Assessing organizational health literacy in hospitals by using the International Self-Assessment Tool for Organizational Health Literacy of Hospitals – a feasibility study in six European countries

Assessing organizational health literacy in hospitals by using the International Self-Assessment Tool for Organizational Health Literacy of Hospitals – a feasibility study in six European countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing organizational health literacy in hospitals by using the International Self-Assessment Tool for Organizational Health Literacy of Hospitals – a feasibility study in six European countries Christa Straßmayr, Hanne Søberg Finbråten, Eva Maria Bitzer, Guglielmo Bonaccorsi, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6672905/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2025 Read the published version in BMC Health Services Research → Version 1 posted 10 You are reading this latest preprint version Abstract Background Hospitals can gain valuable insights into their current level of organizational health literacy (OHL) by using self-assessment tools. OHL self-assessment tools can serve as useful instruments for supporting the planning and implementation of OHL interventions aimed at promoting health equity and improving patient outcomes. This explorative study aimed to pilot the International Self-Assessment Tool for Organizational Health Literacy (Responsiveness) of Hospitals (OHL-Hos) among hospitals across six countries. Methods The OHL-Hos, grounded in a comprehensive theoretical framework consisting of eight standards, 21 sub-standards and 141 indicators, was piloted in seven hospitals: one in Austria, Germany, the Czech Republic, Norway and Serbia, and two in Italy. In each hospital, the feasibility of using the OHL-Hos was investigated regarding acceptability, implementation, practicality, and integration, identifying strengths and areas for improvement using descriptive analyses. The self-assessment process included individual rating of an interdisciplinary and inter-hierarchical assessment team regarding OHL-Hos indicators from their personal perspectives, followed by a joint assessment to reach a consensus on different ratings. The process and experiences were documented in semi-structured forms, while the ratings on the indicators were documented numerically. Results All hospitals successfully self-assessed their OHL, identifying strengths and areas for improvement. The self-assessment process varied slightly among countries. While the tool was considered important but lengthy and complex, introductory workshops facilitated successful implementation. The self-assessment process raised awareness and stimulated discussions on improving OHL, highlighting the tool's potential for organizational development. Conclusions The OHL-Hos can serve as a useful tool to identify strengths and areas for improvement in OHL in hospitals. The overall experience with the tool was positive and the joint assessment with the tool was found to foster consensus and enable reflection on OHL, but its comprehensive nature poses challenges to its implementation, leading to recommendations for developing a shortened version of the tool with simple language. Certain indicators require specific knowledge, suggesting different professional groups should address relevant parts. Organizational health literacy Hospitals Self-assessment Health literate organization Health literacy Assessment tool OHL-Hos Feasibility Heath literacy responsiveness Health promoting hospitals Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The growing appreciation of health literacy (HL) as a relational concept, implying that HL is the product of an individual’s capabilities and the HL-related demands and complexities of a system ( 1 – 3 ), has led to the development over the past two decades of concepts and tools that emphasize organizational settings for improving HL at the system level. Several terms, such as ‘health literate (health care) organizations’ ( 4 ), ‘organizational health literacy’ ( 5 ), ‘health literacy-friendly settings’ ( 6 ) and ‘organizational health literacy responsiveness’ ( 7 ) have been suggested to describe health literate environments, and several definitions have been proposed ( 8 – 10 ). When focusing on hospitals/health care organizations, the definition of a health literate health care organization should be acknowledged, which states that ‘A health literate health care organization makes it easier for stakeholders (patients/relatives, staff/leadership, and citizens) to access, understand, appraise, and use/apply disease- and health-relevant information. It also strives to improve personal HL for making judgments and taking decisions in everyday life concerning health care (co-production), disease prevention, and health promotion to maintain or improve quality of life throughout the life course’ ( 9 , 11 ). According to the definition of the U.S. Department of Health and Human Services ( 12 ), the term ‘organizational health literacy’ (OHL) refers to the degree to which health care organizations equitably enable 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. Aligned with these definitions, a recently published scoping review ( 13 ) defines six criteria and attributes characterizing a health literate health care organization: 1. communication with service users, 2. easy access and navigation, 3. integration and prioritization of OHL, 4. assessment and organizational development, 5. engagement and support of service users, and 6. information and qualifications of staff. By reducing the organizational demands for people with limited HL, OHL interventions have the potential to promote health equity. Recent reviews suggest that OHL interventions contribute positively to patient-related outcomes, such as increased HL skills, participation in health care and increased self-management abilities ( 14 , 15 ). At the professional and organizational level, an increase in professionals’ competencies and practices regarding HL as well as organizational changes such as redesign of services to improve HL practices have also been mentioned as outcomes of OHL ( 14 , 15 ). Furthermore, OHL is considered a determinant of patient satisfaction ( 16 ). OHL (self-)assessments tools are considered useful tools to support the planning and implementation of OHL interventions and have the advantage that they require minimal organizational resources ( 10 ). Tools for OHL (self)-assessment are typically based on the principles of organizational development and quality management, and designed to collect data on the structures, processes, and culture of an organization. Relevant organizational characteristics are thereby defined as criteria or standards. The measurement of OHL characteristics is considered an important step in the quality cycle ( 17 ). As such, a systematic approach to enhancing OHL should include a baseline assessment of current practices to detect gaps in existing OHL practice, inform the development of a flexible and detailed OHL action plan or strategy, and support an ongoing evaluation and monitoring of the progress towards establishing OHL within the organization ( 18 ). In recent years, several tools have been developed to measure or assess OHL in health care settings. A recent scoping review ( 13 ) identified 17 tools to measure OHL. One of these is the Vienna tool of Health-Literate Hospitals and Healthcare Organizations (V-HLO-I). Farmanova et al. ( 10 ) recommended the V-HLO-I for its broad understanding of HL as the coproduction of health, quality, and safety and its roots in the settings approach of health promotion. The V-HLO-I was validated in its original German version ( 19 ), translated and culturally adapted into French ( 20 ) and piloted it in three Belgian hospitals ( 21 ). The study team concluded that the tool is suitable to perform a needs assessment to increase the awareness of hospitals and to formulate targeted actions to further strengthen their HL responsiveness ( 21 ). The V-HLO-I was improved and further developed into an international version by adapting it to different health care contexts on the basis of feedback received from different national contexts resulting in the International Self-Assessment Tool for Organizational Health Literacy (Responsiveness) of Hospitals (OHL-Hos) that was used in our study ( 22 ). The OHL-Hos is intended to promote awareness and discussion of current OHL practice, to highlight what the main attributes of a health literate organization are, and to thereby stimulate an organizational self-learning process, identify strengths and areas for improvement of OHL, gain consensus for prioritizing HL interventions, and stimulate HL strategic planning. It also provides a benchmark for establishing OHL in hospitals in different health care systems ( 22 ). Hence, the OHL-Hos could be considered a promising tool to support hospitals in their efforts to become health literate health care organizations. To our knowledge, to date, the OHL-Hos has not been piloted in any country. Feasibility studies are recommended to evaluate the suitability and sustainability of new interventions prior to widespread implementation ( 23 ). Due to the differences in the organization and funding of health services across European countries, and the aim of implementing the OHL-Hos in these different national settings, a feasibility study was deemed necessary to determine the appropriateness and sustainability of the OHL-Hos and its self-assessment process. This article describes the results and experiences from six European countries in assessing both the feasibility of the tool and the self-assessment process. Methods 1. Objectives and research questions The objectives of the study were to pilot the national versions of the OHL-Hos in hospitals from six countries: Austria (AT), Czech Republic (CZ), Germany (DE), Italy (IT), Norway (NO) and Serbia (RS), and to explore the feasibility of implementing the tool. Specifically, four general areas of feasibility were investigated, as described by Bowen et al. ( 23 ): acceptability, implementation, practicality, and integration. The research questions were: How do users experience the feasibility of the OHL-Hos and the self-assessment process (referring to acceptability, implementation, practicality and integration)? To what extent does the use of the OHL-Hos enable the identification of OHL strengths and areas for improvement? How does the use of the OHL-Hos support benchmarking among different national health care organizations? 2. Material: the OHL-Hos The OHL-Hos as used in this study is a modified version of the V-HLO-I. Like its predecessor, it is based on the Vienna concept as theoretical framework ( 19 ) and the definition of ‘health literate health care organization’ proposed by Pelikan and Dietscher ( 11 ). The OHL-Hos acknowledges HL as a core concept of health promotion and relies on the health promoting settings approach. It is directed towards: (a) patients, (b) staff, (c) the resident population of the community a hospital serves, and (d) organizational structures and processes to implement the comprehensive OHL concept into the everyday practice of the organization across four domains i) access to, living and working in the organization, ii) diagnosis, treatment and care, iii) disease management and prevention and iv) healthy lifestyle development. Based on this framework the tool has eight standards and 21 sub-standards (Fig. 1). The standards and sub-standards are operationalized by 155 indicators including sub-indicators, or 141 indicators without sub-indicators. The indicators operationalize concrete observable or measurable elements that are aligned with the principles for health care standards of the International Society for Quality in Health Care ( 24 ) and standards for health promotion in hospitals ( 25 ). The underlying understanding of the earlier OHL debate in the United States of HL and OHL as a concept for improving the quality of health care services was considered, and accepted quality assurance methods in health care were explicitly applied ( 9 , 11 ). The OHL-hos is embedded in a comprehensive document with an introduction, background information on HL and OHL, and instructions on how to use the tool. Furthermore, a glossary and a template for an action plan are provided. For each indicator, four categories indicating the degree of fulfillment are defined: completely fulfilled (76–100%) (‘yes’), fulfilled to a larger extent (51–75%) (‘rather yes’), fulfilled to a lesser extent (26–50%) (‘rather no’), or not fulfilled (0–25%) (‘no’). If a specific indicator is considered as not applicable (N/A) to the organization, it is categorized as such. For each indicator, the instrument offers additional space for comments that can explain or justify the self-assessment. The OHL-Hos is available at https://m-pohl.net/ReferencesOHL . 3. The self- assessment process The instructions on how to use the OHL-Hos ( 22 ) recommends seven steps (Fig. 2). It starts with obtaining a self-assessment mandate from the responsible management of the hospital after clarifying the scope of the assessment (step 1). Next, the management should appoint a hospital-internal person to coordinate the self-assessment (step 2). An assessment team of five to ten people, ideally from executive management, quality management, health promotion, human resource development, medicine, nursing, therapeutic professions, building service/maintenance, patient-ombudsman/woman, self-help groups and patient representatives, and communications/spokesperson should be established (step 3). Each member of the assessment team should then provide an individual assessment completing the tool from their personal perspective (step 4). The individual assessments of all team members should then be captured on one table (excel-sheet), for ease of comparison and then be discussed in the following joint assessment (team meeting). Collecting documents, where possible, is suggested to assess some of the indicators (these are indicated with * in the tool) (step 5). This step should be seen as a supplement to step 4 and should take place simultaneously. In a joint assessment, the different individual assessments are brought together (step 6). It is recommended that a moderator be appointed to facilitate the discussion. In preparation for the joint assessment (step 6), the first step is to identify indicators with similar ratings. Then the focus should be on indicators with significantly different ratings. The latter should be clarified and discussed during the joint assessment, leading to a diagnosis of the strengths and weaknesses concerning OHL of the institution or of the specific unit. On this basis, areas can be defined for selecting and implementing measures to improve specific aspects of OHL (step 7). A specific focus of this pilot study was on the feasibility of steps 3, 4, and 6 of the proposed self-assessment process, as inspired by the ‘RAND Appropriateness’ method ( 26 ). According to this method, individual members of the internal multidisciplinary assessment team complete the questionnaire, after which the results are discussed in each service during a joint group assessment to achieve consensus. Step 5, collecting documents, was considered optional, and step 7 was considered as out of scope for a pilot study. 4. Data collection and data analyses The study was conducted within the WHO Action Network on Measuring Population and Organizational Health Literacy (M-POHL) ( 27 ). In each country, a national research team coordinated the study on the national level and closely cooperated with the hospital-internal coordinator(s) and/or the participants from the selected hospital(s). The OHL-Hos was translated into German, Czech, Italian, Norwegian and Serbian following a common protocol suggesting two forward translations followed by a meeting to reach consensus on to the most appropriate version. Similar types of difficulties and challenges in the translation process were experienced, and similar strategies were used to address them (e.g. replacing original terms which were imprecise when translated with more precise terms). Next, all language versions of the tool were culturally adapted to the national context of hospitals and health care systems. Thereafter, the OHL-Hos was piloted in seven hospitals in six countries (Table 1 ). All hospitals included are non-profit organizations, except for the Czech hospital, which could be considered both a for-profit and a non-profit organization. The hospitals included from CZ, DE, IT, NO and RS are all government owned either regionally or locally, while the participating hospital in AT is owned by a religious organization (non-governmental organization). Six out of the seven pilot hospitals offer both basic and continuing education/ongoing training for the staff. One of the Italian hospitals offers only basic training. Table 1 Characteristics of the participating hospitals Country AT CZ DE IT-A IT-B NO RS Type of hospital general and acute care general and acute care general and acute care general and acute care general and acute care general and acute care specializing in addiction diseases Basis for self-assessment entire organization entire organization one unit (pediatrics) entire organization entire organization management for the entire organization, staff at department level entire organization Location urban urban large urban urban urban large urban metropolis Staff: full-time equivalents 4500 1808 420 1674 1295 11300 145 Urban: ≥15,000 and < 100,000 inhabitants, large urban: ≥100,000 and < 1,000,000 inhabitants, metropolis: ≥1,000,000 inhabitants. AT = Austria, CZ = Czech Republic, DE = Germany, IT-A = hospital A in Italy, IT-B = hospital B in Italy, NO = Norway, RS = Serbia. Piloting was performed in AT from October 2019 to March 2020, in CZ from April 2023 to June 2023, in DE from February 2023 to June 2023, in IT from September 2023 to July 2024, in NO from October 2022 to November 2022 and in RS from December 2023 to July 2024. The different timing between the participating countries is due to the fact that the first attempt to conduct the study was made shortly before the onset of the Covid-19 pandemic, and that the study was suspended during the pandemic. A reporting template was developed to qualitatively and quantitatively document the process, results and experiences of the piloting by the research teams. The template included descriptive questions regarding the hospital in which piloting was performed as well as questions for assessing the feasibility and usability of the tool. When more than one pilot took place in a country, the template had to be completed separately. For each pilot there was close cooperation between the research team and the hospital-internal coordinators. The feasibility of the piloting process was assessed through direct observation of the joint assessment and semi-structured interviews (see supplementary file 1 for the detailed questions) with the internal coordinators within the hospital and/or directly with the participants either by phone or in person. The reporting template also included numerical data from the self-assessment. To allow descriptive analysis of the pilot data, a numerical score was attributed to each response category (3 = yes, fulfilled completely (76–100%); 2 = rather yes, fulfilled to a large extent (51–75%); 1 = rather no, fulfilled to a lesser extent (26–50%); 0 = no, not fulfilled (0–25%); N/A = indicator is not applicable). N/A responses were treated as missing values for the analysis. In the NO pilot, the labels for the response categories were used slightly differently (fulfilled to a very large extent (76–100%), fulfilled to a large extent (51–75%), fulfilled to some extent (26–50%) and fulfilled to a small extent (0–25%) as the shortened ‘rather yes’ and ‘rather no’ were not well accepted when pre-testing the translation. Calculations were performed for each pilot hospital separately. For each indicator, sub-standard and standard, means and standard deviations were calculated across all participants. The mean value of a standard was calculated from the means of each indicator within the standard for all participants. Sub-indicators were equally weighted as one indicator in the mean of the standard. Each sub-standard was weighted equally in the overall mean (= mean of a standard), regardless of the number of indicators in the sub-standard. Using the results from the joint assessment, means were categorized into three groups, indicating: (i) areas of strengths (mean ≥ 2.0); (ii) areas of the intermediate stage needing attention (mean > 1.0 and < 2.0); (iii) areas of weaknesses (needing attention, mean ≤ 1.0). Standard deviations were categorized, indicating consensus level: (i) high ( sd ≤ 0.75), (ii) medium (0.75 < sd < 1.0), and (iii) low sd ≥ 1.0). Data were anonymized after the joint assessment (step 6) and before submitting it to the research team. General Data Protection Regulations’ compliance was ensured by all countries. Results 1. Feasibility of the tool Acceptability Regarding acceptability (i.e., how the intended individual recipients react to the intervention (i.e., to the self-assessment process and the tool)), all participating countries obtained a mandate from the hospital management to perform the self-assessment, appointed a hospital-internal coordinator and established an assessment team for individual assessments and suggested number of participants for joint assessment (range from seven participants in DE to 24 participants in RS for both individual and joint assessment). The assessment teams were interdisciplinary and inter-hierarchical, allowing for different perspectives to be included (Table 2 ). Table 2 Participants in individual and joint assessments, and time spent on the assessments Selected details on the assessment process Country Individual assessment AT CZ DE # IT-A IT-B NO^ RS° Number of participants 11 10 7 10 9 12 24 Participants’ professional role: Management 3 3 2 2 1 Quality management 2 1 1 1 3 Health promotion 1 1 1 1 1 Human resource development 1 1 1 1 1 Medicine 1 1 3 1 1 6 Nursing 1 1 1 2 4 9 Communications/ spokesperson 1 1 1 Physiotherapist 1 Occupational therapist 1 Other 2 i 2 ii 2 iii 3 iv 4 v 1 vi 3 vii Average duration of the assessment (in minutes) 120 180 + 330 210 105 204 Joint assessment Number of participants 7 10 7 # 10 9 11 24 Participants’ professional role: Management 1 3 2 2 1 Quality management 2 1 1 1 3 Health promotion 1 1 1 1 1 Human resource development 1 1 1 1 1 Medicine 1 1 3 1 6 Nursing 1 1 1 2 4 9 Communications/ spokesperson 1 1 1 Physiotherapist 1 Occupational therapist 1 Other 2 ii 2 iii 3 iv 4 v 3 vii Average duration of the assessment (in minutes) 240 360 60 # 120 90 200 105 AT = Austria, CZ = Czech Republic, DE = Germany, IT-A = hospital A in Italy, IT-B = hospital B in Italy, NO = Norway, RS = Serbia. i patient management, ii patient ombudsman/woman, epidemiologist, iii therapeutic profession and laboratory technician, iv therapeutic professions, building services engineering/maintenance, patient-ombudsman/woman, self-help and patient representatives, v residents of hygiene and preventive medicine, administrative staff vi health worker, vii therapeutic professions, # only Standards 4, 5, and 6 were included in the joint assessment. ^Joint assessment was conducted for the management and health care professionals separately. ° Serbia had four pilot groups based on specific roles in the hospital (group 1: included mainly health care associates who are not considered health care professionals by legislation but provide care together with health care professionals, group 2: mainly managerial capacities, group 3: nurses, and group 4: mainly medical doctors from different wards). + Information not documented. Insert Table 2 here Feedback from the internal coordinators and/or participants within the hospitals indicated that the topic of OHL was considered important, and that people were motivated to engage with the tool. However, concerns were raised about the complexity and length of the tool. In the German hospital a participant suggested that ‘ the tool must be shortened so that it is more manageable and does not have a negative impact on the motivation of the participants to complete the self-assessment and indicators must be optimized in terms of content and terminology’ (participant, DE). Furthermore, the full assessment process was perceived to be time-consuming, resulting in some professionals refusing to participate. Yet, with regard to the learning experience on OHL, the joint assessment was considered highly valuable as it provided an opportunity to reflect on organizational practices and identify strengths and areas for improvement in the hospital’s OHL. Implementation Regarding implementation (i.e., the extent to which the intervention was fully implemented as planned and proposed), the individual and the joint assessments were conducted according to the protocol in the Austrian, Italian and Serbian hospitals, whereas some adaptations were made in other countries. In the Czech hospital, the joint assessment was conducted according to the protocol, but the individual assessments were not collected prior to the joint assessment and instead presented at the joint assessment meeting followed by a discussion. In the German hospital, individual assessments were conducted according to the study protocol, while for the joint assessment, indicators that were of most interest to the participants (Standards 4, 5 and 6) were selected for discussion. In the Norwegian hospital, the individual assessment was conducted according to the study protocol, except that the clinical staff did not respond to sub-standard 1.1 as the content could be considered most relevant for managers. The joint assessment in the Norwegian hospital was conducted separately for the management and clinical staff groups. In the Serbian hospital, the joint assessment was conducted for managerial capacity, nurses, medical doctors and health associates (i.e., therapeutic staff) in four separate groups. In AT, CZ, and RS, the joint assessments were moderated by the internal coordinator of the hospital and a member of the national research team. In the German and Norwegian hospitals, a member of the national research team moderated the joint assessment. In the Italian hospitals the moderation was done solely by the internal coordinator. The hospitals in AT, DE, NO, and RS held an introductory workshop for the assessment participants prior to the individual assessment in which some background information on the concept of OHL was provided as well as instruction as to how to complete the OHL-Hos. Practicality Regarding practicality (i.e., the extent to which the intervention can be delivered when resources, time or commitment are constrained in some way), the tool was considered lengthy and time-consuming to complete. The completion time for the individual assessments ranged from one hour and three-quarters in the Norwegian hospital to five and a half hours in an Italian hospital. The time for the joint assessments ranged from one hour in the German hospital to six hours in the Czech hospital (Table 2 ). The tool could be either completed in a Microsoft Word or Excel version. In NO the clinical staff found the Excel format demanding and would prefer a format on a digital platform. One participant said that (s)he would prefer a print-friendly layout of the tool. In AT, where the Word version was used, it was reported by the hospital-internal coordinator that ” 50 pages were ’much too long, for management it is unrealistic to fill out such a long survey” (hospital-internal coordinator, AT) . As for the usability of the OHL-Hos, all countries reported that some indicators were repetitive and redundant, and that some were hard to understand due to demanding language and several unknown terms. The glossary and the introductory workshop were highly appreciated (NO, DE). The Czech and the Italian team considered the language of the tool to be clear and comprehensive. Some professional groups in AT, DE, IT, NO, RS reported that they did not have sufficient knowledge or insight to respond to all indicators. This was especially true for the indicators of Standard 1, which refers to organizational structures and processes that were mostly considered top level management issues. In the Italian hospitals, Standard 8 was considered not relevant in a hospital context because those responsibilities are primarily fulfilled by other services of the National Health System. Some participants (DE, IT, NO) expressed uncertainty about which part of the organization (the entire hospital or individual departments/units) was to be evaluated, as the degree of fulfilment could vary across departments. Missing or N/A responses for almost all indicators were observed. In several hospitals across different countries, many participants either did not respond or marked N/A for various indicators. For example, half of the participants in AT, DE, IT, and RS did not provide responses for whether automated phone systems have a clear option to repeat menu items. Similarly, indicators related to communication guidelines, pre-testing digital services, HL interventions for hard-to-reach groups, and public reporting of HL activities also had high missing or non-responses in hospitals in AT, DE, IT, and NO. Results from the individual assessments were discussed at the joint assessment with the aim of agreeing on strengths and weaknesses concerning OHL either of the organization or of the organizational unit. In Italian, Norwegian and Serbian hospitals, several indicators with different responses from the individual assessments were observed. Experience from the joint assessment showed that different viewpoints were due to the respondents representing different departments and functions. Following discussion, the assessment teams were usually able to reach agreement on the rating of indicators. Therefore, results from the joint assessment partly differed from the individual assessments. In the German hospital it was reported that relevant aspects that were not originally covered in the tool were identified during the joint assessment. Integration Regarding integration, (i.e., the level of system change needed to integrate a new process into an existing infrastructure), the internal coordinators within the hospitals and/or participants reported that the tool was suitable for assessing OHL. The tool and the self-assessment process led to awareness and valuable insight when it comes to OHL and stimulated reflections and discussions concerning improving OHL in all hospitals. IT reported that the joint assessment was also an opportunity for participants to become aware of certain actions already planned within the hospital. The Serbian hospital-internal coordinator reported: ’By filling in the tool and later with the joint assessment, participants became aware of certain problems, but also how they can work to solve those problems. The different opinions of the participants have opened a space for thinking about how to improve work and relationships with patients. It is also important for the hospital to have an insight into its own shortcomings so that they can implement measures for improvement’ (hospital-internal coordinator, RS) . Based on the individual and joint assessments, the Czech project team identified development priorities, which were then submitted to and approved by the hospital management. To maintain the sustainability of the project and to ensure the implementation of proposed interventions, the hospital management decided to formulate an action plan to be implemented within two years. Interventions of the action plan focus on the education of the public and especially children and students (e.g., visits to primary and secondary schools and in the hospital), improving the communication between the hospital staff and patients in the form of audits, training and regular education, launching a patient portal, and more effective transfer of electronic documentation between doctors and providers. Participants from the Austrian hospital reported that it remained open after the joint assessment who would take responsibility for further actions. 2. OHL strengths and areas for improvement Exploring the OHL strengths and weaknesses, most standards had a high degree of fulfilment in the Czech and Serbian hospitals. Standards 6 ( Promote personal HL of patients and relatives after discharge ) and 7 ( Promote personal HL of staff with regard to occupational risks and personal lifestyles ) obtained a high degree of fulfilment in five out of seven hospitals. Low fulfilment was observed for Standards 2 ( Develop documents, materials and services with stakeholders in a participatory manner ), 3 ( Enable and train staff for personal HL and OHL ), and 8 ( The organization contributes to the improvement of personal HL of the local population ) in several hospitals (Fig. 3). In the Serbian hospital the joint assessment was conducted in four groups. In groups 3 and 4, where the participants were nurses and medical doctors, respectively, all standards obtained a high degree of fulfilment. Other therapeutic professions (group 1) assessed Standards 1, 6, 7, and 8 as highly fulfilled, whereas the others could be considered at the intermediate level (medium fulfillment). The managerial capacities (group 2) identified Standard 3 as an area of weakness (low fulfillment), Standards 2, 5, and 8 at the intermediate level, and Standards 1, 4, 6, and 7 as highly fulfilled (Fig. 4). Discussion The aim of this article is to present the experiences of piloting the OHL-Hos in seven hospitals in six European countries. To that effect, the feasibility of the tool and the self-assessment process were explored. In summary, in all hospitals it was found possible to self-assess the status of OHL using the OHL-Hos following the self-assessment process, although partly with adjustments. Also, in all hospitals, OHL strengths and areas for improvement could be identified and agreed upon. However, the OHL-Hos, being a comprehensive tool with eight standards, 21 sub-standards and 141 indicators, and the self-assessment process consisting of several steps, posed challenges to the self-assessment teams and the internal coordinators within the hospitals. This led to recommendations for the improvement of the tool and the self-assessment process. The acceptability of the tool was reflected by the fact that a mandate was obtained from the management of all hospitals, involving a multidisciplinary assessment team and finalizing the self-assessment process. The joint assessment, in which the members of the assessment team jointly agree on indicator ratings and areas of improvement, was highly valued by the participants. The use of such co-creational strategies for OHL assessments was suggested by Palumbo ( 28 ), ensuring that they are not treated as mere management tools. Another comprehensive tool, the Organizational Health Literacy Responsiveness tool (Org-HLR) ( 29 ) also relies on joint assessment. The inclusion of patients in the OHL self-assessment is considered a facilitating factor ( 15 ). In our study, patient representatives should have been included, but this was only achieved in two hospitals. The complexity and the length of the OHL-Hos as well as the time needed to complete the self-assessment process led to dissatisfaction and decrease in acceptability. Although there were some differences in the self-assessment process in the hospitals (number of participants involved, pre-collection of individual assessment results before the joint assessment, grouping the participants for the joint assessment), all participating countries were able to implement the self-assessment successfully. The hospital-internal coordinators who offered an introductory workshop considered these workshops as very important for the successful implementation of the OHL self-assessment process. Conducting an introductory workshop was also identified as a facilitator in other studies ( 15 ). The self-assessment process allowed hospitals sufficient flexibility to adapt to their needs and resources, as demonstrated by the specific approaches taken by different countries, which we consider an advantage. With respect to practicality , the OHL-Hos was considered lengthy with complex wording, and its format was considered unsatisfactory by some participants who would have preferred an online option. To increase practicality, shortening an instrument/tool is a common process in health and health services research ( 30 , 31 ). Some indicators and even entire sub-standards need specific knowledge depending on the respondent’s position within the hospital (e.g. some parts need managerial insights, some need experience with patient contact), and could not be answered or were not of relevance to some (groups of) participants. This leads to the suggestion that certain indicators of the tool may only be answered by certain professional or managerial/technical groups when assessing OHL in hospitals. Clarifying the scope of the assessment, e.g., a ward or department or the entire hospital, and communicating it to the assessment team may also be considered. Our study showed that integrating an OHL self-assessment process can be conducted based on existing structures and resources with the hospital and without enormous efforts or systems changes. This assumption is supported by literature ( 10 , 21 ). Although supporting the implementation of OHL interventions based on the assessment was outside the scope of this pilot study, the decision to develop and implement an action plan by the Czech hospital illustrates the possibility of such a process. Feedback from internal coordinators within the hospitals shows that the delegation of the responsibilities for the implementation process should also be defined as part of the self-assessment process. The self-assessment process by means of the OHL-Hos can lead to the identification of strengths and areas for improvement of OHL , as the joint assessment promotes a decision-making based on a consensus, even in the case of different ratings of indicators by individual team members. Results from different professional groups from the Serbian hospital indicate that the composition of the assessment team influences the results. This shows the importance of the professional perspective from which results are obtained when interpreting the results. The involvement of a multidisciplinary and inter-hierarchical team in the self-assessment process and bringing together different perspectives in a joint assessment, as suggested by the OHL-Hos instructions, is thus considered highly relevant. We refrained from benchmarking as the results stem from only one hospital in five countries and two in one country. In addition, the selection of hospitals was based on a convenience sample and was opportunistic. Yet we would like to refer to the research question on benchmarking more theoretically. The possibility of creating self-assessments based on standardized response options makes the OHL-Hos basically suitable for future benchmarking. In terms of content, however, such a process must be monitored for usefulness and accuracy. The tool involves quantitative and qualitative indicators, so not all indicators are numerically comparably in terms of strict quantitative measures. Both types of indicators have their respective values and importance, but benchmarking could be problematic for some indicators. In the case of international benchmarking, the impact of different health care systems needs to be taken into account. Likewise, in the case of national benchmarking, regional differences should be considered. Limitations We acknowledge that this study has several limitations. For this feasibility study only one hospital in each country, except for IT with two hospitals, was recruited. Hospital selection was intentionally opportunistic in order to pilot the tool and the process. We cannot generalize experiences and results to other hospitals within a country nor among an international group of hospitals. In our study, hospital-internal coordinators selected and recruited participants for the self-assessment process. Their reasons and motivation for participating may have influenced results. Patient representatives should have been included, but this was only achieved in two hospitals. The statistical analysis of the results is only descriptive and a high number of missing values for some indicators were recorded. But despite these limitations we are convinced that the valuable insights gained, and lessons learned by the seven hospitals are important and meaningful for recommending improvements to the OHL-Hos and the self-assessment process. Recommendations for the OHL-Hos A shortened version of the tool should be developed and applied in its entire version. A shortened version of the tool should use simple/clear language. Wording for the response categories that is suitable for international use should be used. The OHL-Hos should preferably be made available in a modularized format (assessment of selected standards or sub-standards, but not of the entire tool). Recommendations for the self-assessment process Conduct an introductory/orientation workshop for the assessment team. Clearly communicate the scope of the assessment (unit or the whole organization) to the assessment team. As some staff may only be able to assess individual standards or sub-standards, but not all standards/sub-standards, appropriate guidance should be provided on who should complete which part of the tool. Pre-selecting parts to be filled in by participants would help to reduce missing values and save participants time by not having to go through parts they cannot answer. Responsibilities for further improvement of OHL in the hospital should be defined. To support organizations using OHL assessment tools and subsequently to make the necessary further improvements, more supportive regulations, policies and resources are needed. As a prerequisite for this, more attention from health care policy and administration is needed ( 17 ). Some countries already support the implementation of OHL on the political level: AT ( 32 , 33 ), Australia ( 34 ), Canada ( 35 , 36 ), DE ( 37 , 38 ), New Zealand ( 39 ), NO ( 40 ), Scotland ( 41 ) and the Unites States ( 12 , 42 – 45 ). One way of facilitating OHL assessments and interventions is the inclusion of OHL standards or indicators in accreditation systems ( 8 ). Another aspect is to make OHL more legally anchored in the responsibilities of health care organizations and in the education and training of health care professionals. Health care organizations can adapt their policies, structures and processes to mitigate the effect of HL challenges and thereby enhance their OHL ( 46 – 48 ). OHL assessments can support the transformation towards becoming a health literate health care organization, provided that the assessment process and the used tool are feasible and perceived as relevant ( 15 , 18 , 28 ). Conclusions The OHL-Hos was successfully piloted in seven hospitals across six European countries, identifying strengths and areas for improvement in OHL. The comprehensive nature of the tool and the self-assessment process posed challenges, leading to recommendations for simplifying and improving both the tool and the process. The process was generally accepted, with multidisciplinary and multi-hierarchical teams playing crucial roles. Joint assessments were particularly appreciated for fostering consensus. Certain indicators required specific knowledge, suggesting that different professional groups should address relevant parts of the assessment. Flexibility in the self-assessment process and the importance of introductory workshops were noted as key factors for successful implementation. Further validation is needed. Recommendations include developing a shortened version of the tool with simple language. In case the OHL-Hos is used, a modular approach is recommended. The existence of feasible tools and processes for their application is an essential prerequisite for the introduction and sustainable implementation of OHL in hospitals. Abbreviations AT Austria DE Germany CZ Czech Republic HL Health literacy IT Italy IT-A Hospital A in Italy IT-B Hospital B in Italy M-POHL WHO Action Network on Measuring Population and Organizational Health Literacy N/A Not applicable NO Norway OHL Organizational health literacy OHL-Hos International Self-Assessment Tool for Organizational Health Literacy (Responsiveness) of Hospitals Org-HLR Organisational Health Literacy Responsiveness tool Sd Standard deviation RS Serbia V-HLO-I Vienna tool of Health-Literate Hospitals and Healthcare Organizations Declarations Ethics approval and consent to participate This study was conducted as a quality assessment project and did not involve medical research. It adhered to the established ethical principles of research, including informed consent, voluntary participation, confidentiality, and data protection. In NO the project was approved by the Norwegian Agency for Shared Services in Education and Research (Sikt) [no. 825176] and by the data protection representative at the included hospital [no. 22/05688]. In RS ethical approval was obtained from the Research ethics committee of the Faculty of Pharmacy at the University of Belgrade [no. 1764/2]. In AT, DE, CZ and IT no ethical approval was required for such a study. Consent for publication Not applicable Availability of data and materials The OHL-Hos is available in Czech, German, Italian, Norwegian, and Serbian upon request at [email protected] . The English version can be found at https://m-pohl.net/ReferencesOHL. To protect the privacy of participants and hospitals, the data supporting the results of this study are not publicly available. Competing interests The authors declare that they have no competing interests. Funding The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. AT: The work of the research team was funded by the Federal Health Agency and the Ministry of Health. DE: The German participation in the M-POHL network and the work of the research team was funded by internal funds of the University of Education Freiburg, and did not receive external funding. CZ: The study was financed by hospital internal funds and the Czech Health Literacy Institute. IT: The Italian participation in the M-POHL network and the work of the research team was funded by the Ministry of Health (years 2019-2022) and the National Institute of Health (Istituto Superiore di Sanità-ISS) (years 2023-2027) NO: The Norwegian participation in the M-POHL network and the realization of this OHL project was funded by the Norwegian Directorate of Health. RS: This research was funded by the Ministry of Science, Technological Development and Innovation, Republic of Serbia through two Grant Agreements with the University of Belgrade-Faculty of Pharmacy No 451-03-136/2025-03/ 200161 and No 451-03-137/2025-03/ 200161. Authors' contributions Conceptualization (CS, HSF, DS); Design of the work (CS, HSF, EMB, GB, MGC, JD, ZI, DK, CaL, ChL, BM, LP, DS, MLS, AS, IS, PS, BU, PZ); Analysis (CS, HSF, DS, DK, AS, PS); interpretation of data (CS, HSF, EMB, DK); Writing – original draft (CS, HSF, EMB, GB, MGC, JD, ØG, ZI, DK, CaL, ChL, BM, LP, DS, MLS, AS, IS, PS, BU, PZ); Writing – review and editing (CS, HSF, EMB, GB, MGC, JD, ØG, ZI, CJ, DK, CL, DLZ, CaL, ChL, BM, LP, DS, MLS, AS, IS, PS, BU, SVB, PZ). All authors read and approved the final manuscript. Acknowledgements This article is dedicated to the loving memory of Professor Jürgen M. 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Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1SemistructuredinterviewquestionnaireOHLHos.docx Cite Share Download PDF Status: Published Journal Publication published 01 Oct, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 26 Jun, 2025 Reviews received at journal 11 Jun, 2025 Reviews received at journal 04 Jun, 2025 Reviewers agreed at journal 02 Jun, 2025 Reviewers agreed at journal 01 Jun, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers invited by journal 27 May, 2025 Editor assigned by journal 22 May, 2025 Submission checks completed at journal 21 May, 2025 First submitted to journal 21 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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den","lastName":"Broucke","suffix":""},{"id":463030910,"identity":"e358ea5a-ebb8-4a14-9cf0-e27ab1b655b6","order_by":23,"name":"Patrizio Zanobini","email":"","orcid":"","institution":"University of Florence","correspondingAuthor":false,"prefix":"","firstName":"Patrizio","middleName":"","lastName":"Zanobini","suffix":""}],"badges":[],"createdAt":"2025-05-15 13:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6672905/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6672905/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13367-4","type":"published","date":"2025-10-01T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83752088,"identity":"b9091658-3fd8-4f5c-a411-8d9be9c88b1c","added_by":"auto","created_at":"2025-06-02 07:10:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5432851,"visible":true,"origin":"","legend":"\u003cp\u003eStandards and sub-standards (SS) of the International Self-Assessment Tool for Organizational Health Literacy of Hospitals\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6672905/v1/fd3cb4bbc3f74609f210976a.png"},{"id":83752087,"identity":"bfe39468-323d-42b3-910b-5a2cbb68f6bc","added_by":"auto","created_at":"2025-06-02 07:10:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":877658,"visible":true,"origin":"","legend":"\u003cp\u003eThe seven steps of the OHL-Hos self-assessment process\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6672905/v1/218c69daec05b518c1c948b8.png"},{"id":83752313,"identity":"2c2048de-1a1d-4c2d-840a-3148ffc66455","added_by":"auto","created_at":"2025-06-02 07:18:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":950689,"visible":true,"origin":"","legend":"\u003cp\u003eThe average degree of fulfilment for Standards 1–8 for each hospital in six countries\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6672905/v1/5468bb1a193596ef9c45fbda.png"},{"id":83752089,"identity":"f5dba971-d87f-4e41-961e-06bf1a52ec20","added_by":"auto","created_at":"2025-06-02 07:10:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":690527,"visible":true,"origin":"","legend":"\u003cp\u003eThe average degree of fulfilment for Standard 1–8 for the Serbian joint assessment groups\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6672905/v1/777cf199093834788f651960.png"},{"id":92883691,"identity":"4b175261-4562-41d6-a0a8-9f998119f0fa","added_by":"auto","created_at":"2025-10-06 16:07:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9117662,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6672905/v1/45eb018e-5a6d-4b3d-be1b-91b5eeac4f62.pdf"},{"id":83752086,"identity":"23e61a95-f6c9-4788-b5b5-b30e21e6b0d6","added_by":"auto","created_at":"2025-06-02 07:10:57","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":42473,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1SemistructuredinterviewquestionnaireOHLHos.docx","url":"https://assets-eu.researchsquare.com/files/rs-6672905/v1/7a806485677008eb33df847c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing organizational health literacy in hospitals by using the International Self-Assessment Tool for Organizational Health Literacy of Hospitals – a feasibility study in six European countries","fulltext":[{"header":"Background","content":"\u003cp\u003eThe growing appreciation of health literacy (HL) as a relational concept, implying that HL is the product of an individual\u0026rsquo;s capabilities and the HL-related demands and complexities of a system (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), has led to the development over the past two decades of concepts and tools that emphasize organizational settings for improving HL at the system level. Several terms, such as \u0026lsquo;health literate (health care) organizations\u0026rsquo; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), \u0026lsquo;organizational health literacy\u0026rsquo; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), \u0026lsquo;health literacy-friendly settings\u0026rsquo; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and \u0026lsquo;organizational health literacy responsiveness\u0026rsquo; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) have been suggested to describe health literate environments, and several definitions have been proposed (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). When focusing on hospitals/health care organizations, the definition of a health literate health care organization should be acknowledged, which states that \u0026lsquo;A health literate health care organization makes it easier for stakeholders (patients/relatives, staff/leadership, and citizens) to access, understand, appraise, and use/apply disease- and health-relevant information. It also strives to improve personal HL for making judgments and taking decisions in everyday life concerning health care (co-production), disease prevention, and health promotion to maintain or improve quality of life throughout the life course\u0026rsquo; (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to the definition of the U.S. Department of Health and Human Services (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), the term \u0026lsquo;organizational health literacy\u0026rsquo; (OHL) refers to the degree to which health care organizations equitably enable 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. Aligned with these definitions, a recently published scoping review (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) defines six criteria and attributes characterizing a health literate health care organization: 1. communication with service users, 2. easy access and navigation, 3. integration and prioritization of OHL, 4. assessment and organizational development, 5. engagement and support of service users, and 6. information and qualifications of staff. By reducing the organizational demands for people with limited HL, OHL interventions have the potential to promote health equity. Recent reviews suggest that OHL interventions contribute positively to patient-related outcomes, such as increased HL skills, participation in health care and increased self-management abilities (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). At the professional and organizational level, an increase in professionals\u0026rsquo; competencies and practices regarding HL as well as organizational changes such as redesign of services to improve HL practices have also been mentioned as outcomes of OHL (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Furthermore, OHL is considered a determinant of patient satisfaction (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOHL (self-)assessments tools are considered useful tools to support the planning and implementation of OHL interventions and have the advantage that they require minimal organizational resources (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Tools for OHL (self)-assessment are typically based on the principles of organizational development and quality management, and designed to collect data on the structures, processes, and culture of an organization. Relevant organizational characteristics are thereby defined as criteria or standards. The measurement of OHL characteristics is considered an important step in the quality cycle (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). As such, a systematic approach to enhancing OHL should include a baseline assessment of current practices to detect gaps in existing OHL practice, inform the development of a flexible and detailed OHL action plan or strategy, and support an ongoing evaluation and monitoring of the progress towards establishing OHL within the organization (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn recent years, several tools have been developed to measure or assess OHL in health care settings. A recent scoping review (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) identified 17 tools to measure OHL. One of these is the Vienna tool of Health-Literate Hospitals and Healthcare Organizations (V-HLO-I). Farmanova et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) recommended the V-HLO-I for its broad understanding of HL as the coproduction of health, quality, and safety and its roots in the settings approach of health promotion. The V-HLO-I was validated in its original German version (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), translated and culturally adapted into French (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and piloted it in three Belgian hospitals (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The study team concluded that the tool is suitable to perform a needs assessment to increase the awareness of hospitals and to formulate targeted actions to further strengthen their HL responsiveness (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The V-HLO-I was improved and further developed into an international version by adapting it to different health care contexts on the basis of feedback received from different national contexts resulting in the International Self-Assessment Tool for Organizational Health Literacy (Responsiveness) of Hospitals (OHL-Hos) that was used in our study (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The OHL-Hos is intended to promote awareness and discussion of current OHL practice, to highlight what the main attributes of a health literate organization are, and to thereby stimulate an organizational self-learning process, identify strengths and areas for improvement of OHL, gain consensus for prioritizing HL interventions, and stimulate HL strategic planning. It also provides a benchmark for establishing OHL in hospitals in different health care systems (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Hence, the OHL-Hos could be considered a promising tool to support hospitals in their efforts to become health literate health care organizations.\u003c/p\u003e \u003cp\u003eTo our knowledge, to date, the OHL-Hos has not been piloted in any country. Feasibility studies are recommended to evaluate the suitability and sustainability of new interventions prior to widespread implementation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Due to the differences in the organization and funding of health services across European countries, and the aim of implementing the OHL-Hos in these different national settings, a feasibility study was deemed necessary to determine the appropriateness and sustainability of the OHL-Hos and its self-assessment process. This article describes the results and experiences from six European countries in assessing both the feasibility of the tool and the self-assessment process.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e1. Objectives and research questions\u003c/h3\u003e\n\u003cp\u003eThe objectives of the study were to pilot the national versions of the OHL-Hos in hospitals from six countries: Austria (AT), Czech Republic (CZ), Germany (DE), Italy (IT), Norway (NO) and Serbia (RS), and to explore the feasibility of implementing the tool. Specifically, four general areas of feasibility were investigated, as described by Bowen et al. (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e): acceptability, implementation, practicality, and integration. The research questions were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eHow do users experience the feasibility of the OHL-Hos and the self-assessment process (referring to acceptability, implementation, practicality and integration)?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eTo what extent does the use of the OHL-Hos enable the identification of OHL strengths and areas for improvement?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHow does the use of the OHL-Hos support benchmarking among different national health care organizations?\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2. Material: the OHL-Hos\u003c/h2\u003e\n \u003cp\u003eThe OHL-Hos as used in this study is a modified version of the V-HLO-I. Like its predecessor, it is based on the Vienna concept as theoretical framework (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) and the definition of \u0026lsquo;health literate health care organization\u0026rsquo; proposed by Pelikan and Dietscher (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). The OHL-Hos acknowledges HL as a core concept of health promotion and relies on the health promoting settings approach. It is directed towards: (a) patients, (b) staff, (c) the resident population of the community a hospital serves, and (d) organizational structures and processes to implement the comprehensive OHL concept into the everyday practice of the organization across four domains i) access to, living and working in the organization, ii) diagnosis, treatment and care, iii) disease management and prevention and iv) healthy lifestyle development. Based on this framework the tool has eight standards and 21 sub-standards (Fig. 1).\u003c/p\u003e\n \u003cp\u003eThe standards and sub-standards are operationalized by 155 indicators including sub-indicators, or 141 indicators without sub-indicators. The indicators operationalize concrete observable or measurable elements that are aligned with the principles for health care standards of the International Society for Quality in Health Care (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) and standards for health promotion in hospitals (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). The underlying understanding of the earlier OHL debate in the United States of HL and OHL as a concept for improving the quality of health care services was considered, and accepted quality assurance methods in health care were explicitly applied (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe OHL-hos is embedded in a comprehensive document with an introduction, background information on HL and OHL, and instructions on how to use the tool. Furthermore, a glossary and a template for an action plan are provided.\u003c/p\u003e\n \u003cp\u003eFor each indicator, four categories indicating the degree of fulfillment are defined: completely fulfilled (76\u0026ndash;100%) (\u0026lsquo;yes\u0026rsquo;), fulfilled to a larger extent (51\u0026ndash;75%) (\u0026lsquo;rather yes\u0026rsquo;), fulfilled to a lesser extent (26\u0026ndash;50%) (\u0026lsquo;rather no\u0026rsquo;), or not fulfilled (0\u0026ndash;25%) (\u0026lsquo;no\u0026rsquo;). If a specific indicator is considered as not applicable (N/A) to the organization, it is categorized as such. For each indicator, the instrument offers additional space for comments that can explain or justify the self-assessment. The OHL-Hos is available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://m-pohl.net/ReferencesOHL\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e3. The self- assessment process\u003c/h3\u003e\n\u003cp\u003eThe instructions on how to use the OHL-Hos (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e) recommends seven steps (Fig. 2). It starts with obtaining a self-assessment mandate from the responsible management of the hospital after clarifying the scope of the assessment (step 1). Next, the management should appoint a hospital-internal person to coordinate the self-assessment (step 2). An assessment team of five to ten people, ideally from executive management, quality management, health promotion, human resource development, medicine, nursing, therapeutic professions, building service/maintenance, patient-ombudsman/woman, self-help groups and patient representatives, and communications/spokesperson should be established (step 3). Each member of the assessment team should then provide an individual assessment completing the tool from their personal perspective (step 4). The individual assessments of all team members should then be captured on one table (excel-sheet), for ease of comparison and then be discussed in the following joint assessment (team meeting). Collecting documents, where possible, is suggested to assess some of the indicators (these are indicated with * in the tool) (step 5). This step should be seen as a supplement to step 4 and should take place simultaneously. In a joint assessment, the different individual assessments are brought together (step 6). It is recommended that a moderator be appointed to facilitate the discussion. In preparation for the joint assessment (step 6), the first step is to identify indicators with similar ratings. Then the focus should be on indicators with significantly different ratings. The latter should be clarified and discussed during the joint assessment, leading to a diagnosis of the strengths and weaknesses concerning OHL of the institution or of the specific unit. On this basis, areas can be defined for selecting and implementing measures to improve specific aspects of OHL (step 7).\u003c/p\u003e\n\u003cp\u003eA specific focus of this pilot study was on the feasibility of steps 3, 4, and 6 of the proposed self-assessment process, as inspired by the \u0026lsquo;RAND Appropriateness\u0026rsquo; method (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). According to this method, individual members of the internal multidisciplinary assessment team complete the questionnaire, after which the results are discussed in each service during a joint group assessment to achieve consensus. Step 5, collecting documents, was considered optional, and step 7 was considered as out of scope for a pilot study.\u003c/p\u003e\n\u003ch3\u003e4. Data collection and data analyses\u003c/h3\u003e\n\u003cp\u003eThe study was conducted within the WHO Action Network on Measuring Population and Organizational Health Literacy (M-POHL) (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). In each country, a national research team coordinated the study on the national level and closely cooperated with the hospital-internal coordinator(s) and/or the participants from the selected hospital(s). The OHL-Hos was translated into German, Czech, Italian, Norwegian and Serbian following a common protocol suggesting two forward translations followed by a meeting to reach consensus on to the most appropriate version. Similar types of difficulties and challenges in the translation process were experienced, and similar strategies were used to address them (e.g. replacing original terms which were imprecise when translated with more precise terms). Next, all language versions of the tool were culturally adapted to the national context of hospitals and health care systems. Thereafter, the OHL-Hos was piloted in seven hospitals in six countries (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). All hospitals included are non-profit organizations, except for the Czech hospital, which could be considered both a for-profit and a non-profit organization. The hospitals included from CZ, DE, IT, NO and RS are all government owned either regionally or locally, while the participating hospital in AT is owned by a religious organization (non-governmental organization). Six out of the seven pilot hospitals offer both basic and continuing education/ongoing training for the staff. One of the Italian hospitals offers only basic training.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of the participating hospitals\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCZ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIT-A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIT-B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral and acute care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral and acute care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral and acute care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral and acute care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral and acute care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egeneral and acute care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003especializing in\u003c/p\u003e\n \u003cp\u003eaddiction\u003c/p\u003e\n \u003cp\u003ediseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasis for self-assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eentire\u003c/p\u003e\n \u003cp\u003eorganization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eentire\u003c/p\u003e\n \u003cp\u003eorganization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eone unit (pediatrics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eentire\u003c/p\u003e\n \u003cp\u003eorganization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eentire\u003c/p\u003e\n \u003cp\u003eorganization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emanagement for the entire organization, staff at department level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eentire organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eurban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eurban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003elarge urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eurban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eurban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003elarge urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emetropolis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStaff:\u003c/p\u003e\n \u003cp\u003efull-time equivalents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1674\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eUrban: \u0026ge;15,000 and \u0026lt;\u0026thinsp;100,000 inhabitants, large urban: \u0026ge;100,000 and \u0026lt;\u0026thinsp;1,000,000 inhabitants, metropolis: \u0026ge;1,000,000 inhabitants. AT\u0026thinsp;=\u0026thinsp;Austria, CZ\u0026thinsp;=\u0026thinsp;Czech Republic, DE\u0026thinsp;=\u0026thinsp;Germany, IT-A\u0026thinsp;=\u0026thinsp;hospital A in Italy, IT-B\u0026thinsp;=\u0026thinsp;hospital B in Italy, NO\u0026thinsp;=\u0026thinsp;Norway, RS\u0026thinsp;=\u0026thinsp;Serbia.\u003c/p\u003e\n\u003cp\u003ePiloting was performed in AT from October 2019 to March 2020, in CZ from April 2023 to June 2023, in DE from February 2023 to June 2023, in IT from September 2023 to July 2024, in NO from October 2022 to November 2022 and in RS from December 2023 to July 2024. The different timing between the participating countries is due to the fact that the first attempt to conduct the study was made shortly before the onset of the Covid-19 pandemic, and that the study was suspended during the pandemic.\u003c/p\u003e\n\u003cp\u003eA reporting template was developed to qualitatively and quantitatively document the process, results and experiences of the piloting by the research teams. The template included descriptive questions regarding the hospital in which piloting was performed as well as questions for assessing the feasibility and usability of the tool. When more than one pilot took place in a country, the template had to be completed separately. For each pilot there was close cooperation between the research team and the hospital-internal coordinators. The feasibility of the piloting process was assessed through direct observation of the joint assessment and semi-structured interviews (see supplementary file 1 for the detailed questions) with the internal coordinators within the hospital and/or directly with the participants either by phone or in person.\u003c/p\u003e\n\u003cp\u003eThe reporting template also included numerical data from the self-assessment. To allow descriptive analysis of the pilot data, a numerical score was attributed to each response category (3\u0026thinsp;=\u0026thinsp;yes, fulfilled completely (76\u0026ndash;100%); 2\u0026thinsp;=\u0026thinsp;rather yes, fulfilled to a large extent (51\u0026ndash;75%); 1\u0026thinsp;=\u0026thinsp;rather no, fulfilled to a lesser extent (26\u0026ndash;50%); 0\u0026thinsp;=\u0026thinsp;no, not fulfilled (0\u0026ndash;25%); N/A\u0026thinsp;=\u0026thinsp;indicator is not applicable). N/A responses were treated as missing values for the analysis. In the NO pilot, the labels for the response categories were used slightly differently (fulfilled to a very large extent (76\u0026ndash;100%), fulfilled to a large extent (51\u0026ndash;75%), fulfilled to some extent (26\u0026ndash;50%) and fulfilled to a small extent (0\u0026ndash;25%) as the shortened \u0026lsquo;rather yes\u0026rsquo; and \u0026lsquo;rather no\u0026rsquo; were not well accepted when pre-testing the translation.\u003c/p\u003e\n\u003cp\u003eCalculations were performed for each pilot hospital separately. For each indicator, sub-standard and standard, means and standard deviations were calculated across all participants. The mean value of a standard was calculated from the means of each indicator within the standard for all participants. Sub-indicators were equally weighted as one indicator in the mean of the standard. Each sub-standard was weighted equally in the overall mean (=\u0026thinsp;mean of a standard), regardless of the number of indicators in the sub-standard.\u003c/p\u003e\n\u003cp\u003eUsing the results from the joint assessment, means were categorized into three groups, indicating: (i) areas of strengths (mean\u0026thinsp;\u0026ge;\u0026thinsp;2.0); (ii) areas of the intermediate stage needing attention (mean\u0026thinsp;\u0026gt;\u0026thinsp;1.0 and \u0026lt;\u0026thinsp;2.0); (iii) areas of weaknesses (needing attention, mean\u0026thinsp;\u0026le;\u0026thinsp;1.0). Standard deviations were categorized, indicating consensus level: (i) high (\u003cem\u003esd\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.75), (ii) medium (0.75\u0026thinsp;\u0026lt;\u0026thinsp;\u003cem\u003esd\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;1.0), and (iii) low \u003cem\u003esd\u003c/em\u003e\u0026thinsp;\u0026ge;\u0026thinsp;1.0).\u003c/p\u003e\n\u003cp\u003eData were anonymized after the joint assessment (step 6) and before submitting it to the research team. General Data Protection Regulations\u0026rsquo; compliance was ensured by all countries.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1. Feasibility of the tool\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eAcceptability\u003c/h2\u003e \u003cp\u003eRegarding acceptability (i.e., how the intended individual recipients react to the intervention (i.e., to the self-assessment process and the tool)), all participating countries obtained a mandate from the hospital management to perform the self-assessment, appointed a hospital-internal coordinator and established an assessment team for individual assessments and suggested number of participants for joint assessment (range from seven participants in DE to 24 participants in RS for both individual and joint assessment). The assessment teams were interdisciplinary and inter-hierarchical, allowing for different perspectives to be included (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants in individual and joint assessments, and time spent on the assessments\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelected details on \u003c/p\u003e \u003cp\u003ethe assessment process\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCZ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eDE\u003c/b\u003e\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eIT-A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eIT-B\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eNO^\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eRS\u0026deg;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants\u0026rsquo; professional role:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth promotion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuman resource development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunications/\u003c/p\u003e \u003cp\u003espokesperson\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational therapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003csup\u003eii\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003csup\u003eiii\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003csup\u003eiv\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003csup\u003ev\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003csup\u003evi\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003csup\u003evii\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage duration of the \u003c/p\u003e \u003cp\u003eassessment (in minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants\u0026rsquo; professional role:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth promotion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuman resource development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunications/\u003c/p\u003e \u003cp\u003espokesperson\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational therapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003csup\u003eii\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003csup\u003eiii\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003csup\u003eiv\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003csup\u003ev\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003csup\u003evii\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage duration of the assessment (in minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eAT\u0026thinsp;=\u0026thinsp;Austria, CZ\u0026thinsp;=\u0026thinsp;Czech Republic, DE\u0026thinsp;=\u0026thinsp;Germany, IT-A\u0026thinsp;=\u0026thinsp;hospital A in Italy, IT-B\u0026thinsp;=\u0026thinsp;hospital B in Italy, NO\u0026thinsp;=\u0026thinsp;Norway, RS\u0026thinsp;=\u0026thinsp;Serbia.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003ei\u003c/sup\u003epatient management, \u003csup\u003eii\u003c/sup\u003epatient ombudsman/woman, epidemiologist, \u003csup\u003eiii\u003c/sup\u003etherapeutic profession and laboratory technician, \u003csup\u003eiv\u003c/sup\u003etherapeutic professions, building services engineering/maintenance, patient-ombudsman/woman, self-help and patient representatives, \u003csup\u003ev\u003c/sup\u003eresidents of hygiene and preventive medicine, administrative staff \u003csup\u003evi\u003c/sup\u003ehealth worker, \u003csup\u003evii\u003c/sup\u003etherapeutic professions, \u003csup\u003e#\u003c/sup\u003e only Standards 4, 5, and 6 were included in the joint assessment. ^Joint assessment was conducted for the management and health care professionals separately. \u003cb\u003e\u0026deg;\u003c/b\u003eSerbia had four pilot groups based on specific roles in the hospital (group 1: included mainly health care associates who are not considered health care professionals by legislation but provide care together with health care professionals, group 2: mainly managerial capacities, group 3: nurses, and group 4: mainly medical doctors from different wards). \u003csup\u003e+\u003c/sup\u003eInformation not documented.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFeedback from the internal coordinators and/or participants within the hospitals indicated that the topic of OHL was considered important, and that people were motivated to engage with the tool. However, concerns were raised about the complexity and length of the tool. In the German hospital a participant suggested that \u0026lsquo;\u003cem\u003ethe tool must be shortened so that it is more manageable and does not have a negative impact on the motivation of the participants to complete the self-assessment and indicators must be optimized in terms of content and terminology\u0026rsquo; (participant, DE).\u003c/em\u003e Furthermore, the full assessment process was perceived to be time-consuming, resulting in some professionals refusing to participate. Yet, with regard to the learning experience on OHL, the joint assessment was considered highly valuable as it provided an opportunity to reflect on organizational practices and identify strengths and areas for improvement in the hospital\u0026rsquo;s OHL.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eImplementation\u003c/h3\u003e\n\u003cp\u003eRegarding implementation (i.e., the extent to which the intervention was fully implemented as planned and proposed), the individual and the joint assessments were conducted according to the protocol in the Austrian, Italian and Serbian hospitals, whereas some adaptations were made in other countries. In the Czech hospital, the joint assessment was conducted according to the protocol, but the individual assessments were not collected prior to the joint assessment and instead presented at the joint assessment meeting followed by a discussion. In the German hospital, individual assessments were conducted according to the study protocol, while for the joint assessment, indicators that were of most interest to the participants (Standards 4, 5 and 6) were selected for discussion. In the Norwegian hospital, the individual assessment was conducted according to the study protocol, except that the clinical staff did not respond to sub-standard 1.1 as the content could be considered most relevant for managers. The joint assessment in the Norwegian hospital was conducted separately for the management and clinical staff groups. In the Serbian hospital, the joint assessment was conducted for managerial capacity, nurses, medical doctors and health associates (i.e., therapeutic staff) in four separate groups. In AT, CZ, and RS, the joint assessments were moderated by the internal coordinator of the hospital and a member of the national research team. In the German and Norwegian hospitals, a member of the national research team moderated the joint assessment. In the Italian hospitals the moderation was done solely by the internal coordinator. The hospitals in AT, DE, NO, and RS held an introductory workshop for the assessment participants prior to the individual assessment in which some background information on the concept of OHL was provided as well as instruction as to how to complete the OHL-Hos.\u003c/p\u003e\n\u003ch3\u003ePracticality\u003c/h3\u003e\n\u003cp\u003eRegarding practicality (i.e., the extent to which the intervention can be delivered when resources, time or commitment are constrained in some way), the tool was considered lengthy and time-consuming to complete. The completion time for the individual assessments ranged from one hour and three-quarters in the Norwegian hospital to five and a half hours in an Italian hospital. The time for the joint assessments ranged from one hour in the German hospital to six hours in the Czech hospital (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The tool could be either completed in a Microsoft Word or Excel version. In NO the clinical staff found the Excel format demanding and would prefer a format on a digital platform. One participant said that (s)he would prefer a print-friendly layout of the tool. In AT, where the Word version was used, it was reported by the hospital-internal coordinator that \u0026rdquo;\u003cem\u003e50 pages were \u0026rsquo;much too long, for management it is unrealistic to fill out such a long survey\u0026rdquo; (hospital-internal coordinator, AT)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eAs for the usability of the OHL-Hos, all countries reported that some indicators were repetitive and redundant, and that some were hard to understand due to demanding language and several unknown terms. The glossary and the introductory workshop were highly appreciated (NO, DE). The Czech and the Italian team considered the language of the tool to be clear and comprehensive. Some professional groups in AT, DE, IT, NO, RS reported that they did not have sufficient knowledge or insight to respond to all indicators. This was especially true for the indicators of Standard 1, which refers to organizational structures and processes that were mostly considered top level management issues. In the Italian hospitals, Standard 8 was considered not relevant in a hospital context because those responsibilities are primarily fulfilled by other services of the National Health System. Some participants (DE, IT, NO) expressed uncertainty about which part of the organization (the entire hospital or individual departments/units) was to be evaluated, as the degree of fulfilment could vary across departments.\u003c/p\u003e \u003cp\u003eMissing or N/A responses for almost all indicators were observed. In several hospitals across different countries, many participants either did not respond or marked N/A for various indicators. For example, half of the participants in AT, DE, IT, and RS did not provide responses for whether automated phone systems have a clear option to repeat menu items. Similarly, indicators related to communication guidelines, pre-testing digital services, HL interventions for hard-to-reach groups, and public reporting of HL activities also had high missing or non-responses in hospitals in AT, DE, IT, and NO.\u003c/p\u003e \u003cp\u003eResults from the individual assessments were discussed at the joint assessment with the aim of agreeing on strengths and weaknesses concerning OHL either of the organization or of the organizational unit. In Italian, Norwegian and Serbian hospitals, several indicators with different responses from the individual assessments were observed. Experience from the joint assessment showed that different viewpoints were due to the respondents representing different departments and functions. Following discussion, the assessment teams were usually able to reach agreement on the rating of indicators. Therefore, results from the joint assessment partly differed from the individual assessments. In the German hospital it was reported that relevant aspects that were not originally covered in the tool were identified during the joint assessment.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntegration\u003c/h2\u003e \u003cp\u003eRegarding integration, (i.e., the level of system change needed to integrate a new process into an existing infrastructure), the internal coordinators within the hospitals and/or participants reported that the tool was suitable for assessing OHL. The tool and the self-assessment process led to awareness and valuable insight when it comes to OHL and stimulated reflections and discussions concerning improving OHL in all hospitals.\u003c/p\u003e \u003cp\u003eIT reported that the joint assessment was also an opportunity for participants to become aware of certain actions already planned within the hospital. The Serbian hospital-internal coordinator reported: \u003cem\u003e\u0026rsquo;By filling in the tool and later with the joint assessment, participants became aware of certain problems, but also how they can work to solve those problems. The different opinions of the participants have opened a space for thinking about how to improve work and relationships with patients. It is also important for the hospital to have an insight into its own shortcomings so that they can implement measures for improvement\u0026rsquo; (hospital-internal coordinator, RS)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e Based on the individual and joint assessments, the Czech project team identified development priorities, which were then submitted to and approved by the hospital management. To maintain the sustainability of the project and to ensure the implementation of proposed interventions, the hospital management decided to formulate an action plan to be implemented within two years. Interventions of the action plan focus on the education of the public and especially children and students (e.g., visits to primary and secondary schools and in the hospital), improving the communication between the hospital staff and patients in the form of audits, training and regular education, launching a patient portal, and more effective transfer of electronic documentation between doctors and providers.\u003c/p\u003e \u003cp\u003eParticipants from the Austrian hospital reported that it remained open after the joint assessment who would take responsibility for further actions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2. OHL strengths and areas for improvement\u003c/h2\u003e \u003cp\u003eExploring the OHL strengths and weaknesses, most standards had a high degree of fulfilment in the Czech and Serbian hospitals. Standards 6 (\u003cem\u003ePromote personal HL of patients and relatives after discharge\u003c/em\u003e) and 7 (\u003cem\u003ePromote personal HL of staff with regard to occupational risks and personal lifestyles\u003c/em\u003e) obtained a high degree of fulfilment in five out of seven hospitals. Low fulfilment was observed for Standards 2 (\u003cem\u003eDevelop documents, materials and services with stakeholders in a participatory manner\u003c/em\u003e), 3 (\u003cem\u003eEnable and train staff for personal HL and OHL\u003c/em\u003e), and 8 (\u003cem\u003eThe organization contributes to the improvement of personal HL of the local population\u003c/em\u003e) in several hospitals (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eIn the Serbian hospital the joint assessment was conducted in four groups. In groups 3 and 4, where the participants were nurses and medical doctors, respectively, all standards obtained a high degree of fulfilment. Other therapeutic professions (group 1) assessed Standards 1, 6, 7, and 8 as highly fulfilled, whereas the others could be considered at the intermediate level (medium fulfillment). The managerial capacities (group 2) identified Standard 3 as an area of weakness (low fulfillment), Standards 2, 5, and 8 at the intermediate level, and Standards 1, 4, 6, and 7 as highly fulfilled (Fig.\u0026nbsp;4).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this article is to present the experiences of piloting the OHL-Hos in seven hospitals in six European countries. To that effect, the feasibility of the tool and the self-assessment process were explored. In summary, in all hospitals it was found possible to self-assess the status of OHL using the OHL-Hos following the self-assessment process, although partly with adjustments. Also, in all hospitals, OHL strengths and areas for improvement could be identified and agreed upon. However, the OHL-Hos, being a comprehensive tool with eight standards, 21 sub-standards and 141 indicators, and the self-assessment process consisting of several steps, posed challenges to the self-assessment teams and the internal coordinators within the hospitals. This led to recommendations for the improvement of the tool and the self-assessment process.\u003c/p\u003e \u003cp\u003eThe \u003cb\u003eacceptability\u003c/b\u003e of the tool was reflected by the fact that a mandate was obtained from the management of all hospitals, involving a multidisciplinary assessment team and finalizing the self-assessment process. The joint assessment, in which the members of the assessment team jointly agree on indicator ratings and areas of improvement, was highly valued by the participants. The use of such co-creational strategies for OHL assessments was suggested by Palumbo (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), ensuring that they are not treated as mere management tools. Another comprehensive tool, the Organizational Health Literacy Responsiveness tool (Org-HLR) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) also relies on joint assessment. The inclusion of patients in the OHL self-assessment is considered a facilitating factor (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In our study, patient representatives should have been included, but this was only achieved in two hospitals. The complexity and the length of the OHL-Hos as well as the time needed to complete the self-assessment process led to dissatisfaction and decrease in acceptability.\u003c/p\u003e \u003cp\u003eAlthough there were some differences in the self-assessment process in the hospitals (number of participants involved, pre-collection of individual assessment results before the joint assessment, grouping the participants for the joint assessment), all participating countries were able to \u003cb\u003eimplement\u003c/b\u003e the self-assessment successfully. The hospital-internal coordinators who offered an introductory workshop considered these workshops as very important for the successful implementation of the OHL self-assessment process. Conducting an introductory workshop was also identified as a facilitator in other studies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The self-assessment process allowed hospitals\u003c/p\u003e \u003cp\u003esufficient flexibility to adapt to their needs and resources, as demonstrated by the specific approaches taken by different countries, which we consider an advantage.\u003c/p\u003e \u003cp\u003eWith respect to \u003cb\u003epracticality\u003c/b\u003e, the OHL-Hos was considered lengthy with complex wording, and its format was considered unsatisfactory by some participants who would have preferred an online option. To increase practicality, shortening an instrument/tool is a common process in health and health services research (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Some indicators and even entire sub-standards need specific knowledge depending on the respondent\u0026rsquo;s position within the hospital (e.g. some parts need managerial insights, some need experience with patient contact), and could not be answered or were not of relevance to some (groups of) participants. This leads to the suggestion that certain indicators of the tool may only be answered by certain professional or managerial/technical groups when assessing OHL in hospitals. Clarifying the scope of the assessment, e.g., a ward or department or the entire hospital, and communicating it to the assessment team may also be considered.\u003c/p\u003e \u003cp\u003eOur study showed that \u003cb\u003eintegrating\u003c/b\u003e an OHL self-assessment process can be conducted based on existing structures and resources with the hospital and without enormous efforts or systems changes. This assumption is supported by literature (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Although supporting the implementation of OHL interventions based on the assessment was outside the scope of this pilot study, the decision to develop and implement an action plan by the Czech hospital illustrates the possibility of such a process. Feedback from internal coordinators within the hospitals shows that the delegation of the responsibilities for the implementation process should also be defined as part of the self-assessment process.\u003c/p\u003e \u003cp\u003eThe self-assessment process by means of the OHL-Hos can lead to the identification of \u003cb\u003estrengths and areas for improvement of OHL\u003c/b\u003e, as the joint assessment promotes a decision-making based on a consensus, even in the case of different ratings of indicators by individual team members. Results from different professional groups from the Serbian hospital indicate that the composition of the assessment team influences the results. This shows the importance of the professional perspective from which results are obtained when interpreting the results. The involvement of a multidisciplinary and inter-hierarchical team in the self-assessment process and bringing together different perspectives in a joint assessment, as suggested by the OHL-Hos instructions, is thus considered highly relevant.\u003c/p\u003e \u003cp\u003eWe refrained from \u003cb\u003ebenchmarking\u003c/b\u003e as the results stem from only one hospital in five countries and two in one country. In addition, the selection of hospitals was based on a convenience sample and was opportunistic. Yet we would like to refer to the research question on benchmarking more theoretically. The possibility of creating self-assessments based on standardized response options makes the OHL-Hos basically suitable for future benchmarking. In terms of content, however, such a process must be monitored for usefulness and accuracy. The tool involves quantitative and qualitative indicators, so not all indicators are numerically comparably in terms of strict quantitative measures. Both types of indicators have their respective values and importance, but benchmarking could be problematic for some indicators. In the case of international benchmarking, the impact of different health care systems needs to be taken into account. Likewise, in the case of national benchmarking, regional differences should be considered.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe acknowledge that this study has several limitations. For this feasibility study only one hospital in each country, except for IT with two hospitals, was recruited. Hospital selection was intentionally opportunistic in order to pilot the tool and the process. We cannot generalize experiences and results to other hospitals within a country nor among an international group of hospitals. In our study, hospital-internal coordinators selected and recruited participants for the self-assessment process. Their reasons and motivation for participating may have influenced results. Patient representatives should have been included, but this was only achieved in two hospitals. The statistical analysis of the results is only descriptive and a high number of missing values for some indicators were recorded. But despite these limitations we are convinced that the valuable insights gained, and lessons learned by the seven hospitals are important and meaningful for recommending improvements to the OHL-Hos and the self-assessment process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for the OHL-Hos\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eA shortened version of the tool should be developed and applied in its entire version.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA shortened version of the tool should use simple/clear language.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWording for the response categories that is suitable for international use should be used.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe OHL-Hos should preferably be made available in a modularized format (assessment of selected standards or sub-standards, but not of the entire tool).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for the self-assessment process\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eConduct an introductory/orientation workshop for the assessment team.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClearly communicate the scope of the assessment (unit or the whole organization) to the assessment team.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAs some staff may only be able to assess individual standards or sub-standards, but not all standards/sub-standards, appropriate guidance should be provided on who should complete which part of the tool.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePre-selecting parts to be filled in by participants would help to reduce missing values and save participants time by not having to go through parts they cannot answer.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eResponsibilities for further improvement of OHL in the hospital should be defined.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo support organizations using OHL assessment tools and subsequently to make the necessary further improvements, more supportive regulations, policies and resources are needed. As a prerequisite for this, more attention from health care policy and administration is needed (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Some countries already support the implementation of OHL on the political level: AT (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), Australia (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), Canada (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), DE (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), New Zealand (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), NO (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), Scotland (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and the Unites States (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne way of facilitating OHL assessments and interventions is the inclusion of OHL standards or indicators in accreditation systems (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Another aspect is to make OHL more legally anchored in the responsibilities of health care organizations and in the education and training of health care professionals. Health care organizations can adapt their policies, structures and processes to mitigate the effect of HL challenges and thereby enhance their OHL (\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). OHL assessments can support the transformation towards becoming a health literate health care organization, provided that the assessment process and the used tool are feasible and perceived as relevant (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe OHL-Hos was successfully piloted in seven hospitals across six European countries, identifying strengths and areas for improvement in OHL. The comprehensive nature of the tool and the self-assessment process posed challenges, leading to recommendations for simplifying and improving both the tool and the process. The process was generally accepted, with multidisciplinary and multi-hierarchical teams playing crucial roles. Joint assessments were particularly appreciated for fostering consensus. Certain indicators required specific knowledge, suggesting that different professional groups should address relevant parts of the assessment. Flexibility in the self-assessment process and the importance of introductory workshops were noted as key factors for successful implementation. Further validation is needed. Recommendations include developing a shortened version of the tool with simple language. In case the OHL-Hos is used, a modular approach is recommended. The existence of feasible tools and processes for their application is an essential prerequisite for the introduction and sustainable implementation of OHL in hospitals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Austria\u003c/p\u003e\n\u003cp\u003eDE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Germany\u003c/p\u003e\n\u003cp\u003eCZ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Czech Republic\u003c/p\u003e\n\u003cp\u003eHL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health literacy\u003c/p\u003e\n\u003cp\u003eIT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Italy\u003c/p\u003e\n\u003cp\u003eIT-A\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Hospital A in Italy\u003c/p\u003e\n\u003cp\u003eIT-B \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hospital B in Italy\u003c/p\u003e\n\u003cp\u003eM-POHL \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;WHO Action Network on Measuring Population and Organizational Health Literacy\u003c/p\u003e\n\u003cp\u003eN/A\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003eNO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Norway\u003c/p\u003e\n\u003cp\u003eOHL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Organizational health literacy\u003c/p\u003e\n\u003cp\u003eOHL-Hos\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Self-Assessment Tool for Organizational Health Literacy (Responsiveness) of Hospitals\u003c/p\u003e\n\u003cp\u003eOrg-HLR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Organisational Health Literacy Responsiveness tool\u003c/p\u003e\n\u003cp\u003eSd\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Standard deviation\u003c/p\u003e\n\u003cp\u003eRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Serbia\u003c/p\u003e\n\u003cp\u003eV-HLO-I \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Vienna tool of Health-Literate Hospitals and Healthcare Organizations\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted as a quality assessment project and did not involve medical research. It adhered to the established ethical principles of research, including informed consent, voluntary participation, confidentiality, and data protection. In NO the project was approved by the Norwegian Agency for Shared Services in Education and Research (Sikt) [no. 825176] and by the data protection representative at the included hospital [no. 22/05688]. In RS ethical approval was obtained from the Research ethics committee of the Faculty of Pharmacy at the University of Belgrade [no. 1764/2]. In AT, DE, CZ and IT no ethical approval was required for such a study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OHL-Hos is available in Czech, German, Italian, Norwegian, and Serbian upon request at [email protected]. The English version can be found at https://m-pohl.net/ReferencesOHL. To protect the privacy of participants and hospitals, the data supporting the results of this study are not publicly available.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that financial support was received for the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAT: The work of the research team was funded by the Federal Health Agency and the Ministry of Health.\u0026nbsp;\u003cbr\u003e\u0026nbsp;DE: The German participation in the M-POHL network and the work of the research team was funded by internal funds of the University of Education Freiburg, and did not receive external funding.\u0026nbsp;\u003cbr\u003e\u0026nbsp;CZ: The study was financed by hospital internal funds and the Czech Health Literacy Institute.\u0026nbsp;\u003cbr\u003e\u0026nbsp;IT: The Italian participation in the M-POHL network and the work of the research team was funded by the Ministry of Health (years 2019-2022) and the National Institute of Health (Istituto Superiore di Sanit\u0026agrave;-ISS) (years 2023-2027)\u003cbr\u003e\u0026nbsp;NO: The Norwegian participation in the M-POHL network and the realization of this OHL project was funded by the Norwegian Directorate of Health.\u003cbr\u003e\u0026nbsp;RS: This research was funded by the Ministry of Science, Technological Development and Innovation, Republic of Serbia through two Grant Agreements with the University of Belgrade-Faculty of Pharmacy No 451-03-136/2025-03/ 200161 and No 451-03-137/2025-03/ 200161.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization (CS, HSF, DS); Design of the work (CS, HSF, EMB, GB, MGC, JD, ZI, DK, CaL, ChL, BM, LP, DS, MLS, AS, IS, PS, BU, PZ); Analysis (CS, HSF, DS, DK, AS, PS); interpretation of data (CS, HSF, EMB, DK); Writing \u0026ndash; original draft\u0026nbsp;(CS, HSF, EMB, GB, MGC, JD, \u0026Oslash;G, ZI, DK, CaL, ChL, BM, LP, DS, MLS, AS, IS, PS, BU, PZ); Writing \u0026ndash; review and editing\u0026nbsp;(CS, HSF, EMB, GB, MGC, JD, \u0026Oslash;G, ZI, CJ, DK, CL, DLZ, CaL, ChL, BM, LP, DS, MLS, AS, IS, PS, BU, SVB, PZ). All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article is dedicated to the loving memory of Professor J\u0026uuml;rgen M. Pelikan, who led the development of the OHL-Hos and who initially conceptualized and founded the WHO Action Network on Measuring Population and Organizational Health Literacy. He was also the lead of the International Working Group Health Promoting Hospitals and Health Literate Health Care Organizations, who developed the OHL-Hos.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their gratitude to all participants from the seven hospitals and all members of the national research teams. A special thanks goes to Kjersti \u0026Oslash;. 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Glob Health Promot. 2024;31(1):3\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/17579759241234851\u003c/span\u003e\u003cspan address=\"10.1177/17579759241234851\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Organizational health literacy, Hospitals, Self-assessment, Health literate organization, Health literacy, Assessment tool, OHL-Hos, Feasibility, Heath literacy responsiveness, Health promoting hospitals","lastPublishedDoi":"10.21203/rs.3.rs-6672905/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6672905/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHospitals can gain valuable insights into their current level of organizational health literacy (OHL) by using self-assessment tools. OHL self-assessment tools can serve as useful instruments for supporting the planning and implementation of OHL interventions aimed at promoting health equity and improving patient outcomes. This explorative study aimed to pilot the International Self-Assessment Tool for Organizational Health Literacy (Responsiveness) of Hospitals (OHL-Hos) among hospitals across six countries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe OHL-Hos, grounded in a comprehensive theoretical framework consisting of eight standards, 21 sub-standards and 141 indicators, was piloted in seven hospitals: one in Austria, Germany, the Czech Republic, Norway and Serbia, and two in Italy. In each hospital, the feasibility of using the OHL-Hos was investigated regarding acceptability, implementation, practicality, and integration, identifying strengths and areas for improvement using descriptive analyses. The self-assessment process included individual rating of an interdisciplinary and inter-hierarchical assessment team regarding OHL-Hos indicators from their personal perspectives, followed by a joint assessment to reach a consensus on different ratings. The process and experiences were documented in semi-structured forms, while the ratings on the indicators were documented numerically.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll hospitals successfully self-assessed their OHL, identifying strengths and areas for improvement. The self-assessment process varied slightly among countries. While the tool was considered important but lengthy and complex, introductory workshops facilitated successful implementation. The self-assessment process raised awareness and stimulated discussions on improving OHL, highlighting the tool's potential for organizational development.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe OHL-Hos can serve as a useful tool to identify strengths and areas for improvement in OHL in hospitals. The overall experience with the tool was positive and the joint assessment with the tool was found to foster consensus and enable reflection on OHL, but its comprehensive nature poses challenges to its implementation, leading to recommendations for developing a shortened version of the tool with simple language. Certain indicators require specific knowledge, suggesting different professional groups should address relevant parts.\u003c/p\u003e","manuscriptTitle":"Assessing organizational health literacy in hospitals by using the International Self-Assessment Tool for Organizational Health Literacy of Hospitals – a feasibility study in six European countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 07:10:52","doi":"10.21203/rs.3.rs-6672905/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-26T10:26:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-11T16:27:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T13:55:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168713336232965773243017375836730432023","date":"2025-06-02T14:09:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33467873746627408765059922821380596419","date":"2025-06-01T10:44:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43827377715297860834623394594114078274","date":"2025-05-30T06:33:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-27T22:14:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-22T08:09:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-21T12:27:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-21T12:26:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"821005f4-adb6-4a04-bcf0-e1df6169e4ea","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:00:02+00:00","versionOfRecord":{"articleIdentity":"rs-6672905","link":"https://doi.org/10.1186/s12913-025-13367-4","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-10-01 15:57:09","publishedOnDateReadable":"October 1st, 2025"},"versionCreatedAt":"2025-06-02 07:10:52","video":"","vorDoi":"10.1186/s12913-025-13367-4","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13367-4","workflowStages":[]},"version":"v1","identity":"rs-6672905","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6672905","identity":"rs-6672905","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}