping reviews require analytic re-interpretation of the literature [69]. However, a potential limitation of the scoping review is the risk of bias because unlike a systematic review, usually a quality assessment is not conducted in scoping reviews [71][72][73]. This lack of quality assessment may limit the uptake of findings to policy and practice [67] as the present scoping review included a vast range of published as well as gray literature on both HL and its various sub-fields.
This scoping review aimed to explore the prevailing awareness regarding HL in the published literature in Australia. Furthermore, we aimed to understand the prevailing definitions and concepts of HL and constructs, a lack of standardization in measurement tools and agreement on what needs to be measured (e.g., key outcomes), as reported in the Australian studies, for developing an understanding around assessment of HL, its domains and constructs.

Significance of the Study
This scoping review augments current knowledge on HL, offers further clarity in various concepts related to HL, and highlights how HL has advanced both temporally and spatially in Australia. This review attempts to synthesize studies directly focusing on HL, as well as various constructs that have arisen from this domain. An analysis of these constructs under the umbrella term of HL will enhance clarity on how HL fosters agency for healthcare decisions and navigating the healthcare system within the context of a person's life. This scoping review to analyze the research on HL is necessary for the following reasons. First, variability exists in the scientific community about the conceptual understanding of HL and its terminology, leading to different interpretations of HL in health and medical research. Second, there are some difficulties in assessing concepts related to HL such as, interpersonal communication, quality, individual's motivation, empowerment, and decision making and its constructs. Third, low HL or lack of adequate levels of HL have been linked with various negative outcomes, such as, greater utilization of services of health, low medication adherence, less information in consumers, equity issues for disadvantaged groups of Australia, and worsened health outcomes. In response to these aforementioned reasons, this review aims to review, analyze, and summarize previous research studies undertaken in Australia so that future studies can build on the current knowledge to further enhance HL.

Materials and Methods
Arksey's and O'Malley's [74,75] approach for scoping reviews was used. This process for review helps the researchers in examination of the nature and range of research carried out on a specific topic, helps in finding gaps in previously available literature on a specific topic, and analyze the value of carrying out extensive systematic reviews [74,75]. The five stages of scoping review performed are explained below.

Identification of the Scoping Review Question (Inclusion Criteria) (Stage 1)
The research question was identified by noting the HL variables and relationships between HL and multiple factors associated with it in previous studies. Thus, the scoping review question was framed as: What do the previous and current literature explain about the relationship(s) between HL and: (1) concepts and key outcomes of HL; (2) standardization and assessment of HL; and (3) awareness of HL.

Identification of Relevant Studies (Stage 2)
To identify studies fulfilling the inclusion criteria, four databases were searched: MEDLINE; Embase; CINAHL and Eric (Table 1). A systematic literature search strategy was adopted to determine the appropriate studies regardless of theoretical foundations they were affiliated with. For every database, search terms to identify studies included the following: HL (such as, numeracy, literacy, consumer health information, medical literacy, health education, health knowledge, educational status, and names of health literacy instruments), treatment decision (such as, information, awareness of risk, perceived barriers and benefits), mental HL (Mental health, mental illness*, mental disorder*, mental disease*, depression AND literacy/*health literacy), sexual HL (sexual health or sexual health or reproductive health or sexual and reproductive health or maternal health or maternal welfare or neonatal health or perinatal care or perinatal health or prenatal care/ or prenatal health) and Australia*.
These key terms were extracted in order to capture the three levels (i.e., basic or functional level, communicative or interactional level, and critical level) of HL and its constructs [9,10]. We combined the search terms with Boolean operators "OR" and "AND".
These databases retrieved 9696 records (as shown in Figure 1). The reference lists of all the review papers were also searched manually and an additional 12 records were found. The articles that directly mentioned the terms relating to HL, and treatment decision in title or abstract were prioritized. After excluding the studies based on our inclusion criteria and removing duplicates 27 records remained.

Study Selection (Stage 3)
All the authors of this scoping review unanimously formulated the screening criteria comprised of two levels. These criteria were later on applied and initially tested on a small number of records. The first screening criterion was to assess the title as well as abstracts of every record by authors. KM and FRC read in detail all the records that remained after first screening criteria for relevance.
The second criterion helped in deciding whether or not to exclude those studies which did not directly mention HL in the title, abstracts and results section. The studies only mentioning HL in the discussion section were excluded. Figure 1 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA) shows detail of screening procedure. Three authors mutually settled all conflicts that emerged during this process of screening. The inclusion and exclusion criteria developed for this review are shown in Table 2. The PRISMA checklist is available as supplementary file.

Study Selection (Stage 3)
All the authors of this scoping review unanimously formulated the screening criteria comprised of two levels. These criteria were later on applied and initially tested on a small number of records. The first screening criterion was to assess the title as well as abstracts of every record by authors. KM and FRC read in detail all the records that remained after first screening criteria for relevance.
The second criterion helped in deciding whether or not to exclude those studies which did not directly mention HL in the title, abstracts and results section. The studies only mentioning HL in the discussion section were excluded. Figure 1 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA) shows detail of screening procedure. Three authors mutually settled all conflicts that emerged during this process of screening. The inclusion and exclusion criteria developed for this review are shown in Table 2. The PRISMA checklist is available as Supplementary File.

Charting the Data (Stage 4)
A data extraction chart was developed by KM which was later on assessed independently by co-authors FRC, LCM and TMK on five records. After this initial assessment, KM applied this data extraction chart on the rest of the studies. The data extraction chart consisted of information related to the first author and year, study objective, study population and study design.

Collating, Summarizing, and Reporting the Results (Stage 5)
The objective, study population and study design are described in the Table 3. The temporal and geographical distribution narrative account of all the included studies is included in the Table 4. To gather knowledge on eating behaviours, and nutrition-related needs during pregnancy and postnatally of women admitted to the postnatal ward.
Women aged at least 18 years who were admitted to the postnatal maternity ward at a hospital

Study design:
Cross-sectional study Analysis: SPSS, Descriptive statistics, Chi-square and independent samples t-tests Many women reported an interest in nutrition and healthy weight management during pregnancy and in the postnatal period and rated its importance highly, and had poor diet quality, despite identifying healthy eating as a personal priority. 42% of the women self-reported gaining excess weight during pregnancy. One quarter reported knowing their gestational weight gain goals, yet only 1.6% was correct. Half reported interest in receiving nutrition education during pregnancy and post-delivery. Nutrition topics requested included healthy eating for development of baby pre-and post-delivery and maternal weight management.
---------------- Inadequate and at-risk functional health literacy is common and is associated with adverse asthma outcomes in a representative sample of adults with asthma. Increased symptoms, functional impairment, and significant health care use were more common in people with less health literacy in analyses adjusted for age, sex, and education The aim of this study was to explore health information sources accessed by people with schizophrenia and the level of trust invested in them.
People with schizophrenia, general practice attendees N = 309 71 = adults with schizophrenia (recruited from both community and inpatient settings) 238 = general practice attendees.
---------------- There are significant differences in the reported utilization and trust of health information sources between people with schizophrenia and attendees at general practice settings. Those with schizophrenia are less likely to trust and obtain information from a doctor, and less likely to access the Internet To compare young people's preference for a website with self-help books and two face-to-face services-counselling and mental health services.

Study design:
Qualitative, Semi-structured interviews Analysis:

Framework method
Four key themes were identified: (1) identifying a patient's literacy level; (2) perceived impact of literacy; (3) challenges and strategies to communicating concepts and supporting decision-making; and (4) suggested improvements to the health system. Participants described subjectively assessing a person's literacy level by monitoring the types of questions asked; analysing the language used; examining non-verbal behaviour, and considering a person's socio-economic situation. Participants reported the challenges of discussing the subtleties of cancer treatments with lower literacy groups such as the benefits and risks of treatment options and clinical trials, and tended to provide the basic facts to facilitate understanding. Radiation oncologists acknowledged the importance of health literacy in oncology, and employed a number of techniques to tailor their communication to different literacy populations.
Health literacy represents 'the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health' (Nutbeam 2000) [84]. To explore the help-seeking behaviour of Aboriginal men who are mentally unwell in a rural Victorian community.
Aboriginal people in Australia including men, carers and those involved in service delivery.

Study design:
Qualitative design, semi-structured interviews Analysis: Thematic analysis The findings suggest that there is a need for programmes that aim to improve mental health literacy and promote help seeking among Aboriginal men who are mentally unwell. Such programmes need to be developed jointly by mental health services as well as Aboriginal stakeholders, and implemented in a culturally sensitive and acceptable way.   To add that health literacy is likely to play a major role in the ability of patients to access, understand, and apply information in order to make informed decisions about osteoporosis treatment.

Osteoporosis patients
Health Literacy Questionnaire (HLQ) (to assess individual's health literacy needs) Letter to the editor The comprehension of health literacy needs of a person by applying most recent tools of health literacy in order to develop understanding regarding obstacles in medication. This strategy would ensure addressing problems of patients in person-centered way, improved adherence to medication and attaining outcomes of patients.
People who inject drugs ----------------  ---------------- To the editor To the editor ----------------Letter to the editor Australian health initiatives aimed at reducing the burden of chronic and preventable disease should consider the role and challenges of health literacy beyond its application to health services use. The growing understanding of the complex behavioural, social, systemic, and ecological forces that influence health and wellbeing should help guide these efforts.
-     Consumers' knowledge of nurses' roles in the Australian primary healthcare system, and hence system literacy (particularly in terms of navigating the system), was low. Of perhaps greatest importance is the fact that those consumers with low health systems literacy also exhibited a low level of motivation to seek new knowledge. Many consumers relied on the medical profession to direct care.
Health literacy relates not only to individual literacy skills, but also to knowledge of the healthcare context or system Australian Commission on Safety and Quality in Healthcare (ACSQHC 2013). ----------------  Based on the initial competencies identified in the literature review and after two rounds of consultation with experts via a Delphi method, 68 HIS competencies (51 core and 17 ICT-specific) were identified in this consultation. The competencies focused on both the generation and use of data at all levels of the health system, highlighting the importance of embedding a culture of information use. This consultation is one of the first to identify the HIS competencies required among general health workers, as opposed to specialist HIS roles. It is also one of the first attempts to develop a framework on minimum HIS competencies needed in LMICs, highlighting the skills needed at each level of the system, and identifying potential gaps in current training to allow a more systematic approach to HIS capacity-building.
---------------- ----------------  -------------------      The empirical relationships relevant for answering the research question are reported and thematically organized. The first author analysed, organized, and synthesized the data comprehensively through thematic analysis [105]. The analysis was then discussed with all the co-authors and the categories were identified. Approximately, half of the thematic analysis was autonomously carried out by the two authors and all differences were settled through discussion between two and all the authors. The results are presented descriptively.
It is not an integral component of scoping review to appraise the quality of included studies, [74,75]. The limitations in method section of every record, gaps present in previous literature, their implications for further research, formulations of policies and in practice were highlighted in this review.

Results
A total of 9696 records were identified after searching four databases and adding the studies identified through reference lists. After removing duplicates, 7895 records were left. Out of which 812 records were selected for relevance screening criteria and eligibility. The articles that did not measure or focus on HL as the main variable and its relationship with other variables were excluded. Finally, 27 records were retained for this review.

Research Designs and Study Populations
The qualitative studies were the most prevalent (n = 7), followed by experimental (n = 6), and cross-sectional studies (n = 7). There were two (n = 2) letters to editor and two (n = 2) mixed-method studies. There was one each of the following research designs: prospective quasi-longitudinal study, omnibus survey, and telephone survey. Across these studies, the number and socio-demographic characteristics of the participants recruited by the researchers varied. For instance, women aged at least 18 years who were admitted to the postnatal maternity ward at a hospital, people with schizophrenia, general practice attendees; young Australians aged 12-25 years, and South Australian rural and urban young men aged between 15 and 30 years.
We identified three main themes from the collected data: (1) HL and health numeracy (2) HL measurement methods and its domains and (3) HL as knowledge deficiency, knowledge gained knowledge of current health care system. Knowledge deficiency, knowledge gained, problem of current health care system were the focus of 20 studies, and 9 studies contrasted HL with health numeracy. HL measurement methods and its domains were common to all of the 27 selected articles and this theme relates to our review question about the standardization and assessment of HL. The spatial (geographical location) and temporal (time sequence) of HL research conducted was analyzed in all the included papers. The thematic analysis will be discussed in more detail below.

Theme 1-Health Literacy and Health Numeracy
Research studies included in this scoping review explored the associations between HL and health numeracy and health outcomes. The studies defined and interpreted HL differently as well as sexual-, mental and oral-HL [75][76][77]80,81,[86][87][88]91,96]. One study used an adapted framework called Paasche-Orlow and Wolf's model of the pathways linking health literacy and health outcomes [97]. Furthermore, a study showed that despite having knowledge about pregnancy and weight gain, some women experienced excessive gestational weight gain, indicating a need to provide information regarding nutritional ranges and dietary intake portions [76]. The effect of various diseases on health numeracy and literacy of children, as well as the caregivers, was highlighted by the research studies [69,89].
The research studies reviewed revealed that hospitalization, medication adherence and health numeracy were strongly linked. One study proposed that it is vital to assess health numeracy as it can increase the risk of preventable hospital admissions, for example hospitalization due to asthma [77]. Another research study found that medication adherence in patients with osteoporosis was dependent patients' understanding and appraisal of the risks and benefits of a treatment [88]. Similarly, a research study showed that patients made informed decisions if they were acquainted about risks and benefits of various bowel cancer screening procedures [91]. According to the findings, adequate health numeracy assisted patients in calculating cumulative outcomes of the procedures, estimation of efficacy and calculation of percentages of deaths due to absence of such procedures [91]. In the same way, in order to increase HL and health numeracy of their patients, radiation oncologists used a number of approaches to communicate complicated information regarding appointments and medicines intake [83].

Theme 2-Health Literacy as Knowledge Gain, Knowledge Deficiency and Knowledge of Current Health System
This theme emerged from the numerous ways that researchers endeavored to ascertain gains in health literacy knowledge about particular health conditions and the health system. For example, in a study aimed at quantifying functional HL in asthmatic adults and assessing relationships with health status and morbidity [77], findings revealed that incidences of at-risk HL was approximately 25% and of inadequate HL was around 21% [77]. Participants with chronic asthma reported 15% inadequate HL [77]. Another study highlighted the knowledge deficiency in the primary healthcare system of Australia and misperception regarding differences of the roles of nurses. The findings revealed the inadequacy of health-related knowledge (HL) regarding how to utilise the health system [96].
Studies explored the social and cultural factors that impact on health-related knowledge. When the HL of chronic low-back pain patients and non-chronic low-back pain patients were compared, these main findings emerged: chronic low-back pain patients had lower scores on domains measuring attitudes towards health, family errands were the reasons for not performing health-related behaviors, absence of effective coping impeded engagement in health-related behaviors, and exacerbated pain and emotional suffering [90]. A study about knowledge, perceptions and experiences of chronic hepatitis B revealed that Aboriginal respondents had a deficiency of health-related knowledge and exhibited the wish to increase hepatitis B health literacy [73]. Participants in this study also identified the need for translated information that incorporated the cultural context in order to effectively transfer information [73]. In addition to communicating in culturally suitable languages for patients from diverse backgrounds, visual aids were acknowledged as an important means for enhancing transfer of information [97]. Another study revealed how the absence of motivation on part of consumers played a role in low health-related knowledge as consumers that were aware of their deficiency of health-related knowledge, expressed little motivation or eagerness to improve it [96].
These studies also examined the way that patients find and use health-related information. For example, patients with chronic low back pain were challenged by finding and utilizing health-related information. The findings suggested that the HL of chronic low back pain patients seemed to be directly influenced by how they managed themselves, although these patients easily understood information related to health [90]. Aboriginal study participants with chronic hepatitis B and their community members misunderstood information regarding the cause and transfer of hepatitis B [73]. These misconceptions resulted in stigmatizing attitudes among patients and community members [97].
The studies included in this scoping review identified the ways that the health literacy skills and experience of service providers influenced the health literacy of their patients. For example, the language (complexity and dialect) used was reported as a challenge and a significant barrier towards understanding health-related information and knowledge [97]. The findings also revealed that healthcare providers may lack knowledge and have an inadequate understanding of health-related information [73]. Gender was also highlighted as a factor which influenced the transfer of information whereby this was more effective if healthcare providers and patients belong to the same gender as the healthcare provider [97]. Another research study revealed that historical legacy greatly influenced oral health practices, access to oral health services and health-related decision making of individuals [87]. The health literacy of the future health workforce has also been studied. For example, students who were enrolled in a medical or nursing disciplines had highest levels of sexual HL [70]. The findings from this study also showed that when scores of Australian/New Zealander students were compared with overseas-born students, all the overseas-born students had lower scores on sexual HL [102].
The research studies included in this scoping review evaluated the impact of various interventions designed to increase health literacy such as the role of workshops; non-medical providers of health care; activities of schools; awareness campaigns to increase HL levels in consumers; the need to change structure and policies in schools to achieve health outcomes; and the influence of functional, interactive and critical health literacy on health-related decision making [89,90,94].
Within the research studies included in this scoping review, there was a particular focus on mental health which showed a rise in levels of mental HL in rural and urban community. This was evident in the following findings: better understanding and prevention of mental health issues; approval of seeking help from mental health care providers; preferring to access online sources of information; and consulting doctor, or talking to peers or family members about a mental health issue [78][79][80]85,97,101,104]. However, lack of awareness regarding mental health was profound in Aboriginal men who lived alone which was related to not discussing problem within the community, and use of technical language by the health care providers [78]. These studies also explored social and cultural factors that influence mental HL such as the influence of parental beliefs on the choice of resources young individuals use to gain mental health information [79]. Cultural influences were evident in studies that explored perspectives of the western medical model regarding etiology and treatment of mental problems; and the need to educate refugee communities from Iraq and Sudan about etiology and treatment of mental disorders [73,76]. Another research study highlighted the way that health awareness programs were not beneficial for the members of an Aboriginal community because the health messages were targeted at mainstream Australians [78].
The research studies included within this theme of HL knowledge investigated HL within healthcare systems. These investigations included the ways health care professionals assessed and responded to the HL of their patients. For example, a research study conducted with radiation oncologists showed recognition and acceptance of varying levels of HL in their patients. This study used different subjective approaches to analyze HL levels in the patients, however, those oncologists were against the notion of incorporating literacy screening in practice [83].
Another study revealed that caregiver's HL about cancer was multidimensional concept which was based on individual and social aspects; and affected by multiple factors within the community including the healthcare system. This study argued for system-level change through exploring factors that influence HL of caregivers in order to help the healthcare providers, as well as, policymakers to adequately design information, communication and education approaches to meet caregiver requirements [98].
The Australian government has implemented policies and programs to enhance health-related knowledge, particularly through the design of Aboriginal health service delivery models, however, these initiatives have had mixed success. A study on remote dwelling Aboriginal Australians, highlighted the use of technologies especially mobile applications to improve the HL across multiple settings [97]. However, clinical systems for conducting health checks were unclear to staff, and there was a lack of clarity about staff responsibilities for initiating and conducting the health check. Additionally some staff perceived the some of the health check content as sensitive, invasive, culturally inappropriate and of questionable value [93]. A study on older patients taking warfarin revealed limited health literacy [103].

Theme 3-Health Literacy Measurement Methods and Its Domains
The current review included research studies which mentioned the names of tools used to assess HL, its domains or constructs. The included studies also contained other instruments administered for various purposes, but our aim is to focus on those tools which are used to assess HL, its domains or constructs. For instance, one research study used the "Newest Vital Sign" to assess the functional domain of HL in South Australian asthma adults [77]. In the same way, another study mentioned "Health Literacy Measurement Scale (HeLMS)" in order to assess wider aspects of HL. According to the study, the scale has various domains targeting patients' health attitudes, understanding and using information related to health, financial conditions and support system, healthcare services provided by general practitioner, interaction with healthcare provider, and being farsighted regarding management of health issues [90]. Similarly, a timed test, targeting reading comprehension, named as "Short Test of Functional Health Literacy in Adults (S-TOFHLA)" was administered in another study [95]. The "Health Literacy Questionnaire (HLQ)", developed from the HeLMs, was also favored as a HL measurement tool that accounts for a broad range of social and relational factors which impact an individual's HL needs [88,103].
Other studies explored the associations between health literacy and health seeking behaviors. For example, one study explored the associations between health conditions, utilization of health services and academic performance using the "School Entrant Health Questionnaire" [99]. Two instruments were used in a research study which targeted sexual HL; the "ARCSHS Secondary Students and Sexual Health Survey" having two domains (knowledge and HIV/Hepatitis), and "University of Missouri Sexual Health Survey (SHS)" having three domains (knowledge, sexually transmissible infection and pregnancy) [102]. A study aimed at assessing the efficacy of workshop in increasing levels of mental HL utilized two separate instruments; "First Aid Knowledge Test" for evaluating literacy of participants regarding various strategies of aid, and "Mental Health Literacy Questionnaire for Bulimic Type Eating Disorders" to assess HL related to eating disorders [94]. However, the psychometric properties of the HL tools with respect to the population investigated in each study or the HL tools in general were absent.
Various qualitative studies used semi-structured interviews and focus group discussions to explore the broader aspects of HL such as: patients' literacy regarding nurses' role; patients' HL and the need to acquire information regarding hepatitis B; mental HL and help seeking behaviors of individuals belonging to an Aboriginal Victorian community; changes in oral HL, as well as causes and prevention of poor oral health; barriers and facilitators that influenced health seeking behaviors; literacy regarding mental health issues; HL of radiation oncologists regarding patients' comprehension levels; and strategies utilized by radiation oncologists to raise HL of patients [83,86,87,93,96,97,101].
Some research studies directly measured HL through randomized control trials or using tools but did not mention the names of those tools. For instance, one study assessed mental HL through a questionnaire based on symptoms of depression, as well as through an experimental design which involved giving knowledge regarding nature and appraisal of intrusive thoughts. In another study, trust and change in levels of HL due to various audiovisual and electronic means of gaining information was assessed through a questionnaire; and in another study, a self-reported survey was used to collect data regarding HL and various health related aspects of new mothers [76,78,80,85].
Questionnaires and survey tools were used to assess aspects of health literacy relating to knowledge of health and health systems. A questionnaire-based assessment of informed choice and knowledge was carried out to explore the role of decision aids in HL; instrument-based assessment of clinical trial literacy related with hepatitis C virus; and the Delphi method to assess health information system [106]. Other questionnaire tools were used to assess the competencies of low and middle income countries; develop and assess a model of HL for caregivers of cancer; mental health literacy was assessed with a computer-assisted telephone survey as well as interviews; and a randomized controlled trial was used for assessing the usefulness of a first aid linked to mental HL [79,81,89,91,98,100].

Discussion
The large number of empirical studies found in the literature to date shows the importance of HL in medicine and public health. Additionally, interest in the issue is on the rise in Australia and other parts of the world. Past empirical studies on HL in Australia point to the need to enhance the quality of health communication and to integrate HL into health professional care practice and service delivery. This review provided significant insights regarding the status of HL in Australia, as well as the areas which need further investigation from the research community.
This review sought to examine prevailing definitions and conceptualizations of HL, identify standardization of measurement tools of HL and key outcomes, and current awareness regarding HL in Australia. The review also highlights the geographical and temporal distribution of HL studies conducted in Australia and shows that limited research studies have been published among Indigenous Australians, and in some states and territories. The review has shown that research is needed to construct and validate instruments for measuring HL and its key components. This study has also highlighted the presence of low HL in consumers of health care services, misconceptions regarding various aspects of diseases, treatment and healthcare system, and need for longitudinal, mixed methods and qualitative research designs exploring complex causal mechanisms that influence relationship between HL and health outcomes. To attain maximum health gains, there is a need to increase HL of consumers and implement strategies for HL screening as a component of the clinical practice of health professionals.
There are two contrasting approaches to describe HL, either as a polarized or a complex phenomenon with its own features that specify HL or the absence of HLin variety of forms and situations [107]. According to the polarized approach, HL is a permanent state which cannot be improved. However, the complex approach views HL as a dynamic phenomenon, whereby HL varies and depends on the state of the person, the situation, the culture or the environment of that person. The findings of this review also highlight that the complex approach is consistent with research on health outcomes that replaces e formerly accepted and understood knowledge [107]. A dynamic and complex view of HL may be more receptive to broader perspectives that may impact health of a person. The tools for measuring HL and key outcomes are discussed in the review [77,88,90,102] and show the need to develop standardized means of assessing this construct.
Furthermore, complex causal mechanisms influence the relationship between HL and health outcomes. Such causal mechanisms are shown to be affected by different contextual, individual and external factors for instance age, educational levels, financial status, cultural background, social support, and the media [108,109]. Likewise, various models have been proposed to highlight these links [5]. Such models have limited efficacy as there is a dearth of supporting data, moreover, such models have been found to underestimate existing complexity of the elements, associations and interactions [25,35].
A number of factors play roles in weakening the findings of prevailing research studies, such as: (1) Very few studies examined the underpinnings of complex causal mechanisms which influence the relationship between HL and health outcomes [110,111]; (2) Absence of instruments targeting HL and its domains; (3) Significant dearth of studies evaluating current strategies and technologies aimed to improve HL; and (4) A lack of research studies directly analyzing health numeracy. The knowledge deficiency highlighted in HL studies [77,90,96], problems of present health care system [97,98,100], and inadequate levels of health numeracy [76,80,88,91,104] must be taken into consideration and efforts should be made to increase HL knowledge of the consumers as shown by the studies [78][79][80]85,97,101].
The World Health Organization reported a decline in human and economic resources in health systems due to low levels of HL [27]. Prior research has shown HL to be an independent predictor of information of a patient regarding his/her chronic illness and such low levels of HL prove burdensome for the health care industry as patients are not well equipped for self-care including medication management [10,112]. Low HL was found to be associated with declines in level of health knowledge, poor health outcomes, increased vulnerability, unhealthy behaviors, lower utilization of preventive services, worsened status of health, decline in usage of mammography, decline in uptake of vaccination for influenza, rise in rates of hospitalization, poor adherence to medication regimen, increased chances of death at old age and poor health status in old people [22,46,47,84,[112][113][114][115]. Likewise, poor HL in adults has been shown to link to low levels of understanding of information about health and disease, difficulty with self-care management, and increased rates of chronic disease morbidity and mortality [22].
Functional HL skills are shown to be unrelated with the confidence and skills of a person to engage in a conversation with health professional, rather the person's perception of their social position, has been linked with consultation with a health professional [116]. The qualitative studies carried out among patients and health professionals reported a number of important abilities to find, comprehend and utilize health-related information [117,118]. These comprise of awareness regarding when and where to gain health-related information, ability to recollect and process the information, and necessary skills in order to act upon this information. A research study proposed that HL progresses with time and is a staged process of gathering health information, fostering skills and practices related with health, carrying out actions and making informed decisions on the basis of options available [119]. The results show improved information and higher involvement in decision-making [119].
Health care is continuously changing and the responsibility for its rising demands are placed on both individuals and professionals to comprehend and keep abreast with research in the health field. Furthermore, apart from the latest research findings, changes in the welfare system can also impact decisions about health. The individuals and families may be influenced worst by the new principles in social security. Hence, with proper HL, the people may be able to follow and comprehend the meaning of changes from their own social situation. The current review shows that HL is a complex and depends upon the context. Therefore, there is a need to be creative in designing interventions and methods to increase and stabilize HL levels of people. Health literate people will have a better understanding of health system, greater opportunities and abilities to make decisions which may positively affect their health.
Future research needs to overcome these deficiencies by addressing health-related knowledge of consumers, focusing on language and cultural barriers in accessing health related information, formulating strategies to incorporate HL screening in practice and increasing utilization of health-related information amongst health care providers, before imparting knowledge to consumers. This review has brought forth a lack of consistency and comparability in empirical studies exploring instruments of HL and health numeracy with sound psychometric properties as well as highlights the absence of HL in consumers specifically in Australia. This deficiency is problematic as it prevents appraisal of findings of research studies and challenges their external validity. The relationship between low levels of HL and absence of social empowerment and efficacy has been confirmed [120]. This scoping review suggests that research studies investigating HL in Australia should focus on designing new measures to assess the HL of the consumer as well as HL skills of the health care provider, health care system, and how the health care messages are disseminated to the public. To date, the scoping review reveals that scientific bodies have paid little attention to developing standardized measures to assess the health literacy, as well as HL skills of providers.

Strengths and Limitations
Using Arksey and O'Malley's approach provided a robust framework for this scoping review of HL research studies carried out in Australia. Using these rigorous procedures produced a wide range of HL research. However, the purpose of a scoping review does not include to systematically combining the results of earlier studies or appraising the quality of the evidence. To minimize errors in reporting the results of the scoping review, the data entered in all tables were checked twice by the first author of the review in order to confirm the correctness and to ensure correctness and comprehensiveness, all the authors reviewed the tables and necessary modifications were incorporated.
We only included those research studies which directly mentioned the term HL and those conducted in Australia. Furthermore, some studies were conducted over 10 years ago which may have influenced the measurement tools used. Nevertheless, to ensure the specificity and selectivity of the included studies, at least two authors were involved in analyzing the content of the included studies.

Conclusions
While many have been used, there is a dearth of measurement tools with sound psychometric properties to measure HL. Globally, the low level of HL in the population is a grave problem requiring innovative and proactive initiatives. The findings from this scoping review highlight that consumers' levels of HL are still very low in Australia, which is influencing their health behaviours, service utilization and proving burdensome on health-care system. More recent developments have tried to integrate other aspects deemed vital, including introduction of applications to increase HL and exploring HL in Aboriginal communities. The integration of these aspects should increase the accumulated knowledge related to HL, however, extensive work is needed to overcome cultural and language barriers in sharing health-related information. In addition, further work is required to explore health numeracy and develop specific populations' tools to guarantee suitability and cultural competence. Furthermore, it is recommended that the researchers focus on overcoming knowledge deficiencies, find out risk and/or be sensitive enough to measure changes occurring due to educational strategies. Some studies have shown the influence of interventions to augment HL in Australia. Therefore, the health professionals and researchers may focus on designing a HL study using innovative and new methodologies rather than relying on the traditional methods used in the past studies. For this purpose, there is a need for the scientific community to become aware of the issues related to making information and services accessible and interacting optimally with consumers.
The agenda for increasing health information would abet the efforts of government, services and consumer and organisations to fulfill the literacy requirements in a more thorough and systematic way. This will enhance the quality and eventually the participation by consumers of healthcare system and caregivers in health decision making and self-management.
The findings of this review paper can be utilized by consumers of healthcare system, healthcare service providers, administrators, board members and everyone else to assist in enhancing their awareness about HL and inform decision-making about what they, and their organisations, could do to improve HL needs. Findings can also be used by policy makers and managers.
HL should be considered as part of a systems-level approach. This will comprise designing and launching systems and policies at an organizational level, as well as societal level to ensure that the systems respond to health literacy needs. Some examples of such systems include: varying funding mechanisms to promote action on HL; launching strategies which give priority to HL in program planning; and developing healthcare organisations in such a way that removes complexity and promotes navigation and ease of access.
Effective communication (e.g., print, electronic or other communication that is suitable for the needs of consumers) may also assist in meeting HL needs. This includes partnerships, transfer of information and interpersonal relationships between consumers and providers of healthcare system, managers, executive staff and others. The incorporation of HL into education by initiating health enhancing and education strategies, school HL campaigns and social marketing activities, along with education and training of healthcare providers, will also assist to create supportive environments.
A national approach to HL through coordinated and collaborative action in Australia has the potential to enhance the safety and quality of health care. Efforts at national, state and territory, regional and local levels (e.g., health, social, welfare and education sectors) may ensure enhanced and improved HL.
HL specifically in Australia, and generally has a potential for further research as many aspects of HL are unexplored. Future research may include indigenous culture in studies of HL and design continued assessments for capturing the broadness of skills, agents and key outcomes of HL.