University of Groningen Improving communication in healthcare for patients with low health literacy Kaper, Marise

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Improving communication in healthcare for patients with low health literacy

Kaper, Marise

DOI:

10.33612/diss.172455932

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Publication date: 2021

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Kaper, M. (2021). Improving communication in healthcare for patients with low health literacy: Building competencies of health professionals and shifting towards health literacy friendly organizations. University of Groningen. https://doi.org/10.33612/diss.172455932

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559391-L-bw-Kaper 559391-L-bw-Kaper 559391-L-bw-Kaper 559391-L-bw-Kaper Processed on: 27-5-2021 Processed on: 27-5-2021 Processed on: 27-5-2021

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General discussion

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Many people in Europe experience problems because of their limited health literacy skills. Health care professionals and organizations have the potential to mitigate these problems by tailoring their communication and provision of care towards the needs and abilities of patients with low health literacy, and empower them by strengthening their health literacy skills. Therefore,

the main aim of this thesis is to assess how health care professionals and organizations can improve communication with and provision of care to people with limited health literacy. This thesis is based on five studies, in

which we investigated the effectiveness of two comprehensive approaches to promote effective communication by professionals and to improve the tailoring of health services to the abilities of people.

In the first section we present the main findings of this thesis; we discuss them in the second section and reflect on methodological considerations in section three. In the fourth section we elaborate on implications for practice and future research, and in the last section we present our general conclusion.

MAIN FINDINGS

Objective 1 (Chapter 2): To develop and pilot test a comprehensive health literacy

communication training for health professionals in Italy, Ireland, and the Netherlands.

Our comprehensive health literacy communication training consisted of five training components to address functional, interactive and critical health literacy: health literacy education, gathering and providing information, encouraging shared decision-making, enabling self-management, and supporting behaviour change. Health professionals endorsed the training program. The findings of the pilot among thirty health professionals in three European countries showed that this comprehensive training can strengthen their self-reported competencies regarding knowledge of health literacy, and their confidence and skills to communicate with people who have limited health literacy.

Objective 2 (Chapter 3): To evaluate whether: (1) a comprehensive health literacy

training increased self-rated competencies of health professionals to address health literacy related problems, and support the development of people’s autonomy and self-management abilities; after training and 6-12 weeks later, (2) professionals

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were satisfied with the training; and (3) outcomes differed for the three participating European countries.

In the three countries, self-rated health literacy competencies of health professionals (n = 106) significantly increased following this comprehensive training; this increase persisted at 6-12 weeks follow-up. The strongest increase was related to professionals’ ability to enhance shared-decision making and enable self-management, immediately after the training and at follow-up. Professionals were satisfied with the training and perceived it as relevant for practice. Increases in competency did not vary systematically between countries.

Objective 3 (Chapter 4): To assess whether this comprehensive Health Literacy

Medical Consultation Skills (MCS)-training increased the health literacy competencies of undergraduate medical students in a Randomized Controlled Trial (RCT), with a waiting list condition.

The MCS training increased the health literacy competencies of undergraduate medical students and was well received by them (n = 79; intervention: 39; control: 40). Students who had received the training reported significantly better self-rated health literacy competencies, both after the training and five weeks later. The greatest improvements were in providing comprehensible information, encouraging shared decision-making, and enabling self-management. Observations of demonstrated skills confirmed these increases in self-rated competencies.

Objective 4 (Chapter 5): The aim is to summarize the evidence on: (1) the outcomes

of OHL-interventions at patient, professional and organizational levels; and (2) factors and strategies that affect implementation and outcomes of these interventions.

We conducted a scoping review, which yielded 24 articles presenting descriptive studies on outcomes of OHL-interventions. Of these, 23 studies reported on health literacy problems in relation to OHL-assessment tools, showing that patients encounter problems with, for example, communication, navigation, and fragmented health care. Nine out of thirteen studies focusing on OHL-interventions reported that use of OHL-interventions resulted in positive changes regarding comprehensible communication, professionals’ competencies

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and practices, and strategic organizational changes. Evidence on patient related outcomes needs strengthening. Critical factors for organization-wide implementation of OHL-interventions were leadership support, a simultaneous top-down and bottom-up approach, a change champion committee, and staff commitment.

Objective 5 (Chapter 6): To assess the implementation fidelity, moderators (barriers

and facilitators), and the long-term impact of Organizational Health Literacy-interventions in hospitals in Ireland and The Netherlands.

Implementation of OHL-interventions resulted in sustainable and organization-wide health literacy changes in four hospitals. Staff (n = 24) and older adults (n = 40) reported a number of communication problems. OHL-interventions were implemented by staff to promote navigation and comprehensible communication. Several barriers and facilitators were reported to influence implementation processes. In the long term, the OHL-interventions were reported to lead to organization-wide improvements, such as a better embedding of health literacy policies, enhanced patient engagement, and provision of plain language training and more comprehensible information. Findings were similar for the two countries.

DISCUSSION OF MAIN FINDINGS

In the first section we discuss our findings regarding the health literacy training for health professionals, and in the second our findings regarding the OHL-interventions. In the third section we discuss the similarities between study findings in several European countries regarding both the training and the OHL-interventions.

Effects of comprehensive health literacy training for health

professionals

The comprehensive health literacy training for (future) health professionals addressed a wide range of competencies related to communication with patients with low health literacy. These included enhancing of shared decision-making, strengthening patients’ self-management, in addition to gathering information, and using comprehensible communication. The training also

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addressed the integration of these competencies into practice by specifying objectives and action plans, and by strengthening commitment (Chapters 2, 3 and 4). Here we consecutively reflect on the effectiveness of the training regarding its outcomes, health literacy content, and educational strategies.

Among (future) health professionals, on a wide range of self-rated health literacy competencies we found positive outcomes, and these persisted six to twelve weeks after the training (Chapters 2 and 3). An increase in observed competences in a subsample of medical students confirmed the self-reported findings (Chapter 4). This increase in competencies supports findings in other studies on health literacy training [1, 2], many of which also reported increased knowledge and skills in more comprehensible communication; however, many studies had no control group or pre-post measurements [3– 5]. We found, among a variety of health professionals in a multi-centre study in three different European countries (Chapters 2 and 3) and undergraduate medical students participating in an RCT in the Netherlands (Chapter 4), that this newly evaluated training particularly enhanced competencies related to the interpersonal skills: encouraging of shared decision-making and strengthening of self-management.

Our positive findings related to wider health literacy competencies can be explained in several ways. A first explanation is the design of the training, informed by evidence-based components of health literacy training for professionals [3, 4, 6], and effective health literacy interventions for patients, as reported in a review by Brainard et al. (2016) [7]. Significant improvements in health literacy outcomes were found after patients had taken part in these interventions [7], which involved strategies to strengthen health knowledge, self-efficacy, self-management skills, changes in lifestyle, and engagement in health care [7–12]. In the training we therefore focused on strengthening these interpersonal competencies of professionals to empower patients in shared decision-making and self-management skills. This comprehensive training can thus enable professionals to address a wider scope of health literacy problems in vulnerable populations [13, 14].

A second explanation for our positive outcomes is that we tailored the training’s objectives, components, and learning strategies to the needs reported by health professionals in focus group discussions (Chapter 2) [15]. In these discussions professionals described their own practical experiences related to health literacy, and their preferences for interactive and real-world learning strategies based on case vignettes of patients with low health literacy

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(Chapter 2) [3, 15]. Overall, the professionals shared similar perspectives and endorsed the prototype training program (Chapter 2). However, the Irish participants focused on understanding the social context of people with lower health literacy, whereas Dutch professionals emphasized addressing potential facilitators and barriers to the practical application of health literacy strategies (Chapter 2). The suggestions of both were incorporated in the training. The content of the training components was similar for each country, but some examples and role-plays were tailored to country-specific contexts. After the training, professionals reported that it corresponded with their practice, and increased their motivation and competencies to address health literacy (Chapter 2) [3, 15].

A third explanation for our outcomes was that we chose interactive learning strategies, in line with principles for effective learning and with competency-based approaches, as used in health care education [3, 15, 16]. These strategies had several components: (1) a sequence of training sessions and interactive strategies, such as sharing of experiences and small group discussions; (2) role-played consultations to practice communication skills, followed by personalized feedback; and (3) strategies to promote transfer of the training into practice [3, 4, 15–17]. These findings indicate that this approach augmented the effectiveness of the training.

How comprehensive OHL-interventions can improve

organizational health literacy

Our scoping review and empirical study (Chapters 5 and 6) revealed that: (1) frequently identified OHL-related problems were related to complex information and communication, and fragmented and difficult-to-navigate health care services [18–34]; (2) organization-wide implementation of OHL-interventions resulted in promising professional and organizational outcomes, and more limited patient-related outcomes [19, 27, 35–39]. Several barriers and facilitators were found to influence implementation processes (Chapters 5 and 6). All of these findings were based on descriptive studies.

Recent studies, which used a systematic approach to implement OHL-interventions, seemed to result in greater transformation at professional and organizational levels [19, 27, 35–40] (see Chapter 5), compared to the findings reported in the reviews by Farmanova et al. (2018) [41] and Lloyd et al. (2018) [42]. The prevalence of OHL-problems we found across various countries, highlights the urgency to apply comprehensive OHL-frameworks and enlarge

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the health literacy responsiveness of organizations [26, 43–48]. Recent studies we identified, demonstrated this progress on health literacy responsiveness through organization-wide implementation of OHL-interventions [19, 27, 35– 39]. At the professional level we found increased awareness and competencies to address health literacy, which may help to enhance comprehensible communication and provide health care that is health literacy friendly [44, 45]. Organizational changes which we identified involved integration of OHL into strategic policies, improved comprehensibility of oral and written communication, and sustainable programs for staff capacity building and patient engagement [19, 27, 35–37]. Chapters 5 and 6 report our findings that critical facilitators and barriers influenced the implementation of OHL-interventions; this supports findings of other studies [37, 41, 42, 49]. In effect, our findings point to progress in the field of OHL-interventions [41, 42]

Our findings regarding the impact of OHL-interventions may be the result of a systematic approach to their implementation, which also takes into account the influence of critical facilitators and barriers [49]. Our scoping review (Chapter 5) and our empirical study (Chapter 6) showed the following facilitators to be critical for the long-term impact of OHL-interventions: a change champion and project committee, leadership support and sufficient resources, involvement of patients, and commitment of staff [19, 27, 28, 35– 40]. However, when leadership support, resources and a change champion are lacking, and when implementation periods are short, the impact of OHL-interventions is limited [23, 30, 32, 50]. Based on our scoping review and empirical study, we conclude that the greatest impact can be reached with a systematic implementation approach, using simultaneous top-down and bottom-up strategies while taking into account the critical facilitators and complex processes of organizational change [45, 46, 49].

We reported progress in OHL-outcomes, but also concluded that stronger evidence is needed regarding the design and the quality of the OHL-instruments, as we were able to retrieve only descriptive studies [42, 46]. To our knowledge, no experimental studies have been conducted to assess the impact of OHL-interventions using follow-up measurements, and comparing them with controls selected from similar organizations. Several OHL-instruments were tested for usability in various health settings [29, 46, 51], but their reliability and validity need improvement [42, 46]. Recently, several comprehensive OHL-instruments have been designed, but those instruments have not yet been used to evaluate the impact of OHL-interventions [26, 43,

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45, 52, 53]. To summarize, studies with a stronger research design using OHL-instruments of good quality, can help to clarify the association between the implementation and outcomes of OHL-interventions.

Evidence was scarce regarding the effect of organization-wide OHL-interventions on more distant patient-related outcomes as improved health and quality of care [19, 27, 35–39]; such evidence is essential for evaluating their effectiveness. An explanation for the paucity of studies may be that organization-wide change is a long and complex process, requiring leadership support and the commitment and effort of professionals, and involving many resources [46, 49]. In this process of implementing organization-wide interventions, patient-related outcomes are more remote, as OHL outcomes must first be improved at the higher level of organizations and professionals. However, we note that in some of the studies included in our review, small patient-samples were involved in the development and evaluation of interventions [27, 35, 36], which resulted in improvement of health literacy levels, understanding and self-management of patients. This supports findings of two other reviews which reported that specific (educational) interventions directly targeted at patients may result in promising outcomes such as increased understanding of information and skills, behaviour change, more satisfaction, and improved health outcomes [7, 54]. In sum, it may be promising to investigate more distant patient related outcomes when specific patient interventions are implemented in routine-practice of organizations. Such studies are highly needed, given the health gains they can offer for all patients.

More similarity in study findings across countries than anticipated

Three of the five studies in this thesis were conducted in various European countries (Chapters 2, 3 and 6). With regard to the health literacy training (Chapters 2 and 3) and implementation of OHL-interventions (Chapter 6), the study findings across these countries were more similar than we had anticipated. When designing the studies, we had several reasons to expect differences in outcomes between countries. First, although limited health literacy is a wide-spread problem across Europe, its prevalence varies considerably per country and per specific sub-group [13], making it likely that professionals will also differ in their skills. Second, professionals may also have different levels of health literacy competencies and preferences with respect to educational strategies [55, 56]. Third, health care provision may differ across countries, due to differences in culture, organizational context, wealth, and the hierarchical position and education of professionals [57–60].

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Despite differences in these underlying factors, health professionals in three countries reported consistent and positive perspectives on the content of training components and interactive learning strategies (Chapter 2), and showed similar increases in health literacy competency after the training (Chapter 3). In Ireland and the Netherlands the impact of OHL-interventions was also similar with respect to outcomes and the influences of facilitators and barriers during implementation (Chapter 6). Our studies confirm the findings of three studies which, using a Delphi-approach, reached consensus on critical components of European frameworks for health literacy competencies [61], patient-centred communication [62], and health literacy interventions [63]. An explanation may be that our studies addressed the most important concepts of health literacy responsiveness and patient centred communication; this highlights the potential for general application in other European countries.

Two issues should be taken into account regarding the implementation of interventions in other countries. First, that increases in health literacy competencies were similar may be because the core training components in all countries were adequately tailored to different contexts [64]. This confirms the conclusions of several implementation studies [64–68] that the effectiveness of interventions depends on adherence to their critical components, including adaptation to the context in which the intervention is provided. For example, role-plays should be adapted for use in training for specific health-care situations or target-groups (e.g., the elderly), and OHL-interventions should be implemented in line with strategic priorities of the health care organization. Second, we note that the implementation and effectiveness of interventions may vary in countries with differing educational levels, younger versus older populations, and differing structural health care problems. This also applies to lower- and middle income countries vs. high income countries [59, 60, 69, 70]. Pre-conditions for effective transfer of interventions can be that (future) health professionals: develop adequate competencies and self-efficacy levels through training [3, 15, 71]; develop greater insight into principles behind implementation strategies and quality improvement; have leadership support; and have a facilitating work-environment with sufficient resources available [35, 37, 49, 65].

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METHODOLOGICAL CONSIDERATIONS

Combining quantitative and qualitative research methods

A strength of this thesis is that for each study we considered the most suitable research designs, using quantitative and qualitative methods to complement each other [72]. The consistent findings in Chapters 2, 3 and 4 across various research designs and measurements strengthen the conclusion that the training increased the health literacy competencies of (future) health professionals. The findings of the mixed methods study on OHL-interventions were promising, but also indicated the need to further augment the evidence (Chapter 6). We elaborate here on the mixed-method approaches used, first, with regard to the training, and second, with regard to the OHL-interventions.

First, the development of the health literacy training in Chapter 2 was informed by a mixed-method approach consisting of a literature review and focus group discussions to provide in-depth understanding; these were complemented by self-rated questionnaires [72]. Training-outcomes were evaluated in a multi-centre pre-post study (Chapter 3) and an RCT (Chapter 4); use of a larger sample provided broader insight into the outcomes, and augmented generalization of the findings. Overall, findings of the several methods showed a consistent pattern [72]: the focus group discussions, the self-rated questionnaires, and the observations all showed, after the training, that health literacy competencies had increased.

Second, a strength related to the empirical study on OHL-interventions (Chapter 6) is that we assessed implementation fidelity at different time-points, combining information derived from quantitative questionnaires and qualitative interviews [65, 72]. The questionnaires provided a broader understanding, whereas the qualitative interviews provided in-depth understanding related to the implementation, facilitators and barriers, and outcomes of OHL-interventions (Chapter 6). The data from the questionnaires and the interviews showed consistent patterns, and the results confirmed each other. An additional strength is that the scoping review provided a broader overview of the evidence related to the field of OHL [73]. The choice of a mixed-method approach thus seems to have enhanced the strength of the evidence obtained.

Below, we discuss the strengths and limitations of the various studies conducted, with regard to the quality of the sample, the quality of information, and inferences regarding causality.

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7 Quality of the samples

We elaborate here on the quality of the samples used for the quantitative and qualitative studies in the health literacy training, and of the qualitative sample in the OHL-intervention study.

Samples for quantitative studies

One strength of our quantitative studies was the size of the samples used to assess the effectiveness of the health literacy training. In our two studies the samples were large enough to allow for comparisons between different countries in the multi-centre study, and between study conditions in the RCT. Another strength is that, of these two samples, one consisted of a heterogeneous selection of qualified health professionals from varying backgrounds and countries (Chapter 3), and the other of a more homogeneous group of undergraduate medical students (Chapter 4).

A limitation in our research is that the study on health professionals (Chapter 3) did not include a control group. The effects found may thus also be due to spontaneous improvement, potentially enhanced by selective inclusion of more motivated health professionals. It should, however, be noted that the observed increases in health literacy competencies following the training intervention were confirmed in the randomized sample of undergraduate medical students (Chapter 4), a study which did use a control group for comparison of changes.

Samples for qualitative studies

A strength of the health literacy training (Chapter 2) is that we included a variety of professionals from various backgrounds, organizations, and countries in the focus group discussions. This variety of perspectives provided in-depth and broader insight into the potential effectivity of training components, and the training needs and competencies of health professionals [15, 72, 74]. A limitation regarding the training is that patient related outcomes were not investigated. In future studies, this warrants further attention.

Related to the OHL-interventions (Chapter 6), a strength of the qualitative study samples is that perspectives of professionals from various backgrounds and hierarchical levels provided in-depth insight into the implementation processes and impact of the interventions [37, 72, 74]. A limitation is the higher risk of selection bias, as we conducted interviews only with staff who were involved in actual implementation of the interventions. Another

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limitation is that we did not involve older adults during the implementation phase, although professionals reported that the adapted written and digital information products were informed by problems and suggestions reported by service users involved during the assessment.

Quality of information

In this section we elaborate on the quality of information obtained in the studies, first, regarding the health literacy training (Chapters 2, 3 and 4), and second, regarding the OHL-interventions (Chapters 5 and 6).

Quality of information regarding health literacy training

A first strength is that the training-intervention was informed by a literature review of effective health literacy interventions among patients [7] and of training and educational strategies for professionals (Chapter 2). A second strength is that in-depth insights were obtained through focus group discussions with professionals (Chapter 2). To reduce the risk of more socially desirable reactions, detailed topic guides prompted professionals to comment on methods to enhance the quality of the training. Across countries, the coding and thematic analysis of the focus group discussions were conducted in a rigorous manner, using qualitative content analysis [75, 76]; we explored country specific differences, discussed inconsistencies, and reached consensus on both the specific codes and the overarching themes.

A third strength is that we used self-rated instruments of good quality to evaluate the outcomes of the training, which we in turn validated by observation of competencies in a subsample of participants. A strong point of the questionnaire is the adequate internal reliability reported in both samples (Chapters 3 and 4). We selected subscales which had been applied in other studies involving health literacy training, and in case these were not available or were not aligned with our training content, we derived specific questions from frameworks on patient-centred communication. The face validity of the questionnaire seems to be adequate, as its four subscales corresponded with the training components. The results indicated similar increases in competencies between professionals from different countries and medical undergraduate students (Chapters 3 and 4).

Another strength is that, with a subsample of undergraduate medical students, we used observation to rate health literacy competencies in videotaped simulated consultations, in order to minimize the possible bias

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from self-rated questionnaires (Chapter 4). The rating was conducted by two observers to increase inter-rater reliability. The observed increase in health literacy competencies confirmed the positive self-reported outcomes. This finding reduces the likelihood of bias related to social desirability, and overestimation of self-rated competencies.

Limitations of our self-rated questionnaires are that their reliability and validity need further assessment, and that questionnaires are generally more sensitive to information bias than observations (Chapters 3 and 4).

Quality of information regarding OHL interventions

The scoping review had several strengths regarding the quality of its information: we used the framework of scoping reviews of Arksey and O’Malley (2005) [73] to guide our review, and both the search strategy and procedure for inclusion and the selection of studies were comprehensive.

A strength of the empirical study on OHL-interventions (Chapter 6) is that interviews provided in-depth perspectives on the implementation of OHL-interventions [72]. Another strong point was the use of a comprehensive theoretical framework on implementation fidelity [65–68] to structure our assessment of the questionnaires regarding the themes of the interviews conducted in two countries, related to adherence to the OHL-interventions, the influence of moderators, and the outcomes. Also for this study we used qualitative content analysis [75, 76] for coding and analysis of the interviews. We discussed inconsistencies and reached consensus regarding the coding and overarching themes, thereby enhancing inter-coder reliability.

Three limitations of the scoping review (Chapter 5) were that: (1) the quality of the selected studies was not assessed; (2) relevant studies may have been missed due to including only peer-reviewed articles that had abstracts in English; (3) publication bias may have occurred, because fewer studies with negative findings regarding OHL-interventions may have been published. A limitation of the empirical study on OHL-interventions is the potential influence of recall bias and social desirability on answers provided by professionals in interviews and questionnaires.

Causality

Regarding causal inferences based on this study, we address the strengths of the relationships of the outcomes, first with the health literacy training, and second with the OHL-interventions. The consistency of our findings across

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various study designs, quantitative and qualitative measurement methods, and samples from various countries, strongly suggests that the training intervention contributed to increased health literacy competencies among (future) health professionals. A first strength is that the training intervention was evaluated in an RCT, which reduced the possibility of bias and allowed for better estimation of effects in self-rated competency between different conditions. A multi-centre pre-post study in three European countries confirmed the self-rated outcomes among professionals. A second strength is that the self-rated outcomes were validated by an observed increase in competencies of a subsample of students. As a constraint, we note that it was not possible to blind students to their condition in the RCT, as they belonged to the same learning community. This may have increased the risk of contamination and the influence of information bias on findings.

As a limitation, we also note that we did not determine effects over longer periods. Related to the persistence of effects, we note that some studies found improved outcomes up unto six months after training [3, 77], whereas others found that competency levels dropped after twelve months [78]. Therefore, our next step is to observe the long-term effectiveness of the training in provider-patient communication, which is currently being investigated in new studies. A strength of our scoping review (Chapter 5) was its comprehensive search strategy and selection procedure to include the relevant studies. Another strong point is that the included studies were conducted in a variety of health care organizations and countries, thereby contributing to the generalizability of our findings. Some limitations should also be noted. First, in accordance with the method of scoping reviews, we did not assess the quality of the studies. Second, our focus on peer-reviewed articles with English abstracts may have increased the chance that we omitted studies in the grey literature or published in other languages. However, we are confident that we have included the most relevant ones. Despite the relatively weak state of the evidence, we found promising outcomes. Systematic implementation of OHL-interventions may affect large numbers of patients attending health care settings in the long term, and therefore warrant further investigation.

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7 IMPLICATIONS FOR PRACTICE

We found that the health literacy training and long-term implementation of OHL-interventions resulted in increased health literacy competencies of professionals and in organizational changes. We discuss below the implications of this for practice related to professionals and their training, and for health care organizations and health policy.

Health care professionals and their training

Compared to other training programs, we found that the health literacy training improved a wider range of health literacy competencies among professionals in different countries (Chapters 2, 3, and 4). These competencies included communicating comprehensibly, promoting participation in shared decision-making, and stimulating the self-management abilities of patients. This training is relevant for a wide variety of professional disciplines in health care, as it has the potential to increase the effectiveness of prevention and treatment by means of interactions between providers and patients [79–81]. We therefore recommend the training for education and health care settings in other European countries [7, 80–82].

Next to its value for health care professions, we also found that this training led to greater health literacy competencies among undergraduate medical students, and that its integration into a medical curriculum was feasible. Implementation of the training can help to educate medical students in their future key-roles as communicators, health advocates, and collaborators as specified in the CanMEDS model, which is widely applied in medical education [83–85]. This training consists of modules that can easily be integrated into other curricula for undergraduate medical students [79–81, 86]. To date, this training is part of the European project Improving Patient-centred Communication Competencies (IMPACCT) (see http://healthliteracycentre. eu/) [87, 88] and implemented in the undergraduate curricula of Dentistry at the University of Groningen, and Dental Hygiene at the Hanze University of Applied Sciences, where reactions have been positive. Components of the training are also integrated in the research project Dyadic Illness Perception Intervention (DIPI) for occupational physicians, and coordinated by the department of Health Sciences of the UMCG. In order to promote transfer to the clinical education phase we would recommend scheduling additional (brief) training sessions to strengthen sensitivity and flexibility in using

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various health literate communication strategies. We would also recommend providing health literacy training to clinical instructors so that they can provide adequate feedback to students.

Specific further implications related to the training:

• Professionals became aware of the impact of health literacy by receiving evidence-based information, by viewing videos of patient experiences, and by hearing professionals share experiences from their practice [3]. In order to strengthen health literacy awareness and competency by means of future training programs, we recommend stronger exposure of (future) health professionals to the health literacy problems faced by patients. For example, patient ambassadors could share their experiences with (future) professionals, or demonstrate the barriers they experience when visiting a website or navigating through a hospital [46].

• Role-playing with simulation patients increased communication skills. In order to strengthen competency development, we suggest using interactive e-teaching tools with videotaped scenarios illustrating health literacy problems faced by (simulated or real) patients. After watching the video, (future) professionals record their own reactions and practice their communication techniques. We therefore recommend this, especially after receiving reactions from students that although this can be confronting, it also provides valuable feedback.

• The training enhanced competencies related to communicating information more clearly and encouraging shared decision-making and self-management abilities. Future extensions of the training can teach how to address problems in the context of patients, such as diagnosing and addressing health literacy in complex or ambiguous situations, and strengthening social support [7, 79, 80]. Training can also address the organizational context of professionals by stimulating: interprofessional collaboration and leadership to reduce barriers and implement health literacy practices; strengthening of such interprofessional collaboration and leadership; and development of a train-the-trainer module to coach other employees [46, 79, 88].

• Increased competency levels persisted six to twelve weeks after the training. In order to increase commitment of professionals and stimulate transfer of their training into practice, we recommend that training includes helping professionals to specify their own personal learning objectives, make action plans, and take part in follow-up sessions [15, 71].

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7 Health care organizations and health policy

We found that long-term and organization-wide implementation of OHL-interventions can result in improved outcomes at professional and organizational levels, and seem likely to reduce health literacy problems for patients [46, 79–81, 89]. This approach can contribute to a cycle of quality improvement, and we recommend [46]: (1) using a reliable and valid instrument to assess health literacy problems; (2) implementing OHL-interventions in health care organizations, using a systematic approach with simultaneous use of bottom up and top-down methods; (3) taking into account critical facilitators of implementation, like a change champion supported by a project committee, leadership support, adequate resources, patient involvement, and competent and committed staff.

Specific further implications related to OHL-interventions:

• Information on the reliability and validity of OHL-instruments was often not reported (Chapter 5). Therefore, to investigate OHL-related problems at various levels, we suggest using an instrument with adequate reported reliability and validity.

• It is vital to assess OHL-problems from the different perspectives of patients, professionals, and (independent) observers (Chapters 5 and 6). In particular, we found that patients themselves gave unique insight into the health literacy problems they encountered, offering a powerful approach to increase awareness among health professionals. We therefore recommend involving patients in the assessment and implementation phase of OHL-interventions -- for example, in the pilot-testing of these OHL-interventions. • Organizations indicated the importance of starting and undertaking

implementation of OHL-interventions in feasible steps, using elements that are easier to implement, such as written information in leaflets or on web-pages (Chapters 5 and 6). These steps were reported to increase awareness of health literacy, which could lead to greater quality improvements in information. Therefore, we recommend that organizations begin by addressing OHL with a topic that is easier to achieve, such as assessing and improving the clarity of digital and written communication.

• On the other hand, a systematic approach to implement OHL-interventions seemed to result in greater transformation at professional and organizational levels [46, 89]. To achieve greater organization-wide change, we therefore recommend a long-term and systematic approach.

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Organizations could start with a program logic model to brainstorm about priorities, interventions, and potential outcomes. They could then use simultaneous top-down and bottom-up strategies to increase support and commitment of leadership and staff, and work stepwise to realize OHL related priorities. In addition, we recommend training health professionals to increase their health literacy competencies and create opportunities for transfer into practice. This can contribute to health literacy responsiveness and quality of care.

• Several facilitators are critical for the implementation process and impact of OHL-interventions [46]. These facilitators needed to optimize implementation of OHL-interventions include a change champion supported by a project committee, patient involvement, leadership support, sufficient resources, and staff who have expertise in quality improvement.

IMPLICATIONS FOR RESEARCH

We found that health literacy training and long-term implementation of OHL-interventions resulted in increased health literacy competency and responsiveness on the part of professionals and organizations [79, 81, 86]. This confirms the importance of the latter in achieving better health literacy outcomes as specified in the IROHLA model [63]. Future studies could focus more attention on long-term implementation processes, and evaluate the impact of combining training and OHL-interventions during the different implementation stages. Especially when combined, comprehensive health literacy training and OHL-interventions may lead to increased health literacy responsiveness of professionals and organizations, thereby improving communication for all patients who visit a health care setting [46, 79–81, 86]. We discuss below the specific implications for future research regarding the training of health professionals and OHL-interventions.

Specific implications for research on the training of health professionals: • The training-intervention increased health literacy competencies related

to understanding of information, autonomy in shared decision-making, and self-management. Future studies can evaluate training interventions to address health literacy in the organizational context of professionals [88] by promoting inter-professional collaboration and leadership, addressing

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OHL related problems, and strengthening collaboration with and support in communities.

• Self-rated health literacy competency had persistent effects 6-12 weeks after the training-interventions. Future studies should evaluate whether these effects continue over even longer periods. Also, quantitative and qualitative follow-up studies are needed to investigate the transfer from training to practice among health professionals, and during the clinical education phase of students.

• Similar increases in health literacy competency were evident among a variety of (future) health professionals. Future studies could evaluate the effects of the training in other countries with less developed health care systems and fewer resources, and where people in education and practice have less experience with communication training.

• The training-intervention increased competencies among (future) health professionals. Future studies should observe the effects of the training on communication strategies used by (future) professionals in conversations with patients, and also examine recall of information, the quality of the patient-provider relationship, and shared decision-making. Studies should also investigate patient-related outcomes, including satisfaction with the conversation, health literacy levels, adherence to treatment, quality of life, and health outcomes.

Specific implications for research on OHL-interventions:

• In our research on OHL-interventions, we identified only descriptive studies with a mixed-method design. Future evaluation studies should use a more rigorous design to investigate the effects of these interventions: for example, RCT, stepped wedge, or quasi-experimental studies that include an intervention- and control condition by involving comparable health care organizations and follow-up measurements to glean the various perspectives of professionals, patients and observers.

• We also found that the reliability and validity of the applied OHL-instruments was limited. Recently, several comprehensive OHL-instru-ments with adequate reported reliability and validity have been designed for use in Australia and the US [43, 45, 52, 53]. Future studies should focus on OHL-instruments which have been adapted to the European context, and which have satisfactory reliability and validity.

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• We found that organization-wide OHL-interventions resulted in improved (intermediate) OHL outcomes at professional and organizational levels. Future studies should investigate the impact of OHL-interventions on more distant outcomes and larger samples of patients and professionals. This would involve investigating patient related outcomes like health literacy levels, self-management and health, quality of care, patient safety, and cost effectiveness.

GENERAL CONCLUSION

We conclude that comprehensive health literacy training and organizational interventions have the potential to improve the health literacy competency of health professionals and the responsiveness of organizations. The comprehensive training significantly increased the self-reported competencies of (future) professionals, particularly regarding understanding of information and strengthening autonomy and self-management abilities in conversations with patients. Organization-wide implementation of comprehensive OHL-interventions seems to increase health literacy responsiveness of health care organizations and professionals. Although evidence on patient-related outcomes needs strengthening, a wider application of these training programs and organizational interventions to European health care practice and education has great potential to promote effective communication with people with limited health literacy.

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