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
LBIHPR: A-1020 Vienna, Untere Donaustraße 47, Austria | office@lbihpr.lbg.ac.at | www.lbihpr.lbg.ac.at | +43 1 2121493 -10 | FAX - 50
Like literacy, health literacy is a relational concept
Source: Parker, 2009
Skills/Abilities X Demands/Complexity = Health Literacy
Health Literacy Equation: Source: Brach 2013
Health Literacy = f (Personal Skills/Abilities, Situational Demands/Complexity)
Source: Pelikan 2013 (in tradition of Kurt Lewin)
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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How can health literacy be understood? – 4 elements of a comprehensive 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?
A resource for decisions of relevance to health
HL
Specific
General
Science, media, IT
literacy (etc.)
Knowledge
(on health /
disease)
Health
literacy
Motives
(on health / disease)
Basic literacy and numeracy
(PIACC, PISA)
Competences
(health knolwedge
management)
Proficiency in local language & culture
in country of residence
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?
To …
Access
Understand
Appraise
Apply
Health Care
Health-related information
(Source: Sorensen et al. 2012)
Disease
prevention
Health
promotion
 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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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2.1 Health Literacy as a Comprehensive Concept –
Integrated Model and Definition of Health Literacy for the HLSEU 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.”
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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Low Health Literacy Levels are considerable & vary by Country!
Percentage Distributions of Comprehensive HL Levels, for Countries and Total
Sample (HLS-EU 2012)
inadequate comp.-HL
Netherlands
1.8%
10.3%
Poland
10.2%
29.7%
11.0%
TOTAL
12.4%
Spain
0%
38.2%
30%
16.5%
33.7%
9.9%
32.6%
35.2%
20%
19.6%
36.0%
50.8%
10%
15.6%
34.1%
35.2%
26.9%
19.5%
39.6%
35.3%
7.5%
21.3%
35.9%
30.9%
18.2%
Bulgaria
25.1%
38.7%
34.4%
Germany
excellent comp.-HL
46.3%
13.9%
Austria
sufficient comp.-HL
26.9%
Ireland
Greece
problematic comp.-HL
40%
50%
26.6%
60%
70%
80%
9.1%
11.3%
90%
100%
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]
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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Examples for strengthening health literacy-friendly settings
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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 life
2.
For entry to sick role: observation & appraisal of symptoms of disease
3.
In sick role: Decision on self care/ use of the professional health care system
4.
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 tests
7.
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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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


Concerning Quality 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.
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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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A first proposal for a
whole-systems
HL approach
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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)
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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 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
Specific to HL
Relating to specific HP principles
Change / quality / risk management
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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Our proposal for a comprehensive whole-sale (health
promoting) HLO concept
Health literacy
for …
Acessing, living
and working in
the hospital
Diagnosis, cure
and care
Disease
prevention
Health
promotion
Patients
Staff
Community
3 Support navigation and on-site healthy choices
4 Support healthy
decisions in diagnosis, cure, care
2 Foster
communication
competence of staff
7.1 Support
continuity and
cooperation
5 Support future
decisions in relation
to prevention, selfcare and health
promotion
6 Support future
decisions in relation
to prevention, selfcare and health
promotion
7.2 Support future
decisions in relation
to prevention, selfcare and health
promotion
Organizational
structures and
processes
1 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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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The ISQUA process for standard development
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Establishing need for new standards, priorities
Relationships with other standards considered
Standards development plan
Standards based on research, guidelines, technical input
Involvement of interested parties in development process
Clear scope and purpose of standards
Clear standards framework
Clear wording of standards
Testing/Piloting of standards
Approval of standards by standards setting body
Information and education to users and assessors
Timeframes, transitional arrangements for implementation
Satisfaction with standards monitored, data evaluated
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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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)
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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References & Resources
Brach, 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/DiscussionPapers/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
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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THANK YOU FOR YOUR
ATTENTION!
Jürgen M. Pelikan
Christina Dietscher
juergen.pelikan@lbihpr.lbg.ac.at
christina.dietscher@lbihpr.lbg.ac.at
Pelikan, J.M., Dietscher, C. Lorenc, J. (2014): 22nd International HPH Conference Barcelona, April 23-25, Health-Literate Organization
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