International consensus on school health literacy responsiveness: findings from a modified Delphi process

There is a lack of validated tools to assess health literacy responsiveness, defined as the organizational capacity of schools to create accessible and equitable environments that support health literacy development, in school settings internationally. This study, the second phase of a three-part research program, aimed to develop a school-based health literacy assessment tool through a systematic, multi-step development process. Building on a prior scoping review that identified 629 items from existing tools, 210 refined items were presented to 22 international experts via a modified Delphi survey. Experts rated relevance, domain fit, and need for revision. Consensus, derived from qualitative analysis of expert feedback, revealed 47 items as highly important, 119 as potentially relevant, and 44 as unsuitable for schools. Expert feedback informed conceptualization of organizational health literacy in schools. The items reflect practical considerations, cross-national, and multidisciplinary perspectives. Findings highlight strong support for domains such as communication, engagement, and workforce development. The next phase includes pilot testing and validation to support implementation of a tool to promote health literacy among students, teachers, and leaders.