Health literacy in Ireland : Health Promotion International (2025)

Engaging with participants at a community level provides rich information regarding health literacy.
Common goals support health literacy development in rural-urban communities.
Place-based and contextual health focus is required for communities across Ireland.
Recommendations from this study can support future research design, development, and implementation of health promotion opportunities for communities.

BACKGROUND

Health literacy represents the personal competencies and organizational structures, resources, and commitment that enable people to access, understand, appraise, and use information and services in ways that promote and maintain good health (). Globally, health literacy development is required to enable genuine engagement with people to understand how they view their world, and what they know and to seek their interpretations of how the determinants of health in their context influence the ways in which they (as individuals, groups, communities, organizations, and societies) access, understand, appraise, remember and use health information and services ().

In Ireland, low levels of health literacy have been reported (). Further research found over two-thirds (72.4%) of adults have reported difficulty filling out medical forms (), with higher levels of inadequate health literacy reported among those requiring access to free healthcare using a medical card (). Low socioeconomic status (SES) has been identified as a risk factor for low health literacy with those with the lowest socioeconomic variables shown to have the lowest health literacy skills (). Critically improving health literacy in low SES populations could reduce health disparities and promote greater health equity (^,).

Health literacy has been positioned as a relational concept, which emphasizes individuals’ interactions with complex health and social systems (). A requirement to explore health literacy in community settings is therefore warranted with research illustrating an association with where one currently lives (). In 2021, an evidence-based process was undertaken in Ireland to identify community areas in which health and wellbeing risk factors are particularly concentrated. Applying the Pobal HP Deprivation index (the Pobal HP Deprivation Index is Ireland’s primary social gradient tool, used by numerous government departments and state agencies for the identification of geographic disadvantage, in order to target resources and services towards communities most in need) () identified areas with the highest deprivation scores which were named Sláintecare Healthy Communities in Ireland. The link between health literacy and deprivation levels has been established () but the unique context and setting for health literacy in Irish communities is unknown. Furthermore, previous research exploring health literacy in rural and urban demographics is inconclusive (^,^,^,^,). Lower health literacy was found to be associated with older age, lower income, lower SES, and ethnic minority status (^,^,^,). Urban communities have also been observed to have significantly higher education levels when compared to rural areas which may also impact the development of health literacy (^,^,^,^,). This draws a spotlight on investigating the equity of provision between rural and urban populations in terms of knowledge and skills to manage health conditions (^,), especially those known to exist on a social gradient in chronic conditions e.g. diabetes, cardiovascular disease, and chronic obstructive pulmonary disease (). Recent examination of social and economic characteristics of urban and rural life in Ireland () has shed light on different factors such as housing prices, unemployment, and general health ratings but a more contextual understanding of these community areas is required. In particular, lived experience and participant voice are key for community work focussing on health related areas to ensure the development of a sustained and informed approach (). This is especially true for lower SES and traditionally underserved communities, with participants reportedly more difficult to recruit and retain than higher-SES samples, largely because of barriers surrounding trust and accessibility ().

Understanding health literacy on the Island of Ireland is required to support practical implications for policymakers and stakeholders to inform change. Specifically, this includes looking beyond the published literature to provide contextual insights into health literacy for Irish communities, and in doing so, support the shift in health literacy research from a focus on individual health literacy to one that encompasses health interactions and health contexts (^,). This study, therefore, aimed to explore the health literacy strengths, needs, and issues encountered in an urban and rural community area in Ireland.

METHODS

Purposive sampling, with the aim of generating insight and in-depth understanding, was undertaken (). Two community settings in Ireland were selected by Sláintecare for their urban or rural representation. These resulted in identified areas in which health and wellbeing risk factors are particularly concentrated. The rural community area recruited (HP Pobal Deprivation as −1.4 to −18.3) covered a large geographical landscape in the West of Ireland. The urban community recruited (HP Pobal Deprivation −12.7 to −20.3) is formed from a cluster of electoral divisions in Dublin city. Both settings are part of the Sláintecare Healthy Communities Programme.

Sampling was initiated through community health networks within both areas. Similar to the approach by , it was important to recruit participants with lived experience of managing their health, and their wider lives such as during engagement with health and care services. Individuals living and/or working in the community were approached formally through an invitation at the start of the research project from the Local Development Officer for the Sláintecare area, e.g. during an Education Training Board class time, Men’s Shed meeting, etc., to participate in a focus group/ interview. The lead author (MM) also informally approached participants through growing community networks and word of mouth e.g. links through service providers.

In this study, the positionality of the researcher managing recruitment, data collection, and analysis is particularly important. The lead researcher (MM) is an experienced teacher in health education (17 years), and skilled in qualitative investigation with proficiency in working with community populations within both rural and urban areas in Ireland through their volunteer work. Positionality was important for the lead researcher to allow for subjectivity and reflexive engagement in gathering and interpreting data (). This trained researcher (MM) conducted all data collection between November 2023 to February 2024. This study received ethical approval from the host university with data collection approval granted (DCUREC/2023/156).

Participants

In total, 105 individuals were recruited to participate in a semi-structured individual interview or focus group interview (n = 75 female and n = 30 male). The urban community participants included n = 23 females and n = 8 males. The rural community participants included n = 52 females and n = 22 males. See Table 1 for further participant details.

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Data collection

Semi-structured interviews (n = 15) and focus groups (n = 13) were employed, 75% in person dependent on the participant’s needs and preference, and a further 25% conducted online to ensure all had equal opportunity to be involved in the study. Flexibility regarding the ways in which participants can take part in qualitative research has been seen to improve participant access to research, recruitment, and response-rate (). Health literacy research in community settings has yielded positive participant engagement (^,) with individual and focus group interview methods particularly positive in rural health research () and in Ireland (^,^,). Flexibility in this regard also provides a rich blend of perspectives and opinions of community participants in health research (). Of the 13 focus groups, group size ranged according to availability and recruitment with an average group size of seven.

The semi-structured interview guide was developed by an experienced qualitative research team and reviewed and piloted prior to the start of data collection. Examples of questions asked include: ‘Do you understand what you need to do for your health based on the information you find?’ and ‘ Do you think you have good information to be able to manage your health?’.

Participants provided informed consent and were reminded of the ethical procedures employed regarding confidentiality arrangements prior to the start of each interview/ focus group. Focus group interviews averaged 40 minutes and individual interviews averaged 20 minutes in length. All interviews were audio-recorded and transcribed verbatim by two members of the research team.

Data analysis

Transcriptions were uploaded to NVivo (). Data were analysed using Braun and Clarke’s six-phase approach to Reflexive Thematic Analysis (RTA). The application of this approach has been shown to address a wide range of questions in health research (). The RTA approach undertaken in the development of this study method was built upon academic engagement before data collection (^,^,).

Experiential qualitative research methods were utilized to broadly interpret and explore lived experiences of community members as health literacy experiences at the community level were viewed as socially embedded and/ or contextually located within the rural or urban area (). After initial familiarisation with the data, first-level coding was undertaken independently by the lead researcher (MM) for the first six transcriptions. Codes were generated and then discussed with the research team, who acted as ‘critical friends’ and supported a rigorous analysis of the subsequent coding. The initial themes were then reviewed, developed, structured, and renamed until they were deemed appropriate. The findings predominantly reflect the first author’s analysis of the data (MM) and were challenged by co-authors (HG, SM) throughout the reflexive process, leading to a rich and thorough analysis.

RESULTS

Five themes, with further subsequent subthemes, were identified and are illustrated in Table 2. These themes detailed participants’ health literacy strengths, needs, and challenges in their communities.

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Theme 1. Accessing and understanding health information

Accessing health information via the Internet

Health information was accessed in various ways in both urban and rural communities. One recurring method was the use of the internet for exploring health information, e.g. ‘I check the HSE [National Health Service] website sometimes’ (Individual 22: Rural). Across both communities, participants highlighted the ease of searching for information they wanted. Rural community members repeatedly spoke of ‘Dr Google’. The ease of accessibility and immediate contact with information was important for many, ‘somebody can press a button on their laptop and go “Oh, right. That’s all the health stuff”’ (Focus Group 1: Urban).

Critiquing health information

Understanding information provided through internet sources was a challenge for some. A participant spoke of the potential downsides of the amount of available health information:

Because we can all diagnose ourselves…now to me, maybe not to the doctor’s delight…Probably the majority of you have smartphones. (Focus Group 14: Rural)

This was stressed by another participant, who, in speaking about how she accessed health information on social media reflected ‘although TikTok can have misleading information…it’s hard to decipher which is real, and which is not’ (Focus Group 27: Urban). Other participants spoke of being wary of the information obtained online ‘I do double check it’ (Individual 28: Urban) and ‘some of the stuff you mightn’t want to take too much heed of…’ (Individual 7: Urban).

The availability of health information on the internet allowed individuals to feel more informed in making judgements. For example, participants discussed medication ‘if you were put on something [prescribed medication] and you weren’t quite sure what it was. Sometimes I would Google it just to see… And the side effects’ (Focus Group 14: Rural).

Confidence and trust in healthcare professionals

Community members in both areas indicated having confidence and trust in their healthcare professionals when accessing and understanding health information and healthcare. Examples ranged from accessing information from a local community GP, to other medical professionals, e.g. physiotherapists, pharmacists, and other specialists in hospital settings:

Their [community participants in health programme] relationship with their GP, I suppose, is key to them trusting their GP. And they had that trust in this [GP], this was the advice, and that’s the advice I’m going to follow. (Individual 25: Rural)

If you ask questions in the pharmacy, they’re [the pharmacists are] really good. If I wasn’t [sure] what [medication] I was taking or I’m not sure about this or that, they would know. (Focus Group 16: Rural)

Despite this, other participants requested support for particular needs, ‘I’d like to know like better ways of dealing with it [a chronic condition], managing it. I think just more transparency around medical histories in general. That would be amazing’ (Individual 28: Urban).

Trust and confidence were observed in other community healthcare professionals working outside of a medical setting. For example, one focus group discussed the value and importance of a specific physical activity programme, and how it was less about the activity itself, but the informative way it was delivered:

And she [the physical activity programme leader] really focused on letting us know that it was all about being able to maintain the strength and balance, and the range of motion that we have. (Focus Group 16: Rural)

Theme 2. Health literacy changing over time

Lifespan changes

Participants reflected on health literacy as changing over time through observations made in their own lives and the lives of others in their community settings. In the urban area, this was reflected in healthy food choices and the change towards the increased availability of convenience foods ‘I suppose in our generation there wasn’t as much junk food’ (Individual 4: Urban), with others reflecting ‘I just think it’s harder now. It’s definitely harder for younger people’ (Individual 10: Urban) regarding food choices and health-literate environments. Despite these difficulties, other participants in a focus group in the urban setting spoke of an increase in knowledge among young people and cited specific healthy eating programmes, initiatives, and incentives in schools.

In the rural setting, a general comparison of age ranges and differences in a person’s outlook, time, and health choices was observed. This was in relation to changes in lifestyles, e.g. ‘people 20 years ago didn’t have the time to walk, because they were so busy farming and doing turf [Irish traditional source of fuel], doing different things’ (Focus Group 14: Rural).

Impact of COVID-19 on health literacy

The impact of the COVID-19 pandemic contributing to health literacy development over time in community settings was observed. The specific influence of social distancing ‘still, after COVID’ (Focus Group 14: Rural) was observed in relation to increasing rural isolation and less social interaction for individuals in the rural community setting ‘since COVID people definitely aren’t as social in the country, they’re not dropping in and out like they used to’ (Focus Group 13: Rural). Other participants were hopeful for this to improve ‘it’d be great to get back to that [social interaction prior to COVID-19] because I know, both mentally and physically, of all the things that were going on, it’s for the benefit of the community’ (Focus Group 14: Rural).

Theme 3. Perceiving health literacy as an individual responsibility

Having to advocate for your own health and health of loved ones

Advocating for one’s own health and the health of loved ones was demonstrated in a number of different ways. Individual advocacy was observed in health behaviour changes and decisions taken in relation to health literacy: ‘if there’s a slight lifestyle [behaviour] to be changed, I would be prepared to read up about it and go down the road to changing it and like at the end of the day - it’s for my health’ (Individual 4: Urban).

Advocacy for loved ones was found in relation to supporting overall health. This was particularly spoken of in terms of close family members, and was highlighted with frustration ‘I had to fight’ (Focus Group 1: Urban) in chasing medical letters, appointments, referrals and medication. Participants within focus groups also spoke of the importance of asking questions, and preparing written notes and taking notes during an appointment. Yet, one participant highlighted that this responsibility was also on the person delivering the communication ‘I think we have to [ask questions], so we have to learn to speak up and I think doctors have gotten much better at understanding that we don’t, you know, that we [need to] ask questions’ (Focus Group 16: Rural).

Particular community participants were mentioned as needing health literacy advocates as sometimes medical appointments could be ‘too much’ (Focus Group 16: Rural) for the participant to take all the information discussed in at one time. This included ‘the older generation of men that are unwilling to say they have something wrong’ (Focus Group 14: Rural).

Developing your own knowledge and understanding of health literacy

Developing one’s own knowledge and understanding of health literacy was observed in different ways, as participants explained how health knowledge and understanding were established. Notably, this was suggested as how individuals felt responsible for their own health literacy:

When you live on your own… my next step is a nursing home if something happens. You know, my kids won’t be coming back and I’m not saying they wouldn’t come back, what I’m saying is they’re not, I would never have them come back for me. (Individual 8: Urban)

Developing health literacy included knowledge and awareness: ‘I am becoming aware [of my health], and that’s where I am becoming more conscious [of my health]’ (Individual 5: Urban), seeking out health information ‘you kinda learn yourself’ (Focus Group 27: Urban).

There were many conversations about engaging in community-based health services. In the urban area, the importance of access to a communication class in the Education and Training Board (ETB) to support health literacy was evident: ‘I see there’s a difference with me from coming up here [communication class], I’ve noticed a difference in my spelling and my reading and writing. A major difference’ (Focus Group 1: Urban). This also made a difference in taking medications and booking medical appointments ‘we just make it our business, myself and my husband, we say each June we make an appointment with a doctor and we get all our bloods done and that’s it’ (Individual 10: Urban).

In the rural area, knowledge and understanding of health literacy was also focused on individual perceptions of health and their informed choices to become more health literate. This was in relation to physical activity ‘I know I needed to walk as well. Walking was the only thing that helped [an injury] and I also wanted to, to learn the stuff to keep my brain active right’ (Individual 15: Rural) or other health behaviours such as ‘alcohol, trying to cut that down’ (Individual 18: Rural).

Feeling ‘lucky’ when things go right

Consistently positive health outcomes were framed by individuals feeling lucky and grateful. This was around general health ‘I’ve been very lucky, touch wood, with health, I’ve really only in the last couple of years, I’ve had a few kind of issues’ (Individual 7: Urban) or specific events ‘I had a cardiac arrest. No… that’s a good news story, a very good news story, because percentages are not, not great. So I’m in that lucky position’ (Individual 11: Urban).

Participants also spoke of being grateful to get access to medical services and support ‘sometimes we don’t have enough, easy access to stuff. And I might be lucky in the sense that I have a lot of access to stuff. But not everybody would have that same access as I do’ (Individual 5: Urban). Difficulty in accessing medical support was exemplified by participant experiences. Others spoke of how ‘It all depends on your local GPs, and we’re lucky’ and ‘thank God we’ve got two good doctors’ (Focus Group 12: Rural).

Outside of clinical settings, ‘luck’ still played a part in health promotion ‘I’m lucky in the way where I do have role models, and I have people to look up to and people to steer me in the right direction, but like then, not everybody has that’ (Focus Group 27: Urban). ‘Luck’ was also needed to keep health promotion programmes and projects going:

suppose the key thing is sustainability of keeping the links open and sustainability of how you progress a project. And, you know, it can be serendipity, really, because we were very lucky with the group of people [involved in the community project]. (Individual 25: Rural)

In terms of health literacy needs and suggestions for the future, the sustainability of existing community initiatives was also perceived to be in part down to luck. There was a perception that some health programmes may be a ‘once off’, and health messages changed too frequently with these changes in programmes.

Having to become health literate through a lived experience

I think health sneaks… health issues sneak up on people. And I think until you are faced with a health condition, and this is not my opinion, I think I’m being general. I think until you have to contend with something…And then you have to look at the realities of how to manage it, then health is on the radar more so. (Individual 25: Rural)

Health literacy was often spoken about in relation to participant’s prior experiences with health challenges; this included injuries, operations, illnesses, and chronic conditions. Participants also spoke honestly of how illness and bereavement in those close to them had also impacted their own health literacy:

Well I would have went through a lot of that with my son. My son was an alcoholic. So I would have been, I would have, you know, I would have encouraged it [seeking help], I would have, you know, got him help, got him help twice, actually. Unfortunately, in the last two years, he was dry, but the damage… the damage was done. But I would encourage my husband and my own family [to seek help]. (Individual 9: Urban)

Theme 4. Interpersonal and community influences on health literacy

Influence of family and friends

The influence of family on health literacy was exemplified in how health was supported between family members. In a wider discussion around isolation, one participant acknowledged ‘we have a big family, so there’s lots of support’ (Individual 18: Rural). Another participant spoke of how she encouraged her husband to attend a medical screening service:

Well I decided when I turned 60 I was going to do that [be more health conscious]. He ignored me completely. And then I did convince him to start going [to the doctors] I’d say when he was about 65, and I’m glad I did. (Individual 10: Urban)

Formal and informal caring responsibilities within families and between friends also impact a person’s health literacy. One participant spoke of supporting their Mother, ‘I do often ask them [medical practitioners] more questions. My ma struggles sometimes with her memory. So when she gets told something she likes to have me there just for the extra support. And she doesn’t understand a lot of things they’re saying, so I’ll have to translate’ (Individual 28: Urban). Acting as a ‘health translator’ was also a responsibility adopted in these forms of caring roles.

The good neighbour

The ‘goodwill of people’ (Focus Group 20: Rural) was observed where ‘everyone is looking out for each other’ (Individual 15: Rural), where community inhabitants face rural isolation and loneliness. One situation highlighted the importance of community connectedness:

Recently [we] had a problem in swim club with one lady and she was struggling with an illness, and we have about six of us and we took it in turns to go to the hospital, one to her washing, whatever she wanted. We’d speak to her family in the UK. I think it was good that we all worked together. (Focus Group 21: Rural)

However, in some cases, this feeling of a shared community was waning. One participant explained that although they felt comfortable as they were healthy and mobile at present, this wasn’t the case for everyone ‘for older people you know, more people knocking on the door saying “Are you okay?” You know, that doesn’t happen anymore’ (Individual 9: Urban).

Community health literacy champions

Specific individuals were recognized as health literacy champions who ‘gave back’ to their community. Influential individuals in drug and alcohol addiction and recovery were highlighted, and in particular, how those individuals interacted with the community ‘you know, it literally, that’s nearly how you change people, change people through the heart rather than through the mind sometimes’ (Individual 24: Rural).

Formally, community health literacy champions undertook a more active role in influencing a rural community. In some cases, these were supported projects. This support included training and volunteering time to support the local community ‘well, because I go to the ICA [Irish Countrywomen’s Association], and they came and did a presentation. And they wanted someone to do an hour a week, which is not much in the grand scheme of things. So I volunteered’ (Focus Group 14: Rural).

Discussions within the urban community demonstrated support of education in youth so that improvements in health behaviours and choices are supported early in life. Subsequently, teachers were seen as important, but with the understanding ‘it’s not fair dumping stuff on the teachers, but it is a good place for, as in that most children go to school’ (Individual 5: Urban).

Theme 5. Health access through a rural or urban infrastructure

Health service access was a theme evident for both urban and rural areas. Although access to services was found to be similarly challenging in some aspects, there also were different issues contextualized by communities impacting their health literacy needs.

Insufficient health literacy access and provision

Participants reported access changes to healthcare resources such as healthcare professionals in the local area, and challenges providing access to medical knowledge and treatment, as well as accessible health resources. Commentary on retirement of local GPs ‘when the doctor retired... It all went downhill’ (Focus Group 17: Rural) and the reduction of staff in local rural settings, formed part of the concerns raised by the rural community ‘if you can’t get a doctor, like what do you do?’ (Focus Group 20: Rural).

I think it’s on their mind that, you know, it’s an ageing, they’re [community members] very aware that they are an ageing population, and they’re very aware that their health services are reduced, because of the number of GPs that have been reduced. (Individual 25: Rural)

Waiting times to access GP services in the urban area were observed as a concern:

I can remember the GP, you could phone the GP and I remember him calling down to see my mam or dad or whatever it was, and, you know, he would say yeah, I’ll be down in half an hour or whatever. And he’d come down. Now, you can’t, if you were trying the clinic oh yeah you’re gonna have to ring the d-doc. Yeah, I think we’ve lost a lot. Yeah. We’ve lost a lot on our modernisation. (Individual 5: Urban)

Consequently, participants anticipating the difficulty getting a doctor’s appointment meant people ‘put things on the long finger. And then there’s a crisis situation’ (Individual 11: Urban).

Insufficient access to healthcare practitioners with experience and knowledge on specific health needs was a concern for communities. A female participant highlighted concern for supporting women’s health, ‘there’s not a lot of help out there for women going through menopause. I mean I have a male doctor and I’m even a bit reluctant even going down to him’ (Focus Group 1: Urban). Subsequently, the insufficient breadth of resources was spoken about in relation to how one participant accessed cancer treatment but provision was not targeted for other health challenges as well ‘… going into the health system, it’s fairly obvious that I’m clinically obese, I’m very heavy and I have difficulty with that. And it’s more difficult to get practical information about perhaps diet, or snacking are all the contributory things’ (Focus Group 12: Rural). In this way, insufficient resources in one’s ability to access information that may be at the peripheral of the immediate access to healthcare is a cause for concern.

Limited healthcare practitioners available in rural areas, coupled with lack of specific knowledge in addiction and recovery support was particularly poignant:

Some of them [GPs] don’t, still don’t understand, some of the older ones don’t really understand the drug problem, my GP didn’t even really, … I don’t know if I was the first person that went to him with a bad [addiction] problem. (Individual 22: Rural).

Pressures on healthcare providers were acknowledged by participants. However, the perceived impact health literacy of patients ‘I find that sometimes the GP is kind of rushed, and doesn’t particularly have time to maybe elaborate or be a bit more wanting to hear what you’re thinking about’ (Individual 5: Urban) was discussed.

Diet and nutrition formed focal themes in the urban community as challenges to access quality food were reported due to the limited provision, affordability and availability of nutritional resources to support health in an urban area:

So I don’t really have time to exercise regularly, I try to eat more on the better side, but that’s also hard when the access to just good quality food is horrific and the price, so you can’t even buy it. So you just have to be stuck with the not the best food anyways. (Individual 28: Urban).

Incentives were suggested to support population behaviour change such as diet planning and utilizing existing resources to their full extent to support the community needs. For example, this included halls, beaches, parks, etc. These locations were also viewed as a platform for sharing information on community initiatives to support wider health aspects ‘it would probably be good to have like a community notice board. I know we all have our own individual groups. But if there was something that you could put up what’s on locally?’ (Focus Group 14: Rural). Advertising, social media, parish newsletters, and local radio were also identified as potential avenues for sharing health information.

Insufficient transport/ travel to access health literacy needs through a rural infrastructure

A significant focus for rural participants was found in the limited transport availability and access to their local health literacy needs. This was due to the distance and time required to access specific healthcare services. Primary services were limited in the rural community setting, with one participant stating ‘Our district hospital has been completely let down in the last 20 years’ (Focus Group 12: Rural). This was seen as a particular barrier for older people in the community ‘it’s not right, that they [older members of the community] have to travel these bad roads to get to services that should be on our doorstep’ (Focus Group 17: Rural), and a particular worry for medical emergencies ‘If you have an emergency. We have the worst road to travel to get help…You could be waiting up to four hours for an ambulance to come to you’ (Focus Group 17: Rural).

Challenges to general rural community life were prominent in conversations describing access in relation to insufficient infrastructure and public spaces. Challenges were cited as limited road networks, public transport, and community pathways. The financial implications of limited infrastructure were also a focal point regarding conversation on supporting family life in general, including the financial implications of infrastructure within a rural community:

We had a chiropodist, a HSE [National Health Service] chiropodist in this area. She was taken out to the areas about three, four years ago, her contract was not renewed. So if you need footcare, you have to go to Castlebar [rural town]. Or pay privately for it. (Focus Group 17: Rural)

Consequently, many calls were made to develop infrastructure (e.g. improve roads, set up primary care clinics) and consideration was given by participants to different challenges in engaging specific groups (e.g. male only sessions).

DISCUSSION

Participants spoke of the many factors impacting health literacy development for themselves and those in their community. This is reflective of wider research which has observed people’s social and cultural contexts as inextricably linked to how they perceive and act on health information, and how they derive meaning (). This perhaps mirrors the developing contemporary understanding of health literacy as not just an individual capability, but as an organizational structure, reliant on the health literacy practices of social connections and settings. Within the current study, contextual factors such as the societal environment, education level, family status, habitation and employment were highlighted in both community areas. Similarly to , these contextual factors could be seen to add support to the relational concept of health literacy development, and what this looks like for Irish communities ().

Developing health literacy over time, and the impact of challenging health situations in one’s lifespan, contributed to personal advocacy for health and the health of loved ones. Urban community members cited the modern day availability of convenience foods, while age range differences and comparisons to earlier life experiences were more specifically demonstrable for rural community lifespan changes. Similar to the findings by , personal experiences help people clarify their own values and reasoning with information. However, this can be concerning as it may add to the delay in community members developing better health literacy as they only interact with healthcare when health becomes an issue in an emergency (). Specifically, proactive advocacy for individual health literacy development is preferred () by empowering individuals to improve their own health across their lifecourse. This study found that community individuals reviewed luck as a contributing factor to their health, potentially illustrating a fatalistic outlook on health and health supports within their community. Empowerment of individuals, through health literacy development, could contribute to negating this outlook and removing the belief that luck plays a role in determining positive health. Wider research demonstrates health literacy as a modifiable factor that can be influenced by education (^,). Education in community settings in Ireland has been seen to be transformative in respect to developing health literacy in populations (). Encouragingly, participants in this study identified the importance of delivering health literacy education at a young age in order to inform young people on how best to make healthy choices, live healthier lives, and build healthier families. This preventative outlook highlighted by study participants, supports previous research interventions to foster health behaviours earlier in life through targeted intervention (^,).

Evidence from the current study highlights community members’ awareness of how they had developed their own health knowledge through a variety of sources, such as healthcare professionals and trusted internet sources. Ease of access for community members, in listing the internet and associated search engines as their preferred method for accessing health information, was particularly relevant. Study findings also highlighted the issue of misinformation, or indeed too much information, from internet sources. Similar to and , accessing health information demonstrates challenges for individuals, e.g. the exhaustion of information causing limitations in accessing and utilizing healthcare services appropriately. Given the wide range of misinformation and disinformation readily available on the internet, it is crucial that adequate health literacy education is provided so that people can critique the health sources and health information provided online (^,).

Further to this, in both communities healthcare professionals were seen as trusted links to health knowledge, information, and care and practical challenges were discussed. Indeed, the GP within the community setting was highlighted as a particularly common ally for the development of these areas. In the urban community, availability and consistency of healthcare professionals were a barrier. In the rural community, however, access to a healthcare professional was frequently cited as a significant challenge due to the geographical distance and span of the area. This is an issue echoed in previous findings on rural healthcare challenges (^,). Trusted healthcare and healthcare professional access is key to supporting health literacy in deprived communities, therefore it is important to note that communities are perhaps limited in their understanding of the roles of different health professionals and where they can support particular preventative healthcare challenges as an extension to the GP service. These findings highlight the need for positive interventions and informed consideration of the differences between urban-rural settings (^,).

The natural emergence of health literacy champions in Irish community settings saw participants speak of individuals taking on both formal () and informal roles. Regardless of their role, these local champions were noted for their positive influence on health () particularly as most are community-situated individuals. Within the rural context, the impact of geographical isolation could be seen to underpin the emphasis of these roles compared to the urban community setting. Resulting in rural community members highlighting a more formal role of health literacy champions as leaders within their community for positive health. Multiple health literacy champions working simultaneously in a coordinated way () would build on interpersonal relationships and community influence when it comes to managing one’s health. This type of health literacy support can empower individuals and communities to exert greater control over their health (^,). Network structures, however, may be more effective than solo champions (). In line with this study's findings, more research into the role of informal health literacy champions would be required to understand how this network approach can support Irish communities. These networks could be utilized for health literacy partnerships for community stakeholders, which in turn could enhance the impact of health literacy interventions to ensure that the most disadvantaged population groups are reached (). In Ireland, the health and social care system is complex and presents challenges for individuals and their health literacy. Focusing on health literacy in communities in Ireland, can cement good practices already in place, and extend interventions towards gaps in health provision for more equitable health outcomes for community members in all regions.

Strengths and limitations

A strength of the research is reflected in the rich qualitative participant dataset. The breadth of community participants from across two different geographical areas in Ireland strengthened these findings. Methods for data collection strove to be equitable and target hardly reached community members. Sampling of community members from both areas at most stages was initiated through established networks of relationships within both community areas. These methods supported the time restrictions in completing qualitative research investigation, and although a large sample size for community engagement was observed (>100), the authors recognize that data collection does not represent all community members.

CONCLUSION

Rural-urban health literacy challenges should be contextualized to better understand the health-promoting customs embedded in the cultural beliefs and norms of communities. Common issues were observed across both community areas in Ireland, however, more research is required to understand these challenges in their particular community setting. Equitable access to adequate healthcare is an emerging challenge observed in Irish rural communities and follows the trend in previous research highlighting this globally (). The geographical aspects of a rural landscape should be central to the considerations to supporting health literacy development ().

Individual advocacy for health is a strong theme in both communities, however, there is a call for early intervention and education to develop sustainable health literacy. Prevention of future health issues is a desired approach from both rural and urban settings (^,). Utilizing a combined approach for health literacy intervention through education and support of health literacy champions, in a sustainable way, requires a systems approach. The constantly changing demands on healthcare across the lifespan of individuals are complex. Higher health literacy levels, across all ages, can support individuals in facing health challenges. Extending health literacy research across more community settings in Ireland will support this contextual approach, informing future comprehensive action in developing future healthcare policy and practice in Ireland.

Acknowledgements

We would also like to acknowledge and extend our gratitude to all the individuals who participated in this project.

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