Competencies of health personnel for the practice of health literacy in Brazil: A Delphi consensus survey.

OBJECTIVE: The aim of this study was to identify a set of competencies of health personnel for the practice of health literacy in Brazil.
METHODS: Scoping review and online interviews with healthcare practitioners, followed by three rounds of the modified e-Delphi method with health literacy specialists from November/2020 to March/2021. During the rounds, the items were revised, new items added for review, and their importance was rated on a five-point Likert scale in an online form. Those items that achieved a mean Likert rating of 4+ (rated important to very important) and ≥ 90.0% agreement among the experts were maintained in each round.
RESULTS: The initial competencies list contained 30 items from the literature scoping review and online interview with 46 Brazilian healthcare practitioners. 25 experts (health personnel with publications on health literacy) were invited to participate in the e-Delphi rounds. Of the total of 56 items evaluated, 28 reached consensus among the experts. The Brazilian competencies list differed from other consensuses by the emphasis on professional commitment to the literacy in health, autonomy and social context of the patient.
CONCLUSION: For the Brazilian context, 28 competencies are relevant to the practice of health literacy in health care. This study is an initial step to develop the HL competences of Brazilian health professionals and an update of the skills evidenced in previous international studies.

Introduction

Health literacy (HL) is defined as competences to access, understand, evaluate and use health information and services in order to make decisions for health promotion [1]. HL is more than a mental phenomenon or a set of skills, it must be understood as a set of social practices inserted in a given context [2].

Satisfying the needs of health service users is a challenge for healthcare personnel (HCP), considering the high prevalence of inadequate HL in the population of different countries. Studies suggest that 50.0 to 90.0% of the European, North American and Asian population have insufficient HL [3-5]. In Brazil, studies with specific populations, such as those with chronic diseases and the elderly, estimate that 45.4% to 66.0% of the population have inadequate HL [6-9].

Inadequate HL has important implications for well-being and has been associated with increased risk of death [10], non-adherence to medication [11], poor quality of life [12], less control of chronic diseases [13] and increased hospital readmission [14]. Therefore, the HCP need to assume as a universal principle the addition of health care models that incorporate the HL as a public health issue and quality of care.

Professional training for HL has been associated with the development of knowledge, skills and attitudes that enhance the effective response of professionals to the needs of patients with low HL [15]. Thus, professional competence is a starting point for literate health teams.

The first consensus on professional competences in HL was proposed by Coleman, Hudson and Maine [16]. The authors used a literature review and a panel of North American experts to establish a set of competencies in HL for HCP. Subsequent studies showed that most of these listed competencies could be applicable in European countries [17], Chinese [18] or in specific professions, such as nursing [19]. However, the removal and addition of items that occurred in these studies made clear the need to reapply and adapt the skills proposed by the original instrument to other places and cultures.

The establishment of consensus on HL competencies is supported by the new roles expected for HCP as health promoters in clinical settings, as professionals and researchers, according to the Shanghai Declaration on Health Promotion [20]. This declaration focuses on promoting HL, linking the capacity of individuals and communities, as well as the capacity of professionals and health systems to respond to this demand. In addition, the theme is aligned with the need for research in communication and health information provided for in the Agenda of Research Priorities in Brazil [21].

Currently, consensus on HCP competencies in HL is restricted to the European continent [17], North American [16] and Asia [18]. The lack of a model of competence in HL for Latin American countries like Brazil is a barrier to the construction of curricula for the formation of HCP and for the permanent education of professionals in HL. Therefore, this study aimed to identify a set of competencies of HCP for the practice of HL in Brazil.

Methods

We use a modified e-Delphi study [22] composed of two stages: 1) development of a preliminary list of HL competencies through literature review [23] and online interviews with health professionals; 2) establishment of consensus through three evaluation rounds with HL experts. All competences developed in the study were written in Portuguese and only at the time of publication of the manuscript did we translate it into American English. We had co-authors with English (KLM) and Spanish (MAB) language experience during this process.

A scoping review of domains of professional competencies in HL

The first stage of the study was a scoping review of the literature that was published in May 2022 [23]. We searched Medline (PubMed), CINAHL (EBSCO), PsycInfo, ERIC (ProQuest), Lilacs (BVS), and EMBASE (Elsevier) for original studies and documents in April 2020. We combined the descriptors “Health literacy” AND (Competence OR “Health Personnel”) and similar ones in each database. Articles published in English, Spanish and Portuguese were included, regardless of the year of publication. The selected publications should address the topic of health literacy among health professionals in the care or academic environment, including: knowledge: studies that evaluated or described predominantly cognitive aspects of HCP on HL; Skills: studies that evaluated or described actions of HCP considering the patient’s HL, in clinical practice or mental activities that stimulate critical thinking; Attitudes: studies that evaluated or described preferences, values and attitudes of HCP in relation to patients’ HL.

Interviews with healthcare professionals

The results of the scoping review were used to guide the content analysis of the interviews. We identified several competencies in health literacy through the scoping review. These were semantically approximated and repeated competencies were excluded. Thus, the items identified in the literature served to confirm competences with the specialists in national health literacy, allowing for additions.

We considered experts in health literacy to be professionals who had at least six months of experience in a care activity that involved carrying out educational activities with the patient. This time of experience in care can be considered minimal to allow the opportunity to experience HL practices, as shown by the result of a previous study [24].

The experts in health literacy were identified through e-mail accessed in health services, educational institutions and scientific publications on health literacy. Snowball sampling was used to identify other eligible participants by requesting the e-mail indication of reference professionals in patient health education in the survey form.

The process of recruiting participants and conducting the interviews continued until the inclusion of professionals from different categories and regions of the country was verified, and new categories did not enter the data set. The interviews were carried out from March to July 2020.

Individual online interviews lasting 15 to 40 minutes were conducted with 46 health professionals who worked in health services in Brazil. All interviews were conducted by the first author. All study authors have experience in qualitative research and health literacy and contributed to the interpretation of data.

Operationalization of modified e-Delphi method rounds

The competencies identified in the literature review and interviews constituted the previous list that was submitted to the consensus of Brazilian specialists in HL.

Specialists in HL were identified considering the criterion of authorship in books or peer-review articles, this strategy has been used in studies with the Delphi method, indicating mastery of the topic [25].

The identification of participants for this committee of experts was carried out through a search with the term “Health Literacy” and a filter for the region of Brazil, in the last five years, in PubMed, Web of Science and LILACS. The search identified significant authors from different regions of the country, totaling 83 researchers from different professional categories in the health area publishing on HL in the Brazilian context.

All identified HL specialist researchers were invited to participate in the research (n = 83). Subsequently, the specialists who returned the invitation e-mail were submitted to the following inclusion criteria: having a degree in the health area; have experience in direct patient, family or community care, have at least one HL publication in the last five years. Exclusion criteria were being in function deviation; being away from work activities for more than five years; have exercised only administrative function in the health area. The characteristics of the specialists are described in Table 1.

Table 1

Characterization of health literacy specialists (n = 25).

Brazil, 2021.

Variable		n	%
Sex	Female	21	84.0
	Male	04	16.0
Age (in years)	Less than or equal to 30	04	16.0
	Between 31 and 40	11	44.0
	Greater than 40	10	40.0
Region of the country	North	01	4.0
	Northeast	05	20.0
	Midwest	03	12.0
	Southeast	08	32.0
	South	08	32.0
Academic level	Specialization	01	4.0
	Masters	06	24.0
	Doctorate	18	72.0
Type of service	Public	18	72.0
	Private	04	16.0
	Both	03	12.0
Professional category	Nurse	11	44.0
	Dentist	05	20.0
	Pharmacist	03	12.0
	Audiologist	02	8.0
	Physical educator	01	4.0
	Physical therapist	01	4.0
	Nutritionist	01	4.0
	Doctor	01	4.0
Time working on direct patient care (in years)	Less than or equal to 5	10	40.0
	Between 6 to 10	03	12.0
	Greater than 10	12	48.0

The modified e-Delphi method consisted of three rounds of data collection by e-mail, each of which had varied duration, round 1 from 24.11.20 to 07.01.21; round 2 from 16.01.21 to 09.02.21 and round 3 from 15.02.21 to 10.03.21, making a period of 100 days between the months of November 2020 and March 2021. During Delphi, the number of participants varied in round 1 = 25, 100.0%; round 2 = 16, 64.0% and round 3 = 12, 48.0%.

In each round, the experts were invited to evaluate the importance of each question using a five-point Likert scale, ranging from 1 (not important) to 5 (very important), according to a previous study [18].

The experts received feedback and a summary of the results of each round, and their modified individual items were color-coded to avoid misunderstandings while reading in the second and third rounds.

In statements for which consensus was not reached, feedback and comments from participants were used to adjust the statement for the next round. It has been suggested that experts fill out the form preferably within 15 days and reminders of the activity were sent every five days by email.

In round 3, the data were reorganized, giving rise to consensus on skills in HL for Brazilian health professionals.

Data analysis

The transcripts of the interviews with HCP were submitted to thematic content analysis proposed by Bardin [26] with the help of Atlas Ti software. This framework allowed the identification of the corpus of analysis, through the recording units (excerpts from the participants’ speeches). The registration units were approximated by similarity, resulting in initial categories in Atlas Ti. Subsequently, thematic grouping was performed, resulting in intermediate categories or subthemes. These sub-themes originated the themes, they were approximated and resulted in the final categories, presented here as competences.

Data from the e-Delphi rounds were analyzed using the statistical software Statistical Package for the Social Sciences (SPSS) version 20. Initially, a descriptive analysis of the sociodemographic variables and the list of competencies was performed using percentage [27].

Items suggested by participants in rounds 1 and 2 of the modified e-Delphi method were included in the Brazilian version if they reached ≥ 90% agreement among participants [7]. There is no consensus on the standard for the level of agreement between authors in the e-Delphi methodology, with a variation of 51.0% - 80.0% in the literature [6]. The cut-off point of 90.0% allowed: increasing the sensitivity of the participants’ choice, reducing the risk of entering redundant items and increasing the possibility of including items that are really relevant and feasible to be applied to reality.

Items excluded for not reaching 90.0% were checked and approximated by their semantic similarity in order to confirm whether they would have their correspondents represented in the final list. Thus, it was possible to ensure that the 90.0% cut-off point did not exclude relevant items.

The Brazilian consensus was compared by the authors to the three previous consensuses, American, European and Chinese, through the evaluation of the INESC-ID@ASSIN system to identify semantic similarity on a Likert scale divided into: 1. Completely different, on different subjects; 2. Not related, but more or less on the same subject; 3. Something related. They may describe different facts, but share some details; 4. Strongly related, but some details are different; 5. Essentially the same thing [28].

Ethics statement

The project was approved by the Research Ethics Committee of the Federal University of Goiás (CAEE registration number: 17226919.10000.5083). The right of refusal free of damages and the confidentiality of the identity of all participants were guaranteed.

Results

Nurses (n = 16) and physicians (n = 13) constituted the majority of respondents, 58.0% (n = 17) of the participants had a time greater than or equal to 10 years of experience in patient care and health literacy had already been heard by 41.3% (n = 19) or studied during the master’s or doctorate by 8.6% (n = 4) of the participants (Table 1).

Eighteen professional competences were identified for SL practice based on the synthesis of the content of 34 articles. The categorization of the content of the interviews showed 12 professional competencies in health literacy.

The initial competency list contained 30 items distributed in knowledge (5 items), skills (16 items) and attitudes (9 items), resulting from the literature review and interviews. In the first round, 22 items were added and in the second round, three items were added. However, of the total of 56 items evaluated, only 28 reached consensus among experts. Only items that achieved evaluation (3- important; 4- very important or 5- extremely important) in ≥ 90.0% of the evaluations in round 1 and/or 2 were evaluated in the third round (Table 2).

Table 2

Consensus of competencies of health personnel for the practice of health literacy in Brazil (n = 12).

Brazil, 2021.

Competencies in health literacy (HL) practices	Source	Round accepted	Round final	Level of semantic similarity of the approved item with lists from other studies*
			Percentage of ≥ 4**	USAa	Europeb	Chinac
Knowledge
Recognize at least one definition of HL	[16, 18, 29–33]	Excluded	50.0	-	-	-
Recognize the impact of HL on patient care	[16, 18, 29–33]	2	100.0	4	4	4
Identify low HL signs	[16, 18, 29, 34]	1	91.7	5	5	5
Know guidelines for assertive communication in health	[35–42]	Excluded	83.3	-	-	-
Know strategies to evaluate interventions in HL	[16, 18]	Excluded	83.4	-	-	-
Have knowledge about the subject to be taught	Interview	3	91.6	1	1	1
Know the patient’s HL assessment tools	Round 2 specialists	Excluded	83.3	-	-	-
Know the difference between functional health literacy and literacy	Round 1 specialists	Excluded	-	-	-	-
Recognize people-centered care, health care models, health self-management, self-efficacy	Round 1 specialists	2	91.7	1	1	1
Recognize aspects of the HL of the patient’s community/context	Round 1 specialists	Excluded	-	-	-	-
Recognize ease and difficulty of access and whether the material allows or favors understanding of the topic addressed	Round 1 specialists	2	100.0	4	4	3
Consider human freedom of choice	Round 1 specialists	Excluded	-	-	-	-
Recognize whether the patient or person being health literate can make healthy or unhealthy choices.	Round 1 specialists	Excluded	83.3	-	-	-
Recognize whether the patient or person needs governmental social support to put what they have learned into practice	Round 1 specialists	2	91.6	3	3	1
Knowing learning styles for interventions in professionals with limited HL	Round 1 specialists	Excluded	-	-	-	-
Skills
Use simple language in the transmission of health information	Round 1 specialists	3	100.0	5	5	5
Identify the need to adapt the conduct and learning materials to the patient’s health literacy level	[16, 18]	1	100.0	4	4	4
Develop and adapt educational materials to each target audience according to HL fundamentals	Round 1 specialists	2	100.0	4	4	5
Assess the level of health literacy of patients	[16, 36, 38, 43–45]	Excluded	75.0	-	-	-
Use strategies to reinforce patient learning in health	[16, 18, 36, 40, 43, 45–49]	2	100.0	4	4	4
Check patient learning in health	[16, 18, 36, 40, 43, 45–49]	2	100.0	5	5	5
Use the health literacy assessment to plan strategies appropriate to each individual’s level of sufficiency	Round 2 specialists	Excluded	83.3	-	-	-
Apply health patient education strategies designed with the assumptions of health literacy	[16, 18]	3	91.6	4	4	4
Develop communication focused on health literacy through dialogue, simple language, cultural/regional terms, imagery language, eye contact and teaching materials	Interview	1	100.0	4	4	4
Guide and enable clients for health self-management	[39, 50, 51]	1	91.6	1	1	5
Involve patients in the consolidation of their health rights and care plan	Interview	1	100.0	1	1	1
Build shared decision-making and relationship with the patient/family/caregiver	[16, 18, 34, 38, 46, 50, 51]	2	100.0	3	3	1
Strengthen the individual’s autonomy	Round 1 specialists	2	100.0	1	1	1
Build interprofessional collaboration through sharing and discussing cases with peers	[18]	Excluded	75.0	-	-	-
Evaluate the patient’s biopsychosocial, emotional, educational, cultural and linguistic characteristics that may interfere with their teaching-learning process	Interview	Excluded	83.3	-	-	-
Associate educational content with the patient’s reality	Interview	1	100.0	5	5	5
Identify social context, general and health literacy, usual patient knowledge sources and health determinants	Interview	1	91.6	1	1	1
Adapt the care plan and learning materials to the patient’s biopsychosocial, emotional, educational, age group, cultural, linguistic and health literacy level	Interview	1	100.0	4	4	4
Use information and communication technology whenever possible to assist in the process of teaching patients	Interview	1	91.6	4	4	4
Teach the patient to access reliable health information	Round 1 specialists	3	91.6	1	1	1
Implement strategies to promote greater health literacy and learning among patients	Round 1 specialists	Excluded	83.3	-	-	-
Promote patient empowerment	Round 1 specialists	Excluded	83.3	-	-	-
Carry out a diagnosis of the territory of insertion of the actions	Round 1 specialists	Excluded	75.0	-	-	-
Perform diagnosis of the support network	Round 1 specialists	Excluded	75.0	-	-	-
Work with pounds if necessary	Round 1 specialists	Excluded	66.6	-	-	-
Involve social and family support network in the therapeutic plan	Round 1 specialists	Excluded	75.0	-	-	-
Identify the patient’s feelings and emotions that can interfere with the teaching process	Round 1 specialists	Excluded	83.3	-	-	-
Use strategies that suit both insufficient and sufficient health literacy	Round 1 specialists	Excluded	-	-	-	-
Atitudes
Demonstrate intent and confidence in using health literacy skills	[47, 48, 51]	Excluded	66.6	-	-	-
Demonstrate having become an agent of change in health literacy	[35]	Excluded	58.3	-	-	-
Demonstrate changing perspectives, assumptions and expectations as a result of health literacy actions	[35]	Excluded	-	-	-	-
Feeling co-responsible for the patient’s health literacy	[42]	2	91.6	4	4	1
Be sensitive and empathetic to patients’ unsuccessful experiences in the healthcare system	Round 2 specialists	3	91.6	3	3	1
Feeling responsible for taking care of patients’ communication needs	[16]	1	91.6	5	5	1
Demonstrate a respectful and non-critical attitude towards individuals with limited health literacy skills	[16]	1	100.0	5	5	4
Demonstrate continuous learning intent in health literacy practices or willingness to learn	Interview	Excluded	50.0	-	-	-
Demonstrate an educational attitude, expressing liking what you do, being committed, dynamism, proactivity, patience and the desire to help the patient to develop their health literacy	Interview	1	100.0	1	1	1
Manage your emotions during the educational process, such as anguish, ego, frustrations	Interview	Excluded	83.3	-	-	-
Seeking the patient’s commitment to health care, without blaming him, but trying to make him co-responsible.	Round 1 specialists	2	100.0	1	1	1
Demonstrate self-efficacy, compassion, empathy, motivation and control	Round 1 specialists	Excluded	-	-	-	-
Ability to recognize the patient	Round 1 specialists	Excluded	-	-	-	-

Note

*Sistema INESC-ID@ASSIN [28]—- 1. Completely different, on different subjects; 2. Not related, but more or less on the same subject; 3. Something related. They may describe different facts, but share some details; 4. Strongly related, but some details are different; 5. Essentially the same thing.

**percentage of experts who assigned a rating greater than or equal to four for the item’s level of importance.

abcReferences A- Coleman, Hudson (16); B- Karuranga, Sørensen (17); C- Chang, Chen (18).

The experts attached great importance to the practical knowledge of the HL, encompassing its impact and low HL signals. The skills assessed by experts as important mainly included the aspect of adequacy of language and materials, learning verification and reinforcement strategies. In the context of attitudes, the experts chose items related to the expression of sense or conscience in HL, selecting items with terms of co-responsibility, sensitivity, empathy, respect and commitment. The assessment of the need for social support, the educative attitude and attitudes that make patients co-responsible in the educational process were differentiators of our study in relation to other lists of HCP competences in HL (Table 2).

Discussion

Most of the participants in our study being nurses is consistent with surveys on the composition of health teams in the world, in which 59.0% of the workforce is composed of nurses [52]. In addition, studies suggest that nurses are leaders in building a health-literate society [53]. Thus, the expertise of this professional group brings to the analysis of the study an essential theoretical-practical component, without disregarding the multidisciplinary approach made possible by the inclusion of HL specialists from other professional categories.

The higher frequency of participants with a doctorate observed in our study may be associated with the fact that the HL is still timidly part of the national curricula [54]. It is likely that HCP have a greater chance of coming into contact with the concept of HL in the context of postgraduate studies. This hypothesis can be supported by a review that evidenced the expressive Brazilian scientific production in the master’s and doctorate [55].

The assessment of the need for social support, the educative attitude and attitudes that make patients co-responsible in the educational process were differentials of our study in relation to other lists of HCP competences in HL. Previous studies have suggested that HL theoretical knowledge is an important competency, including concepts, definitions and guidelines [16, 17, 24]. Em contraponto, o conhecimento teórico do HL não foi priorizado pelos nossos especialistas refletindo uma proposta prática para os itens de competência.

The skills related to adaptations in HL practices present in the current study reflect phenomena such as globalization, migratory movements and social disparities. These result in idiomatic, cultural and social determinants challenges in the practice of HL. Recent studies have highlighted the relationship of HL in predicting health disparities among immigrants at the national level [56] and the mediating role of HL in the established social inequalities [57].

The ability to assess HL through instruments was excluded, probably because it is not very applicable to reality, despite being recommended in the literature [18], it may require a time of attention not available by professionals [33]. In addition, current instruments may have complex application or may not address cultural and clinical issues relevant to different care contexts. For example, most instruments are not available in Brazilian Portuguese, they make an indirect assessment through health behaviors and are limited to functional aspects of the HL [58].

In this sense, universal precaution presupposes that health information is offered in a simple way and that health services are organized and accessible to their users, regardless of the HL level of individuals [32, 59]. Our experts, in line with this perspective, have understood that assessment skills are less important than the application or use of HL-based strategies.

In the context of attitudes, items related to empathy, responsibility, respect and commitment reached consensus. Understanding these items as important is associated with the emotional and relational characteristic of the attitude domain [60]. According to Perrenoud [60], this domain of competences is characterized by values and principles, following a subjective perspective and intrinsically linked with knowledge and action.

Our study differed from the other consensuses by developing a list that provides a transversal approach to professional competence in HL, with a view to proposing minimum components for the formation of HCP from graduation to professional training. In addition, the social context, favoring patient autonomy and professional commitment were points that our study identified and that had not been evidenced in other studies on HL competencies [16-18].

Although the Delphi method is recognized for allowing consensus, some limitations of this study need to be considered in our results. The limitations of the study included the intentional sampling and the greater number of nurses, doctors and civil servants that may restrict the application of competences in scenarios with different professional profiles. Although the scoping literature review and heterogeneous sampling may have allowed for a large number of items.

Conclusions

The Brazilian consensus resulted in 28 items distributed in knowledge, skills and attitudes for the practice of HL by HCP. Although the consensus has been established to the practice of HL in Brazil, the items included in the Brazilian version may reveal important aspects for HCP in other countries, such as the assessment of the patient’s social context and share responsibility for the educational process with patients (Table 2).

This study is an initial step to develop the HL competences of Brazilian health professionals and an update of the skills evidenced in previous international studies [16, 18].

18 Mar 2022

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Thank you very much for giving me the chance to review your manuscript. I have included the following general comments:

The topic is very interesting and current issue on the health literacy of health professionals since the quality of the health system a little beat lowered. But this study is best used as an initial step to develop or update the healthcare competencies before being incorporated into the curricula. Because developing a competency may necessitate addressing a variety of factors such as healthcare provider and patient interaction, administration, personal factors, psychosocial factors, behavioral and cultural factors or indicators, and so on in order to be included in curricula and training tools, So the authors would do well to modify the conclusion part and also address the limitations of this study. The authors also need to correct the grammatical errors.

Introduction part

In lines 42 and 43, what is the abbreviation LS and SL stands for, respectively? Please try to write in detail if these were used for the first time in your manuscript.

Methods part

Articles published in English, Spanish, and Portuguese were included. How and in which language will the competencies be developed if this becomes real? How did you interview the expert? If there is language variation, how will it affect the standard? How did you control any bias that might exist because of such a difference?

The author used mean for judgment, but which measure of central tendency would be more appropriate: is that median or mean? This is because the experts’ consensus is 50%/50%.

The experts (health personnel with publications on health literacy) were selected based on their previous publications. Can you conclude that all of these are really experts? The agreement or consensus is also 50%. Again, they are selected online based on their publications. Do you think these publications are free from publication bias? Do you think that people who have many publications have expertise? Do you think that these health professionals represent the experts in Brazil?

The data was collected using an online interview. Was the data collector the author/s by himself/themselves? Is the problem due to competency or due to other factors?

How did the authors check the validity and reliability of the questionnaire to reach such a conclusion?

Table 1: Is the age category mutually exclusive? Again, the variable time working category too. Please make it clear. Percentage should be indicated with period “.” rather comma“,”

Conclusion part

The authors concluded that competencies should be embedded in health team training and academic curricula. Is it possible to incorporate and conclude in this manner based on a single finding because the issue is medial or a life issue, and embedding a program in curricula and providing training based on these competencies may necessitate additional steps such as including other stakeholders, findings, guidelines, principles, and discussions and others.

The authors considered experts in health literacy to be professionals who had at least six months of experience in a care activity that involved carrying out educational activities with the patient (line 82). Do you think these HPs are experts? Do you have a good understanding of healthcare literacy? Do you understand the healthcare system well?

Reviewer #2: Thank you very much for coming up with such an interesting topic. Your study might advance the health care delivery system by pointing problems related to health literacy. Saying this I have the following questions and comments…..

Introduction section line 40....the abbreviation LS should be defined in its first use...

Introduction section line 43....Define the abbreviation SL in its first use

Introduction section line 43....Inadequate SL has important implications for well-being and has been associated with increased risk of death hospital readmission....I am not clear with sentences...could you revise this sentences...I haven't understand it or it my be due to unknowing of the abbreviation SL....

Generally it’s better if you add the experiences of other countries competence in HL. Also, its better if you describe common competence's applied in various countries to convince reader about your topic of interest

Method section Line 70...you have included researches done in three languages (English, Spanish and Portuguese). Why only this three languages....?

Since you intention is to develop competencies in HL could you think that considering six month of professional experience is enough to select participants... Can we say that health professional with six months of experience as an expert. Can you define operationally what we mean an expert. Since the competence's you developed are going to be the part of curricula it needs high experts…

Its better if you move line 101-105 of method section to result part.

Method section line 166. Do you have any references to include >= 90% as a cut point.

In discussion section you used other language than english.....Em contraponto, o conhecimento teórico do HL não foi priorizado pelos nossos especialistas refletindo uma proposta prática para os itens decompetência. Please could you write it in English,,,as long as you used English as a primary language in this study.

**********

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Reviewer #1: Yes: Abiyot Wolie Asres

Reviewer #2: No

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6 Jun 2022

Dear Academic Editor and Reviewers,

We appreciate your feedback on our manuscript. We describe below the changes and explanations about our study in two parts, the first refers to the Academic Editor's comments and the second part contemplates the responses to the reviewers.

Part 1

Dear Academic Editor,

We would like to thank you for your evaluation of our manuscript, we are delighted with your valuable suggestions. We inform you that to meet the requirements of the journal, we carry out a review of the manuscript, as described below.

Regarding the item 1:

“1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf”

Authors' response: We reviewed the formatting of the entire manuscript according to the templates provided in the links above.

Regarding the item 2:

2. Please ensure that you include a title page within your main document. We do appreciate that you have a title page document uploaded as a separate file, however, as per our author guidelines (http://journals.plos.org/plosone/s/submission-guidelines#loc-title-page) we do require this to be part of the manuscript file itself and not uploaded separately.

Could you therefore please include the title page into the beginning of your manuscript file itself, listing all authors and affiliations.

Authors' response: We carry out the inclusion of the title page at the beginning of our manuscript.

Regarding the item 3:

3. Please include a copy of the PRISMA-Scr checklist and flow chart in support of the scoping review aspect of the study.

Authors' response:

Our scoping review was published in the journal Health literacy research and practice [1]. In this publication we have included Flow diagram for the scoping review process adapted from the PRISMA Extension for Scoping Reviews. We have included a copy of the PRISMA-Scr checklist to support our published scoping review [1]. We cite the reference in the method and explain how we use the article in the research.

The first stage of the study was a scoping review of the literature that was published in May 2022 [1]. The detailed combination of search terms is described in the study protocol available at https://figshare.com/s/161960aa6503ee329208

Regarding the item 4:

4. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Authors' response:

We would like to inform you that we do not have a repository of study data, so we have updated our Data Availability statement. Our data is saved in files in docx and xlsx format, in Portuguese. We can make them available if you request.

Part 2

Dear reviewers,

We would like to thank you for your important and careful analysis carried out on our manuscript. We inform you that we accept your suggestions for changes for our study. We review the manuscript, as described below:

Reviewer #1: Comments to the Authors

Thank you very much for giving me the chance to review your manuscript. I have included the following general comments:

The topic is very interesting and current issue on the health literacy of health professionals since the quality of the health system a little beat lowered. But this study is best used as an initial step to develop or update the healthcare competencies before being incorporated into the curricula. Because developing a competency may necessitate addressing a variety of factors such as healthcare provider and patient interaction, administration, personal factors, psychosocial factors, behavioral and cultural factors or indicators, and so on in order to be included in curricula and training tools, So the authors would do well to modify the conclusion part and also address the limitations of this study. The authors also need to correct the grammatical errors.

Authors' response:

We followed reviewer #1's suggestion by changing the study's conclusion to:

“The Brazilian consensus resulted in 28 items distributed in knowledge, skills and attitudes for the practice of HL by HCP. Although the consensus has been established to the practice of HL in Brazil, the items included in the Brazilian version may reveal important aspects for HCP in other countries, such as the assessment of the patient's social context and share responsibility for the educational process with patients (S2 Table).

This study is an initial step to develop the HL competences of Brazilian health professionals and an update of the skills evidenced in previous international studies [2, 3]”.

Reviewer #1: Comments to the Authors

Introduction part

In lines 42 and 43, what is the abbreviation LS and SL stands for, respectively? Please try to write in detail if these were used for the first time in your manuscript.

Authors' response:

We fixed the typo. The two abbreviations refer to Health Literacy (HL).

Reviewer #1: Comments to the Authors

Methods part

Articles published in English, Spanish, and Portuguese were included. How and in which language will the competencies be developed if this becomes real? How did you interview the expert? If there is language variation, how will it affect the standard? How did you control any bias that might exist because of such a difference?

Authors' response:

The items generated from the publications in English, Spanish and Portuguese resulted in a list of competencies in the Portuguese language. This list was presented to practical experts for correction, inclusion and adaptation to the Brazilian context.

We have two types of specialists, practical specialists (health professionals with experience in patient education) and health literacy specialists (health professionals with experience in patient education who also have experience in studying and application of the term health literacy in their work). All interviews with practical experts were by video call by the lead author (FCRC) through the Google Meet app. The audio and image of all interviews were recorded. Health literacy experts evaluated the list resulting from the literature review and interview with health professionals in Brazil through an online form.

The interviews were conducted in Brazil in Portuguese. Data analysis also took place with reference to the Portuguese language. Only the manuscript was translated by the authors into the English language. The control of possible translation biases was controlled through the participation of co-authors in the construction of the competency list. We have co-authors with English (KLM) and Spanish (MAB) language experience during this process. In the manuscript, the changes suggested by the translation specialists were made. Co-author KLM has experience and publications on translation and cross-cultural adaptation of a health literacy instrument from English to Portuguese. Some KLM publications can be found at

https://www.scielo.br/j/ape/a/XC8t5yGWj7f78vLjt3QWRyL/abstract/?lang=en

https://dx.doi.org/10.1590%2F1518-8345.4362.3436

All competences developed in the study were written in Portuguese and only at the time of publication of the manuscript did we translate it into American English.

Reviewer #1: Comments to the Authors

The author used mean for judgment, but which measure of central tendency would be more appropriate: is that median or mean? This is because the experts’ consensus is 50%/50%.

Authors' response:

The experts' judgment was performed considering the analysis steps of the Delphi method and theoretical references related to the expert consensus [4]. Consensus on the e-Delphi method is commonly established by averaging participants' responses. The analysis of agreement using the percentage is in accordance with classical references of expert consensus [4]

Reviewer #1: Comments to the Authors

The experts (health personnel with publications on health literacy) were selected based on their previous publications. Can you conclude that all of these are really experts? The agreement or consensus is also 50%. Again, they are selected online based on their publications. Do you think these publications are free from publication bias? Do you think that people who have many publications have expertise? Do you think that these health professionals represent the experts in Brazil?

Authors' response:

As described in our manuscript in lines 131-139, the initial identification of health literacy specialists was performed using the criteria of scientific publications on health literacy in Brazil. We used the e-mail address of the corresponding author as a reference, who generally assumes greater responsibility for the published study. Furthermore, the authorship criterion is commonly used in Delphi studies. [4] and replicated in a study similar to ours [5].

In addition, as described in lines 140-147, participants who returned to the invitation email filled out an online form that allowed them to apply the inclusion criteria: having a degree in the health area; have experience in direct patient, family or community care, have at least one HL publication in the last five years. Exclusion criteria were being in function deviation; being away from work activities for more than five years; have exercised only administrative function in the health area.

Thus, in addition to the scientific publication criteria, we are concerned with identifying the experience of our specialists in health services. We have professionals from all regions of the country and 60.0% of the participants had more than six years of experience in care. A previous study showed that the time of six months of experience was enough for the specialists to be able to contribute to the list of competence in health literacy in the Chinese context [2].

Finally, the selection of our experts followed the principle of the power of information [6]. In accordance with this 'principle, our health literacy experts met the objectives of the study, contained specific knowledge about HL, the selection criteria were based on an established theory [4] and our analysis strategy considered the reflection of the group for the consideration of the items, reducing potential individual biases [7]. All participants marked the online form that they considered themselves to be experts in health literacy.

Reviewer #1: Comments to the Authors

The data was collected using an online interview. Was the data collector the author/s by himself/themselves? Is the problem due to competency or due to other factors?

How did the authors check the validity and reliability of the questionnaire to reach such a conclusion?

Authors' response:

The first author (Cesar, F.C.R) conducted all interviews alone. All interviews were audio and video recorded. The analysis of the interviews was carried out by the group of researchers, all of whom have experience with qualitative research.

Data quality was guaranteed considering the criteria proposed by Lincoln and Guba [8]: confirmability, credibility, dependability and transferability.

Reliability comprises the extent to which the study results express the participants' ideas and experiences [8]. For this, an analysis of the collection report in pairs was performed, where the authors examined the presence of preconceptions of the interviewer researcher, building an individual analysis with a level of understanding and agreement of the research team.

Credibility means how coherent the research results are and make sense to the people studied and the readers. It was carried out considering that the authors have different experiences and interests. Reading and discussing the interpretation among peers helps to identify preconceptions in the data and to identify whether there was any influence from the interviewer on the research.

Dependability means how consistent and stable research development is over its duration [8]. To meet this criterion, all materials related to the data and analysis of the study were collected in a comprehensive and chronological way, forming an operational trail that allows it to be audited.

Finally, transferability is the secure realization that the results of a study are applicable to other contexts [8]. In this sense, contextual information about the research results was described in as much detail as possible, so that readers could assess whether the results could be transferable or not. For this, we describe professional characteristics of the specialists interviewed, such as professional category, region of activity in the country and level of assistance in which they were inserted.

The perspective of validity and reliability of the questionnaire does not apply in the present study. We are building consensus among experts on a certain topic. For this, we followed the use of the Likert-type scale to classify the importance of the items. In each round, experts were invited to evaluate the importance of each question using a five-point Likert scale, ranging from 1 (not important) to 5 (very important), according to a previous study [2].

Reviewer #1: Comments to the Authors

Table 1: Is the age category mutually exclusive? Again, the variable time working category too. Please make it clear. Percentage should be indicated with period “.” rather comma“,”

Authors' response:

Yes, each category is mutually exclusive.

The suggested change to the percentage was made in the manuscript.

Reviewer #1: Comments to the Authors

Conclusion part

The authors concluded that competencies should be embedded in health team training and academic curricula. Is it possible to incorporate and conclude in this manner based on a single finding because the issue is medial or a life issue, and embedding a program in curricula and providing training based on these competencies may necessitate additional steps such as including other stakeholders, findings, guidelines, principles, and discussions and others.

Authors' response:

We have updated our conclusion to consider our result as an initial step towards the development of health literacy competencies in Brazil and as an update of international competencies.

Reviewer #1: Comments to the Authors

The authors considered experts in health literacy to be professionals who had at least six months of experience in a care activity that involved carrying out

educational activities with the patient (line 82). Do you think these HPs are experts? Do you have a good understanding of healthcare literacy? Do you understand the healthcare system well?

Authors' response:

In addition to the scientific publication criteria, we are concerned with identifying the experience of our specialists in health services. We have professionals from all regions of the country and 60.0% of the participants had more than six years of experience in care. A previous study showed that the time of six months of experience was enough for the specialists to be able to contribute to the list of competence in health literacy in the Chinese context [2].

Finally, the selection of our experts followed the principle of the power of information [6]. In accordance with this principle, our health literacy experts met the objectives of the study, contained specific knowledge about SL, the selection criteria were based on an established theory [4] and our analysis strategy considered the reflection of the group for the consideration of the items, reducing potential individual biases [7]. All participants marked the online form that they considered themselves to be experts in health literacy.

To clarify our understanding of health literacy, we highlight that:

The lead author (F.C.R.C.) is part of the communication department of the Brazilian Health Literacy Network (REBRALS). Pioneer organization in Brazil to bring together researchers from different regions of the country who study health literacy. The researcher is a professor in the medical course at the University Centro Universitário de Mineiros (UNIFIMES) in the discipline of public health. The author developed her thesis on the topic of professional competences in health literacy to obtain her doctorate degree.

The third author (A.G.A.) is a Doctor in Nursing and is part of the Center for Studies in Assistance Paradigms and Quality of Life – NEPAQ at the Federal University of Goiás. In the city of Goiânia, Goiás, she worked as a supervising nurse at the Cidade Jardim Hospital and Maternity Hospital (1990-1993), director of the São Vicente de Paulo Nursing Technician and Assistant School (1992-1998), Nursing Manager (1994-2005) and general manager in the area of Psychiatry and Mental Health (2011-2016) at Clínica Isabela, and supervisory nurse in Psychiatry at Universidade Salgado de Oliveira (2007-2009). She served as special administrative supervisor (2014-2015) of the Municipal Health Department of Senador Canedo-GO. She worked as a teacher at the Pontifical Catholic University of Goiás (1999, 2002-2008), and at the Salgado de Oliveira University (2007-2009).

The fourth author (K.L.M.) has a Doctorate in Nursing, experience in the area of Nursing, with an emphasis on Fundamental Nursing and Public Health. She works as a researcher mainly on topics related to health literacy, cross-cultural adaptation and validation of health measurement instruments; health education, non-communicable chronic diseases and quality of life. Member of the Center for Studies in Assistance Paradigms and Quality of Life (NEPAQ) and the Research Group on Health Promotion and Comprehensive Care (GIPIC) at the Pontifical Catholic University of Goiás. Current vice-coordinator of the Brazilian Health Literacy Network (REBRALS) and member of the International Health Literacy Association (IHLA).

Maria Alves Barbosa is a senior professor at the Faculty of Nursing at the Federal University of Goiás. She has a PhD in Nursing from the University of São Paulo (1994). She is currently a volunteer professor at the Postgraduate Program in Health Sciences at the Faculty of Medicine and at the Postgraduate Program in Nursing, both at the Federal University of Goiás, working on the following topics: Quality of Life, Research Ethics, Health of Worker, Complementary Therapies, Administration of Services and Nursing Assistance, Assistance Paradigms. She coordinates the Center for Studies in Assistance Paradigms and Quality of Life-NEPAQ.

Lizete Malagoni de Almeida Cavalcante Oliveira is a PhD in Health Sciences. Professor at UFG, assigned to the Faculty of Nursing (FEN) in 1983, being a Full Professor from 2014 to 2021. She was Coordinator of the Graduate Program in Nursing (PPGENF) at FEN/UFG from 2016 to 2020. Retired in 02/2021, she is a volunteer Professor at UFG, performing activities as Permanent Professor and Vice-Coordinator of PPGENF-FEN/UFG. Master's and Doctoral advisor at PPGENF-FEN/UFG, in the research lines "Theoretical, methodological and technological foundations for health and nursing care" and "Health and nursing management". Member of the Qualitative Health and Nursing Study Group (NEQUASE), of the International Health Literacy Association and of the Brazilian Health Literacy Network (REBRALS). She works in the areas of quality of life, health literacy, and emergency and critical care nursing care.

Reviewer #2: Comments to the Authors

Introduction section line 40....the abbreviation LS should be defined in its first use...

Introduction section line 43....Define the abbreviation SL in its first use

Authors' response:

The correction was made in the manuscript.

SL and LS stand for health literacy. The correct abbreviation is HL and has been updated in the manuscript.

Reviewer #2: Comments to the Authors

Introduction section line 43....Inadequate SL has important implications for well-being and has been associated with increased risk of death hospital readmission....I am not clear with sentences...could you revise this sentences...I haven't understand it or it my be due to unknowing of the abbreviation SL....

Authors' response:

We rewrite the sentence to: Inadequate HL has been associated with increased risk of death [9], non-adherence to medication [10], poor quality of life [11], less control of chronic diseases [12] and increased hospital readmission [13]. Therefore, the HCP need to assume as a universal principle the addition of health care models that incorporate the HL as a public health issue and quality of care.

Reviewer #2: Comments to the Authors

Generally it’s better if you add the experiences of other countries competence in HL. Also, its better if you describe common competence's applied in various countries to convince reader about your topic of interest

Authors' response:

To address the suggestions, we have added the paragraphs below in the introduction:

The first consensus on professional competences in HL was proposed by Coleman, Hudson and Maine [3]. The authors used a literature review and a panel of North American experts to establish a set of competencies in HL for HCP. Subsequent studies showed that most of these listed competencies could be applicable in European countries [14], Chinese [2] or in specific professions, such as nursing [5]. However, the removal and addition of items that occurred in these studies made clear the need to reapply and adapt the skills proposed by the original instrument to other places and cultures.

The establishment of consensus on HL competencies is supported by the new roles expected for HCP as health promoters in clinical settings, as professionals and researchers, according to the Shanghai Declaration on Health Promotion [15]. This declaration focuses on promoting HL, linking the capacity of individuals and communities, as well as the capacity of professionals and health systems to respond to this demand. In addition, the theme is aligned with the need for research in communication and health information provided for in the Agenda of Research Priorities in Brazil [16].

.

Reviewer #2: Comments to the Authors

Method section Line 70...you have included researches done in three languages (English, Spanish and Portuguese). Why only this three languages....?

Authors' response:

The choice of the English language considered the fact that most publications on the subject are in that language [2, 3, 14]. We consider that Brazilian authors publish mostly in Portuguese, English and Spanish. Thus, including Portuguese and Spanish increased the possibility of considering national publications in the composition of the list of competencies in health literacy.

Reviewer #2: Comments to the Authors

Since you intention is to develop competencies in HL could you think that considering six month of professional experience is enough to select participants... Can we say that health professional with six months of experience as an expert. Can you define operationally what we mean an expert. Since the competence's you developed are going to be the part of curricula it needs high experts…

Authors' response:

As described in our manuscript in lines 131-139, the initial identification of health literacy specialists was performed using the criteria of scientific publications on health literacy in Brazil. We used the e-mail address of the corresponding author as a reference, who generally assumes greater responsibility for the published study. Furthermore, the authorship criterion is commonly used in Delphi studies. [4] and replicated in a study similar to ours [5].

In addition, as described in lines 140-147, participants who returned to the invitation email filled out an online form that allowed them to apply the inclusion and exclusion criteria: having a degree in the health area; have experience in direct patient, family or community care, have at least one HL publication in the last five years. Exclusion criteria were: being in function deviation; being away from work activities for more than five years; have exercised only administrative function in the health area.

Thus, in addition to the scientific publication criteria, we are concerned with identifying the experience of our specialists in health services. We have professionals from all regions of the country and 60.0% of the participants had more than six years of experience in care. A previous study showed that the time of six months of experience was enough for the specialists to be able to contribute to the list of competence in health literacy in the Chinese context [2].

Finally, the selection of our experts followed the principle of the power of information [6]. In accordance with this 'principle, our health literacy experts met the objectives of the study, contained specific knowledge about SL, the selection criteria were based on an established theory [4] and our analysis strategy considered the reflection of the group for the consideration of the items, reducing potential individual biases [7]. All participants marked the online form that they considered themselves experts in health literacy.

Reviewer #2: Comments to the Authors

Its better if you move line 101-105 of method section to result part.

Authors' response:

We made the requested change in the manuscript and marked it in red.

Reviewer #2: Comments to the Authors

Method section line 166. Do you have any references to include >= 90% as a cut point.

Authors' response:

There is no consensus on the standard for the level of agreement between authors in the e-Delphi methodology, with a variation of 51.0% - 80.0% in the literature [7]. For the purposes of this study, the value of 90.0% was adopted to define agreement among experts to achieve a high level of consensus and increase the credibility of the study [5]. The cut-off point of 90.0% allowed: increasing the sensitivity of the participants' choice, reducing the risk of entering redundant items and increasing the possibility of including items that are really relevant and feasible to be applied to reality.

Reviewer #2: Comments to the Authors

In discussion section you used other language than english.....Em contraponto, o conhecimento teórico do HL não foi priorizado pelos nossos especialistas refletindo uma proposta prática para os itens de competência. Please could you write it in English,,,as long as you used English as a primary language in this study.

Authors' response:

We made the correction to standardize the language of the manuscript in English.

REFERENCES

1. Cesar FCR, Moraes KL, Brasil VV, Alves AG, Barbosa MA, Oliveira L. Professional Responsiveness to Health Literacy: A Scoping Review. Health literacy research and practice. 2022;6(2):e96-e103. Epub 20220506. doi: 10.3928/24748307-20220418-02. PubMed PMID: 35522856.

2. Chang LC, Chen YC, Wu FL, Liao LL. Exploring health literacy competencies towards patient education programme for Chinese-speaking healthcare professionals: a Delphi study. BMJ open [Internet]. 2017 18 Maio 2019 [cited 2020 jun 10]; 7(1):[e011772 p.]. Available from: http://dx.doi.org/10.1136/bmjopen-2016-011772.

3. Coleman CA, Hudson S, Maine LL. Health literacy practices and educational competencies for health professionals: a consensus study. J Health Commun [Internet]. 2013 18 Maio 2019 [cited 2020 jun 10]; 18(Suppl 1):[82-102 pp.]. Available from: https://doi.org/10.1080/10810730.2013.829538.

4. Baker J, Lovell K, Harris N. How expert are the experts? An exploration of the concept of 'expert' within Delphi panel techniques. Nurse Res [Internet]. 2006 18 Maio 2019 [cited 2020 jun 10]; 14(1):[59-70 pp.]. Available from: https://journals.rcni.com/doi/abs/10.7748/nr2006.10.14.1.59.c6010.

5. Toronto CE. Health literacy competencies for registered nurses: an e-Delphi study. J Contin Educ Nurs [Internet]. 2016 18 Maio 2019 [cited 2020 jun 10]; 47(12):[558-65 pp.]. Available from: https://doi.org/10.3928/00220124-20161115-09.

6. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res [Internet]. 2016 [cited 2020 jun 10]; 26(13):[1753-60 pp.]. Available from: https://doi.org/10.1177/1049732315617444.

7. Keeney S, Hasson F, McKenna HP. The Delphi technique in nursing and health research. United Kingdom: Wiley Online Library; 2011 [cited 2020 jun 10]. Available from: https://onlinelibrary.wiley.com/doi/book/10.1002/9781444392029.

8. Lincoln YS, Guba EG. Naturalistic inquiry. 1st ed. Newbury Park: Sage; 1985. 329 p.

9. Fan ZY, Yang Y, Zhang F. Association between health literacy and mortality: a systematic review and meta-analysis. Arch Public Health [Internet]. 2021 [cited 2021 Jul 21]; 79(1):[119 p.]. Available from: https://doi.org/10.1186/s13690-021-00648-7.

10. Suhail M, Saeed H, Saleem Z, Younas S, Hashmi FK, Rasool F, et al. Association of health literacy and medication adherence with health-related quality of life (HRQoL) in patients with ischemic heart disease. Health Qual Life Outcomes [Internet]. 2021 Apr 13 [cited 2021 Jul 21]; 19(1):[118 p.]. Available from: https://doi.org/10.1186/s12955-021-01761-5.

11. Zheng M, Jin H. The relationship between health literacy and quality of life: a systematic review and meta-analysis. Health Qual Life Out [Internet]. 2018 18 Maio 2019 [cited 2020 jun 10]; 16(1):[201 p.]. Available from: https://doi.org/10.1186/s12955-018-1031-7.

12. Saeed H, Saleem Z, Naeem R, Shahzadi I, Islam M. Impact of health literacy on diabetes outcomes: a cross-sectional study from Lahore, Pakistan. Public health [Internet]. 2018 18 Maio 2019 [cited 2020 jun 10]; 156(1):[8-14 pp.]. Available from: https://doi.org/10.1016/j.puhe.2017.12.005.

13. Morley CM, Levin SA. Health literacy, health confidence, and simulation: a novel approach to patient education to reduce readmissions. Prof Case Manag [Internet]. 2021 May-Jun 01 [cited 2021 Jul 21]; 26(3):[138-49 pp.]. Available from: https://www.ingentaconnect.com/content/wk/ncm/2021/00000026/00000003/art00005;jsessionid=1h0rnorog38le.x-ic-live-03.

14. Karuranga S, Sørensen K, Coleman C, Mahmud AJ. Health literacy competencies for european health care personnel. Health Lit Res Pract [Internet]. 2017 18 Maio 2019 [cited 2020 jun 10]; 1(4):[e247-e56 pp.]. Available from: https://doi.org/10.3928/24748307-20171005-01.

15. Organização Mundial da Saúde. Shanghai declaration on health promotion. China: OMS; 2016 [cited 2020 jun 10]. Available from: https://www.who.int/healthpromotion/conferences/9gchp/shanghai-declaration.pdf?ua=1.

16. Ministério da Saúde. Agenda de Prioridades de Pesquisa do Ministério da Saúde - APPMS. Brasília: Ministério da Saúde; 2018 [cited 2021 jun 29]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/agenda_prioridades_pesquisa_ms.pdf.

Submitted filename: Response to reviewers - Copia.docx

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29 Jun 2022

COMPETENCIES OF HEALTH PERSONNEL FOR THE PRACTICE OF HEALTH LITERACY IN BRAZIL: A DELPHI CONSENSUS SURVEY

PONE-D-22-06015R1

Dear Dr. Cesar,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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12 Jul 2022

PONE-D-22-06015R1

Competencies of health personnel for the practice of health literacy in Brazil: a Delphi consensus survey

Dear Dr. Cesar:

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Academic Editor

PLOS ONE