Background
1. Outcomes focused | • Improved health and reduced health inequities |
2. Equity driven | • All activities at all stages prioritise disadvantaged groups and those experiencing inequity in access and outcome |
3. Co-design approach | • In all activities at all stages, relevant stakeholders engage collaboratively to design solutions |
4. Needs-diagnostic approach | • Participatory assessment of local needs using local data |
5. Driven by local wisdom | • Intervention development and implementation is grounded in local experience and expertise |
6. Sustainable | • Optimal health literacy practice becomes normal practice and policy |
7. Responsiveness | • Recognise that health literacy needs and the appropriate responses vary across individuals, contexts, countries, cultures and time |
8. Systematically applied | • A multilevel approach in which resources, interventions, research and policy are organised to optimise health literacy |
Methods
Participating sites
Site ID. Service type | Relevant services delivered | Initial project aims/target group for needs assessment |
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Site #1 Metropolitan municipal council | Ongoing home and community care services (aged care support for activities of daily living, planned activity groups) | To support clients to improve social connectedness, physical/mobility and remain connected to their community while living at home.
Target group: Clients aged 65+ with mobility issues who are difficult to motivate and engage |
Site #2 Metropolitan municipal council | Ongoing home and community care services (aged care support for activities of daily living, delivered meals) | Understand how vulnerable clients find, understand and use health information. Specifically to identify indicators for assessment officers to improve their capacity to identify clients with health literacy needs
Target group: All delivered meals clients (a vulnerable client group, i.e. frail aged and socially isolated) |
Site #3 Metropolitan community nursing service | Ongoing care for clients at home with chronic conditions including education of clients in self-management | Improved awareness and uptake among all nurses of a standardised approach to diabetes education so that clients are better able to independently self-manage their condition.
Target group: Clients with diabetes and long term wounds |
Site #4 Rural community health service | Ongoing and episodic care for clients and community members (on-site and outreach allied health, outreach health promotion including community activity groups) | Engage people from rural and remote communities with (or at risk of) chronic disease to better manage their health, navigate the health system and develop effective relationships with health professionals.
Target group: All clients eligible for services including those with complex conditions |
Site #5 Rural community health service | Ongoing and episodic care for clients and community members (on-site allied health, outreach health promotion including community activity groups) | To support clients living with chronic disease and who are disadvantaged to access services and programs. Goals are that clients will: 1) be aware of what health professionals are involved in their care; 2) be aware of how to access health services to assist with chronic disease self-management.
Target group: All clients with chronic disease eligible to receive our services |
Site #6 Metropolitan community health service | Ongoing and episodic care for clients and community members (on-site allied health services, community- and centre-based activity groups) | To tailor services to meet the different health literacy needs of clients and to improve clients’ skills and capacity to access services
Target group: Clients with chronic and complex conditions attending planned activity groups and those who receive 1:1 clinical interventions |
Site #7 Outer metropolitan community health service | Ongoing and episodic care for clients and community members (on-site allied health services, community nursing service) | To increase community awareness of, and engagement with the service to help people develop the skills to self-manage their health conditions.
Target group: Community members not currently engaged; Existing clients who do not achieve ongoing engagement; Clients with chronic conditions who would benefit from improved self-management skills |
Site #8 Metropolitan hospital Admission Risk Program | Ongoing (6–12 weeks) intensive case management for clients with chronic disease at risk of hospital admission. Allied health, nursing | To evaluate and improve the service’s response to patients who are in a crisis (defined by patient) to determine if the response is flexible, appropriate and timely resulting in reduced unplanned readmissions.
Target group: All current clients of the service |
Site #9 Regional metropolitan Hospital Admission Risk Program | Ongoing (6–12 weeks) intensive case management for clients with chronic disease at risk of hospital admission. Allied health, primarily nursing | To improve clients’ capacity to access and understand health information and attend appointments. To provide clinicians with a consistent framework for approaching care
Target group: All current clients of the service |
Measurement of health literacy
Application of the Ophelia process
Data analysis
Results
Phase 1
Needs assessment findings | Intervention aim and overview | Focus of intervention |
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Site #1 Metropolitan municipal council | ||
Many clients lacked confidence in their ability to find and appraise health information, and actively manage their health. Many clients also indicated a low level of social support for health, and difficulties engaging with healthcare providers. Some were found to have higher health literacy overall | The intervention aimed to support volunteers with higher health literacy to act as mentors for disadvantaged, frail, older community members during exercise programs run by the municipal council. | Community volunteers act as local health mentors and so build community members’ capacity to achieve better health outcomes |
Site #2 Metropolitan municipal council | ||
Many clients had poor information appraisal skills and found it difficult to engage with healthcare providers. In the workshop staff noted some clients were passive in their interactions with their general practitioner (GP) and were unwilling to discuss their failing health with GPs in case they were put into institutional care. | The intervention aimed to empower clients to optimise their relationship with their GP by screening for client-GP engagement issues and then providing appropriate guidance to clients | Directly improve clients’ health literacy through providing resources or targeted training |
Site #3 Metropolitan community nursing service | ||
Many clients experienced difficulties actively managing their health, and struggled to find and appraise health information. Higher scores were seen for trusting healthcare providers. Staff identified inconsistencies in the way diabetes education was delivered across the service, and reported clients were provided with information from multiple sources, which is often unread. | The intervention aimed to improve the quality of diabetes education within the service by using an education checklist and online library of staff resources, tailoring education to each client’s learning style, and use of the teach-back method. | Target clinicians through provision of skills training and resources to support them to build clients’ capacity to self-manage their long term condition |
Site #4 Rural community health service | ||
Many clients lack sufficient health information, and reported difficulties navigating the health care system and appraising and understanding health information. Many clients had geographical challenges to accessing care and information. The service has an active pool of volunteers, many of whom would like to be more involved. | The intervention aimed to build community capacity to self-manage health by training existing volunteers of the health service to act as health mentors in their local rural community | Community volunteers act as local health mentors and so build community members’ capacity to achieve better health outcomes |
Site #5 Rural community health service | ||
Many clients did not have sufficient information to manage their health, lacked social support for health, had limited ability to appraise health information, and were unable to find good health information. The area has transport limitations, restricting people’s ability to access healthcare and leading to increased social isolation. | The intervention aimed to build community capacity to navigate health information on the web by providing training and resources primarily in community settings. | Directly improve clients’ health literacy through providing resources or targeted training |
Site #6 Metropolitan community health service | ||
Many clients had limited ability to navigate the healthcare system or to find and understand health information. Clients reported not knowing the role of the service or how to access it. An opportunity for improving service access between co-located Dental Health and Primary Health Services was identified. | The intervention aimed to build clients’ capacity to navigate local services by implementing a referral pathway between co-located dental (for low-income clients) and primary health care services. | Focus on redesigning existing service procedures to improve access to services |
Site #7 Outer metropolitan community health service | ||
Many clients had low scores for social support for health, having sufficient information, navigating the health system and finding health information. Scores for engagement with healthcare providers were higher. Staff in the workshop highlighted difficulties for clients with chronic disease to keep up-to-date with their knowledge. | The interventions included 1) a patient-held record to help clients manage appointments and monitor health goals, 2) a process for Care Coordination in the District Nursing Team was also developed. | 1) Directly improve clients’ health literacy through providing resources; 2) Redesign existing service procedures to improve access to services |
Site #8 Metropolitan Hospital Admission Risk Program | ||
Many clients had low scores for social support for health, having sufficient information, navigating the health system and finding health information. Scores for engagement with healthcare providers were higher. The workshop highlighted a need for the service to evaluate how clients in crisis are managed. | The intervention aimed to support clients with service navigation during crises. Involved’navigation’ plans and use of the teach-back method in client education about managing health crises. | Target clinicians through provision of skills training and resources to support them to build clients’ capacity to self-manage their long term condition. |
Site #9 Regional metropolitan Hospital Admission Risk Program | ||
Many clients lacked information to manage their health and had limited capacity to find, understand and appraise health information. Most clients reported a good relationship with healthcare providers. In the workshop, HARP clinicians reported needing a consistent framework for approaching care, and a need for clients to understand the things they can do to manage their health after discharge from the service. | The intervention aimed to improve the way in which clients’ understand and use their care plans by tailoring education to each client’s learning style, and training clinicians in use of teach-back. | Target clinicians through provision of skills training and resources to support them to build clients’ capacity to self-manage their long term condition. |
Phase 2
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three interventions targeted clinicians through provision of skills training and resources to support them to respond to a range of health literacy strengths and limitations in working to build clients’ capacity to self-manage their long term condition (sites 3, 8 and 9);
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two interventions utilised community volunteers to act as local health mentors and so build community members’ capacity to achieve better health outcomes (sites 1 and 4);
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three interventions aimed to directly improve clients’ health literacy through providing clients with resources or targeted training (sites 2, 5 and 7); and
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two interventions focused on redesigning existing service procedures to improve access to services for people with different health literacy strengths and limitations (sites 6 and 7).
Expected outcomes from program logic model | Evaluation activities | Participants | Results |
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Interventions utilising community volunteers | |||
Site #1 Metropolitan municipal council | |||
Longer term: Improved knowledge of falls prevention. Increased motivation to undertake health promoting behaviours; Medium term: Community members feel cared for; gain practical support and information; mentors improve communication skills and understanding of specific health problems; mentors and community members have increased social connectedness; Short term: Mentors engage with community members. | 1) Evaluation of HLQ scales 2, 3 & 4 pre-post intervention in mentors and senior citizens (including Arabic speaking women’s group) 2) Satisfaction surveys – mentors; 3) Interviews with mentors and all clients. | 8 mentors, 18 senior citizens participated in evaluation. Mean (SD) age of mentors = 69.8 (5.8) years, 100% female and 100% spoke English as their first language. | In HLQ scales, mentors showed small to large improvements with ES ranging from 0.26 (95% CI −0.73, 1.24) for scale 3 to 0.92 (−0.13, 1.94) for scale 2. For the senior citizens group, HLQ scores showed no improvement in scale 4 (ES 0.10 (−0.95, 1.14)). Interviews and focus groups with 18 senior citizens and mentors found most participants reported regularly applying what they learnt, increased mobility, and benefits from the social engagement. Mentors also reported an increase in their own confidence to support others and all reported a desire to continue in the mentorship role. |
Site #4 Rural community health service | |||
Longer term: Increased community members’ capacity to navigate and engage with health services; improved health literacy and engagement of volunteers; increased social connectedness; Short to medium term: Community members are educated about the local health service, including navigation and engaging with GPs; reduced social isolation | 1) Administration of HLQ scales 2, 5 & 6 at pre and post intervention with community members and volunteers. 2) Interviews with community members and volunteers. 3) Capturing of potential wider community effects via interviews. | 14 mentors participated in training and evaluation; 7 community members participated in evaluation, with an estimated n = 100 reached by the intervention. Demographic data on participants not collected. | In the HLQ scales, participants completing both pre and post questionnaires (n = 18) showed moderate increases, with moderate ES ranging from 0.52 (95% CI −0.13, 1.16) for scale 5 to 0.56 (−0.09, 1.20) for scales 2 and 6. In interviews participants reported some GP's provided positive feedback on the Good Questions form. The form helped participants feel prepared and assertive during GP visits. The Better Health Channel: Improved awareness was evident. Some participants sought the help of a family member to gain access. Using volunteers who were active community members to deliver simple, word-of-mouth messages was reported as successful. Volunteers reported feeling useful and proud. Discussing one's health within immediate circles (family and community groups) reported frequently suggesting a ripple effect in terms of spread of the intervention's messages within existing circles |
Interventions aimed at directly improving the health literacy of clients | |||
Site #2 Metropolitan municipal council | |||
Longer term: Increased management of health and adherence to recommendations; able to find out about supports/services and information as required; Medium term: Open and insightful exchange between clients and their GP; Short term: Clients use new skills and strategies during GP visits | 1) Pre and post questions from HLQ scales 6 & 9. Scale scores not calculated as questions were modified. 2) A brief survey of the utility of the tool for clients 3) Focus group with assessment officers | 8 clients completed modified HLQ scales pre-post intervention; 5 completed the utility survey. 88% were female; age >65 years. Focus group with four assessment officers | Overall client results showed slight increase in modified HLQ question scores. All 5 clients completing the utility survey felt discussions with the assessment officer about how to talk with the GP were useful. There were mixed responses to resources; some clients reported they were useful and others reported they were too long. Assessment officers reported that clients initially said they were happy with their relationship with their GP, but further questioning revealed many felt unheard by the GP. Case studies of positive outcomes when clients were encouraged to raise issues such as incontinence with their GP were discussed. Assessment officers reported being more aware of the need to question clients on this topic. |
Site #5 Rural community health service | |||
Longer term: Clients are able to apply learnings to future situations; Medium term: Improved ability to find health information on the web; improved capacity to understand and appraise health information; Short term: Targeted participants (older adults) attend and or/or access information (wider community) | 1) Administration of HLQ scales 1, 2, 5 & 7 pre and post-intervention (scale 1 as comparison in which no change expected); 2) Client interviews at 2–4 weeks post intervention 2 3) Number of people attending computer course | 11 clients participated in intervention 1 (computer course), 27 in intervention 2 (presentation of DVD and checklist during planned activity groups). Pre-post HLQ scales collected on 32. Interviews with 12 participants from intervention 2. Demographic data not collected. | Changes in HLQ scales showed moderate increases with ES ranging from 0.43 (95% CI −0.07, 0.92) for scale 2 to 0.50 (0.00, 0.99) for scale 7. No change was seen in the comparison scale. Interviews with participants from intervention 2 found 4 participants reported an increase in using the internet to search for health-related information post-intervention. Barriers were not having a computer/internet and a lack of need for any health related information; 6 participants reported Increased levels of confidence or increased awareness in ability to appraise online information. The checklist was described as a useful resource |
Site #7 Outer metropolitan community health service – Intervention 1 | |||
Longer term: Community are optimally engaged with the service. Clients feel empowered to self-manage their health; Medium term: Increased awareness about the service; Staff are using a range of tools and strategies to engage and communicate with clients; The ‘My Health Diary’ is being used by 50% of eligible clients; Short term: Community engagement activities and promoting the service more broadly; Staff training around understanding the importance of health literacy and effective communication |
My Health Diary: 1) Number of diaries taken; 2) Number of diaries being used, assessed by brief interviews with clients who consented to interview; 3) Clinician interviews |
My Health Diary: 44 clients participated, 26 (62%) contacted for interview; mean age = 59 (17.0) years, 71% female; 92% with chronic condition. Interviews with n = 5 clinicians |
My Health Diary: Of 26 clients interviewed, 6 reported using the diary. Interviews with clinicians found that staff felt uptake was low as diary was not formally promoted to clients, most of whom did not bring the diary with them to appointments. Different parts of the diary were felt to be more or less useful, with some replicating existing record systems. Two of the 5 clinicians interviewed reported the diary was easily understood by clients, who appeared to value having a concise record of health information. |
Interventions focusing on developing health literacy skills of health personnel | |||
Site #3 Metropolitan community nursing service | |||
Longer term: Clients feel understood and supported by healthcare providers; clients have sufficient information to manage their health; clients understand health information well enough to know what to do; Medium term: Nurses integrate resources and techniques into everyday practice; Short term: Increased awareness of the resources and techniques among nurses; nurses have sufficient knowledge and confidence to apply appropriately | 1) Administration of HLQ scales 2, 5, 9 pre and post intervention (scale 2 was comparison scale in which no change was expected) 2) The Diabetes Knowledge Questionnaire (DKN) (pre and post intervention) 3) Interviews with clinicians | 24 clients participated in the intervention; 15 provided pre-post HLQ data. Mean age 75 (13.2) years, 67% female. Mean years with diabetes 9.8 (9.5), 96% had type 2 diabetes. Interviews with 9 clinicians | Client results for pre and post HLQ scales showed no improvement with ES of 0.08 (95% CI −0.64, 0.79) for scale 9 to 0.15 (−0.57, 0.87) for scale 5. Change in scale 2 = 0.04 (−0.67, 0.76). DKN scores indicated a small trend of improvement (ES = 0.24 (95% CI −0.43, 0.79). Interviews with clinicians found the diabetes education checklist was user-friendly and helped staff reframe education content/delivery to suit needs of individual clients. Using teach-back helped staff identify clients’ learning requirements and built a rapport. Using the learning styles tool reinforced the importance of the learning trajectory to both clinicians and clients. Staff discussed case studies of clients who became more proactive, asked more questions or showed improvements in self-management of their care. |
Site #8 Metropolitan Hospital Admission Risk Program | |||
Longer term: Optimal use of health services by clients, preventing readmissions; Medium term: Clients have increased confidence to self-manage health and health crises; Short term: Improved client capacity to understand and use new health information and navigate health service. | 1) Pre and post questions from HLQ. Scale scores not calculated as questions were modified; 2) Identification of client learning preferences; 3) Interviews with participating clinicians | In total, 70 clients participated; mean age = 76, 49% female, mean number of health conditions = 3. Interviews with clinicians (n = 8) | Preferred methods of learning information were: Talking through with someone (83%); writing down (53%). Least popular methods were brochures (33%) and pictures or diagrams (26%). Preferred methods for receiving information were face to face (93%). Email was least preferred (9%). Interviews with clinicians found teach-back 1) ensures client has an accurate understanding of what they need to do; 2) identifies gaps in clients' understanding; and 3) allows for better rapport between client and clinician. The health service navigation plan provided clients with a better knowledge of their services at the point of discharge. The learning styles tool was useful particularly for identifying clients with reading and language issues. |
Site #9 Regional metropolitan Hospital Admission Risk Program | |||
Longer term: Increased appropriate demand for early intervention health services; Medium term: Improved client capacity to understand and appraise new health information relevant to their needs; Increased confidence to self-manage health and health crises; increased capacity to effectively and appropriately engage with health services and providers; Short term: HARP clinicians collaborate with clients | 1) Administration of HLQ scales 2, 4, 8 pre and post-intervention (scale 4 as comparison in which no change was expected). 2) Interviews with clients 2) Focus group and interviews with clinicians | 48 clients completed the HLQ pre-post intervention; 11 participated in the interviews; mean age 63.9 (15.7) years; 45% female; mean number of health conditions 6.3 (4.3); 11 clients and 10 clinicians participated in interviews | Changes in HLQ scales showed no to small increases with ES ranging from 0.02 (95% CI −0.41, 0.45) for scale 2 to 0.24 (−0.19, 0.67) for scale 8. No change was seen in the comparison scale (scale 4). Findings from the client interviews showed clients felt comfortable with the experience and with showing their understanding through actions or words. 4 clients expressed confidence using the appointment planner and reported it was a helpful resource. Clinician interviews found the benefits of using teach-back were: 1) allows clients to take more ownership of their health; 2) builds on client's capabilities; 3) revealed clinicians’ misconceptions about client's level of understanding. The appointment planner was used less often. Clinicians noted it was a useful tool, but needed to be embedded into their practice. Clients appeared to have their own systems of managing appointments, although forgetfulness played a prominent role in recalling appointments. The Learning Styles Tool was praised by clinicians who felt it alerted them to client's literacy needs, and allowed tailoring their practice to the client's requirements. Others felt it helped focus on client preferences in contrast to clinician's expectations and assumptions. |
interventions focused on redesigning existing service procedures | |||
Site #6 Metropolitan community health service | |||
Longer term: Increased access and links with local health services; strengthened relationship, trust and engagement with local health service; Medium term: improved client access local health services; Short term: Referral pathways between services are developed and clinicians undertake referrals. | 1) Focus group with central intake staff; 2) Telephone survey with dental clients | 7 clients, 3 dentists and 3 intake staff participated in the study and evaluation activities. Telephone survey with 7 dental clients. Demographic data not collected on clients. Focus group with 3 central intake staff | Telephone survey with dental clients indicated all clients were comfortable with the dentists raising health issues, and all thought the intervention was a good idea. In total, 4 clients were referred to new services of which 3 were pleased with the outcome. One person reported waiting a long time for their initial appointment with the primary health service provider. Focus group with central intake and dental staff found the referral process between dental services and primary health care was efficient and not overly time-consuming. Staff reported the process increased clients' awareness of services available to them. |
Site #7 Outer metropolitan community health service – Intervention 2 | |||
Longer term: Improved quality of life and health outcomes; Medium term: Increased capacity of clients to navigate the healthcare system resulting in early response to declining health to prevent unplanned readmission.
Short term: Increased knowledge of clients in engaging with the health system |
For Care coordination: 1) Client case studies and interviews; 2) Clinician focus group |
Care coordination: Focus group with 4 staff, |
Care coordination: Staff focus group found the intervention avoided the need to repeatedly question clients and allowed recording of case-management information more efficiently, especially for short term clients with more acute needs. A case study of one client found that over 8-months, 22 episodes of care coordination were documented by 5 separate nurses, resulting in closer engagement with the GP and avoidance of one hospital admission |
Phase 3
Ophelia principle | Evidence of application | Limits, difficulties, lessons learned |
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1. Outcomes focused | Phase 1: establishing project aims that were focused on improving health outcomes either in vulnerable clients or that took a population-based approach to selection of the target group; Phase 2: use of program logic models, which by their nature are outcomes focused, Phase 3: ensuring these logic models were used as the basis of implementation and evaluation plans and that evaluation measures captured these outcomes where possible. | Most sites had some difficulty defining a specific target group at the start and narrowed their focus during the project. Tools were developed during the project to assist selection of a focus. |
2. Equity driven | Design process deliberately focused on clients who may not be receiving the full range of services or not achieving the full range of outcomes. Examples include: • embedding brief interactive health literacy screening into a service’s assessment process to identify all clients experiencing difficulty engaging with health providers, • developing a process that enables low-income clients to access a primary health service. While not directed to do so, many sites incorporated elements that made them available to disadvantaged groups as well as to core client groups. The process steered clinician’s thoughts towards equity including through use of vignettes that focused on how the health literacy profile could cause people to miss out. | There can be difficulties ensuring an adequate number of responses to the HLQ from people most at risk, especially people who have very little engagement with health services. Collaborative and outreach projects to collect data from high risk groups in community settings may be a useful supplement. |
3. Co-design approach | Co-design was inherent in all activities; from data collection and interpretation, to development and pilot-testing of intervention plans, through to conducting evaluation activities. In Phase 1, the process of engaging clinicians in ‘their’ data and interventions may have been enhanced by the use of narratives. This approach to presenting data was very engaging for clinicians and managers, generating multiple intervention ideas. | The researchers probably underestimated the time, training and support required for sites to work through all stages of the project. Many tools and exemplars have been developed to assist future users. |
4. Needs-diagnostic approach | Health literacy and demographic data were collected from a pre-defined target group in whom health literacy was thought to contribute to inequitable service access or poor health outcomes. Collection of health literacy data using a comprehensive and robust measurement tool, designed for this purpose, supported this process. The multidimensional tool allowed identification of different profiles of strength and weakness rather than just single health literacy scores. | Potential contextual or other barriers to access should be considered in detail at the outset so that additional questions (other than health literacy) can be included in needs assessment. |
5. Driven by local wisdom | The co-design workshops allowed local clinicians and managers to draw on their knowledge and provide intervention ideas in response to needs identified from the local data collection. Interventions were: tailored to local context (such as the outreach nature of interventions from rural organisations); took existing organisational processes into account (e.g. formalising the case-management role of community nurses), and; utilised existing resources (e.g. using volunteers already in place). During implementation of the interventions, use of quality improvement cycles allowed clinicians to refine and further tailor the intervention according to their local knowledge. Design of intervention evaluation was also driven by local knowledge, with project teams determining the most appropriate indicators for their client or community group. | Allowing time in the co-design workshops for detailed discussion of the issues raised within the vignettes is essential if solutions are to be responsive. At all stages of the process, involving the people who know the client group and who will be delivering the intervention is also essential. |
Ophelia principle | Evidence of application | Limits, difficulties, lessons learned |
6. Sustainable | Since completion of the study, several sites have commenced using existing organisational quality improvement processes to ensure their interventions remain relevant and effective. For some sites, interventions are seen as stepping-stones to broader objectives with plans to use small interventions at one level to build up over time to achieve organisational priorities and objectives. For example, the intervention to develop a client access point between dental and primary health services will be used as the basis for developing an organisational policy on service access within 5 years. | Having management visibly support the project from the start helped ensure continuity of the intervention at some sites. External factors (such as changes to the chronic disease funding model) influenced sustainability. |
7. Responsiveness | Responsiveness was considered in terms of how the organizations responded to health literacy diversity and other unique needs in the target population. It was most clearly demonstrated through use of cluster analysis to capture the diverse range of health literacy profiles. In relation to diversity in the delivery of interventions, three sites selected similar activities (teach-back and learning styles assessment). However, these interventions were applied to achieve different outcomes. Any large or diverse organisation seeking to apply the Ophelia process will need to consider that health literacy will vary considerably between clients, and apply the process accordingly. For example, organisations with different cultural groups using their services may need to collect sufficient needs assessment data to ensure that diversity is adequately captured, and then will need to tailor interventions to these different groups’ needs, or in some cases, develop specific interventions. | More recent Ophelia projects have conducted co-design workshops with consumers or community members, separate to those held with clinicians, but using the same vignettes. This ensures consumers’ perspectives are included. More than one workshop may be needed if there is important cultural or other diversity in the target group. |
8. Systematically applied | We have previously identified that health literacy is a potential barrier at multiple access points within a service [7]. Health literacy interventions are therefore required at all levels of client engagement [26]. In this study, interventions focused on multiple levels including: • directly targeted at improving individual client’s skills, • enabling clinicians to respond appropriately to health literacy needs (existing clients, clients who approach the service, community outreach), • changes in organisational processes, • engagement with external agencies Several interventions encompassed more than one level. | Using these 4 levels to categorise the intervention ideas helps to demonstrate how an intervention can be refined to encompass more than one level. Some recent Ophelia projects have also incorporated a further workshop to discuss and select interventions; these workshops can include representatives from external agencies and funding bodies. |