20171022 how can healthliteracy be used to support reaching the sdgs by prof. jürgen m. pelikan

Prof. em. Jürgen M. Pelikan, Ph.D. University of Vienna, Austria, Director, WHO-CC Health Promotion in Hospitals and Health

Care at Austrian Public Health Institute, Vienna / Austria

2017 International Conference on Health Promotion and Health Care Services. For the Healthy Future – Healthy Hospital Development,

Taipei / Taiwan, October 21st 2017

Health Literacy in Health Promoting Hospitals

1Pelikan - Taiwan Int HPH Conf 21-10-2017

Overview

1. Why is health literacy relevant for Health Promoting Hospitals?

2. What is health literacy about in more detail?3. How can health literacy be implemented in Health

Promoting Hospitals?


1. WHY IS HEALTH LITERACY RELEVANT FOR HEALTH PROMOTING HOSPITALS?


1.1 HL IS LINKED TO RELEVANT OUTCOMES OF HEALTH CARE AND TO HEALTH


Low health literacy impacts use & outcomes of health care

Empirical evidence from patient studies in the USA (Berkman et al. 2011, Brach et al. 2012) shows that persons with low health literacy» Need more emergency treatment» Have more hospital admissions» Have more problems to understand health related information» Are less able to take their medications correctly and » Have worse self-management of chronic conditions» Are less able to co-produce in treatment and care » Have worse treatment outcomes» Have higher risks of complications» Have more unplanned readmissions» Use less preventive services » And by that cause 3-5% of treatment expenses (Eichler, Wieser & Brügger 2009)

Therefore:Improving health literacy in health care services contributes to strengthening effectiveness & efficiency of the healthcare system!


FOR GENERAL POPULATIONS THERE IS EMPIRICAL EVIDENCE FROM THE EUROPEAN HEALTH LITERACY SURVEY (HLS-EU) & FOLLOW UP STUDIES EUROPE & ASIA


HLS-EU Project 2009-2012


HLS-EU Survey Overview: Sampling, Data collectionCountries Austria (AT), Bulgaria (BG), Germany (DE) (only NRW), Greece (EL) (only Athens +), Spain (ES),

Ireland (IE), Netherlands (NL), Poland (PL)

Survey Institut TNS Opinion on behalf of the HLS-EU Consortium

Survey Periode Summer 2011

Target Population, Population Coverage EU citizens (!) aged 15 years and over (Euro-barometer Methodology)

HL Instrument HLS-EU-Q86 (including HLS-EU-Q47 and NVS Test)

Data collection by computer-assisted personal interviewing technique (CAPI) (BG, IE = PAPI)

Sampling design Euro-barometer MethodologyStratified probability sampling (multistage random sample):• National sampling points selected randomly (applying random-walk procedure) after

stratification for population size and population density (metropolitan, urban and rural areas).

Response Rates Austria (67%), Bulgaria (75%), Germany (DE) (53%), Greece (65%), Spain (62%), Ireland (69%), Netherlands (36%), Poland (67%)

Sample Sizes Austria (1015), Bulgaria (1002), Germany (DE) (1057), Greece (1000), Spain (1000), Ireland (1005), Netherlands (1023), Poland (1000)

Weights National samples were weighted by gender, age group and size of locality, based on national census data Country size was not used as a weighting criterion for the analyses of the total sample. Total sample values therefore represent a ‚country average‘ where all countries are represented with equal weights regardless of their population size.


Health literacy(47)

Access/obtain information

relevant to health (13)

Understand information

relevantto health (11)

Process / appraiseinformation


Apply / use information


Health care (16)

1) Ability to access information on medical or clinical issues(4 Questions)

2) Ability to understand medical information and derive meaning(4 Questions)

3) Ability to interpret and evaluate medical information(4 Questions)

4) Ability to make informed decisions on medical issues(4 Questions)

Disease prevention (15)

5) Ability to access information on risk factors for health(4 Questions)

6) Ability to understand information on risk factors and derive meaning (3 Questions)

7) Ability to interpret and evaluate information on risk factors for health(5 Questions)

8) Ability to make informed decisions on risk factors for health (3 Questions)

Health promotion (16)

9) Ability to update oneself on health related issues(5 Questions)

10) Ability to understand health related information and derive meaning(4 Questions)

11) Ability to interpret and evaluate information on health related issues(3 Questions)

12) Ability to make a informed decision on health related issues(4 Questions)

Measurement of Health Literacy in the HLS-EU-Q47? -Number of questions in the cells of the HLS-EU Definition Matrix


Selected examples of questions of the HLS-EU-Q47

Format of questions» „On a scale from very easy to very difficult, how easy would you say it is

to …. “very easy” - “fairly easy” - “fairly difficult” - “very difficult”, (don´t know)

Five examples Health care 5. … understand, what your doctor says to you?12. … judge if the information about illness in the media is reliable?Disease prevention18. …find information on how to manage mental health problems like stress or depression?29. …decide if you should have a flu vaccination?Health promotion38. … understand information on food packaging?47. … take part in activities that improve health and well-being in your community?


The HLS-EU health literacy measures indices & levels» A comprehensive index & 7 sub-indices standardized on a scale

from a minimum of 0 to a maximum of 50 (=best possible HL)» 12 sub-sub-indices standardized on a scale from a minimum of 0 to

a maximum of 5 (= best possible HL)» For the 8 main HLS-EU indices thresholds and levels were defined

» Inadequate HL = scores of 25 or less points (at least 50% of the items have been rated as difficult or very difficult)

» Problematic HL = scores >25-33 points (2/3 of possible index points)

» Sufficient HL = scores >33-42 points» Excellent HL = scores >42-50 points (5/6 of possible index

points)» Inadequate + problematic = limited health literacy = -33 points

» Cronbach´s alphas for comprehensive HL index are very high!AT BG DE (NRW) EL ES IE NL PL TOTAL

GEN HL 0,96 0,97 0,96 0,97 0,96 0,97 0,95 0,98 0,97


ASSOCIATIONS OF THE TWO HL MEASURES -THEIR HEALTH RELATED CONSEQUENCES


Percentage Distribution of Physical Activity by Grouped Health Literacy Index (for Total Sample, HLS-EU 2012)> There is a considerable rather continuous relationship!

7.6 5.419.9 23.1 25.6 29.5 32.8 36.4

9.5 16.2

18.923.2

25.328.2 26.3

26.1

5.7

16.915.8

17.416.6 14.7

16.1

77.162.9

44.337.9

31.8 25.8 26.2 21.4

0

10

20

30

40

50

60

70

80

90

100

<15 15-20 20-25 25-30 30-35 35-40 40-45 45-50

Percentageof

PeopleExercising

byFrequency

Grouped Scores of Comprehensive Health Literacy Index

Noexercising

A few timesthis month

A few timesa week

Almostevery day

<15[N=102] 15-20[N=259]|20-25[N=598]|25-30[N=1344]|30-35[N=2184]|35-40[N=1530]|40-45[N=1046]|45-50[N=704]| TOTAL[N=7767]


Physical Activity by 5 social and 2 HL determinants(Beta Weights and Adjusted R-Square for Total Sample & Countries) (HLS-EU 2012)

BG -.034 COMP.-HL -.176 AT

ES .018 FIN. DEP. .140 BG

BG .005 SOCIAL STATUS -.108 DE

DE -.003 NVS -.116 IE

IE .008 EDUCATION -.110 DE

ES -.105 AGE .137 IE

AT -.049 GENDER .097 EL

Physical Activity

-.119

.092

-.088

-.048

-.046

.042

Adj. R2= .079(NL .013 /.102 DE)

.033


Chronic Illness by 5 social and 2 HL determinants(Beta Weights and Adjusted R-Square for Total Sample & Countries) (HLS-EU 2012)

IE -.275 AGE -.478 BG

IE .016 FIN. DEP. -.207 DE

ES .014 COMP.-HL .169 AT

DE .015 GENDER -.080 PL

AT -.006 EDUCATION .066 EL

AT -.019 SOCIAL STATUS .092 PL

PL -.052 NVS .142 IE

Chronic Illness

-.388

-.082

.080

-.045

.023

.018 Adj. R2= .195(NL .098 / .366 BG)

-.004


Percentage Distributions of Self-Assessed Health (SF-36) by Grouped Health Literacy Index (for Total Sample, HLS-EU 2012)> There is a considerable rather continuous relationship!

10.8 10.8 15.2 17.724.1

34.0 35.243.818.6

25.1

32.740.2

43.7

42.4 42.037.4

31.4

35.9

35.3

31.425.9

18.7 19.4 16.1

26.4

22.414.7

9.3 5.6 4.4 2.8 2.712.7

5.82.2 1.3 0.7 0.5 0.7 0.1

0

10

20

30

40

50

60

70

80

90

100

<15 15-20 20-25 25-30 30-35 35-40 40-45 45-50

Percentages of Categories of

Self-assessedHealth Status


Very bad

Bad

Fair

Good

Very good

<15[N=102]|15-20[N=259]|20-25[N=600]|25-30[N=1348]|30-35[N=2185]|35-40[N=1531]|40-45[N=1048]|45-50[N=704]| TOTAL[N=7777] 16Pelikan - Taiwan Int HPH Conf 21-10-2017

Self-assessed health by 5 social and 2 HL determinants (Beta Weights and Adjusted R-Square for Total Sample and Countries) (HLS-EU 2012)

NL .144 AGE .496 EL

BG -.103 CHL -.205 AT

AT -.020 SOC.STATUS -.158 NL

IE .053 FIN. DEPRIV. .212 DE

PL -.027 GENDER .077 ES

NL -.007 EDUCATION -.131 IE

AT .000 NVS -.081 IE

.365

-.168

-.112

.071

.039

-.036

-.026

a…not significant on the 0,05 level

Adj. R2= .268(NL.88 / .452 EL)


Self-assessed health by 5 social, 2 HL and 2 risk factors (Beta Weights and Adjusted R-Square) (NVS were not significant!), for Countries and Total Sample (HLS-EU 2012)

ES -.369 LT-ILLNESS -.556 IE

NL -.039 AGE .279 EL

EL -.063 CHL -.176 ES

ES/IE -.009 SOCIAL STATUS -.147 NL

NL .013 PHYS ACTIVITY .135 DE

EL -.029 BMI .131 NL

IE -.001 NVS -.041 EL

AT -.003 EDUCATION -,121 IE

PL -.061 GENDER .073 ES

-.459

.161

-.125

-.095

.075

.066

-.027

Adj. R2= .447(NL .330 / .630 EL)

.026

EL .032 FIN DEPRIVATION .132 PL

.018

-.018


Path Model for variables explaining variation of self-assessed health (Beta weights for TOTAL, HLS-EU 2012) Explained Variance of SAH by CHL: direct .133, indirect .63, total .196

Gender

Age

Educ.

Fin. Dep.

Soc. St.

NVS CHL PHA BMI LTI SAH-.458

-.133

.066

.180

.030

.078

-.021

.030

-.102.123.158

-.058

.236 .135 -.188 .098 -.092-.056

.030 .062 -.119

-.249 -.037

-.242

.102

.090

-.373.250

-.123


Doctor´s Visits by Grouped Health Literacy Index (for Total Sample, HLS-EU 2012)> There is a slight relationship between Health literacy and doctor´s visits!

<15[N=102] 15-20[N=256]|20-25[N=599]|25-30[N=1348]|30-35[N=2186]|35-40[N=1534]|40-45[N=1046]|45-50[N=705]| TOTAL[N=7777]

24.5%15.6% 13.5% 15.7% 17.8% 21.8% 18.7% 23.8%

20.6% 32.8% 36.1% 37.3%42.2%

43.8% 44.7% 39.9%

24.5% 20.3%24.9% 23.2%

22.4%20.7% 21.1% 22.1%30.4% 31.3%

25.5% 23.7%17.6%

13.7% 15.4% 14.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>1 5 15 - 20 20 - 25 25 - 30 30 - 35 35 - 40 40 - 45 45 - 50

Percentages of

categories of

Doctor VisitsIn the last 12

month


6 times ormore

3 - 5 times

1 - 2 times

0


Effects of 5 Social Determinants and Health Literacy (HL) as Multiple Predictors on Doctor´s Visits (Beta Weights and Adjusted R-Square for Total, HLS-EU 2012)> The effect of health literacy on doctor´s visits stays on, when social determinants are controlled for!

AGE

GENDER

HL

SOCIAL STATUS

EDUCATION

FIN. DEPRIVATION

,285

,131

,065

-,049

-,037

-,018a

a…not significant on the 0,05 level

Adj. R2= ,125


Combined Shares of ‘Fairly Difficult’ and ‘Very Difficult’ Answers of HL Health Care Items for HLS-EU8 according to Self-Reported Health Status

0% 10% 20% 30% 40% 50% 60% 70% 80%

16...follow instructions from your doctor or pharmacist?

8...understand your doctor’s or pharmacist’s instruction on how to take a prescribed medicine?

14...follow the instructions on medication?

15...call an ambulance in an emergency?

4...find out where to get professional help when you are ill? (Instructions:such as doctor, pharmacist,psychologist)

5...understand what your doctor says to you?

9...judge how information from your doctor applies to you?

7...understand what to do in a medical emergency?

3...find out what to do in case of a medical emergency?

1...find information about symptoms of illnesses that concern you?

13...use information the doctor gives you to make decisions about yourillness?

2...find information on treatments of illnesses that concern you?

6...understand the leaflets that come with your medicine?

11...judge when you may need to get a second opinion from another doctor?

10...judge the advantages and disadvantages of different treatment options?

12...judge if the information about illness in the media is reliable?(Instructions: TV, Internet or other media)

On a scale from very easy to very difficult. How easy would you say is it to:

very goodgoodfairbad to very badTotal


Combined Shares of ‘Fairly Difficult’ and ‘Very Difficult’ Answers of HL Health Care Items for HLS-EU8 according to Self-Reported Long-Term Health Problems

0% 10% 20% 30% 40% 50% 60% 70% 80%

16...follow instructions from your doctor or pharmacist?

8...understand your doctor’s or pharmacist’s instruction on how to take a prescribed medicine?

14...follow the instructions on medication?

15...call an ambulance in an emergency?

4...find out where to get professional help when you are ill? (Instructions: such asdoctor, pharmacist,psychologist)

5...understand what your doctor says to you?

9...judge how information from your doctor applies to you?

7...understand what to do in a medical emergency?

3... find out what to do in case of a medical emergency?

1... find information about symptoms of illnesses that concern you?

13...use information the doctor gives you to make decisions about your illness?

2...find information on treatments of illnesses that concern you?

6...understand the leaflets that come with your medicine?

11...judge when you may need to get a second opinion from another doctor?

10...judge the advantages and disadvantages of different treatment options?

12...judge if the information about illness in the media is reliable? (Instructions:TV, Internet or other media)

On a scale from very easy to very difficult. How easy would you say is it to:

Yes more than oneYes oneNoTotal


1. 2 A CONSIDERABLE PROPORTION OF GENERAL AND PATIENT POPULATIONS HAVE LIMITED HEALTH LITERACY


Percentage Distributions of Comprehensive HL Levels for Countries and Total Sample (HLS-EU 2012) > Levels of health literacy vary considerably by country!

AT [N=996] BG [N=955] DE (NRW) [N=1041] EL[N=998] ES[N=981] IE[N=972] NL[N=993] PL[N=946] TOTAL [N=7883]

1.8%

10.3%

10.2%

13.9%

11.0%

12.4%

18.2%

7.5%

26.9%

26.9%

29.7%

34.4%

30.9%

35.3%

35.2%

38.2%

50.8%

35.2%

46.3%

38.7%

35.9%

39.6%

34.1%

36.0%

33.7%

32.6%

26.6%

25.1%

21.3%

19.5%

15.6%

19.6%

16.5%

9.9%

9.1%

11.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Netherlands

Ireland

Poland

Greece

Germany

TOTAL

Austria

Spain

Bulgaria

inadequate comp.-HL problematic comp.-HL sufficient comp.-HL excellent comp.-HL


Percentages of Individuals with Limited HL Levels in Vulnerable Groups (Total (N=8000), HLS-EU 2012)

73.9%

72.8%

68.0%

67.1%

66.5%

65.6%

65.6%

63.6%

63.4%

61.0%

60.8%

60.0%

47.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Social status

Self-perceived health

Education (Isced Level)

Able to pay for medication

Able to afford doctor

Limited by health problems

Monthly household income

Able to pay for medication

Difficulties paying bills

Long term illness

Age

Social status

Total (N=8000)

Very low

Bad, very bad

Level 0, Level 1

Very difficult

Fairly difficult, very difficult

Severely limited

Less than €800

Fairly difficult

Most of the time

Yes, more than one

76 or older

Low

For groups with weak socio-economic or bad health status percentage of limited HL is much higher!


Measuring health literacy in Asia: Validation of the HLS-EU-Q47 survey tool in six Asian countries


Health literacy levels of gen. populations in Europe and Asia

19.9

5.4

27.7

22.2

23.3

10.7

49.9

12.4

18.2

26.9

11

13.9

7.5

10.3

1.8

10.2

38.2

39.1

39.2

31.3

35.4

53.1

35.5

35.2

38.2

35.2

35.3

30.9

50.8

29.7

26.9

34.4

30.8

41.6

23.8

32.3

28.7

32

10.4

36

33.7

26.6

34.1

39.6

32.6

38.7

46.3

35.9

11.0

13.9

9.3

14.2

12.6

4.3

4.2

16.5

9.9

11.3

19.6

15.6

9.1

21.3

25.1

19.5

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Asian total

TW

VN

KZ

MM

ID

JP

European total

AT

BG

DE

EL

ES

IE

NL

PLInadequate Gen-HL Problematic Gen-HL Sufficient Gen-HL Excellent Gen-HL

Presentation: Tuyen V. Duong, Altyn Aringazina, Gaukhar Baisunova, Nurjanah Nj, Thuc V. Pham, Khue M. Pham, Tien Q. Truong, Kien T. Nguyen, Win Myint Oo, Emma Mohamad, Tin Tin Su, Hsiao-Ling Hwang, Kristine Sørensen, Jürgen M. Pelikan, Stephan Van Den Brouke, Peter Wushou Chang: Health literacy in Five Asian countries: A population-based cross-sectional study, 3rd AHLA conference, Tainan/ Taiwan 9-11-2015 28Pelikan - Taiwan Int HPH Conf 21-10-2017

1.3 THERE IS A SOCIAL GRADIENT FOR HEALTH LITERACY AS THERE IS ONE FOR HEALTH > HEALTH LITERACY IS CONTRIBUTING TO THE HEALTH GAP!


Comprehensive Health Literacy by 5 social determinants & NVS(Beta Weights and Adjusted R-Square for Total Sample & Countries) (HLS-EU 2012)

ES -.066 FIN. DEP. -.327 PL

NL .028 NVS .226 BG

DE -.007 SOCIAL STATUS .195 IE

IE .003 EDUCATION .194 EL

NL .044 AGE -.141 EL

ES .024 GENDER .093 DE

Comp. Health Literacy

.122

.100

-.063

.058 Adj. R2= .188(NL .076 /.291 EL)

-.231

.134


2. WHAT IS “HEALTH LITERACY” ABOUT IN MORE DETAIL?


2.1 HEALTH LITERACY IS AN EVOLVING, WIDENING AND INTERACTIVE CONCEPT


Health literacy - an “evolving concept” (Nutbeam 2008) –but with 3 observable trends (Pelikan & Ganahl 2017)

» Broadening of understanding of » Health: Disease & positive health and wellbeing» Literacy: Literacy & other information/communication

competences» Roles & tasks: Patient role & other roles in everyday

life» > important for measuring HL of populations

» Differentiating of HL for specific contexts & contents » Interactive /relational/contextual/dual understanding of

HL > measure & increase personal competences & decrease situational demands » > organizational HL, HL sensitive organizations

/settings 33Pelikan - Taiwan Int HPH Conf 21-10-2017

The HLS-EU comprehensive & integrated definition for measuring health literacy in general populations

Health literacy is linked to literacy and it entails people’s

knowledge, motivation and competences to access, understand, appraise and apply

informationto take decisions in everyday lifein terms of healthcare, disease prevention and

health promotionto maintain and improve quality of life during

the life course.

> HL is a comprehensive multi-dimensional concept!(The HLS-EU Consortium – Sørensen et al. 2012)


The Generic Vienna Model of Health Literacy: Determinants & consequences for collection & analysis of data (Pelikan et al 2014)

0. Situational Determinants (Country, Province, District, Urban/Rural, etc.)

1. Personal Determinants

2. Individual Health Literacy

3. Health BehaviorsLife-style

4. Health StatusNCDs

5. Illness Behaviors


Health Literacy is a relational concept –with consequences for measurement and interventions

(Parker, 2009)

Measure personal HLcompetences

Measure situational HL demands and support

Measure fit of HL competencesto HL demands

Improve individual/population HL by offers for personallearning (education,training)

Improve organizational HL by reducing situational demands & offering specific institutional support > develop health literate settings

Compensate for HL deficits of disadvantaged groups by specific compensatory measures

Personal Skills/Abilities

Situational Demands/ComplexityHealth

Literacy


2.2 HEALTH LITERACY AND HEALTH PROMOTION – THE PERSPECTIVE OF WHO


How does Health Literacy relate to Health Promotion? The engagement of WHO1986 Ottawa Charter „HP is the process to enable people to increase control over, and to improve their health”HP principles: Enable, mediate, Advocate» Action area 1: Build healthy public policy (HLiaP)» Action area 2: Create supportive environments (HL Settings)» Action area 4: Develop personal skills (HL competences)» Action area 5: Reorient health services (HLHCO)

1998 Definition & HL is critical to empowerment (WHO 1998), 1998 HL as a HP outcome (Nutbeam 1998)2009 Nairobi Call to Action (specific part on HL & health behaviors) 2012 Health 2020 – Policy Framework and Strategy 2013 Solid Facts Health Literacy 2016 Shanghai Declaretion2017 WHO-EHII Action network on health literacy measurement


What is the added value of and specific contribution of Health Literacy to Health Promotion?

39

1. HL is a measurable concept with different instrumentsavailable

2. HL focuses on information management & communication of people in different roles & settings

3. There evidence for social gradient of HL4. There is evidence that HL has an impact on

» health care (patient compliance, outcomes, costs etc.) » health behaviors » health

5. HL is a modifiable social determinant of health6. Effective interventions to deal with low HL or improve HL are

available for people, organizations and systems

Pelikan - Taiwan Int HPH Conf 21-10-2017

Health 2020 Policy framework and strategy

40

In the short version health literacy is mentioned twice:1. Priority area 1:Investing in health through a

life-course approach and empowering people» Health promotion programmes based on

principles of engagement and empowerment offer real benefits: These include creating better conditions for health, improving health literacy, ….

» A strategic focus on healthy living for both young and older people in particular: … For young people , these can include peer-to-peer education, involvement of youth organizations and school-based health literacy.

In the long version health Literacy is explicitly mentioned another 9 times!…


WHO´s Health Literacy –The solid Facts (2013-)

WHO Regional Office for Europe (2013): Health Literacy. The Solid Facts. http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf


http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf

Shanghai Declaration 2016Health literacy empowers and drives equity » Health literacy empowers individual citizens and enables their engagement in

collective health promotion action. » A high health literacy of decision-makers and investors supports their

commitment to health impact, co-benefits and effective action on the determinants of health.

» Health literacy is founded on inclusive and equitable access to quality education and life-long learning. It must be an integral part of the skills, and competencies developed over a lifetime, first and foremost through the school curriculum.

» We commit to » – recognize health literacy as a critical determinant of health and invest in its

development; » – develop, implement and monitor intersectoral national and local strategies for

strengthening health literacy in all populations and in all educational settings; » – increase citizens’ control of their own health and its determinants, through

harnessing the potential of digital technology; » – Ensure that consumer environments support healthy choices through pricing

policies, transparent information and clear labelling.


3. HOW CAN HEALTH LITERACY BE IMPLEMENTED IN HEALTH PROMOTING HOSPITALS?


3.1 SPECIFIC APPROACHES TO CONSIDER HEALTH LITERACY IN HEALTH CARE


Reactions to low / limited Health Literacy in health care services the in USA

» To develope of and test patients with (short) tests of functional health literacy (e.g. TOPHLA, REALM, NVS) to adapt professional communication to low health literacy of specific individual patients

» To develope easier to read and understand clinical materials for patients

» To better train health professionals for communication» To improve navigation systems in hospitals» To define 10 characteristics of health literate health care

organizations» This whole system health literacy initiative has been taken up

in Europe, Asia and Australia


Health literacy can be better tackled than other determinants of health – in two ways!

» By learning offers for improving personal health literacy» In school education» In adult education» By the media» By specific health education» By patient education in health care

» Problems of education: ability & motivation of learners!» By developing organizational settings & systems to be less

demanding and more supporting concerning information and communication for their users in all sectors of society


3.2 AN INTEGRATED APPROACH – HEALTH LITERATE (SENSITIVE) ORGANIZATIONS AND SYSTEMS


Understand

Health information

Find

Appraise

Apply

Competences / Abilities Situational Demands / complexity

Availability, accessibility

Health literacy

Language, Reading level, Images, Layout,

…

Availability of references, evidence

Ask, investigate, usecontacts, …

Education (literacy, numerady, language

competence …)

Life experience, judgment, …

Applicability of content & individualized

support (e.g. consultation)

Practical & problem-solving abilities creativity

…

PersonalCompetences / abilities

Ask, investigate, use contacts, …

Education (literacy, numerady, language

competence …)

Life experience, judgment, …

Practical & problem-solving abilities creativity

…

HL is relational & comprehensive!


IOM Concept of Health Literate Health Care Organizations

51

“A health literateorganization makes iteasier for people tonavigate, understand,and use informationandservices to take careof their health.”

(Brach et al. 2012)


Ten attributes of health literate (healthcare) organizations

A health literate organization …

1. Has leadership that makes HL integral to its mission, structure, and operations.2. Integrates HL into planning, evaluation, patient safety, quality improvement.3. Prepares the workforce to be HL and monitors progress .4. Includes populations served in the design, implementation, and evaluation of

health information and services .5. Meets the needs of populations with a range of HL skills & avoids stigmatization.6. Uses HL strategies in interpersonal communications and confirms understanding

at all points of contact.7. Provides easy access to health information and services & navigation assistance.8. Designs / distributes print, audiovisual, social media content that is easy to

understand and act on .9. Addresses HL in high-risk situations, including care transitions and

communications about medicines.10. Communicates clearly what health plans cover and what individuals will have to

pay for services.

52

Specific HL content Relating to participation principleGeneral Change / quality / risk management

(Brach et al. 2012)


Cognitive map of the Vienna-HLO study

53

HL of

HL for

Stakeholder groups D) Organizational structures &processes –capacitiesimplementation

A) Patients B) Staff C) Community

1) Access to, living & working in the organization

A1) HL for living & navigating

B1) HL for navigating & working

C1) HL for navigating & access

Di) Basic principles & capacity building for implementing HL

Dii) Monitoring of HL structures & processes

Diii) Advocacy & networking for HL

2) Diagnosis,treatment & care

A2) HL for co-producing health

B2) HL for health literate patient communication

C2) HL for co-production of continuous & integrated care

3) Disease management & prevention

A3) HL for diseasemanagement & prevention

B3) HL for diseasemanagement & prevention

C3) HL for diseasemanagement & prevention

4) Healthylifestyle development

A4) HL for healthy lifestyle development

B4) HL for healthy lifestyle development

C4) HL for healthy lifestyle development


Self-assessment tool following the Vienna-HLO model

54

Patients Staff Community

Organizational structures & processes – capacities implementation

Domain1: Access to, living & working in the organization

Standard 4: Navigation assistance4.1 Barrier-free contact via website and telephone

4.2 Provision of information relevant for arrival and hospital stay4.3 Availability of support at main entrance

4.4 Clear and easy-to-understand navigation system4.5 Free availability of health information for patients and visitors

Standard 1: Management policy and organizational structures1.1 HL as corporate responsibility1.2 Quality assurance of HL

Standard 2: Participative development of materials and services2.1 Participation of patients2.2 Participation of staff

Standard 9: Dissemination and further development9.1 support of the dissemination and further development of health literacy

Domain 2: Diagnosis, treatment& care

Standard 5: HL in patient communication5.1 in spoken communication 5.2 in written communication5.3 support by language translators and interpreters5.4 also in high-risk situations

Standard 3: Develop HL skills of staff for patient communication3.1 for all situations that involve communication

Standard 8: Contribute to HL in the region8.1: promotion of continuous and integrated care

Domain 3: Disease management & prevention

Standard 6: Promote HL of patients and relatives6.1 for disease-specific self-management

Standard 7: Promote HL of staff7.1 for the self-management of occupational health and safety risks

Domain4: Healthy lifestyledevelopment

Standard 6: Promote HL of patients and relatives6.2 for healthy lifestyle development

Standard 7: PromoteHL of staff HL7.2 for healthy lifestyles

Standard 8: Contribute to HL in the region8.2 contribution to public health within the realm of possibility


The 9 standards of the Vienna-HLO model (with 22 sub-standards, 160 indicators)

1. Provide (organizational) capacities, infra-structures & resources for health literacy in the organization

2. Develop & evaluate materials and services in participation with users3. Qualify staff for HL communication4. Develop a supportive environment – provide navigation assistance5. Apply HL communication principles in all routine communications –

in spoken, written, audio-visual and digital communication & by providing interpreting and translation support

6. Improve personal HL of patients & significant others by learning offers

7. Improve personal HL of staff by learning offers8. Improve HL in the organization’s community & catchment area9. Share experiences & be a role model for HL in the HC community


Standard 1: Make HL a priority across all levels of the organization & across all communication channels

Organizational health literacy is integrated into organizational structures and processes, including organizational self-assessment.

Sub-standards1.1 The organization understands health literacy as a corporate

responsibility (5 indicators) e.g. organizational health literacyis part of the organization’s mission statement

1.2 The organization ensures quality management of health literacy (11 indicators) e.g. health literacy relevant data are routinely collected in patient surveys


Standard 2: Develop and evaluate materials and services in a participatory mannerThe organization participatorly involves patients and staff who are targeted by specific documents and services in the development and evaluation of these.

Sub-standards:2.1 The organization involves patients in the development and

evaluation of documents and services (5 indicators), e.g. information sheets, legal information, informed consent forms, apps

2.2 The organization involves staff in the development and evaluation of documents and services (2 indicators), e.g. guidance system of the organization is tested by new staff members or non-local colleagues


Standard 3: Build health literacy skills of staff for patient communicationHealth literacy is part of staff development processes. The organization has curricula for basic and continuous staff training in health literate communication with patients.

Sub-standards:3.1 Staff training on health literate patient communication refers

to all situations that involve communication (14 indicators), e.g. when hiring new staff, importance is given to the health literacy and communication competencies of applicants


Standard 4: Provide easy-to-access health information and services – ensure navigation assistanceThe organization is designed with features that help people find their way. Easily understood language and symbols on signage are used and information that is available about local resources and services can be understood by consumers with low levels of literacy.

Sub-standards:4.1 The organization enables first contact via website navigation and

telephone (14 indicators), e.g. the organization is easy-to-find via internet search engines

4.2 The organization provides information which is relevant for arrival and hospital stay (6 indicators), e.g. all entrance signs are clearly visible from the street

4.3 Support is available at the main entrance to help patients and visitors (7 indicators), e.g. admission is clearly indicated

4.4 The navigation system is clear and easy-to-understand (7 indicators), e.g. signage considers height, location, color and font size

4.5 Health information for patients and visitors is available for free (5 indicators), e.g. menus indicate nutrients and calories to support healthy decisions 59Pelikan - Taiwan Int HPH Conf 21-10-2017

Standard 5: Use health literacy best practices in patient communication

Sub-standards:5.1 Spoken patient communication is easy-to-understand and act on (10 indicators),

e.g. patients are encouraged to ask questions concerning their situation5.2 Design and distribution of written materials are easy-to-understand and act on (9

indicators), e.g. written materials are routinely used as memory aid in patient communication

5.3 Design and distribution of computer applications and new media are easy-to-understand and act on (5 indicators), e.g. computer applications and new media are pre-tested with representatives of target groups

5.4 Native communication is supported by personnel and material resources (11 indicators), e.g. all interpreters / translators use plain, everyday words and phrases

5.5 Communication is easy-to-understand and act on, also in high-risk situations (8 indicators), e.g. a reporting and performance monitoring system for communication errors is available

Patient communication follows health literacy best practices. This is applicable to all forms of communication and to diverse situations, e.g. admission, anamnesis, ward rounds and discharge. Thereby, communication needs of all patient groups are considered.


Standard 6: Improve health literacy of patients and relatives beyond hospital stay

Sub-standards:6.1 The organization supports patients in gaining and improving

health literacy with regard to their disease-specific self-management (6 indicators), e.g. if patients receive recommendations of action, they are informed how to put it into practice at home

6.2 The organization supports patients in gaining and improving their health literacy with regard to the development of healthy lifestyles (4 indicators), e.g. patients' lifestyle and need for change are routinely inquired and documented

The organization promotes health literacy of patients and relatives beyond stay in the hospital.


Standard 7: Improve health literacy of staff

Sub-standards:7.1 The organization supports staff in developing and improving

health literacy for the self-management of occupational health and safety risks (8 indicators), e.g. managers are aware of the effects of their communication on staff health and adapt their management style accordingly

7.2 The organization supports staff in developing and improving health literacy for healthy lifestyles (3 indicators), e.g. the organization offers trainings on healthy lifestyles for staff

The organization promotes health literacy of staff both with regard to the self-management of occupational health and safety risks and with regard to healthy lifestyles.


Standard 8: Contribute to improvement of health literacy in the region

Sub-standards:8.1 The organization promotes continuous and integrated care

(11 indicators), e.g. if needed, relatives or social services are involved in discharge management

8.2 The organization contributes to public health within the realm of its possibilities (3 indicators), e.g. the organization also runs interventions for hard to reach groups in the region, e.g. socio-economically disadvantaged or migrant communities

When discharged, patients are well informed about their future treatment and recuperation process. The organization is publicly engaged, and collaborates with others to improve population health.


Standard 9: Share experiences and act as role model

Sub-standards:9.1 The organization supports the dissemination and further

development of health literacy (5 indicators), e.g. the organization participates in health literacy research and development projects

The organization actively supports and promotes the implementation of organizational health literacy practices across organizational boundaries.


Feasibility study of the Vienna-HLO self-assessment tool

− Aim was to explore whether:• Standards, sub-standards and indicators are understandable and

relevant• Procedure of self-assessment is understandable and doable• Results are useful for organizational diagnosis and

benchmarking

− Methods: • Descriptive analysis of self-assessment data and of feedback on

the tool • Follow-Up interviews with coordinators of the self assessment in

hospitals

− Participants:• 9 hospitals differing in type out of 5 federal states of Austria

− Study took place between October 2014 and March 201565Pelikan - Taiwan Int HPH Conf 21-10-2017

Results of the Vienna-HLO feasibility study

1.7

2.1

1.7

2.01.91.8

1.6 1.6 1.6

1.8 1.81.9 1.9 1.9

2.2

2.4

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

Standard 4 -supportive

environment

Standard 7 -improving staff

HL

Standard 6 -improving

patients' HL

Standard 8 -improving

community HL

Standard 5 -communicationwith patients

Mean Standard 3 -qualifying staff

Standard 9 -networking

Standard 1 -organizational

policy

Standard 2 -participationwith users

Hospital 1

Hospital 2

Hospital 3

Hospital 4

Hospital 5

Hospital 6

Hospital 7

Hospital 8

Hospital 9

Mean

Wide variation

Small variation


Major conclusions from the Vienna-HLO feasibility study

− The model is comprehensive, but can be modularized for implementation

− The standards are seen as relevant & the self-assessment tool as comprehensible and feasible

− Self-assessment can support organizational diagnosis & benchmarking & identification of areas in need for development

− Specific improvements can be initiated by using the tool box

To make the tool accessible to other countries as well as to HPH, the tool has been translated into English!


Working group on HPH & HLO – terms of reference

The HPH-GB approved the working group in December 2016!Its terms of reference are:1. Adaptation to and translation of tools and indicators for different health

care contexts based upon the “Vienna Concept of a Health Literate Health Care Organization (V-HLO)” and recent developments for monitoring, benchmarking and improving organizational HL in health care;

2. Giving examples on best evidence practices of HLO related to HPH models and tools (evidence, staff competences and patient preferences);

3. Disseminate best practice examples of HLO and HPH models and tools through the International HPH Network;

4. Support the increase of health professionals’ competence on health literate health care;

5. Establishing a database for health literate hospitals and health services programs.

The WG is working by interactive workshops at international HPH ICs and virtual meetings in between.Members come from Austria, Belgium, Germany, Israel, Italy and Taiwan


There is a growing number of resources and tools for Good Practice Health Literacy Interventions and Measures

WHO Regional Office for Europe (2013): Health Literacy. The Solid Facts.


World Health Communication Association. (2011): Health Literacy „The Basics“ Revisited Edition.

http://www.whcaonline.org/uploads/publications/WHCAhealthLiteracy-The%20Basics.pdf

DeWalt, DA., Callahan, LF., Hawk, VH., Broucksou, KA., Hink, A. (2010): Health Literacy Universal Precaution Toolkit. Edited by the Agency for Healthcare Research and Quality.http://www.nchealthliteracy.org/toolkit/Toolkit_w_%20appendix.pdf



http://www.whcaonline.org/uploads/publications/WHCAhealthLiteracy-The%20Basics.pdf

DEVELOPING HEALTH LITERATE HEALTH CARE ORGANIZATIONS CAN BE SUPPORTED BY NATIONAL EFFORTS FOR HEALTH LITERATE SYSTEMS AND SOCIETY


USA (2003-2010)

» National Action Plan to Improve Health LiteracyThe National Action Plan to Improve Health Literacy seeks to engageorganizations, professionals, policymakers, communities, individuals, and families in a linked, multi-sector effort to improve health literacy. The Action Plan is based on 2 core principles:» All people have the right to health information that helps them make

informed decisions» Health services should be delivered in ways that are easy to understand

and that improve health, longevity, and quality of lifeThe Action Plan contains 7 goals that will improve health literacy and strategies for achieving them:1. Develop and disseminate health and safety information that is accurate, accessible, and actionable2. Promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and educationthrough the university level4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community5. Build partnerships, develop guidance, and change policies6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy7. Increase the dissemination and use of evidence-based health literacy practices and interventions.Many of the strategies highlight actions that particular organizations or professions can take to further these goals. It will take everyone working together in a linked and coordinated manner to improve access to accurate and actionable health information and usable health services. By focusing on health literacy issues and working together, we can improve the accessibility, quality, and safety of health care; reduce costs; and improve the health and quality of life of millions of people in the United States.


Minnesota (2015 - 2016)

Minnesota Action Plan to Improve Health Literacy» Table of Contents» Foreword …i » Executive Summary (1-)» Approach to Developing the Action Plan (3-» •Co-sponsors (3-)» Understanding Health Literacy (5-)» •Glossary (6-)» Barriers to Health Literacy (8-)» Priorities for Improving Health Literacy (10-)•Adopt and use health literacy best practices across all verbal, written and visual communication (10-)•Make information about health relevant and accessible (13-)•Increase and improve patient-centered resources (14-)•Implement and enhance education opportunities at all levels (15-)•Streamline processes within the health care system (17-)•Invest in language and cultural resources (17-)» Conclusion (20_)


Scotland (2009 – 2014)» Making it Easy» Highlights the hidden problem of low health

literacy and the impact that this has on our ability to access understand, engage and participate in our health and social care.

» Explains that low health literacy leads to poor health outcomes and widens health inequality.

» Calls for all of us involved in health and social care to systematically address health literacy as a priority in our efforts to improve health and reduce health inequalities.

» Sets out an ambition for all of us in Scotland to have the confidence, knowledge, understanding and skills we need to live well, with any health condition we have.

» Lays out the actions the Scottish Government and partners are taking to help all of us in health and social care collaborate and help realise this ambition.

To explore the rationale, evidence and processes that led to the development of Making it Easy, please visit the Health Literacy Place at www.healthliteracyplace.org.uk

Focus on health literate society!Actions:Training of health professionalsUse of specific methodsNational web siteImplementation by national coordination center


Australia (2014): Health Literacy: Taking Action to Improve Safety and Quality A coordinated approach & summaries for stakeholders

Pelikan - Taiwan Int HPH Conf 21-10-2017 74

» Improving your organisation’s health literacy environment

» Five fact sheets have been developed to support health service organisation’s improve their health literacy environment. The next version of the NSQHS Standards has a greater emphasis on partnerships with consumers and embedding health literacy into your organisation’s systems. The following fact sheets link staff working in quality improvement to a range of tools and examples to help you plan how to improve your organisation’s health literacy environment.

» Fact sheet 1: An introduction to improving health literacy in your organisation (PDF 389 KB)

» Fact sheet 2: Making health literacy part of your policies and processes (PDF 302 KB)

» Fact sheet 3: Making way-finding easier (PDF 385 KB)» Fact sheet 4: Writing health information for

consumers (PDF 326 KB)» Fact sheet 5: Supporting staff to meet health literacy

needs (PDF 335 KB)» NSQHS Standards and health literacy

A tip sheet is also available on how action to improve health literacy will help your organisation meet the requirements of the NSQHS Standards

» NSQHS Standard 2 – Partnering with consumers Tip Sheets

Australia (2014): Iconographies & Fact sheets


https://www.safetyandquality.gov.au/wp-content/uploads/2017/07/Health-Literacy-Fact-Sheet-1-Introduction-to-improving-health-literacy.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2017/07/Health-Literacy-Fact-Sheet-2-Making-health-literacy-part-of-policies-and-processes.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2017/07/Health-Literacy-Fact-Sheet-3-Making-way-finding-easier.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2017/07/Health-Literacy-Fact-Sheet-4-Writing-health-information-for-consumers.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2017/07/Health-Literacy-Fact-Sheet-5-Supporting-staff-to-meet-health-literacy-needs.pdf

https://www.safetyandquality.gov.au/publications/nsqhs-standard-2-partnering-with-consumers-tip-sheets/

76

New Zealand (2015)


77

We have developed A Framework for Health Literacy to support each level of the health and disability system in responding to the health literacy needs of all New Zealanders.http://www.healthliteracy.co.nz/page/about-health-literacy/


http://www.health.govt.nz/publication/framework-health-literacy

http://www.healthliteracy.co.nz/page/about-health-literacy/

New Zealand – Guide for a health literate organization

» When your organisation decides to carry out a health literacy review, it is committing to making health literacy business as usual.

Building health literate organisations» Because of the way health systems and services are designed and delivered,

consumers sometimes face a series of demands on their health literacy. These demands impact on consumers’ ability to access health information, care and services.

» This guide has been developed with input by health literacy experts and piloted by 3 DHBs to support health organisations reduce those demands on consumers, and provides practical tools to support everyone working in a health care setting build a health literate health system.

A health literacy review will:1. identify what your organisation is already doing well2. identify the actions you need to take to improve3. lead to the development of a Health Literacy Action Plan4. help make health literacy business as usual.


New Zealand -Health Literacy Review: A Guide

» Health Literacy Review: A Guide has been developed to take you through the review process and show you how to develop a Health Literacy Action Plan. The pages below provide:

» more information about the Guide» advice from 3 district health boards who have trialed the Guide» videos and documents to help you conduct a review and design the Action Plan.» If you have any feedback on the Guide and training materials, let us know using our

Feedback form.A health literacy review is an opportunity to:» look at your organisation’s health care services» identify what supports consumers and their families to access your services and manage

their health» identify the barriers that consumers and their families come across when accessing your

services and managing their health.A health literacy review could focus on:» a known service issue for your organisation» a service that is interested in health literacy and wants to improve the health outcomes

of consumers» services related to an area of high health needs.


http://www.health.govt.nz/publication/health-literacy-review-guide

http://www.health.govt.nz/about-site/feedback?ref=https://www.health.govt.nz/our-work/health-literacy/health-literacy-reviews

Health literacy in the Austrian (health) policy context


National activity area 1: Health literate healthcare organizations: The „Viennese concept of health literate healthcare organizations“ –Self-assessment tool with 9 Standards (22 Sub-Standards, 160 Indicators) – since 2013

National activity area 2: Quality of communication in healthcare (since 2015)

National activity area 3: Quality of health information (since 2017)

CONCLUSIONS


Conclusions

1. Health Literacy is a core concept of Health Promotion, therefore it should also be an integrative part of Health Promoting Hospitals

2. Health Literacy is a mesuarable and modifiable concept which easily can be integrated into quality management in Health Care Services

3. There is empirical evidence for considerable proportions of people with limited HL, for a social gradient of HL, and for HL as a relevant social determinant of health

4. There is specific empirical evidence for detrimental impacts of low HL on use and outcomes of Health Care Services

5. There are many single measures which can be taken to improve HLin Health Care Services, but the holistic, integrative approach of the Health Literate Organization or Setting is to be preferred

6. There are quite a number of tools and resources for implementing Health Literate Health Care Organizations already availabe

7. A national HL policy on the macro level, can support implementing Health Literate Organizations on the meso level.


“The single biggest problem with communication is the illusion that it’s taken place” (George Bernard Shaw)


Prof. em. Jürgen M. Pelikan, Ph.D. Director, WHO-CC HPH

Stubenring 61010 Vienna, AustriaT: +43 1 515 61-F: +43 1 513 84 72E: [email protected]

http://www.lbihpr.lbg.ac.athttp://www.health-literacy.eu

84

Thank you so much for your kind attention!


http://www.goeg.at/

20171022 how can healthliteracy be used to support reaching the sdgs by prof. jürgen m. pelikan

Health & Medicine