Introduction

Enhancing health literacy is crucial, not only for individual wellbeing, but also for bolstering public health and ensuring the long-term sustainability of healthcare systems. Health literacy is concerned with the capacities of people to meet the complex demands of health in a modern society [1], and a critical, modifiable determinant of health [2]. Health literacy supports people, communities, and organisations in addressing non-communicable diseases and their determinants, taking meaningful action to reduce risk factors, and support health and wellbeing for all [3]. Addressing the issue of low health literacy has the potential to increase health, health equity and health system effectiveness through building citizens' capacities for health [4], [5]. In line with this, in 2022, the WHO published a report entitled ‘Health literacy development for the prevention and control of noncommunicable diseases’ which aimed to support countries and partners build health literacy responsive environments and interventions across countries, sectors and stakeholders [6]. The critical role of organisations, societal structures, and resources to support health literacy at a systems level has become increasingly recognised in modern discourse [3], [7].

In Ireland, low health literacy levels have been reported in adults [8], [9] suggesting that more needs to be done to support health literacy promotion in the region. Globally, a social gradient in health literacy and associated consequences for health has been observed [4], [10]. Analysis of Irish data from the European Health Literacy Survey (HLS-EU) suggests strengthening health literacy within the population through targeted means can be considered as a mechanism for addressing socio-economic disparities in health and healthy behaviours [9]. Ireland is recognised as one of the only countries in the European Union without universal healthcare coverage for all citizens, offering a ‘two-tiered system’ which contributes to, and exacerbates, rising health inequalities [11]. While there are organisations and policies in place aiming to reduce the health inequality gradient, the responsibility for health, and subsequently health literacy, often falls to and between multiple stakeholders.

The Sláintecare Healthy Communities Programme, which was launched in 2021 by Sláintecare Healthy Ireland in the Department of Health, working with the Health Service Executive (HSE) and local authorities and community agencies, focuses specifically on promoting health and wellbeing at the community level. This involves initiatives aimed at preventive healthcare, health promotion, and addressing the social determinants of health. The programme takes a place-based approach to tackling health inequalities with a focus on the determinants of health and has identified 19 communities of focus across Ireland following an evidenced based process to identify local areas in which health and wellbeing risk factors are particularly concentrated. In these areas, local authorities have employed Local Development Officers and have been provided funding to improve public realm and fund locally identified projects to improve health and wellbeing. The Department of Health are working across Government with the Sláintecare Oversight Group to coordinate interventions and policy responses. This involves initiatives aimed at preventive healthcare, health promotion, and addressing the social determinants of health. With this in mind, as a modifiable determinant of health, health literacy is a key area of focus for the Sláintecare Healthy Communities Programme. At this stage of the Sláintecare Healthy Communities Programme, developing evidence-informed pilot projects, focused on a smaller number of identified communities, is a strategic priority.

One of these projects was a health literacy needs analysis, focussing on one urban Sláintecare Healthy Community (Finglas and Cabra) and one rural Sláintecare Healthy community (Mayo) in Ireland [12]. Driven by local health literacy needs, strengths and challenges identified by Murray et al. (in submission; in submission), this study proposed to co-design a series of recommendations with stakeholders, suggesting targeted actions for the future. Among other advantages, co-produced research can: i) recognise, value, and utilise experiential knowledge, ii) support the prioritisation of research topics, aims, and questions by people who are typically excluded from or marginalised in the research process, iii) address inequities in power and amplify marginalised or excluded voices through the recruitment of a diverse range of research participants and iv) deliver impactful research that can provide solutions to problems and positively influence people's lives [13]. Therefore utilising a co-design process to check, challenge, collaborate and create recommendations for health literacy solutions is an invaluable process to “disrupt the status quo” (p.20) and build the case for developing health literacy system capacity leveraging user engagement [3].

A significant scientific gap remains regarding how place-based, community-level structural barriers interact with individual health literacy capabilities within highly centralised or unequal healthcare systems like Ireland's. While traditional frameworks often default to educational or individual-focused solutions, contemporary health literacy models demand a transition towards health literacy-responsive systems [3]. This manuscript addresses this specific gap by offering empirical insights into how regional stakeholders conceptualise system-level adaptations. It bridges the divide between theoretical framework assumptions and localised, actionable realities, contributing a replicable, experience-based co-design blueprint for public health policy.

A specific method of experience-based co-design is the Double Diamond Design Approach (DDDA) that has been used to develop service improvements in health and social care [14], [15]. The DDDA is a framework often used in design thinking to tackle and solve complex problems. Co-design, within the context of the Double Diamond, refers to involving end-users, stakeholders, and relevant parties throughout the design process, ensuring that their perspectives, needs, and insights are integrated into the solution. With DDDA, stakeholders progress through a four-stage reflective process to discover, define, develop, and deliver an innovative solution to a problem. Therefore, the aim of this study was to revise the health literacy strengths, barriers, needs, and generate recommendations for health literacy supports in each Sláintecare Healthy Community of focus, using an adapted DDDA.