Organizational health literacy as a determinant of patient satisfaction

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Original Research

Organizational health literacy as a determinant of patient satisfaction b € O. Hayran a,*, O. Ozer a ı - Beykoz Istanbul Medipol University, School of Medicine, Kavacık Mah. Ekinciler Cad. No.19 Kavacık Kavs‚ag 34810 Istanbul, Turkey b Istanbul Medipol University, Graduate School of Health Sciences, Kavacık Mah. Ekinciler Cad. No.19 Kavacık ı - Beykoz 34810 Istanbul, Turkey Kavs‚ag

article info

abstract

Article history:

Objectives: To assess the organizational health literacy (OHL) of a group of hospitals and

Received 16 March 2018

investigate the relationships among OHL, patient satisfaction, and patients' health literacy.

Accepted 12 June 2018

Study design: This cross-sectional study is conducted in one state hospital, one university hospital, and one private hospital in Istanbul. OHL of the hospitals, patient satisfaction, and health literacy of a sample group of patients were investigated.

Keywords:

Methods: OHL data were collected from six managers of each hospital by filling out the

Organizational health literacy

‘Health Literate Health care Organizations-10’ (HLHO-10) questionnaire during face-to-face

Hospitals

interviews. Patient satisfaction and patient health literacy data were collected from repre-

Patient satisfaction

sentative samples of inpatients in each hospital (n ¼ 491 for the university hospital, 482 for

Health Literate Health care

the state hospital, and 486 for the private hospital). The ‘Rapid Estimate of Adult Literacy in

Organizations-10 (HLHO-10)

Medicine’ test was used for measuring health literacy. Collected data were analyzed by the SPSS program. Results: The Turkish version of HLHO-10 questionnaire had high internal consistency (Cronbach's alpha ¼ 0.916). Health literacy and patient satisfaction levels of the university hospital inpatients were significantly higher (P < 0.001) than those of the other hospitals. A high level of OHL was associated with high patient satisfaction. Conclusions: OHL seems to be a significant determinant of patient satisfaction. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction The issue of health literacy has gained importance in recent decades. A national survey on a representative sample group found that more than 89 million American adults have limited health literacy.1 The European Health Literacy Survey (HLSEU) conducted across eight European countries (Austria, Bulgaria, Germany [North Rhine-Westphalia], Greece, Ireland,

the Netherlands, Poland, and Spain) has found that about 12% of respondents have inadequate general health literacy and more than one-third (35%) have problematic health literacy, thus nearly every second respondent shows limited health literacy.2 The HLS-EU study indicated that, as in the USA, a large proportion of the population does not have adequate health literacy and that variation exists between countries participating in the project. The situation is not better in many other countries; 61% in South Korea and at least one-third of

* Corresponding author. € E-mail addresses: [email protected] (O. Hayran), [email protected] (O. Ozer). https://doi.org/10.1016/j.puhe.2018.06.011 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

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Taiwanese have inadequate health literacy.3,4 Findings of a national survey in Turkey have also found that 64.6% of the population has limited or problematic health literacy.5 Health literacy is defined as ‘the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment’.6 It is a lifelong learning activity that needs to be continuously developed. Health literacy has become an increasingly important issue in the healthcare sector owing to its close association to the effectiveness and efficiency of health services, decreases in health expenditures, and better health outcomes. Several studies show that the expected outcomes and success of health services are closely related to the individual's health literacy.7e12 Adults with limited health literacy experience more serious medication errors,13 higher rates of emergency room visits and hospitalizations,14 worse preventive care and health outcomes for their children,15 and increased mortality16,17 compared with individuals with adequate health literacy. With the increase in research on health literacy, it is now understood to be an issue not solely regarded as an area of individual responsibility, but the situation of healthcare organizations is also vital. Health literacy is the product of the interaction between individuals' capacities and the health literacyerelated demands and complexities of the healthcare system.18 Issues such as approach of the organizations to patients with respect, easiness of the services to access, easiness of the information to understand, appropriate directional signs and correct answers given to patient questions are as effective as the literacy of the individuals, at least on the correct use of the services.19e21 Current healthcare systems and settings are not designed to enhance patients' ability to handle health information and navigate the health system, and they also need to be health literate for raising low literacy level of the patients. Organizational health literacy (OHL) is defined as ‘the ability of health organizations to provide services and information that are easy for patients to find, understand, and use, to help patients make decisions, and to remove existing barriers’.19,22 It is important that these skills and traits are independent of the level of health literacy of the individuals and that they have specifically targeted individuals with low health literacy. In other words, a healthcare literate organization must have the ability to help individuals in the best possible way to reach, understand and use services and information, regardless of the level of literacy.23 Published research outcomes from health literacy studies that assessed OHL practices and their influence on patients' health outcomes found that improvements in OHL practices not only improved health outcomes but also increased patients' satisfaction with health providers.19,24e27 In today's multicultural and multilingual societies, development of organizational literacy is especially vital. Patients who are not fluent in the language of the healthcare provider must be able to understand their situation and care. There is currently no definitive list of actions for organizational literacy. A good start would be for healthcare services and information to be user friendly. All facets of care must be easily understandable by the individual, such as the institution's physical structure and directional signs, their website, and their communication

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style with the patient. In other words, responsibility for understanding and use of services and information should be transferred from individuals to organizations.28 In Turkey, there are various studies on the measurement of individual health literacy. However, no studies on the assessment and evaluation of OHL could be found. In this study, we aimed to examine the relationship between individual health literacy and patient satisfaction with organizational literacy at the hospital care.

Methods This cross-sectional study is conducted among the managers and inpatients of three accredited hospitals in Istanbul. One of the hospitals is a state hospital. It is a public hospital, owned and managed by the Ministry of Health. It is accredited nationally and has a building of 4 years old. The second hospital is a university hospital, a non-profit hospital owned and run by a university. It is Joint Commission International (JCI) accredited and has a building of 7 years old. The third hospital is a private, for-profit hospital. It is accredited by JCI and has a building of 10 years old. The number of hospital beds is more than 250 in each of the three hospitals. The university hospital and private hospital are engaged in medical tourism and have a separate organization for this purpose. The public hospital is also open to medical tourism but has no specific activities and organization in this area. Data were collected between February and July 2017. In the first stage of the study, data regarding organizational heath literacy were collected during face-to-face interviews with hospital managers. Interviews were conducted with six managers from each hospital who are directly or indirectly related with OHL (CEOs, medical directors, vice medical directors, quality department managers, nursing directors, continuing education managers). A Turkish version of Health Literate Health Organizations (HLHO)-10 attribute questionnaire was completed during the interviews. HLHO-10 was found to have good psychometric properties for assessing the extent to which the hospitals were implementing OHL practices based on Brach et al.'s (2012) ten attributes of HLHO.29 HLHO-10 was adapted into Turkish and content of the questionnaire was found to be valid and reliable.30 Internal consistency coefficient (Cronbach's alpha) was 0.916, which meant high reliability. In the second stage, data regarding health literacy and patient satisfaction were collected from the sample groups of inpatients during their discharge in AprileJune 2017. Sample groups were consecutively discharged patients aged over 15 years. The sample size needed to represent each hospital's inpatient population was calculated to be 384. The number of interviewed patients was 491 in the university hospital, 482 in the state hospital, and 486 in the private hospital. Two questionnaires were filled out during these interviews. Health literacy data were collected by the Turkish version of Rapid Estimate of Adult Literacy in Medicine (REALM) test. The REALM is a health literacy tool that assesses patients' reading level using 66 medical words.31 Patients are asked to read and pronounce loudly the words ranging easy words (e.g. flu, pill) to difficult ones (e.g. osteoporosis, impetigo). The test can be completed in 3 min. The REALM is useful for

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predicting reading level only and does not measure math skills. It was translated and adapted to Turkish and found to be reliable and valid.32 The number of correctly read and pronounced words is counted and recorded as the score of each individual. A patient satisfaction questionnaire was prepared by using different questionnaires used in accredited hospitals. It included 5-point Likert-type scale questions about various dimensions of the health and hospital services. Answers are scored as ‘very insufficient ¼ 1, 2, 3, 4, 5 ¼ very sufficient’. Each participant's total satisfaction score was computed and mean scores of various subgroups were compared.

Data analysis Collected data were analyzed by using SPSS 23.0 program. Mean, standard deviation, and percentages were computed for descriptive purposes. Comparisons between groups are made by performing Chi-squared test, analysis of variance, ttest, and ManneWhitney test. A ‘p’ value less than 0.05 was considered as significant. Pearson's correlation analysis is used for analyzing association among variables.

Results The total number of inpatients who participated in the study was 1459. Among these, 491 (33.7%) were from the university

hospital, 482 (33.0%) from the state hospital, and 486 (33.3%) from the private hospital. Table 1 presents the distribution of the demographic and some social characteristics of the study groups according to the hospitals. The difference between the totals of the tables is due to incomplete information from some of the individuals. As can be seen in Table 1, the differences between sex, age group, education level, and types of health insurance distribution of the participants by hospitals are statistically significant. Thus, the interviewed patients' profiles are not similar between the hospitals. Less than half (46.9%) of the participants are males, and 53.1% are females. Sex distribution between hospitals is statistically significant (P ¼ 0.04). The proportion of females in the university hospital and males in the state hospital is higher than the others. The majority (57.3%) of all participants are between the ages of 25 and 44 years. The difference between the age groups of the inpatients by the hospitals is also statistically significant (P < 0.001). The percentage of participants older than 64 years (47.9%) is significantly higher in the private hospital compared with the other two hospitals. Among all participants, 23.8% are primary school graduates, 47.1% are secondary school graduates, and 29.1% are university graduates. The difference between the education levels of the participants is statistically significant by the hospitals (P < 0.001). The proportion of the primary school graduates is highest in the state hospital, while the proportion

Table 1 e Characteristics of the study groups by hospitals. Characteristic

Sex Male Female Total Age groups in years 15e24 25e34 35e44 45e54 55e64 >64 Total Education Primary Secondary University Total Health insurance Social (working) Social (retired) Private Others* Total

Hospitals

Total, n (%)

University, n (%)

State, n (%)

Private, n (%)

209 (31.0) 279 (36.5) 488 (33.9) x2 ¼ 6.22 df ¼ 2

242 (35.9) 234 (30.6) 476 (33.1) P ¼ 0.04

224 (33.2) 251 (32.9) 475 (33.0)

675 (100.0) 764 (100.0) 1439 (100.0)

56 (27.3) 189 (39.0) 118 (34.2) 58 (29.0) 41 (34.5) 26 (27.7) 488 (33.7) x2 ¼ 41.45

89 (43.4) 122 (25.2) 126 (36.5) 81 (40.5) 39 (32.8) 23 (24.5) 489 (33.1) df ¼ 10

60 (29.3) 174 (35.9) 101 (29.3) 61 (30.5) 39 (32.8) 45 (47.9) 480 (33.1) P < 0.001

205 (100.0) 485(100.0) 345 (100.0) 200 (100.0) 119 (100.0) 94 (100.0) 1448 (100.0)

81 (23.8) 230 (34.2) 179 (42.8) 490 (33.8) x2 ¼ 115.59

166 (48.7) 257 (37.8) 59 (14.1) 482 (33.9) df ¼ 4 P < 0.001

94 189 180 463

(27.6) (28.0) (43.4) (32.3)

341 676 418 1435

(100.0) (100.0) (100.0) (100.0)

286 (38.3) 81 (33.7) 40 (20.7) 77 (30.0) 484 (34.0) x2 ¼ 88.62

241 (32.3) 74 (32.9) 39 (20.2) 119 (46.3) 473 (33.2) df ¼ 6 P < 0.001

219 73 114 61 467

(29.4) (33.3) (59.1) (23.7) (32.8)

746 228 193 257 1424

(100.0) (100.0) (100.0) (100.0) (100.0)

*Social insurance and charity funds for the poor.

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of the university graduates is significantly higher in the university and private hospitals. All participants have health insurance. The majority of the groups (68.4%) have Social Health Insurance and only 13.5% have private health insurance. Distribution of the participants according to their health insurance type varies significantly by the hospitals (P < 0.001). Inpatients with private health insurance are significantly more in private hospitals, while the proportion of the participants with social insurance is higher in the university and state hospitals. The distribution of the health literacy and patient satisfaction scores of the study groups according to demographic, social variables, and hospitals is presented in Table 2. There is a significant difference between the health literacy (REALM) scores of the participants by their sex (P ¼ 0.013), education level (P < 0.001), and types of health insurance (P < 0.001). Females are more health literate than males, university graduates are more literate than primary and secondary school graduates, and the participants with ‘other’ type of health insurance have significantly lower health literacy level than the social and private insurance owners. In Tables 3 and 4, mean scores of the individual health literacy (REALM), patient satisfaction, and OHL (HLHO-10) are presented by hospitals. The difference between the REALM scores of the participants by hospitals is statistically significant (F ¼ 53.847, P < 0.001). The university hospital inpatients have significantly higher and state hospital inpatients have

Table 2 e Health literacy and patient satisfaction scores by various characteristics of the study groups. Characteristic Sex Male (n ¼ 675) Female (n ¼ 764) Total (n ¼ 1439) Age groups in years 15e24 (n ¼ 205) 25-34 (n ¼ 485) 35-44 (n ¼ 345) 45-54 (n ¼ 200) 55-64 (n ¼ 119) >64 (n ¼ 94) Total (n ¼ 1448)

REALM score, mean ± SD

Patient satisfaction score, mean ± SD

55.36 ± 9.52 166.46 ± 18.79 56.56 ± 8.79 166.67 ± 20.69 56.00 ± 9.16 166.57 ± 19.81 t ¼ 2.500, P ¼ 0. 013 t ¼ 0.364, P ¼ 0.846 55.04 ± 8.81 56.51 ± 8.79 56.09 ± 8.79 55.07 ± 10.95 54.79 ± 10.29 57.32 ± 8.22 55.92 ± 9.23 F ¼ 1.925, P ¼ 0.087 F

164.27 ± 20.51 166.62 ± 20.24 164.82 ± 21.06 169.21 ± 15.85 167.66 ± 17.62 168.58 ± 23.54 166.43 ± 20.00 ¼ 2.012, P ¼ 0.074

51.39 ± 10.92 55.75 ± 8.80 59.83 ± 6.52 55.90 ± 9.30 F ¼ 86.842, P < 0.001 F

167.69 ± 19.05 165.68 ± 20.86 167.01 ± 18.44 166.54 ± 19.76 ¼ 1.338, P ¼ 0.263

Health insurance Social (working; n ¼ 746) 56.11 ± 8.92 Social (retired; n ¼ 228) 56.90 ± 8.60 Private (n ¼ 193) 57.22 ± 10.00 Others (n ¼ 257) 53.61 ± 9.74 Total (n ¼ 1424) 55.93 ± 9.24 F ¼ 7.687, P < 0.001 F

166.75 ± 19.85 167.67 ± 19.46 165.22 ± 21.85 165.47 ± 19.09 166.46 ± 19.94 ¼ 0.793, P ¼ 0. 498

Education Primary (n ¼ 341) Secondary (n ¼ 676) University (n ¼ 418) Total (n ¼ 1435)

REALM, Rapid Estimate of Adult Literacy in Medicine; SD, standard deviation.

Table 3 e Individual health literacy (REALM) and patient satisfaction scores by hospitals. Hospitals University (n ¼ 491) Private (n ¼ 486) State (n ¼ 482) Total (n ¼ 1459)

REALM score, mean ± SD

Patient satisfaction score, mean ± SD

58.34 ± 6.95 56.79 ± 8.99 52.58 ± 10.55 55.92 ± 9.26 F ¼ 53.847, P < 0.001

169.73 ± 17.70 167.12 ± 20.43 162.47 ± 20.99 166.46 ± 19.96 F ¼ 16.855, P < 0.001

REALM, Rapid Estimate of Adult Literacy in Medicine; SD, standard deviation.

significantly lower health literacy scores compared with the other hospitals. The difference between the mean patient satisfaction scores according to the hospitals is also significant (F ¼ 16.855, P < 0.001). The university hospital inpatients have higher satisfaction and the state hospital inpatients have lower satisfaction than the others. The difference between HLHO-10 scores of the hospitals is statistically significant (P ¼ 0.017); and the university hospital has higher HLHO-10 score than the other hospitals. There is a weak, positive, and statistically significant association between health literacy scores and patient satisfaction scores (r ¼ 0.074, P < 0.05). Some of the patient satisfaction questionnaire items are, in fact, items that assess OHL and are as follows:  Assistance received from patient counselors  Accessibility to patient counselors when needed  Clarity of the physicians about diagnosis and treatment options  Comprehensibility of the nurses about the procedures and patient education  Information about the care after discharge  Directional signs within the hospital  Regulations for handicapped people Mean scores of the patient answers to these specific items are presented in Table 5. All items had highest scores in the university hospital patients and lowest in the state hospital. The differences between the hospitals were statistically significant for five of the six items. Only the mean scores of the item ‘regulations for handicapped people’ were not statistically different between the hospitals. This finding supports the HLHO-10 results presented in Table 4. In other words, the university hospital has the highest

Table 4 e Organizational health literacy (HLHO-10) scores by hospitals. HLHO-10 score, Mean ± SD

Hospitals University (n ¼ 6) Private (n ¼ 6) State (n ¼ 6) Total (n ¼ 18) KruskaleWallis test HLHO, Health deviation.

Literate Health

55.66 ± 4.22 40.50 ± 15.05 46.00 ± 8.85 47.39 ± 11.68 X2 ¼ 8.113, P ¼ 0.017 Organizations; SD, standard

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Table 5 e Mean scores of the items of patient satisfaction questionnaire related with OHL by hospitals. Items of patient satisfaction questionnaire related with OHL

Assistance received from patient counselors Accessibility to patient counselors when needed Clarity of the physicians about diagnosis and treatment options Comprehensibility of the nurses about the procedures and patient education Information about the care after discharge Directional signs within the hospital Regulations for handicapped people

Hospitals

ANOVA test

University, mean ± SD

Private, mean ± SD

State, mean ± SD

4.60 ± 0.75 4.64 ± 0.68 4.71 ± 0.67

4.53 ± 0.80 4.56 ± 0.82 4.66 ± 0.71

4.38 ± 0.86 4.39 ± 0.90 4.55 ± 0.77

F ¼ 10.49, P < 0.001 F ¼ 13.92, P < 0.001 F ¼ 7.39, P < 0.001

4.73 ± 0.58

4.59 ± 0.77

4.49 ± 0.83

F ¼ 14.44, P < 0.001

4.68 ± 0.58 4.58 ± 0.70 4.57 ± 0.67

4.51 ± 0.78 4.52 ± 0.81 4.53 ± 0.80

4.47 ± 0.80 4.44 ± 0.90 4.49 ± 0.79

F ¼ 13.19, P < 0.001 F ¼ 3.79, P ¼ 0.023 F ¼ 1.46, P ¼ 0.232

OHL, organizational health literacy; SD, standard deviation; ANOVA, analysis of variance.

level of OHL, according to the perspectives of both the patients and the managers in our study groups.

Discussion Our study findings show that health literacy level is significantly higher in the university hospital patients, females, university graduates, and patients with private health insurance. The HLS-EU study has also found that the average health literacy is higher for individuals with high-level education and for females.2 In a national health literacy survey, males were found to be more health literate than females in Turkey.5 However, similarities and differences may be due to the different study populations and different measurement tools used for health literacy. Patient satisfaction level is significantly higher in the university hospital patients, but no significant difference was found for other variables. Both health literacy and patient satisfaction scores are lowest in the state hospital patients. There is a positive but weak correlation between health literacy and patient satisfaction scores of all participants (r ¼ 0.074, P < 0.05). Mean OHL assessment (HLHO-10) score was found to be significantly higher in the university hospital than the others. These findings together can be concluded as existence of an association among OHL, patient satisfaction, and individual health literacy. Among the items of the patient satisfaction questionnaire, some were related with organizational literacy (Table 5). When the mean scores from these items are compared between the hospitals, it is seen that the university hospital patients' scores are significantly higher than the others, and this result is compatible with high organizational literacy assessments of the university hospital managers (HLHO-10). The high rates of patient satisfaction and individual health literacy measured in the university hospital may be due to the fact that this hospital is really more competent in this regard, as well as the nature of the patient profile. Among the patients in the university hospital, the proportions of higher education graduates and females are higher than those in the other hospitals, and the average scores of individual health literacy of these two groups are higher than those of others. It is, therefore, possible to say that the high level of individual literacy is due to the nature of the patients. However, there is no similar situation in terms of patient satisfaction scores. For

this reason, we conclude that organizational literacy has a decisive influence on the level of high patient satisfaction at least in the university hospital in our study. As a matter of fact, managerial evaluations are also in this line. These results are similar to the results of various studies showing that OHL has positive effects on patient satisfaction, in addition to better health outcomes.24e27 Nevertheless, it is not correct to interpret this association as a cause-and-effect relationship because of the crosssectional nature of the study. Follow-up and intervention studies are needed to show such causal relationships. According to a report by the American Medical Association, the effect of health literacy is a more important variable than age, income level, and level of education of the individuals on their health status.33,34 On the other hand, it is not possible to think about individual health literacy and patient satisfaction independently from OHL. Particularly in view of the rapid increase in health-related information and the increasing complexity of health services, OHL may be as significant as the individual health literacy for better access to understand and use these services. For this reason, individual health literacy must be seen as an issue in connection with organizational literacy, and in many cases it can develop with the improvement of organizational literacy.35,36 As we have stated in the introduction of this article, there is no definitive list of actions for implementation of OHL. Its implementation and improvement goals must be addressed in a systematic and flexible manner. Systematic changes are required in how healthcare organizations communicate with patients. The following three important steps are recommended to facilitate organizational change when promoting OHL practices:37 (1) Encouraging leaders to promote health literacy; (2) creation of a health literacy change vision that is effectively communicated throughout the organization; and (3) providing training and education for all staff to ensure a smooth transition. The studies on OHL are very inadequate in Turkey. Existing studies are more or less focused on measurement of individual health literacy.38e40

Study limitations The cross-sectional nature of the study is an important limitation that prevents assertive interpretations of causeeeffect

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relations. Therefore, conclusions based on associations from this study should be viewed cautiously. The REALM scale, which is easy and fast to implement, is not an appropriate scale to examine all dimensions of individual health literacy. The Turkish version of the HLS-EU Questionnaire, developed by the European Union, was found to be the most appropriate among the existing scales, but it has not been used in our research because of its length and impractical implementation. Another limitation of the study was related to the measurement of OHL. The tool used in our study (HLHO-10) was based on personal assessments of the hospital managers and may be biased.

Author statements Acknowledgments The authors would like to thank all the hospital managers and patients for their response to the questionnaires and also _ ¨ BITAK TU for funding the study.

Ethical approval This study was approved by the Ethical Committee of the _ Istanbul Medipol University of Turkey (No: 10840098e 604.01.01-E.2739 Date: 09/10/2015).

Funding _ ¨ BITAK-Turkish The work was funded by TU Scientific and Technological Research Institution (3001-Bas‚langıc¸ AR-GE, No: 215S955).

Competing interests None declared.

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