Enhancing health literacy among immigrant women.

The number of immigrants coming to Canada has increased in the last three decades. As a result, there is greater emphasis on health care providers and the health care system to provide culturally appropriate and equitable care. It is well documented that many immigrant women suffer from serious mental health problems and experience difficulties in accessing and using mental health services. In this paper we advocate for new ways of research inquiry in exploring immigrant women's mental health care experiences, ones that move beyond the individual experiences of health and illness toward recognition that the health of immigrant women must be addressed within the social, cultural, economic, historical, and political context of their lives. Drawing on past research we demonstrate how the postcolonial feminist perspective can be used to illuminate the ways in which race, gender, and class relations influence social, cultural, political, and economic factors, which, in turn, shape the lives of immigrant women. We suggest that postcolonial feminism provides an analytic lens to (a) generate transformative knowledge about immigrant women's mental health care experiences; (b) improve equitable health care; and (c) increase understanding of what would be helpful in meeting the immigrant women's health care needs.

Physicians’ Roles in Creating Health Literate Organizations: A Call to Action

Within the European context Austrian health policy rather early got interested in measuring and improving population health literacy (HL) and systematically invested in integrating HL in its health reforms in the last decade. Therefore within a HEN report on policies of HL (Rowlands et al 2018) Austrian HL policy is well represented and Austria is the only European county included in a recent article on national policies and strategies for HL (Trezona, Rowlands and Nutbeam, 2018). Based on the early experiences in measuring population HL in the US, Canada and Australia, but also in Switzerland, Austria became interested in measuring HL and was active in initiating the first European comparative study on population HL (HLS-EU). It did not only take part in this study but was responsible for the work package on analyzing and reporting results of this study and undertook follow up studies on HL in Austrian regions, HL of adolescent, HL of selected migrant groups and on organizational HL of hospitals. Comparative results of the HLS-EU study were published at the time when Austrian health targets were in discussion and these results showed that HL in Austria was rather limited compared to the other participating European countries. Therefore HL got high attention in the process of defining and deciding of all in all 10 health targets with target no. 3 on ＂Improving the Health Literacy of the Population＂. Health targets and further measures were developed in a participatory transparent process involving many relevant stakeholders and citizens. Further on the HL health target was prioritized and a catalogue of measures was developed. Aspects relating to the healthcare field are being implemented through the ongoing healthcare reform process, while aspects relating to the 'health in all policies' dimensions of HL are being implemented through the newly established intersectoral Austrian Health Literacy Platform. This platform among other activities organizes national annual HL conferences (with about 300 participants on average), offers a web site and a regular newsletter. From early on, among the chosen topics the relational character of the HL concept has been considered and measures for improving organizational HL respectively health literate organizations have been supported. Due to the wish of the Austrian government to have regular comparative surveys in Europe for monitoring and benchmarking population and organizational HL, Austria together with Germany, Switzerland, Luxemburg and Liechtenstein engaged in initiating an Action Network Measuring Population and Organizational Health Literacy (M-POHL) within the European Health Information Initiative (EHII) of WHO-Europe. Austria is chairing M-POHL in its initial phase. At M-POHLs kick-off meeting in Vienna The Vienna Statement on the measurement of population and organizational health literacy in Europe＂ was launched. About 20 counties from the WHO-Europe region are already involved in the action network; a first HL population survey is prepared for 2019. First Conclusions: To get public and political attention population health literacy has to be measured comparatively and results have to be reported and discussed publicly. Measures for improving health literacy have to be integrated into ongoing general health reforms and policy, but specific institutions supporting continuous development of HL have to be created, installed and supported. To be successful many different stakeholders have to be recruited and coordinated. International monitoring of HL can support national policies.

Objectives: Introduce the Organisational Health Literacy approach to primary care practitioners Discuss the challenges posed by introducing OHL in primary care Share potential solutions for best practice in OHL in primary care Reflect on appropriate process and outcome measures for OHL in primary care Rationale: The move towards active patient participation and informed decision making in health care has raised the interest in health literacy. Informed decision making requires sufficient knowledge about the possibilities, consequences, benefits and risks of interventions to make decisions that align with one’s personal values and preferences. As such, health literacy, defined as a person’s knowledge, motivation and skills to obtain, understand, evaluate, and apply health information, plays a key role in making informed health decisions. While the importance of health literacy is generally recognized by primary care practitioners, to date most efforts to address it have focused on enhancing the skills of patients to understand and apply the information given by professionals, and of professionals to adjust their communication to patients with low health literacy. Yet, as the health care systems is often complex and demanding, health care organizations can also try to reduce the demands they place on patients and families by implementing policies, practices, and systems that make it easier for people to navigate, understand, and use information and services to take care of their health. This strategy is known as Organizational Health Literacy (OHL). Critical components of OHL include (1) improving access to and navigation of health care facilities and systems; (2) encouraging patient engagement in the health care process; (3) enhancing communication with patients and families; (4) establishing a workforce with OHL-related knowledge and skills; (5) creating an organizational culture and infrastructure supportive of OHL; and (6) meeting patient needs, such as provision of interpreter services and self-management support. Efforts to introduce OHL are increasingly implemented with success in the hospital setting and, to a lesser extent, in other health organizations such as health insurance companies, but have thus far rarely been applied in the primary care setting. The workshop will address the challenges posed by introducing OHL in primary care, drawing on the first-hand experience with 18 OHL projects launched in 2022 in Belgium with support of the Dr. Daniël De Coninck Fund (managed by the King Baudouin Foundation) and functioning as a learning network. Audience: Primary care practitioners and managers of primary care networks. Workshop content: 1.A short introduction to the concept and criteria of OHL and the 18 Belgian projects (10min) 2.Three short presentations of projects focusing on OHL in primary care (20min) 3.Discussion in breakout groups on challenges to introducing OHL in primary care (30min): (1)Embedding health literacy in the organizational mission, structure and functioning (2)Building relationships between health care professionals and service users around HL (3)Developing HL through language, action and experience (4)Co-creating with service users throughout the care journey (5)Learning and evaluating across organizational boundaries 4.A plenary debate (20min) 5.Conclusion and summary of the learnings (10min)

Organizational health literacy (OHL) has been defined as the degree to which healthcare organizations equitably enable/empower people, through organizational structures, policies, and processes, to find, understand, appraise, and use information and services to make health-related decisions and actions for themselves and others. By adopting an OHL approach, healthcare organizations enhance health service delivery by simplifying interaction with health systems by making information and services more comprehensible. An OHL approach not only reduces health literacy demands of patients, but also of workforce and the resident population of the community that they serve. The workshop focuses on two theory-based initiatives that focus at promoting OHL in Europe: (1) the Organizational Health Literacy for All (OHL-ALL) initiative, which developed a practice-oriented OHL approach for organizations promoting equity explicitly to support people in vulnerable positions with or at risk for diabetes or other non-communicable diseases, and (2) the World Health Organization (WHO) Action Network on Measuring Population and Organizational Health Literacy (M-POHL) which aims at initiating and facilitating the (self-) assessment of OHL in healthcare organization by developing, providing, and disseminating OHL assessment tools. Both initiatives strive to support organizational change and workforce responsiveness. While the first initiative goes beyond health literacy responsiveness of healthcare organizations intending to offer guidance for organizations on how to give all individuals the best possible opportunities to achieve their optimal health and well-being, the second initiative specifically focuses on OHL in healthcare organizations using a settings approach with a focus on health care, prevention, and health promotion. The initiatives enrich and complement each other. The workshop consists of five short presentations, followed by a discussion among the presenters and the audience. The first presentation focuses on the development of the theory-informed and coherent OHL approach of the OHL-ALL initiative. The second presentation provides an overview of the M-POHL initiative and its innovative tools. Then three presentations will showcase results, experiences, and outcomes from European countries on assessing OHL in different healthcare settings. Expected impact: Theory-based guidance for implementing organizational development will be provided. Results from the M-POHL initiative will contribute to greatly needed insights into OHL needs and opportunities of healthcare organizations. The insights from these real-world assessments and implementation can inform future public health practice, policy, and research. Key messages • An OHL approach contributes to better equity. It helps meet health literacy needs of patients, health and care workforce and the resident population of the community that are served. • New tools have been developed to support management and health and care workforce in assessing and improving OHL responsiveness, to better serve patient communities.

Tools zur Stärkung der organisationalen Gesundheitskompetenz in Einrichtungen der Gesundheitsversorgung

It is well documented that serious mental health problems such as depression, schizophrenia, and post migration stress disorders exist among immigrant women. Informed by Kleinman's explanatory model, this qualitative exploratory study was conducted with seven health care providers who provided mental health services to immigrant women.Analysis of the data revealed that (a) immigrant women face many difficulties when accessing mental health care services due to cultural differences, social stigma, and unfamiliarity with Western biomedicine, (b) spiritual beliefs and practices that influence immigrant women's mental health care practices, and (c) the health care provider-client relationship, which exerts great influence on how immigrant women seek mental health care. The study also revealed that cultural background exerts both positive and negative influences on how immigrant women seek mental health care. We suggest that although cultural knowledge and practices influence immigrant women's coping choices and strategies, awareness of social and economic differences among diverse groups of immigrant women is necessary to improve the accessibility of mental health care for immigrant women.

Purpose:To provide perspectives from heterogenous cisgender immigrant women and service providers for immigrants in New York City (NYC) on how restrictive sexual and reproductive health (SRH) care delivery environments during COVID-19 shape immigrant's access to health care and health outcomes to generate insights for clinical practices and policies for immigrant women's health care needs.Methods:A qualitative study was conducted in 2020 and 2021, including in-depth interviews with 44 immigrant women from different national origins and 19 direct service providers for immigrant communities in NYC to explore how immigrants adapted to and were impacted by pandemic-related SRH care service delivery barriers. Interviews were coded and analyzed using a constant comparative approach.Results:Pandemic-related delays and interrupted health care, restrictive accompaniment policies, and the transition from in-person to virtual care compounded barriers to care for immigrant communities. Care delays and interruptions forced some participants to live with untreated health conditions, resulting in physical pain and emotional distress. Participants also experienced challenges within the health care system because of changes to visitor policies that restricted the accompaniment of family members or support persons. Some participants experienced difficulties accessing telehealth and technology, while others welcomed the flexibility given the demands of frontline work and childcare.Conclusions:To mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies, clinical practices like expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care play an important role.

This workshop aim is to explore the call that is proposed by the WHO declarations of Nairobi and Shangai, that institutions should move forward to become health literate organizations. This workshop addresses qualitative and quantitative health literacy research work settings of health and non-health professionals. Health literacy has evolved into a significant public health and health promotion goal which is especially influenced by the social and cultural background, the availability of resources, and the settings in which it is practised. Basically, health literacy can be defined as the knowledge and skills to access, understand, appraise and apply health information in order to promote health and well-being. For a long period most research had focused on adult patients in clinical settings, but in the recent past there have been significant efforts from research, practice, and policy towards citizens in other organizational settings, which is due to findings stating that effective health literacy promotion begins and continues across all settings in a whole society approach since health is mostly shaped outside the health care setting. Such approaches can also be influential when addressing the reduction of health inequalities. The main objective of this workshop is to present first time empirical findings and developments from ongoing research projects of the Health Literacy in workplace (ProLiSa). Thereby, it will shed light on the health literacy of professionals, and link the current debate with contemporary public health approaches to advance the field of health literacy. The workshop will include 5 presentations with up to 15 minutes input followed by discussions. The first presentation is a tentative to understand health literacy and ehealth tools to improve quality of life. From Brazil a second presentation will consider health care organizations (hospitals) and the perspective to move to health literate organizations. From Portugal a third presentation will consider migration and integration and the case of health literacy as a foundation to promote cultural sensitiveness in the organizational setting. A forth presentation will consider how communicating with migrants can be a challenge and how children’s health literacy, digital technology can become and critical help. Finally the last presentation considers the role of health literacy and physical activity as buffers to counter act work related stress. This workshop offers a forum for researchers, practitioners and policy-makers interested in health literacy. By dialogue and two-way communication lively interaction and vivid discussions will be facilitated. This will allow discussing results with regard to their benefit for improving health literacy research, practice, and policy-making, support further synergies, break down barriers between research infrastructures, facilitate networking and collaboration, and support international capacity building. Key messages There is need for empirical health literacy research in work settings. It will allow informing sustainable and effective interventions and the development and application of better tools. Addressing the social environment will have impact on public health research & practice, will facilitate the development of health literate organizations, new concepts/strategies for health promotion.

Background:Wisconsin Literacy Incorporated is a statewide adult and family literacy coalition representing 75 community-based literacy organizations. This coalition focuses its work in four areas: (1) building capacity of its member agencies, (2) advocating for literacy, (3) preparing adults in worker readiness and career pathways, and (4) improving how health information is communicated through its division, Wisconsin Health Literacy (WHL).Brief Description of Activity:This article outlines how an adult basic education coalition successfully developed a statewide health literacy coalition that later transformed into a division of Wisconsin Literacy through a three-phase approach that included: (1) raising awareness and educating health care and literacy providers about health literacy, (2) implementing health literacy interventions through various grant funding, and (3) disseminating and sharing findings from such health literacy interventions to a broad audience.Implementation:Beginning its awareness work in 2003 with help from a physician champion, WHL implemented best practices within each of the three areas of approach. After being implemented, the initial volunteer-based health literacy coalition was transformed into a division of Wisconsin Literacy Incorporated.Results:The division now includes a full-time director, its own website, funding for community interventions, and a business plan for fee-for-service efforts with health care providers, public health agencies, and other stakeholders. Key relationships with Wisconsin health care organizations provided WHL venues to present about health literacy throughout the state and beyond. Wisconsin Literacy Incorporated helped secure a solid infrastructure by hosting two planning retreats and implementing both strategic and business plans for the newly formed division. Offering fee-for-service health literacy training to health care providers brought in new revenue to sustain the division and obtain buy-in from health care agencies on the importance of health literate organizations. Finally, participating in key partner coalitions and Communities of Practice allowed WHL to share experiences and best practices with a national audience.Lessons Learned:The importance of intentionally raising awareness in strategic health care settings across the state fostered many partnerships. Investing in a strategic planning retreat and a business plan guided the division's success. Delivering educational workshops in community-based literacy organizations and trusted settings where adults regularly go to learn was key to successful implementation. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S8–S14.]Plain Language Summary:Wisconsin Literacy Incorporated is an adult basic education coalition that built a health literacy division over several years. Using best practices such as raising awareness, implementing pilot projects, and broadly sharing its experience, the Wisconsin Health Literacy division advanced the understanding and commitment to health literacy in and beyond Wisconsin.

Organizational health literacy is described as an organization-wide effort to transform organization and delivery of care and services to make it easier for people to navigate, understand, and use information and services to take care of their health. Several health literacy guides have been developed to assist healthcare organizations with this effort, but their content has not been systematically reviewed to understand the scope and practical implications of this transformation. The objective of this study was to review (1) theories and frameworks that inform the concept of organizational health literacy, (2) the attributes of organizational health literacy as described in the guides, (3) the evidence for the effectiveness of the guides, and (4) the barriers and facilitators to implementing organizational health literacy. Drawing on a metanarrative review method, 48 publications were reviewed, of which 15 dealt with the theories and operational frameworks, 20 presented health literacy guides, and 13 addressed guided implementation of organizational health literacy. Seven theories and 9 operational frameworks have been identified. Six health literacy dimensions and 9 quality-improvement characteristics were reviewed for each health literacy guide. Evidence about the effectiveness of health literacy guides is limited at this time, but experiences with the guides were positive. Thirteen key barriers (conceived also as facilitators) were identified. Further development of organizational health literacy requires a strong and a clear connection between its vision and operationalization as an implementation strategy to patient-centered care. For many organizations, becoming health literate will require multiple, simultaneous, and radical changes. Organizational health literacy has to make sense from clinical and financial perspectives in order for organizations to embark on such transformative journey.

Parker, Ratzen and Lurie (2003) pointed out that a silent epidemic is affecting the health status of the American population, namely poor health literacy. Actually, inadequate health literacy is the main cause of the patients’ inability to navigate the health care environment, paving the way for inappropriateness in the provision of care as well as for poor health outcomes. Moreover, it has been esteemed that a third of the European population is not able to properly understand, process and use health information (HLS-EU Consortium, 2012). The same issue has been identified in several Asian countries (see, for example, Nakayama et al., 2015; Pednekar, Gupta & Gupta, 2011). What is striking is that—until today—the attention has been focused on the individual determinants of low health literacy, while studies concerning the organizational health literacy—that is to say, the ability of health care organization to establish friendly and comfortable relationships with the patients—are uncommon (Weaver, Wray, Zellin, Gautam & Jupka, 2012). This article is aimed at exploring the way health care organizations deal with patients living with inadequate health literacy. Drawing on the prevailing literature (Brach et al., 2012; DeWalt et al., 2013; Matthews & Sewell, 2002; Murphy-Knoll, 2007; Stableford & Mettger, 2007) the main approaches to improve organizational health literacy are examined. Then, a distinction between formal and informal tools to address organizational health literacy is suggested and the effectiveness of both of them is compared. The findings of the research suggest that informal tools are more common than formal tools, even though the former have lower perceived effectiveness as compared with the latter. Health care organizations seem to be still far from effectively activating comprehensive organizational health literacy pathways. There is a desperate need for systemic efforts to enhance the awareness of organizational health literacy and to encourage processes of change towards health literate organizational environments.

The promotion and enhancement of health literacy in school-aged children is an important public health and education goal. To ensure healthy behaviours and attitudes in adulthood, children and adolescents have to learn about health and well-being early in life. Toward this goal, schools are considered the most important setting to address health literacy. Interventions delivered in schools can reach all children regardless of their social, cultural or development background. In the education sector, health literacy interventions can address not only the skills, attitudes and knowledge of students, but that of teachers, principals, health and education staff, as well as the whole school setting. Health literacy is linked to education, while it mainly addresses how people manage health information. In this context, health literacy enables children and adolescent to find, understand and critically appraise health information and use it to guide informed health decisions and promote health behaviour. While this understanding targets personal competencies of individuals, health literacy is also directed towards the environment. For example, the concept of organizational health literacy aims at increasing health literacy capacities of the environment and within settings, such as schools. This makes health literacy an important concept at the intersection of behaviour change (agency: personal health literacy) and social change (structure: organizational health literacy). While the behavioural approach is most promising to equip students with the necessary skills to act as their own agents of health information management and improve their health agency capacities, the social approach further includes consideration of social determinants of health to provide child- and adolescent-friendly environments and conditions. Therefore, effective health literacy interventions should aim at combining behavioural and social approaches, especially in such vulnerable groups as children and adolescents. The purpose of this workshop is to present and discuss four interventions on health literacy drawing on behavioural and social sciences. (i) The first presentation will introduce the Health Literacy Toolbox for Schools (Tool-HLCA). (ii) The second presentation will introduce a school curriculum for classroom based Mental Health Literacy (HLCA-IMPRES). (iii) The third presentation will provide the organizational health literacy school intervention: Health Literate Schools (HeLit-Schools). (iv) The fourth will present applied data on mental health literacy in teachers and an instrument to measure action competencies of teachers with respect to promoting their students’ mental health (MHAC). Each project will be given ten minutes to present their interventions and main findings, including time to discuss with the audiences and get feedback. The participants in turn will learn about recent empirical findings they can use in health literacy practice and policy. Key messages • Children and adolescent will benefit from early interventions to develop healthy behaviours and lifestyles in their life-course. • Health literacy is an important school topic and should be addressed within behavioural and social approaches.

The European network on Measuring Population and Organizational Health Literacy (M-POHL) was founded in 2018 under the umbrella of the European Health Information Initiative (EHII) of the World Health Organization - Regional Office for Europe. Health literacy (HL) is increasingly recognized as a critical determinant, mediator or moderator of health, and large parts of populations have been shown to have limited HL. Therefore, it is one of the aims of M-POHL to install international comparative population HL surveys at regular intervals. These can provide a valuable and valid basis for developing evidence-informed recommendations for policy, research and practice in the field of HL. To meet this purpose, M-POHL brings together experts from research and policy. Following up on the first European HL survey (HLS-EU), the first project of M-POHL was the international HLS19 survey, with 17 participating countries from the WHO European region. In addition to general population HL, the survey also covered specific HL's such as digital, communication, navigation, and vaccination HL. Despite the obstacles posed by the Corona pandemic, the survey could be administered, and an international comparative report was prepared by the HLS19 project consortium. On this basis, M-POHL will hold two workshops in June and August 2021 to develop resulting recommendations for policy and research in Europe. It is expected that these recommendations will a. o. focus on: population groups in most need of support in their HL; how to improve different dimensions of HL (such as finding, understanding, assessing, and applying relevant health information); HL as applied to health care, disease prevention, and health promotion; and aspects relating to the specific HL's measured. The presentation will describe the process of development, and give an overview of the M-POHL recommendations.

Health care organizations (e.g., hospitals, nursing homes, facilities for people with disparities) are increasingly required to create health literate structures and processes, to train staff in such a way that they make it easier for their users to behave in a health literate manner, to deal competently with health information and to navigate competently through facilities and the entire health care system. This approach is known as the concept of organizational health literacy (OHL). Meanwhile, different standards (fields of action) of organizational health literacy and assessment tools to measure health literacy on an organizational level are available, which address, among other issues, health literacy as part of the quality management system, the development of health-related information by involving users, or to facilitate navigation within and to health care facilities and through the health care system. In order to assess and to strengthen OHL in health care settings, an increasing number of projects in Europe and internationally conduct needs assessments and interventions to implement tools to strengthen OHL at the patient-/client-, staff- and organizational-level. The assessment and implementation is accompanied by different requirements, challenges and needs at different levels (i.e. clients, staff, management).Thus, the workshop emphasizes the following objectives:1. to present findings from OHL projects in European countries (Austria, Belgium, Germany, the Netherlands, Switzerland).2. to present and to discuss methodological issues (e.g., needs assessment),3. to highlight practical experiences when implementing measures to strengthen OHL, and4. to discuss beneficial factors, challenges and helpful approaches (e.g., participatory or co-creation setups) for the implementation of OHL.A total of five experts on the topic of ‘health literacy in health care settings’ will present and discuss the implementation of health literacy in health care settings in Central European countries.Key messages• The Workshop highlights a synthesis of challenges and future needs that are evident for organizations and users at different levels (management, staff, clients).• Beneficial factors are a supporting management and leadership staff, participatory approaches, communication tools, training staff in health literacy skills as well as clients/patients.