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Further Developing concept and tools of the Health Literate Health Care Organization using HPH, HLS-EU and quality management methodology
Jürgen M. Pelikan, Christina Dietscher, Jakob Lorenc
Ludwig Boltzmann Institut Health Promotion Research, WHO-CC Health Promotion in Hospitals and Health Care
2Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Like literacy, health literacy is a relational concept
Source: Parker, 2009
Skills/Abilities X Demands/Complexity = Health LiteracyHealth Literacy Equation: Source: Brach 2013
Health Literacy = f (Personal Skills/Abilities, Situational Demands/Complexity)Source: Pelikan 2013 (in tradition of Kurt Lewin)
3Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
How can health literacy be understood? – 4 elements of a compre-hensive definition used for the HLS-EU survey (Sorensen et al 2012)
1) What is the core of health literacy? 2) What general literacies does health literacy build up on?
3) What specific competences are needed to manage health related knowledge and information?
4) What health-related decisions and actions is health literacy needed for?
A resource for decisions of relevance to health
Health literacy
Motives (on health / disease)
Competences (health knolwedge management)
Knowledge (on health /
disease)
HLSpecific
General
Science, media, IT literacy (etc.)
Basic literacy and numeracy (PIACC, PISA)
Proficiency in local language & culture in country of residence
Health Care Health promotion
Disease prevention
Access Understand Appraise Apply
To …
Health-related information (Source: Sorensen et al. 2012)
Find / access: in data sources or by asking lays / experts Understand: texts / spoken language / pictures, tables, graphs Appraise: quality of information / of information source Apply: in own context / situation
4Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
2.1 Health Literacy as a Comprehensive Concept – Integrated Model and Definition of Health Literacy for the HLS-EU Study (Sorensen et al. 2012)
“Health literacy is linked to literacy and encompasses people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in
everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course.”
5Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Low Health Literacy Levels are considerable & vary by Country!Percentage Distributions of Comprehensive HL Levels, for Countries and Total Sample (HLS-EU 2012)
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]
Netherlands
Ireland
Poland
Greece
Germany
TOTAL
Austria
Spain
Bulgaria
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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%
inadequate comp.-HL problematic comp.-HL sufficient comp.-HL excellent comp.-HL
6Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Examples for strengthening health literacy-friendly settings
7Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Why is health literacy of patients important within the health care system? In the health care system health is restored by co-production (not by „compliance“!) of patients
and health professionals, based on partnership in diagnosis and therapy by Shared Decision Making Collaboration in actions
Requirements for co-production are Sufficient competence (i.e. health literacy of patients) for decision-making & ability to cooperate
These requirements have to be guaranteed by representatives of the health care system by Enablement, empowerment & participation of patients
This is necessary for normative reasons (patient rights & patients expectations etc.), for practical reasons, since co-production serves the evidence-based quality of health care
(effectiveness, efficacy & sustainability). Better suitable entry to the professional health care system Better collaboration of patients regarding diagnosis & therapy Better diagnosis Better compliance in therapy Less medical errors Less clinical costs
8Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Health literacy is important in different stages of a patient´s career 1. For healthy living: appraisal and taking into account of health risks & health
resources continuously in everyday life2. For entry to sick role: observation & appraisal of symptoms of disease3. In sick role: Decision on self care/ use of the professional health care system4. For entry to patient role: Decision to use of specific institutions of health care
system (navigating the system)5. In acute patient role: Description of symptoms and own life situation (&
ability to ask relevant questions) during anamnesis, medical round, exit interview
6. In acute patient role : Cooperation in diagnostic tests7. In acute patient role : Cooperation in therapy within and outside the health
care system (shared decision making; compliance)8. For role of chronic patient: self-management capacity to live a healthy life
with a chronic condition
9Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
How can health literacy be integrated into health care and what specific difference does it make?
Health literacy emphasizes the relevance and conditions of information & communication & decisions of all involved parties for the processes & results of health care
Concerning Health Care HL is a developable & measurable, individual & organizational resource, which is an input
as well as an output of processes & results in health care with a strong link to the concepts of shared decision making & self-care-management.
Concerning Quality HL is A specific measurable quality of individuals and systems with a strong link to the
concepts of effectiveness and efficacy resp. of user-/patient-orientation and employee-orientation
Concerning Health Promotion (and Public Health) HL is A measurable core concept of HP applicable to individuals & settings with a strong
link to other core concept of HP like empowerment (enablement) & participation, social determinants of health
10Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
A first proposal for awhole-systems HL approach
11Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
The concept of a health literate health care organizations
„A health literate organization makes it easier for people to navigate, understand, and use information and services to take care of their health.” (Brach et al. 2012)
12Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Ten attributes of health literate healthcare organizations (and systems) (Brach et al. 2012): A HL organization …
1. Has leadership that makes HL integral to its mission, structure, and operations2. Integrates HL into planning, evaluation, patient safety, quality improvement3. 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 stigmatization6. Uses HL strategies in interpersonal communications and confirms understanding
at all points of contact7. Provides easy access to health information and services & navigation assistance8. 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 medicines10. Communicates clearly what health plans cover and what individuals will have to
pay for services Specific to HLRelating to specific HP principlesChange / quality / risk management
13Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
The current HLO approach – yes, but …
Inductively developed approach without a clear theoretical background Focused mainly on outcomes of clinical care with potential to expand
the HLO impact by also addressing future decisions in relation to healthcare, self management and health-related choices in daily life
Focused on patients only Insufficiently connected to other healthcare reform approaches such
as quality, Health Promoting Hospitals Strongly driven by US healthcare context – legal and financial
incentives such as capitation-based healthcare financing not automatically applicable to other contexts
Need for further development
14Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Learning from quality
Clear differentiation between structures, processes and outcomes needed important for defining indicators, supporting measurement
and continuous further development Build capacities to support CQI of HLO Focus on staff not only as service providers but as target
group themselves Development of comparable indicators / standards to
support learning and exchange across organizations Benchmarking
15Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Learning from Health Promoting Hospitals and other health promotion settings In addition to focusing on cure and care, include also:
Living in the hospital Future disease prevention Future health promotion
not only compensate low health literacy but actually empower for better health literacy
Expand target groups from patients to also Staff Community
Adapt concept to local healthcare system and strategies – establish conceptual links to liaise with potential allies
16Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Our proposal for a comprehensive whole-sale (health promoting) HLO concept
Health literacy for … Patients Staff Community
Organizational structures and
processes
Acessing, living and working in the hospital
3 Support navigation and on-site healthy choices1 Developing a HLO management policy and supportive organizational structure
8 Involve target groups in the development and evaluation of communication strategies and tools
9 Support concept dissemination
Diagnosis, cure and care
4 Support healthy decisions in dia-gnosis, cure, care
2 Foster communication competence of staff
7.1 Support continuity and cooperation
Disease prevention 5 Support future
decisions in relation to prevention, self-care and health promotion
6 Support future decisions in relation to prevention, self-care and health promotion
7.2 Support future decisions in relation to prevention, self-care and health promotionHealth
promotion
17Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
The ISQUA process for standard development
1. Establishing need for new standards, priorities2. Relationships with other standards considered3. Standards development plan4. Standards based on research, guidelines, technical input5. Involvement of interested parties in development process6. Clear scope and purpose of standards7. Clear standards framework8. Clear wording of standards9. Testing/Piloting of standards10. Approval of standards by standards setting body11. Information and education to users and assessors12. Timeframes, transitional arrangements for implementation13. Satisfaction with standards monitored, data evaluated
18Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Further information on health literacy concepts at this conference Plenary 2 (Thursday, 09.00-10.30): Health literacy – an emerging concept for more
patient-oriented healthcare Rima Rudd (Harvard): Health Literacy – an Emerging Concept for More Patient-Oriented
Healthcare Rosa Suñer (HL working group, HPH Catalunya): Making healthcare organizations more
healthy – Literacy settings for patients Hans Kluge (WHO-Euro): The contribution of health literacy to patient safety
Session O1.1 (Thursday, 11.00-12.30): Developing health literate healthcare systems and organizations Further Developing concept and tools of the Health Literate Health Care Organization
using HPH, HLS-EU and quality management methodology? (Pelikan, Dietscher, Lorenc)
Health Literacy, Chronic Illness, and Use of Primary, Secondary and Tertiary Healthcare - Making the Case for Health Literate Organizations (Levin-Zamir, Baron-Epel, Elhayany)
A Path to becoming a Health Literate Organization: Lessons Learned from the Experience of a Public Health Authority in Canada (Massé, Lemieux)
Health Literacy as a system strategy in Emilia-Romagna (Gazzotti, Ricco, Chiarenza, Ruozi)
19Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
References & ResourcesBrach, C., Keller, D., Hernandes, LM., Baur, C., Parker, R., Dreyer, B., Schyve, P., Lemerise, AJ., Schillinger, D. (2012): Attributes of Health Literate Organization, Discussion Paper, Institute of Medicine of the national academies. http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_HLit_Attributes.pdf
Brach, C. (2013): Becoming a Health Literate Organization: Tools for Community Health Centers. Presentation 3.April 2013 at the Center for Delivery, Organization and Markets.
DeWalt, D.A., Callahan, L.F., Hawk, V.H., Broucksou, K.A., Hink, A., Rudd, R. & Brach, C. (2010). Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD: Agency for Healthcare Research and Quality.
Kickbusch,I., Maag, D. (2008): Health Literacy. In: Heggenhougen,H.K., Quah,S.R. (Eds.), International Encyclopedia of Public Health, Vol. 3. (pp.204-211). San Diego: Academic Press.
Kickbusch I, Pelikan J M, Apfel F, Tsouros A D (Eds.) (2013): Health literacy. The solid facts. Copenhagen: Copenhagen: World Health Organization – Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf
Levin-Zamir, D, Peterburg Y. (2001): Health literacy in health systems – perspectives on patient self-management Health Promotion International,16;1:87-94.
Nutbeam,D. (2000): Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15 (3), 259-267.
Nutbeam,D. (2008): The evolving concept of health literacy. Social Science & Medicine, 67 (12), 2072-2078.
Parker, R. in World Health Communication Association (2009): Health Literacy, Part 1 „The Basics“. WHCA Action Guide.
Pelikan,J.M., Dietscher,C., Schmied,H. (2013): Health Promotion for NCDs in and by Hospitals: A Health Promoting Hospital Perspective. In: McQueen,D. (Ed.), Global Handbook on Noncommunicable Diseases and Health Promotion (pp.441-460). New York, Heidelberg, Dordrecht, London: Springer.
Pleasant, A. & Kuruvilla, S. (2008): A tale of two literacies: public health and clinical approaches to health literacy. Health Promot. Int. 23(2) 152-159.
Rudd,R. (2005): Navigating Hospitals: Literacy Barriers. Literacy Harvest
Rudd, R.E. & Anderson, J.E. (2006).The Health Literacy Environment of Hospitals and Health Centers – Partners for Action: Making your healthcare facility literacy-friendly. National Center for the Study of Adult Learning and Literacy and the Health and Adult Literacy and Learning Initiative, Harvard University School of Public Health.
Sorensen,K., Broucke,S., Fullam,J., Doyle,G., Pelikan,J., Slonska,Z., Brand,H., (HLS-EU) Consortium (2012): Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12 (80).
WHO (1986): Ottawa Charter for Health Promotion. In World Health Organization (Ed.), Geneva: WHO.
WHO (1998): Health promotion glossary. Geneva: WHO
20Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
Jürgen M. Pelikan [email protected] Dietscher [email protected]
THANK YOU FOR YOUR ATTENTION!