jürgen m. pelikan, christina dietscher, jakob lorenc

LBIHPR: A-1020 Vienna, Untere Donaustraße 47, Austria | [email protected] | www.lbihpr.lbg.ac.at | +43 1 2121493 -10 | FAX - 50

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)


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)

HL

Specific

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


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.”


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


Examples for strengthening health literacy-friendly settings


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


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


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


A first proposal for awhole-systems HL approach


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)


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 HLRelating to specific HP principlesChange / quality / risk management


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


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


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


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


The ISQUA process for standard development

1. Establishing need for new standards, priorities

2. Relationships with other standards considered

3. Standards development plan

4. Standards based on research, guidelines, technical input

5. Involvement of interested parties in development process

6. Clear scope and purpose of standards

7. Clear standards framework

8. Clear wording of standards

9. Testing/Piloting of standards

10. Approval of standards by standards setting body

11. Information and education to users and assessors

12. Timeframes, transitional arrangements for implementation

13. Satisfaction with standards monitored, data evaluated


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)


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


Jürgen M. Pelikan [email protected] Dietscher [email protected]

THANK YOU FOR YOUR ATTENTION!

jürgen m. pelikan, christina dietscher, jakob lorenc

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