Organizational Health Literacy in Schools: Concept Development for Health-Literate Schools. — TEI-tagged view

Sandra KirchhoffpersName, Kevin DadaczynskipersName, Jürgen M. PelikanpersName, Inge Zelinka-RoitnerpersName, Christina DietscherpersName, Uwe H. BittlingmayerpersName, Orkan OkanpersName (2022date). “Organizational Health Literacy in Schools: Concept Development for Health-Literate Schools..” International Journal of Environmental Research and Public Healthtitle·j.

Object of study — a concept of organizational health literacyterm·dom adapted to schools

Research question — what characterizes a health-literate schoolterm·dom

Contribution — the HeLit-Schools concept of eight standards as guidelines for a health-literate schoolterm·dom

Full text — tagged

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Organizational Health Literacyterm·dom in Schools: Concept Development for Health-Literate Schoolsterm·dom.

Abstract (1) Background: Health literacyterm·dom is considered a personal asset, important for meeting health-related challenges of the 21st century. Measures for assisting students’ health literacyterm·dom development and improving health outcomes can be implemented in the school settingterm·key. First, this is achieved by providing students with learning opportunities to foster their personal health literacyterm·dom, thus supporting behavior changeterm·key. Second, it is achieved by measures at the organizational level promoting social changeterm·key within the proximal and distal environment and supporting the school in becoming more health-literate. The latter approach is rooted in the concept of organizational health literacyterm·dom, which comprises a settings-based approach aiming at changing organizational conditions to enhance health literacyterm·dom of relevant stakeholders. The HeLit-Schools project aims to develop the concept of health-literate schoolsterm·dom, describing aspects that need to be addressed for a school to become a health-literate organization. (2) Method: The concept development builds on existing concepts of organizational health literacyterm·dom and its adaptation to the school settingterm·key. (3) Results: The adaptation results in the HeLit-Schools concept describing a health-literate schoolterm·dom with eight standards. Each standard depicts an area within the school organization that can be developed for fostering health literacyterm·dom of school-related persons. (4) Conclusions: The HeLit-Schools concept offers an approach to organizational developmentterm·dom for sustainably strengthening health literacyterm·dom.

1. Introduction Health literacyterm·dom can be understood as an important competence for dealing with and managing health-related information and knowledge and it is regarded as a core concept of health promotionterm·key [ 1 ]. It is commonly defined as follows: “Health literacyterm·dom is linked to literacy and entails people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotionterm·key to maintain or improve quality of life during the life course” [ 2 ] (p. 3).

The importance of health literacyterm·dom has never been more apparent than in times of societal developments and challenges such as digitalization [ 3 , 4 ] or health crises such as the current COVID-19 pandemic [ 5 , 6 ]. Although information overload was already a major challenge prior to COVID-19 [ 7 ], it was immensely exacerbated by the pandemic, which was accompanied by an information epidemic (“infodemicterm·dom”). The WHO describes an infodemicterm·dom as “an over-abundance of information, some accurate and some not, which makes it hard for people to find trustworthy sources and reliable guidance when they need it” [ 8 ].

These examples demonstrate the need for personal resources, i.e., health literacyterm·dom, for managing health-related information. As health literacyterm·dom is a result of socialization and educational processes [ 9 ], international experts argue that it should be marked as a significant educational goal and that measures to strengthen health literacyterm·dom should be implemented as early as possible in life [ 10 ]. Hence, educational settings such as schools can play a critical role in fostering health literacyterm·dom. Educational interventions at school can teach students basic skills, knowledge, and attitudes at an early age, which, in turn, support them in developing high levels of health literacyterm·dom during their lives [ 1 ]. Furthermore, educational outcomes and health literacyterm·dom are indirectly linked: while health literacyterm·dom influences health behaviors and health status, these health outcomes can have a positive impact on educational outcomes. At the same time, education is a determinant of health literacyterm·dom. In this way, health and education mutually influence each other [ 4 ]. Moreover, studies imply that health equity can be increased by health literacyterm·dom. This is because there is a social gradient for health literacyterm·dom [ 11 ] and because health literacyterm·dom is considered a critical determinant of health that can be influenced and modified, specifically through different support measures [ 12 , 13 , 14 ]. The degree of health literacyterm·dom depends very much on a schoolchild’s social background, which is, as most other factors, determining healthy life years linked to the family of origin’s income and educational background, as indicated by studies on primary [ 15 ] and secondary [ 16 ] schoolchildren conducted in Germany and internationally [ 17 , 18 ].

In addition to directly addressing students’ personal health literacyterm·dom, in order to initiate behavior changeterm·key, and thereby support the development of more healthy behavior, the school organization can be approached about initiating social changeterm·key by promoting their so-called organizational health literacyterm·dom, health-literacy responsiveness, or health literacyterm·dom friendliness [ 19 , 20 ]. This way, strengthening health literacyterm·dom is not limited to individualistic measures for behavior changeterm·key but includes measures for systemic social changeterm·key, including structural and organizational change and development. Such intervention approaches address environmental factors that often have a greater influence on competence, behavior and health [ 4 ].

1.1. Organizational Health Literacyterm·dom Today, health literacyterm·dom is characterized by its relational nature [ 21 , 22 ]. Whether or not a person possesses a high level of health literacyterm·dom and can act in a health-literate manner depends on the extent to which their personal abilities and the complexity of the environmental conditions (e.g., the comprehensibility and accessibility of health information or services) fit together. Accordingly, when dealing with health literacyterm·dom, the respective environment and its requirements must always be considered, making social changeterm·key an important goal of health literacyterm·dom, in addition to behavior changeterm·key. This so-called duality of health literacyterm is presented in the relational model by Parker and Ratzan (2010) [ 21 ]. Recently, Sørensen et al. (2019) [ 22 ] added to the model by proposing that it is equally important to consider the competencies within a system (e.g., those of the staff or the facility) in interaction with the complexities of the individuals using the respective system or services.

Hence, strengthening health literacyterm·dom can be approached in two ways: (i) by educational interventions to directly improve or enhance personal competences (behavior changeterm·key model), and; (ii) by systemic interventions to modify environmental factors (e.g., accessibility, comprehensibility of health-related information, transparency of services, and organizational capacities) [ 23 ], including the responsiveness of organizations [ 24 ] (social changeterm·key model). In the social changeterm·key model, the organization’s conditions and environment can be altered to be more health-literate and better meet the health literacyterm·dom needs of individuals. In this way, they function as a facilitator for the management of health-related information, fostering personal health literacyterm·dom and supporting the development of health-promoting attitudes and behaviors.

The organizational health literacyterm·dom concept includes both the behavioral and social changeterm·key approaches, which are addressed within a holistic, settings-based approach to strengthen health literacyterm·dom. Organizational health literacyterm·dom originated in the US, where it was developed in order to improve the quality of health services and health promotionterm·key in health care and clinical facilities. The concept describes how health-care organizations can be developed and adjusted to be more health-literate. It describes how different organizational changes can be made to better meet patients’ needs (accessibility, transparency, user-friendliness, etc.), to enhance treatment outcomes and communication between professionals and patients, and to positively influence individual health behavior [ 25 ]. Thus, an organization can be described as health-literate if it “equitably enable[s] individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.” [ 26 ] (p. 1084).

Different approaches to organizational health literacyterm·dom have been developed in the past [ 20 , 27 ]. The most well-known, and frequently used, concept was presented by the Institute of Medicineterm·dom (IOMterm·dom) with an integrated model describing ten attributes of health-literate health-care organizations in 2012 [ 28 ]. This concept was further developed in Europe into the Vienna Concept of Health-Literate Hospitals and Healthcare Organizationsterm (V-HLOterm) [ 23 , 29 ], which was first validated and piloted in Austrian hospitals. It was also translated into French and Mandarin and piloted in Belgian and Taiwanese hospitals [ 30 ], later being developed into an International Self-Assessmentterm·key Tool for Organizational Health Literacyterm·dom (Responsiveness) of Hospitals (OHL-Hos) by an international working group of the international network of Health Promoting Hospitals and Health Services (HPH).

Similarly to health-care and social-care organizations, for which the organizational health literacyterm·dom approach is already being used [ 23 , 31 , 32 ], schools can be understood as organizations. In this sense, the concept of the health-literate organization seems transferable. With regard to schools or educational settings in general, work is being undertaken by use of similar concepts in the US [ 33 ], Australia [ 24 , 34 , 35 ], and Austria [ 36 ]. A school is a health-literate organization if its organizational capacities, structures, cultures and processes contribute to developing, practicing, and strengthening personal health literacyterm·dom for everyone at or related to the school [ 37 ]. Previous work in Austria suggests that holistic or systemic approaches and organizational developmentterm·dom are more comprehensive and, therefore, more sustainable and cost-effective than individual measures promoting health literacyterm·dom [ 23 , 25 , 29 ]. Translated to the school settingterm·key, this means that measures should address both behavioral and social changeterm·key driven by the entire school organization, the school environment, and key stakeholders, but should also include improvements of the core functions of the school, i.e., learning arrangements, opportunities, and motivation, as well as fostering skills of students and staff. In addition, addressing the organizational developmentterm·dom of schools can contribute to closing the social gap between schoolchildren from socially disadvantaged and underserved backgrounds and those from privileged backgrounds, as they experience encouragement and educational support from early childhood onwards. A change for health-literate schoolsterm·dom must, therefore, include a change in the educational system itself in order to make it more equitable for all.

1.2. HeLit-Schools Project The “Health-Literate Schoolsterm·dom” research project (“HeLit-Schools”) was launched in 2019 to explore and use the potential a holistic and systemic approach to organizational developmentterm·dom of schools regarding health literacyterm·dom can have. The project is funded by the German Federal Ministry of Health (2019–2023) and is being carried out in the German school context by researchers from Bielefeld University and the Technical University of Munich.

The main aims of the HeLit-Schools project are to adapt the organizational health- literacy concept for the school settingterm·key, to develop a self-assessmentterm·key questionnaire, and to apply this assessment tool in an online survey to measure schools` organizational health literacyterm·dom for the first time [ 37 , 38 , 39 ]. The project is based on a mixed-method study design, combining qualitative research methods (participatory workshops and interviews with central stakeholders, e.g., teachers and principals) and quantitative research methods (online survey to assess organizational health literacyterm·dom of schools). Organizational health literacyterm·dom contributes, and is linked to, school-based organizational developmentterm·dom, whereby organizational developmentterm·dom is described as a process-oriented, holistic approach with a highly systemic character, long-term-oriented planning, and continuous development of the school organization [ 40 ]. Its own members are involved in development and changes in the organization and its environmental features and processes. These members are central actors in planning, realization, and monitoring of these developments. Through this approach, the structures, frameworks, networks, and collaborations of the school can be assessed, reflected upon, and changed to be more beneficial for health-literacy promotion [ 38 , 39 ].

Additionally, the project aims at promoting the implementation and evaluation of this concept in the school settingterm·key. In order to achieve these goals, (i) practical tools are created for supporting schools in becoming more health-literate; e.g., a guideline for implementation, a toolbox of existing teaching materials to enhance personal health literacyterm·dom in school, and the aforementioned self-assessmentterm·key tool for measuring a school’s organizational health literacyterm·dom. (ii) In terms of evaluation, a measurement of organizational health- literacy of schools based on the HeLit-Schools concept will be conducted to gather empirical data and review the conceptualization. (iii) Considering that the organizational health literacyterm·dom approach represents a whole-of-school or settings-approach, and that the WHO-driven health promoting school framework [ 41 ] is already being implemented in selected German schools, including state networks [ 42 , 43 ], the HeLit-Schools project also aims to interlink both concepts and avert conflict between the two whole-of-school approaches that promote health. (iv) Finally, another important goal was to launch a nationwide network for school health literacyterm·dom. This was realized in 2021 with the creation of the German Alliance Health Literacyterm·dom in Schools [ 44 ] in collaboration with researchers, practitioners, and policy actors. The Alliance brings professionals, networks, and interested parties together for collaboration on health literacyterm·dom in schools, serving as a network hub to support the inclusion of health literacyterm·dom in the school settingterm·key and in educational policies.

The objective of this article is to present the development of a concept for organizational health literacyterm·dom for schools that has taken place within the HeLit-Schools research project. First, the development process that builds on adaptation work will be presented, followed by an introduction of the Health-Literate Schoolsterm·dom concept (HeLit-Schools concept) as a result of the adaptation work. On the one hand, this concept provides answers as to what characterizes a health-literate schoolterm·dom. On the other hand, it specifies content-related and school-specific organizational aspects that must be addressed in order to develop a school into a health-literate organization, which helps its students, staff, and those in the school environment to improve their health literacyterm·dom and, in turn, their health.

2. Materials and Methods 2.1. Concept Development: Adaptation of Existing Concepts Concept development was informed by earlier work on organizational health literacyterm·dom in Austria and builds mainly upon two concepts developed for different settings: the original Vienna Concept of Health-Literate Hospitals and Healthcare Organizationsterm (V-HLOterm) [ 23 , 45 ] and the concept of Health-Literate Extracurricular Youth Work of the Austrian Network for Open Youth Work and the Austrian Youth Information Center (“bOJA/BÖJI”) [ 31 , 46 ]. The V-HLOterm concept partly builds upon the “10 Attributes of Health Literate Health Care Organizations” [ 28 ] developed in the US. It aims at addressing organizational capacities, structures, cultures, and processes that are relevant to further developing hospitals into health literacy-friendly settings [ 29 ]. In contrast to the US 10 Attributes, this concept follows the theory-based comprehensive health-promotion settings approach [ 47 ], ISQUA quality methodology, and a wider definition of health literacyterm·dom [ 23 , 29 ]. The bOJA/BÖJI working group used the V-HLOterm concept as a blueprint and adapted it for settings of open youth work. These concepts were chosen because (1) they were already available in the German language, (2) they provide many organizational health-literacy dimensions that are relevant to our own project agenda, and (3) they were developed in collaboration with stakeholders in practice. This was perceived as fundamentally important to increase user involvement and ensure that the concept meets the needs of schools regarding health literacyterm·dom. The bOJA/BÖJI-concept, especially, was regarded as highly relevant and suitable to be adapted within the HeLit-Schools project. This is because the fields of extracurricular youth work and educational work in schools have the same target group, with both settings playing a significant role in the lives of young people. In addition, both settings show parallels regarding educational content and responsibilities, even though the conditions of the settings partially differ. Furthermore, the development of the HeLit-Schools concept was guided by the methodological approach used in that project.

2.2. Adaptation Procedure The planned procedure originally involved on-site workshops in which central stakeholders of the health sector, health-literacy research, and those working in the context of school and education could take part in the adaptation process and share their expertise. This was changed as the COVID-19 pandemic restricted possibilities for meeting. In order to benefit from the expertise of relevant stakeholders such as teachers, principals, practitioners, and researchers, they were asked to comment, review, and validate the developed conceptualization at different stages of the adaptation process.

The project staff developed a first draft version of the HeLit-Schools concept. The two reference concepts mentioned above were analyzed and discussed in-depth. All dimensions, as well as the concepts as a whole, were examined to identify how the corresponding aspects must be adapted in order to fit the framework and reality of the school settingterm·key. Changes were made to make the concept more applicable to schools: Some aspects were deleted and some added, according to the specifics of the school settingterm·key, as described in the following. Additionally, the wording was critically reviewed and adjusted to fit to schools.

The first draft of the concept describing standards of the health-literate schoolterm·dom, including indicators specifying contents and objectives of every standard, was sent to project partners and advisory board members from ministries, academia, and practice to be reviewed and commented on. Their feedback was reviewed and assessed independently by two members of the project staff following a discussion of necessary and well-founded modifications. After reaching consensus, modifications were made. This procedure was repeated every time new comments were received. Comments from the partners and advisory board members mainly targeted the conceptual structure of the standards and indicators, which led to reduction and merging of standards, revision of indicators, and removal of sub-indicators.

A modified version of the concept was then presented and discussed at a meeting of the Interdisciplinary Centre for Health Literacyterm·dom Research at Bielefeld University with health literacyterm·dom and school experts from academia. The project team collected comments, recommendations and critical remarks, subsequently reviewing them in order to update the concept draft. The updated version was again sent for review by principals of schools in Bielefeld. This feedback loop revealed modification needs regarding educational and school-related content. Modifications were requested for aspects such as organizational processes, tasks of school supervisors and school boards, and interaction with the immediate school environment and parents, which had been previously unconsidered or described imprecisely. Recommendations were made regarding the allocation of indicators to standards. Some aspects, for instance, are located within the responsibilities of school principals (definition of the school’s mission statement and philosophy, support of health promoting measures, communication with authorities), whereas other aspects structurally belong to the standard that addresses school development (use of resources, school development plans, extracurricular activities, in-service teacher training). Furthermore, suggestions were made, e.g., regarding offers and activities for parents (such as parents’ evenings), teacher trainings, the depiction of functions in the school, as well as the linking of school content and topics of health promotionterm·key and prevention already embedded in everyday school life. Critical remarks pointed at unrealistic requirements within the concept with regard to tasks for strengthening health literacyterm·dom. In particular, the underlying, but not intentional, expectation that schools must address all these aspects simultaneously and on their own needed to be clarified, as the concept is meant to serve as a guideline for school development.

During the adaptation process, our Austrian project partners from “Styria vitalis” developed and released the guide “Schools for Health Literacyterm·dom” [ 36 ]. As the work of Styria vitalis is based on the same concepts of organizational health literacyterm·dom that we used in the HeLit-Schools projects (bOJA/BÖJI-concept and V-HLOterm), we decided to analyze their concept in order to refine our own. This guideline contributed to the further refinement of our concept and, in particular, led to a simplification of the HeLit-Schools concept and the reduction of indicators.

3. Results The HeLit-Schools concept resulted from the adaptation work. This concept offers a comprehensive approach for the organizational developmentterm·dom of schools into health-literate schoolsterm·dom. Within the concept, a health-literate schoolterm·dom is defined as follows: A health-literate schoolterm·dom optimizes processes, structures and frameworks in such a way that health literacyterm·dom can be developed, practiced and enhanced within and through its setting. A health-literate schoolterm·dom enables everyone involved in the school—students, school principals, teachers and non-teaching staff, parents and caregivers as well as persons in the extended school environment—to deal with and manage health information and to improve and reinforce health-literate behavior [ 37 ].

In order to enhance health literacyterm·dom in the whole school, the concept builds on both behavior and social changeterm·key and addresses different aspects of the school organization crucial to processes of organizational change. From a systems and organizational perspective, schools are complex, socio-ecological systems [ 40 ] that can have a significant influence on everyone at or related to the school. Therefore, it is essential to consider all relevant areas of organizational developmentterm·dom in order to adequately meet the complexity of the school organization and its health-promoting potential [ 44 , 48 ]. The main benefit of this approach is that improvements of the socio-ecological system, i.e., focusing on the school in this case, will facilitate improvement of individual behavior. In this context, this means that improving organizational health literacyterm·dom will support the enhancement of students’ personal health literacyterm·dom.

Developing a school into a health-literate organization can best be embedded into school development processes involving systematic planning and implementation of structural and cultural changes. In doing so, different levels need to be considered in a complementary manner as they are reciprocal. According to theoretical models describing school development processes, these levels address (i) organizational developmentterm·dom, (ii) instructional development, and (iii) the school staff development [ 40 ]. In addition, schools are only one component influencing and determining the living environment next to other systems (e.g., the family). Accordingly, the wider school environment represents a fourth relevant level (iv) that also needs to be considered in a holistic approach to school development regarding health literacyterm·dom and health [ 44 , 49 ].

HeLit-Schools Concept The HeLit-Schools concept comprises eight dimensions of development areas which are called “standards” and can be understood as guidelines for a health-literate schoolterm·dom. These standards address the four developmental areas referred to above and fulfill the requirements of a holistic health promoting setting approach to school development. Each standard comprises six measurable indicators that further describe the objectives and contents of the respective standard. The standards, including a brief summary of the indicators, are presented in Table 1 .

The standards and indicators of the HeLit-Schools concept are the basis for a questionnaire that assesses the organizational health literacyterm·dom of schools. Within the questionnaire, the six measurable indicators are presented for every standard, accompanied by a four-point scale to insert the respective rating and an open box for comments and notes. Thus, the questionnaire functions as a self-assessmentterm·key tool. It guides a school’s evaluation of its health-literacy-related capacities: Which structures, framework conditions, processes, cultures, etc., already foster health literacyterm·dom in everyday school life? Where are the gaps and starting points for planning and realizing changes to further develop the school into a health-literate schoolterm·dom? This questionnaire will be published and made available for schools to use in the near future.

4. Discussion The HeLit-Schools concept describes a holistic approach to organizational developmentterm·dom regarding the strengthening of health literacyterm·dom in schools. It includes measures on the individual level in terms of behavior changeterm·key, and measures on the organizational level of the school in terms of social changeterm·key. When we started our project and the development of this concept in Fall 2019, it was, to our knowledge, the first comprehensive concept of organizational health literacyterm·dom for schools. Parallel to our project, our colleagues from “Styria vitalis” in Austria developed a similar concept, also based on the V-HLOterm and bOJA/BÖJI concepts to be used by schools in Austria [ 36 ].

Within the standards, all relevant levels of school development mentioned above are represented (school staff, teaching, organization, wider school environment). These also reflect common fields of action of school health-promotion approaches [ 4 ]: Standards 3, 4 and 5 focus on strengthening the personal health literacyterm·dom of students and the school team. Thus, they are located within the individual field of action. Strengthening personal health literacyterm·dom among students in the school settingterm·key has been emphasized internationally for some time [ 1 , 4 , 9 , 19 , 50 ]. In addition, the school team is an important addressee for health literacyterm·dom promotion: school principals, due to their key function in school development and the facilitation of health promotionterm·key, are crucial for fostering health literacyterm·dom at schools [ 51 , 52 ]; and teachers, as they are central actors regarding learning and interaction [ 1 ].

Standards 1, 2 and 6 can be placed within the field of action of the school level. Previous work regarding school health promotionterm·key, but also organizational health literacyterm·dom, indicate that environmentally oriented approaches are promising. This is because changes at the system level are considered more sustainable and more effective than solely addressing the individual level [ 4 , 19 ].

Finally, Standards 7 and 8 are directed at the wider school environment. Schools do not act as isolated organizations but are rather integrated into wider community systems. Therefore, the cooperation of local organizations, and services, etc., is described as a significant factor within the community field of action to promote health literacyterm·dom in schools [ 1 , 4 ].

To further develop a school into a health-literate organization can be seen as rewarding, but also demanding, as the approach includes adjustments within the entire school organization. While the presented benefits offer sustainability and effectiveness regarding the early promotion of health literacyterm·dom, the practical implementation can be seen as challenging. Systematic efforts on different levels as well as time, personnel, and financial resources are required.

To support schools in becoming more health-literate, the HeLit-Schools project also aims to provide different tools based on the HeLit-Schools concept: an implementation guideline, a collection of existing materials and programs to strengthen health literacyterm·dom in the school settingterm·key, and a self-assessmentterm·key tool to measure schools’ organizational health literacyterm·dom. These tools are intended to guide their organizational developmentterm·dom: from baseline inventory to developing and implementing changes and measures, and finally, reviewing the development process. As of now, the development of these tools has been completed and they will be published shortly.

Currently, there is not yet an empirical basis with regard to practicability and implementation processes of the concept in schools. Thus, there is no detailed information about facilitators and barriers. However, the HeLit-Schools project goals also include the measurement of the organizational health literacyterm·dom of schools. School principals will be invited to assess their school using the developed questionnaire. Analysis of the generated data promises empirical validation of the concept and insights into potentials and necessities across schools regarding the organization-based, systemic strengthening of health literacyterm·dom in the school settingterm·key. After identifying supporting factors and barriers, these will be transferred into practical recommendations.

5. Conclusions As the importance of health literacyterm·dom grows, settings-based interventions and approaches are much needed in order to foster personal health literacyterm·dom more effectively. Schools can play a crucial role in enhancing the health literacyterm·dom of students and virtually every individual at the school. The HeLit-School concept is based on the organizational health-literacy approach adopted to the school settingterm·key. The concept guides the organizational developmentterm·dom of schools in order for them to become health-literate organizations. The concept includes a combination of skill-promoting measures in terms of behavior changeterm·key and measures for altering the structures and organizational conditions of the school and its entire environment in terms of social changeterm·key. Thus, this holistic concept, originally developed for schools in Germany, seems to be a promising approach for effectively and sustainably strengthening health literacyterm·dom in and through schools, including those beyond Germany in the wider international context.