Health literacy is an independent determinant of health, and the relationship between health literacy and preventive health behavior is well-established (Aaby, Friis, Christensen, Rowlands, & Maindal, 2017; Pelikan, Röthlin, & Ganahl, 2012). Health literacy is also associated with other social health determinants, (Bo, Friis, Osborne, & Maindal, 2014; Pelikan et al., 2012) and research suggests that health literacy constitutes an intermediary factor in the distribution of health and well-being, including chronic disease prevention (Stormacq, Van den Broucke, & Wosinski, 2019). However, addressing equity in preventive services through health literacy initiatives calls for comprehensive approaches, including organizational adaptions (Batterham, Hawkins, Collins, Buchbinder, & Osborne, 2016; Paasche-Orlow, Schillinger, Greene, & Wagner, 2006; Willis et al., 2014).
Organizational health literacy responsiveness is “the way in which services, organizations and systems make health information and resources available and accessible to people according to health literacy strengths and limitations” (IUHPE Global Working Group on Health Literacy, 2018, p. 6). Although there are few intervention studies on organizational health literacy responsiveness, several frameworks exploring the concept are available (Farmanova, Bonneville, & Bouchard, 2018). Recently, the Organizational Health Literacy Responsiveness (Org-HLR) framework was developed, involving seven domains characterizing health literacy responsive organizations: (1) external policy and funding environment; (2) leadership and culture; (3) systems, processes, and policies; (4) access to services and programs; (5) community engagement and partnerships; (6) communication practices and standards; and (7) workforce (Trezona, Dodson, & Osborne, 2017). Based on this framework, the Org-HLR process seeks to support organizations in analyzing strengths and weaknesses with regard to health literacy responsiveness, and to develop local action plans to address their challenges (Trezona, Dodson, & Osborne, 2018).
The aim of this organizational case study was to investigate the feasibility of the Org-HLR process in developing a health literacy strategy in a Danish municipal rehabilitation unit.
The study was conducted at Randers Municipal Rehabilitation Unit (RMRU) in Denmark, with a catchment area of approximately 98,000 people. The unit offers public rehabilitation programs after referral from general practitioners or hospitals. All services are free of charge. RMRU is organized with eight therapeutic teams comprised of 3 to 10 staff members. At management level, the unit includes the head of unit, professional manager, and development manager (S.P.). The managers and four therapeutic teams were involved in the Org-HLR process.
We adhered to an early unpublished version (beta) of the Org-HLR process (Table 1) (Trezona et al., 2018). The process included three workshops each with an appertaining tool. A team of four researchers (including A.A. and H.T.M.) facilitated the workshops.
The Org-HLR Process in Randers Municipal Rehabilitation Unit
The reflection tool was comprised of five open-ended questions guiding group discussions about health literacy concepts. The self-assessment tool included 110 items distributed on 22 sub-domains within 6 of the 7 domains in the Org-HLR framework (external policy and funding environment was not included). Participants discussed and noted good practices, opportunities for future improvement, and scored the units performance on each item on a scale ranging from 0 (not at all) to 4 (fully). In the prioritization tool, participants assessed each improvement idea on importance (scale ranging from 1 [not important] to 5 [essential]) and urgency (low [any time], medium [within 6–12 months], or high [within 3 months]) and determined the resources required for the idea.
The tools were translated by a professional translator and a researcher (A.A.).
Ethics and Approvals
According to Danish law, no ethical approval is necessary for an organizational case study in which no personal data are involved. Data were stored and handled according to Danish Data Protection Agency (reference number 2015-57-0002).
The research team extracted views on health literacy in RMRU and communicated these in a pamphlet. This provided a collective starting point for the self-assessment workshop.
Sixty-two ideas were generated through the self-assessment. Not all teams were able to respond to or distinguish between all items. In the following text, we indicate the average rating and summarize workshop findings within each domain.
Supportive Leadership and Culture
The average rating score for this domain was 2.77. The self-assessment identified a managerial commitment to equity. However, the allocation of financial resources is largely defined by national program guidelines, and the commitment appears more as a managerial declaration of intent than a supported strategy.
Supportive Systems, Processes, and Policies
The average rating score for this domain was 1.72. Although some policies and procedures exist, the self-assessment disclosed unsystematic needs identification, monitoring, and evaluation. The teams expressed a need for an assessment tool to use on new referrals.
Supporting Access to Services and Programs
The average rating score for this domain was 2.29. The teams agreed that the unit has a user-friendly physical environment with easy access to services. Outreach activities were few, but not identified as an urgent need.
Community Engagement and Partnerships
The average rating score for this domain was 1.69. A lack of engagement of users in the development and evaluation of services was identified. All teams expressed a wish to improve this.
Communication Practices and Standards
The average rating score for this domain was 2.56. The teams judged oral and written communication to be appropriate and respectful. They acknowledged that no systematic evaluation of learning needs was conducted among users.
Recruiting, Supporting, and Developing the Workforce
The average rating score for this domain was 1.93. Health literacy is not yet integrated in staff recruitment and work environment. However, the participants felt that being part of this project had improved their health literacy skills and they expressed a desire to get systematic feedback within the field.
The pre-set timeframe proved insufficient to complete this workshop. Therefore, a research team member (A.A.) and the development manager (S.P.) in collaboration finished a draft prioritization that was approved by all participants in the workshop before the action plan was drawn. Table 2 shows the action plan derived from the prioritization workshop.
The Action Plan Resulting from the Org-HLR Process in the Randers Municipal Rehabilitation Unit
This organizational case study has demonstrated the feasibility of the Org-HLR process in a municipal rehabilitation setting in Denmark. The process resulted in a health literacy responsiveness action plan developed by staff and managers based on self-assessment and prioritization of activities.
This is the first study to report on the Org-HLR process outside the Australian context in which it was developed. Existing literature supporting the effectiveness of health literacy responsiveness interventions is still limited (Farmanova et al., 2018). However, since the emergence of the first guides in 2006 many frameworks has been published and to some extent positively validated (Farmanova et al., 2018). The Org-HLR is one of the first frameworks developed empirically using a concept-mapping approach with health care professionals (Trezona et al., 2017).
A growing literature in health care accentuates co-design (a participatory approach involving staff, users, or other stakeholders in the development of health care initiatives) as central in bridging the gap between research-driven intervention development and successful implementation (Beauchamp et al., 2017; Greenhalgh, Jackson, Shaw, & Janamina, 2016; Jessup, Osborne, Buchbinder, & Beauchamp, 2018). We have not evaluated the workshop participants' experiences and understandings directly; therefore, we cannot report on the local adoption of health literacy concepts. However, a review by Willis et al. (2014) identified strategies associated with improved organizational capacity for delivering health literacy responsive services. These include engaging staff to adapt to local contexts, creating ownership, ensuring broad involvement, promoting a learning culture, and strengthening teams (Willis et al., 2014). By empowering the staff throughout the Org-HLR process, we have strived to achieve that.
Before the Org-HLR process, the staff and managers in RMRU had limited knowledge on health literacy concepts. Even so, the Org-HLR process was effective in identifying feasible action within the Org-HLR domains (Table 2). However, some issues were not addressed in the action plan in spite of poor scores in self-assessment. For example, despite access to services and user involvement being frequent elements of organizational health literacy guides (Frosch & Elwyn, 2014; Geboers, Reijneveld, Koot, & de Winter, 2018; Koh, Brach, Harris, & Parchman, 2016) the RMRU action plan did not include improved outreach services or target the general lack of user involvement. In a context of limited resources, it is not surprising that not all organizational health literacy challenges can be addressed at once, but this only emphasizes the importance of regular follow-up activities to allow new priorities as daily practice, policies, and funding environments changes.
With regard to urgency of the initiatives, the action plan (Table 2) show a skewness toward communication and workforce domains. This may indicate a downside of the staff involvement if strategic elements are given a lower priority. Literature confirms the need for policy and strategic level interventions to improve equity and health literacy (Public Health England, 2015; Willis et al., 2014), and the observed distortion, if left unaddressed, may increase the risk of implementing isolated actions that come to nothing in a longer perspective.
Our study has some important limitations. First, not all teams in the unit took part in the process (Table 1). This may have skewed the action plan toward the participating teams' needs. Second, the time span between the first two workshops was long (6 months), and a repetition of health literacy concepts was necessary before the self-assessment. In the future, we would recommend more densified Org-HLR processes. Third, the translation process of the Org-HLR tools was not ideal. We focused on the immediate face validity, leading to some cultural adaptations. The tools were reported acceptable and meaningful by the participants, but they felt the self-assessment tool was too long and with too little distinction between items. leading to a repetition of statements. Further cultural adaption and validation is warranted. The results of the Org-HLR process in RMRU may not be directly generalizable to all other settings. However, because of its simplicity and the comprehensive guide and tools, the Org-HLR process as a method is easily carried out in other settings and may yield comparable action plans in other contexts. In our view, working toward improved organizational health literacy responsiveness using self-assessment and co-creation may prove a practical, well-accepted, and sustainable approach to local action against inequity in health.
- Aaby, A., Friis, K., Christensen, B., Rowlands, G. & Maindal, H. T. (2017). Health literacy is associated with health behaviour and self-reported health: A large population-based study in individuals with cardiovascular disease. European Journal of Preventive Cardiology, 24(17), 1880–1888 doi:10.1177/2047487317729538 [CrossRef] PMID:28854822
- Batterham, R. W., Hawkins, M., Collins, P. A., Buchbinder, R. & Osborne, R. H. (2016). Health literacy: Applying current concepts to improve health services and reduce health inequalities. Public Health, 132, 3–12 doi:10.1016/j.puhe.2016.01.001 [CrossRef] PMID:26872738
- Beauchamp, A., Batterham, R. W., Dodson, S., Astbury, B., Elsworth, G. R., Mcphee, C. & Osborne, R. H. (2017). Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia). BMC Public Health, 17(1), 230 doi:10.1186/s12889-017-4147-5 [CrossRef] PMID:28253883
- Bo, A., Friis, K., Osborne, R. H. & Maindal, H. T. (2014). National indicators of health literacy: Ability to understand health information and to engage actively with healthcare providers - A population-based survey among Danish adults. BMC Public Health, 14(1), 1095 doi:10.1186/1471-2458-14-1095 [CrossRef] PMID:25339154
- Farmanova, E., Bonneville, L. & Bouchard, L. (2018). Organizational health literacy: Review of theories, frameworks, guides, and implementation issues. Inquiry: A Journal of Medical Care Organization, Provision, and Financing, 55, 46958018757848 doi:10.1177/0046958018757848 [CrossRef] PMID:29569968
- Frosch, D. L. & Elwyn, G. (2014). Don't blame patients, engage them: Transforming health systems to address health literacy. Journal of Health Communication, 19(Suppl. 2), 10–14 doi:10.1080/10810730.2014.950548 [CrossRef] PMID:25315579
- Geboers, B., Reijneveld, S. A., Koot, J. A. R. & de Winter, A. F. (2018). Moving towards a comprehensive approach for health literacy interventions: The development of a health literacy intervention model. International Journal of Environmental Research and Public Health, 15(6), E1268 doi:10.3390/ijerph15061268 [CrossRef] PMID:29914065
- Greenhalgh, T., Jackson, C., Shaw, S. & Janamian, T. (2016). Achieving research impact through co-creation in community-based health services: Literature review and case study. The Milbank Quarterly, 94(2), 392–429 doi:10.1111/1468-0009.12197 [CrossRef] PMID:27265562
- IUHPE Global Working Group on Health Literacy. (2018). International Union for Health Promotion and Education position statement on health literacy: A practical vision for a health literate world. Retrieved from https://www.iuhpe.org/images/IUHPE/Advocacy/IUHPEHealth_Literacy_2018.pdf
- Jessup, R. L., Osborne, R. H., Buchbinder, R. & Beauchamp, A. (2018). Using co-design to develop interventions to address health literacy needs in a hospitalised population. BMC Health Services Research, 18(1), 989 doi:10.1186/s12913-018-3801-7 [CrossRef] PMID:30572887
- Koh, H. K., Brach, C., Harris, L. M. & Parchman, M. L. (2016). A proposed ‘health literate care model’ would constitute a systems approach to improving patients' engagement in care. Health Affairs, 32(2), 357–367 doi:10.1377/hlthaff.2012.1205 [CrossRef]
- Pelikan, J. M., Röthlin, F. & Ganahl, K. (2012). Comparative report on health literacy in eight EU member states (second extended and revised version). HLS-EU Consortium. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/135/2015/09/neu_rev_hls-eu_report_2015_05_13_lit.pdf
- Paasche-Orlow, M. K., Schillinger, D., Greene, S. M. & Wagner, E. H. (2006). How health care systems can begin to address the challenge of limited literacy. Journal of General Internal Medicine, 21(8), 884–887 doi:10.1111/j.1525-1497.2006.00544.x [CrossRef] PMID:16881952
- Public Health England. (2015). Local action on health inequalities: Improving health literacy to reduce health inequalities. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/460709/4a_Health_Literacy-Full.pdf
- Stormacq, C., Van den Broucke, S. & Wosinski, J. (2019). Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promotion International, 34(5), e1–e17 doi:10.1093/heapro/day062 [CrossRef] PMID:30107564
- Trezona, A., Dodson, S. & Osborne, R. H. (2017). Development of the organisational health literacy responsiveness (Org-HLR) framework in collaboration with health and social services professionals. BMC Health Services Research, 17(1), 513 doi:10.1186/s12913-017-2465-z [CrossRef] PMID:28764699
- Trezona, A., Dodson, S. & Osborne, R. H. (2018). Development of the Organisational Health Literacy Responsiveness (Org-HLR) self-assessment tool and process. BMC Health Services Research, 18(1), 694 doi:10.1186/s12913-018-3499-6 [CrossRef] PMID:30189874
- Willis, C. D., Saul, J. E., Bitz, J., Pompu, K., Best, A. & Jackson, B. (2014). Improving organizational capacity to address health literacy in public health: A rapid realist review. Public Health, 128(6), 515–524 doi:10.1016/j.puhe.2014.01.014 [CrossRef] PMID:24923994
The Org-HLR Process in Randers Municipal Rehabilitation Unit
||Participants were guided by the reflection tool to discuss the local application of health literacy concepts
||Staff and managers
||Each participating therapeutic team performed an assessment of the local organizational health literacy responsiveness using the self-assessment tool
||Staff from four therapeutic teams
||Staff and managers in communion rated and prioritized each improvement idea generated in the self-assessment workshop using the prioritization tool
||Staff representatives from four therapeutic teams and managers
The Action Plan Resulting from the Org-HLR Process in the Randers Municipal Rehabilitation Unit
||Urgency of the Activity Within 1–3 Months
||Within 3–12 Months
||After 12 Months
|Leadership and culture
||Develop and implement a local definition of vulnerability
Develop and cultivate health literacy responsiveness in the unit
||Implement equity and health literacy in strategy documents
|Systems, processes, and policies
||Advocate health literacy (responsiveness) as a local service quality goal
|Access to services and programs
||Improve collaboration with referring institutions to improve service access
|Community engagement and partnerships
||User satisfaction survey among users
|Communication practices and standards
||Implement tool for evaluation of user health literacy level and needs
||Develop video-based user information
||Carry out staff training in equity, health literacy and needs identification
||Carry out video-based supervision and feedback on communication and identification of health literacy level and needs
||Implement equity and health literacy in introduction of new employees