Abstract
Background
Primary care organizations (PCOs) are crucial in promoting organizational health literacy (OHL), which helps individuals access, understand, and use health information. However, research on OHL in primary care is limited and often reflects a single perspective. This study aimed to develop the Primary Care Organizations Organizational Health Literacy Scales (PCO-OHL Scales) from the dual perspectives of clients and healthcare providers.
Methods
The study consisted of two phases. In Phase I, a framework was adapted, and items were developed via literature review, interviews, and field observations. After expert review and two Delphi rounds, an 18-item Parent Version was created and then adapted into parallel client and healthcare provider versions. Phase II assessed content validity via expert ratings and tested reliability (Cronbach’ s α and test-retest) with 348 clients and 326 healthcare providers from 11 PCOs.
Results
The final scales included six dimensions: Leadership and Management, Workforce, Access and Navigation, Communication, Consumer Involvement, and External Cooperation. Content validity (S-CVI/Ave) was 0.944 (client) and 0.956 (healthcare provider). Cronbach’ s α was 0.926 and 0.889, and ICCs were 0.772 and 0.895, respectively. Survey data showed client and healthcare provider scores of 59.97 ± 10.01 and 65.81 ± 6.77. Among 18 item pairs, 5 received high ratings from both groups, 7 received relatively lower ratings from both groups, and 6 showed differences in ratings between clients and healthcare providers.
Conclusions
The PCO-OHL Scales are reliable, valid tools that capture both client and provider views. By incorporating dual perspectives, the scales enable a more comprehensive assessment of organizational practices and user experiences in primary care.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12913-026-14687-9.
Keywords: Organizational health literacy, Primary care organizations, Scale development, Psychometrics
Introduction
Health literacy (HL) is commonly defined as an individual’s ability to obtain, understand, and use basic health information and services to make informed decisions and promote health [1]. It is widely recognized that limited health literacy represents a major challenge in both developed and developing countries [2]. In the United States, one in three people has inadequate health literacy, highlighting its widespread impact [3]. In 2024, only 31.87% of Chinese residents demonstrated adequate health literacy [4]. Limited or inadequate HL is associated with increased hospitalization [5, 6], higher rates of medication non-adherence [5, 7], lower uptake of preventive interventions [5], as well as increased healthcare costs [8]. Although factors such as age, education, and residence influence HL, it is not just a personal characteristic [9]. Rather, HL is shaped by the broader social and organizational environment in which people seek, process, and utilize health information and access healthcare services [10]. Thus, improving HL should extend beyond interventions directed at individuals and encompass strategies to strengthen the health literacy capacities of healthcare organizations.
Organizational health literacy (OHL) has gained prominence as a key component of health systems, highlighting the role of organizations in enabling individuals to access, understand, and use health information and services. Defined in Healthy People 2030 as “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions,” OHL emphasizes institutional responsibility in promoting health literacy [11]. In other words, a truly health-literate organization fosters clear communication, accessible information, and supportive environments that empower individuals to manage their health effectively.
As frontline providers of essential services and preventive care, primary care organizations (PCOs) play a pivotal role in advancing OHL [12]. By equitably enabling individuals to find, understand, and use health information and services to inform health-related decisions and actions [13], OHL aligns closely with the mission of PCOs. However, its implementation remains limited in many settings [14, 15]. PCOs in China face persistent barriers such as communication difficulties between providers and patients [16], limited staff time [17], and insufficient employee training [17]. Without a health-literate organizational environment, patients may find it difficult to navigate services, build trust in care, or follow recommended treatment plans [18].
Assessing OHL is a critical prerequisite for its improvement. Over the past decade, approximately five instruments have been developed to measure OHL in PCOs. The Primary Care Health Literacy Assessment (PCHLA), originally released by the U.S. Agency for Healthcare Research and Quality in 2010 and updated in 2024, evaluates how well providers support patients in understanding information, accessing services, and managing their health [19]. The Health Literate Primary Care Practice Screener (HLPC) focuses on staff communication and responsiveness to diverse literacy needs [20], while the Organizational Health Literacy Self-Assessment Tool for Primary Care (OHL Self-AsseT) offers a modular framework to assess clarity of communication, staff training, and patient engagement [21]. In China, Wei et al. proposed an indicator system for evaluating the health literacy environment in primary health institutions [22]; however, the framework diverges from the core principles of organizational health literacy (OHL) and shows inconsistencies with the ten attributes of OHL outlined by the U.S. Institute of Medicine (IOM) [23], which may limit its applicability in practice. More recently, Chang et al. developed a tool for community health centers in Taiwan that captures multiple dimensions of OHL [24].
These instruments can be broadly categorized by their respondent type: provider-oriented tools, which gather input from healthcare staff or researchers within healthcare organizations, and client-oriented tools, which capture the perspectives of patients. Provider-oriented instruments-such as the PCHLA [19], OHL Self-AsseT [21], the indicator system for evaluating the health literacy environment in primary health institutions, and Taiwan’ s OHL assessment tool [24]-facilitate internal evaluations of organizational practices, including communication approaches, patient education efforts, and system-level support. While these tools yield important insights into institutional operations, they often fail to capture patients’ firsthand experiences, such as how easily they navigate facilities or comprehend written materials. Conversely, client-oriented tools like the HLPC reflect patients’ experiences [20], but typically lack information on organizational elements-such as leadership commitment or the integration of OHL principles into quality improvement efforts-that are not directly observable from the client perspective.
Because OHL is shaped by dynamic interactions between healthcare providers and patients, relying on a single perspective may obscure how institutional strategies and resource allocation ultimately affect patient outcomes. To address these limitations, this study aims to develop and validate the Primary Care Organizations-Organizational Health Literacy Scales (PCO-OHL Scales), a dual-perspective instrument informed by both providers and clients. By capturing the interplay between client health literacy needs and organizational responsiveness, this scale seeks to bridge critical gaps in existing tools and support more targeted, evidence-based improvements in primary care settings.
Methods
This study was conducted in two phases (Fig. 1). In Phase I, the PCO-OHL Scales were developed based on the New Zealand Ministry of Health’ s Health Literacy Review Framework (2015), and refined through a systematic literature review, expert consultations, and pilot testing. In Phase II, the scale’ s reliability and validity were evaluated through a cross-sectional survey conducted in 11 primary healthcare centers, involving both healthcare providers and clients.
Fig. 1.
Research process for developing the PCO-OHL scales for clients and healthcare providers
Phase I: Development of the PCO-OHL scales
Adaptation of the theoretical framework
This study adopted the Health Literacy Review Framework developed by the New Zealand Ministry of Health (2015), which was designed to assist healthcare organizations in assessing their practices and fostering health-literate environments [25]. The framework outlines six core dimensions: Leadership and Management, Consumer Involvement, Workforce, Meeting the Needs of the Population, Access and Navigation, and Communication.
To enhance its applicability in primary care settings, we made two adaptations. “Meeting the Needs of the Population” refers to organizations ensuring that individuals with limited health literacy can participate effectively in their care, and that their health literacy needs are identified and addressed. Since the statement in the Workforce dimension: “The health workforce plays a crucial role in communicating oral and written information to consumers and families and ensuring they understand that information” [25], and the statement in the Access and Navigation dimension: “Health care organizations may find it difficult to identify individuals with limited health literacy within their consumer population, so they adopt a universal precautions approach to avoid making assumptions about who may or may not need assistance” [25], both reflect the core idea of the “Meeting the Needs of the Population’ dimension, this dimension was therefore removed.
Additionally, previous research has underscored the importance of external collaboration-such as partnerships with media outlets, community organizations, and other institutions-in strengthening organizational health literacy [26]. These refinements resulted in a revised framework composed of six interconnected dimensions (see Table 1), which holistically address both internal capacity and external engagement.
Table 1.
Six dimensions of the PCO-OHL scales
| Dimension | Description |
|---|---|
| Leadership and management | Organizational leaders prioritize health literacy by embedding it in the organizational culture, integrating it into strategic and operational plans, and demonstrating commitment at all levels. |
| Workforce | Organizations support the health workforce in developing effective health literacy practices, identify training and capacity needs, and evaluate workforce performance in this area. |
| Access and navigation | Organizations ensure that consumers can easily locate and use appropriate health and related services, offer assistance when needed, and streamline service pathways. |
| Communication | Organizations communicate with consumers and families orally and in writing, convey information clearly and effectively, and co-develop materials in collaboration with users. |
| Consumer involvement | Organizations engage consumers in designing, developing, and evaluating their mission, vision, services, and organizational structure. |
| External cooperation | Organizations collaborate with hospitals, community groups, and local institutions to carry out health literacy promotion activities and share resources. |
Development of the measurement item pool
Item extraction from literature, interviews, and observations
We identified measurement items through a three-step approach involving literature reviews, semi-structured interviews, and field observations. A systematic search (PubMed, Web of Science, EBSCO, Scopus, CNKI, VIP, Wanfang) employed keywords such as “health literacy/organization and administration,” “health facilities/organizations,” and “primary health care,” covering records up to July 2024. Studies focusing on health literacy in primary care organizations or OHL assessment tools, published in English or Chinese, were included; those lacking full-text access, conference papers, or book chapters were excluded. After removing duplicates and irrelevant studies, 16 articles (13 in English, 3 in Chinese) were included. Two more tools were identified through literature tracing, bringing the total to 18. Qualitative content analysis of these 18 studies produced 19 items.
Semi-structured interviews were conducted with healthcare providers (≥ 3 years of professional experience) and clients (≥ 18 years old, with either at least three outpatient visits or five or more days of hospitalization in the past 6 months). Based on the theoretical framework, the guide for healthcare providers was organized into five domains: (1) whether and how service users were invited to participate in improving service processes or developing/optimizing health information materials; (2) the ways in which institutions and contracted family doctors supported patients’ access to and use of health information (e.g., through educational materials, navigation facilities, or guidance on self-service machines and official WeChat accounts); (3) managerial measures to support providers in addressing patients’ health literacy needs, including the existence of related institutional policies or procedures; (4) communication strategies used to help patients and families better understand health information; and (5) collaborations with other medical institutions, universities, organizations, or government departments to improve clients’ health literacy. The interview guide for clients likewise comprised five domains: (1) their experiences of participating in the evaluation or improvement of medical services or health information materials; (2) perceptions of institutional culture, policies, or facilities that facilitated or hindered care-seeking and understanding of health information, along with unmet needs and suggestions for improvement; (3) the role of family doctors in facilitating access to, comprehension of, and effective use of health information and services; (4) communication techniques used by healthcare providers that aided understanding; and (5) activities organized by medical institutions in collaboration with communities or other organizations to strengthen clients’ health knowledge and skills. A total of 22 participants (12 providers and 10 clients) contributed to the generation of 11 preliminary items through qualitative content analysis.
Field observations were then conducted over one day at each of two primary care organizations in Zhejiang Province—one urban and one rural. The observations involved reviewing institutional policies, observing clinical workflows, and focusing on patient challenges and provider communication. On-site note-taking and photography informed the final content analysis, yielding 12 additional items.
A total of 42 items—19 from the literature reviews, 11 from interviews, and 12 from field observations—formed the foundation of the assessment tool.
Expert panel review and establishment of the measurement item pool
An expert panel was assembled to refine the preliminary item pool. Experts were eligible if they had at least 10 years of professional experience in relevant fields (hospital administration, health management, clinical medicine, or nursing), held a bachelor’s degree or higher, possessed a senior professional title, and had theoretical or practical experience in health literacy or organizational health literacy. The panel comprised five experts aged 30–49 years, three of whom held a master’s degree or higher.
Two rounds of structured discussions were conducted, each lasting 1–2 h. During these sessions, the panel reviewed the items generated from the qualitative phase, mapped them to the six dimensions of the theoretical framework, and merged overlapping content. Each item was assessed for scientific rigor, relevance, and feasibility—particularly with regard to evaluation from the client perspective. Items deemed irrelevant or impractical to assess were removed.
Following expert review, a finalized measurement item pool of 17 items was established, distributed across the six dimensions as follows: Leadership and Management (2 items), Workforce (2 items), Access and Navigation (3 items), Communication (4 items), Consumer Involvement (3 items), and External Cooperation (3 items).
Delphi method for developing the parent version of the PCO-OHL scales
A Delphi consultation was conducted to refine the PCO-OHL Scales Parent Version, using an expert questionnaire consisting of three sections. The first section introduced the study, outlining its objectives, procedures, timeline, and acknowledgment of expert participation. The second section included an importance rating form, where experts rated each item on a five-point Likert scale (1 = “not important” to 5 = “very important”) and provided open-ended feedback for revisions or suggestions for new items. Space was also provided for suggestions regarding item deletion, modification, or addition. The third section collected demographic information, self-assessed familiarity with the topic, and the basis for the expert’ s evaluations.
Experts were selected according to the following criteria: (1) a minimum of five years of professional experience in hospital administration, health management, clinical medicine, or nursing; (2) a bachelor’ s degree or above; and (3) an intermediate-level or higher professional title.
The finalized Parent Version of the PCO-OHL Scales included 18 items across six dimensions: Leadership and Management (2 items), Workforce (2 items), Access and Navigation (4 items), Communication (4 items), Consumer Involvement (3 items), and External Cooperation (3 items).
Development of the PCO-OHL scales for clients and healthcare providers
To develop conceptually equivalent versions of the PCO-OHL Scales for clients and healthcare providers, the Parent Version-finalized through Delphi consultation-was adapted through a second expert panel discussion. The same panel of five experts participated in two rounds of discussion (each lasting 1–2 h), during which each item was reviewed and revised to ensure linguistic clarity and contextual appropriateness for each target group. The goal was to maintain consistency in the conceptual framework and measurement structure while reflecting the distinct roles and perspectives of providers and clients.
A pilot test was subsequently conducted in October 2024 at a primary healthcare center in Zhejiang Province using convenience sampling. Eligible healthcare providers had at least one year of work experience at the institution. Clients were included if they were aged 18 years or older, had received outpatient or inpatient care, and were able to communicate effectively. To enhance response rates and data quality, researchers provided brief guidance or assistance when necessary.
Phase II: validation of the client and healthcare provider versions of the PCO-OHL scales
Content validity evaluation
The criteria for expert selection were consistent with those used in the preceding Delphi consultation; however, a different group of experts was recruited for this phase than those who participated in the Delphi consultation and the two rounds of expert panel discussions. Experts assessed the relevance of each scale item in relation to the study objectives and the conceptual alignment between the provider and client versions. A 4-point Likert scale (1 = “not relevant” to 4 = “highly relevant”) was used for item rating.
Internal consistency analysis
Convenience sampling was used to recruit participants from PCOs in Zhejiang and Guizhou provinces, representing eastern and western regions of China, respectively. Eligible institutions were those delivering both basic medical and public health services. Inclusion criteria for healthcare providers and clients were consistent with those used in the pilot phase.
The required sample size was calculated as six times the number of scale items, with an additional 20% added to account for potential invalid or incomplete responses. Internal consistency was assessed using Cronbach’ s alpha, with a value above 0.70 considered indicative of acceptable reliability.
Test-retest reliability evaluation
A two-week interval test-retest assessment was conducted with the same healthcare providers and clients to assess the temporal stability of the scale. The Intraclass Correlation Coefficient (ICC) was calculated to evaluate test-retest reliability, confirming the consistency of results under similar conditions and supporting the scale’ s suitability for repeated use in diverse settings.
Statistical methods
Data analysis was conducted using SPSS version 27.0. Descriptive statistics (frequencies and percentages) were used to summarize sample characteristics. Independent sample t-tests were performed to compare mean scores between clients and healthcare providers, with adjustments made for unequal variances where necessary. Statistical significance was determined based on p-values.
Content validity was assessed using the Content Validity Index (CVI), including Item-level (I-CVI) and Scale-level (S-CVI) indices. An I-CVI > 0.78 and S-CVI/Ave > 0.9 indicate adequate content validity. Reliability was evaluated using Cronbach’ s alpha, targeting a value > 0.7, with test-retest reliability assessed using the ICC.
Results
Development of the PCO-OHL scales (Phase I)
Results of the Delphi expert consultation for the parent version
A two-round Delphi consultation was conducted to refine the Parent Version of the PCO-OHL Scales. The experts involved in the Delphi consultation were different from those who participated in the expert panel discussions. In the first round, 12 experts were invited and 10 completed the survey, yielding a response rate of 83.3%. The same 10 experts participated in the second round, achieving a 100% response rate. The panel consisted of professionals from fields related to organizational health literacy (OHL), most of whom had over 10 years of experience, held senior professional titles, and possessed at least a bachelor’s degree (see Table 2).
Table 2.
Demographic information of Delphi consultation experts(n = 10)
| Category | Frequency (%) | |
|---|---|---|
| Field | Hospital Administration | 2(20.0%) |
| Health Management | 1(10.0%) | |
| Clinical Medicine | 2(20.0%) | |
| Clinical Nursing | 5(50.0%) | |
| Age | 30 ~ 39 | 4(40.0%) |
| 40 ~ 49 | 4(40.0%) | |
| >50 | 2(20.0%) | |
| Gender | Male | 2(20.0%) |
| Female | 8(80.0%) | |
| Years of Work Experience | 5 ~ 10 | 1(10.0%) |
| 10 ~ 20 | 3(30.0%) | |
| >20 | 6(60.0%) | |
| Educational Level | Bachelor’s Degree | 7(70.0%) |
| Master’s Degree or Above | 3(30.0%) | |
| Professional Title | Intermediate | 1(10.0%) |
| Associate Senior | 6(60.0%) | |
| Senior | 3(30.0%) | |
In the first round, experts evaluated the importance of 17 preliminary items. Items with a mean score ≤ 4.00 or a coefficient of variation (CV) ≥ 0.25 were considered for revision or elimination. Based on the feedback, one item was removed, two new items were added, and seven were revised. The Kendall’s W coefficient was 0.167 (p < 0.05), and the authority coefficient (Cr) was 0.845. In the second round, all items met the inclusion criteria (mean > 4.00, CV < 0.25), and no further changes were proposed. The Kendall’s W coefficient improved to 0.216 (p < 0.05), indicating increased expert consensus.
Results of the second expert panel discussion and pilot test
The same experts participated in both rounds of the panel discussions. The expert panel successfully adapted the Parent Version into two parallel versions of the PCO-OHL Scales: one for healthcare providers and one for clients. Both versions retained the same six dimensions, the same distribution of items within each dimension, and the same total number of items (18), thereby preserving the structural integrity and conceptual equivalence of the original scale.
In the pilot test, 16 healthcare providers and 20 clients participated. Clients had a mean age of 41.3 years (SD = 14.6); 7 were male and 13 female, with 8 having attained a high school education or above. Healthcare providers had a mean age of 36.8 years (SD = 4.7); 4 were male and 12 female, all held at least a bachelor’s degree, and 10 had intermediate or senior professional titles.
Based on pilot feedback, 3 ambiguous items in the provider version and 7 unclear expressions in the client version were revised. The finalized PCO-OHL Scales for Clients and Healthcare Providers (see Table 3) each consist of 18 items, rated on a 4-point Likert scale: “Strongly agree” (4), “Agree” (3), “Disagree” (2), “Strongly disagree” (1), plus an optional “No opinion” response. Total scores range from 18 to 72 points.
Table 3.
Comparison of scores on the PCO-OHL scales for clients and healthcare providers (n1 = 348; n2 = 326)
| Items | Healthcare providers ’ Score (M ± SD) | Clients’ Score (M ± SD) | t-value | p-value |
|---|---|---|---|---|
| Dimension I: Leadership and Management | ||||
| 1–1 Our organization has established a “client-centered” culture and has included improving health literacy for both staff and clients as part of our mission and development goals. * | 3.67 ± 0.53 | 4.214 | <0.001 | |
| 1–2 The healthcare organization cares about me, values my health needs, and prioritizes my healthcare experience. # | 3.48 ± 0.61 | |||
| 2 − 1 The organization standardizes the creation and distribution of health education materials to ensure they are suitable for readers with varying levels of health literacy. * | 3.66 ± 0.50 | <0.001 | ||
| 2–2 The health education materials provided by the healthcare organization are well-structured, easy to understand, and appropriate for my level of comprehension. # | 3.42 ± 0.63 | 5.448 | ||
| Dimension II: Workforce | ||||
| 3 − 1 The organization requires us to adopt a “patient-centered” service approach. * | 3.72 ± 0.46 | <0.001 | ||
| 3 − 2 Healthcare providers adopt a “patient-centered” approach and strive to meet my needs. # | 3.47 ± 0.59 | 6.091 | ||
| 4 − 1 The organization trains us to use various communication techniques, such as breaking information into smaller chunks, using language that clients can understand, slowing down speech, and using feedback to ensure understanding. * | 3.72 ± 0.46 | <0.001 | ||
| 4 − 2 Healthcare providers use various communication techniques with me, such as breaking information into smaller chunks, speaking in language I understand, slowing down speech, and using feedback to ensure I understand the health information. # | 3.43 ± 0.61 | 6.962 | ||
| Dimension III: Access and Navigation | ||||
| 5 − 1 The organization’ s integrated chronic disease process (e.g., follow-up, registration, consultation, payment) is designed to be easy for clients to understand and use. * | 3.72 ± 0.47 | <0.001 | ||
| 5 − 2 I find the organization’ s integrated chronic disease process (e.g., follow-up, registration, consultation, and payment) easy to understand and use. # | 3.37 ± 0.72 | 7.288 | ||
| 6 − 1 The hospital’ s information platforms (e.g., WeChat official account) are designed to be easily accessible and user-friendly for clients. * | 3.67 ± 0.48 | <0.001 | ||
| 6 − 2 The hospital’ s information platforms (e.g., WeChat official account) are designed in a way that makes it easy for me to find information and navigate. # | 3.36 ± 0.71 | 6.414 | ||
| 7 − 1 The organization provides self-service medical machines (e.g., lab report printers) to streamline the consultation process. * | 3.72 ± 0.48 | <0.001 | ||
| 7 − 2 I find medical self-service machines (e.g., lab report printers) easy to use and helpful in streamlining the consultation process. # | 3.36 ± 0.69 | 7.778 | ||
| 8 − 1 The organization has a medical information desk to provide guidance and counseling services. * | 3.73 ± 0.46 | <0.001 | ||
| 8 − 2 The organization has a medical information desk that offers me guidance and counseling services. # | 3.55 ± 0.57 | 4.542 | ||
| Dimension IV: Communication | ||||
| 9 − 1 We strive to provide clients with comprehensive treatment and health guidance information, emphasizing key details such as medication instructions and test results. * | 3.72 ± 0.46 | <0.001 | ||
| 9 − 2 Healthcare providers inform me in detail about treatment and health guidance, emphasizing key details such as medication instructions and test results. # | 3.49 ± 0.62 | 5.363 | ||
| 10 − 1 Clients are encouraged to ask questions about medical and preventive services during their visits. * | 3.66 ± 0.52 | <0.001 | ||
| 10 − 2 Healthcare providers encourage me to ask questions about medical and preventive services during my visit. # | 3.40 ± 0.68 | 5.621 | ||
| 11 − 1 In addition to verbal communication with clients, we offer health information in multiple formats (e.g., text messages, printed materials, videos) to optimize communication. * | 3.67 ± 0.50 | <0.001 | ||
| 11 − 2 In addition to verbal communication, healthcare providers provide me with health information through text messages, printed materials, and videos. # | 3.36 ± 0.72 | 6.487 | ||
| 12 − 1 The graphic or video materials provided to clients use simple, clear language with appropriate fonts, sizes, line spacing, color contrasts, and images. * | 3.66 ± 0.50 | <0.001 | ||
| 12 − 2 The graphic or video materials provided by healthcare providers use clear and simple language, with appropriate font sizes, colors, line spacing, and images, making it easier for me to read and understand. # | 3.27 ± 0.73 | 7.928 | ||
| Dimension V: Consumer Involvement | ||||
| 13 − 1 We follow up with outpatients or discharged patients by phone or text to collect their feedback on health information. * | 3.60 ± 0.57 | <0.001 | ||
| 13 − 2 I receive calls or texts from healthcare providers asking for my feedback on health information. # | 3.39 ± 0.70 | 4.334 | ||
| 14 − 1 We invite client representatives from all levels to participate in the development of health materials and service programs. * | 3.58 ± 0.55 | <0.001 | ||
| 14 − 2 Healthcare providers invite me or other patient representatives to participate in the development of health materials and service programs. # | 3.32 ± 0.70 | 5.281 | ||
| 15 − 1 We invite client representatives from all levels to participate in improving medical and preventive service processes and collect their feedback. * | 3.63 ± 0.51 | <0.001 | ||
| 15 − 2 Healthcare providers invite me or other patient representatives to participate in improving healthcare processes and gather our feedback. # | 3.34 ± 0.74 | 5.640 | ||
| Dimension VI: External Cooperation | ||||
| 16 − 1 Doctors from higher-level hospitals regularly visit our organization to provide consultation and health-related services to clients. * | 3.72 ± 0.49 | <0.001 | ||
| 16 − 2 Primary care organizations regularly invite specialists from higher-level hospitals to provide consultation and health-related services. # | 3.42 ± 0.66 | 6.722 | ||
| 17 − 1 Our organization has established an efficient and convenient referral process with higher-level hospitals within the medical community, including prioritizing beds for referred patients and streamlining the admission process. * | 3.68 ± 0.52 | <0.001 | ||
| 17 − 2 If needed, I can easily transfer to a higher-level hospital within the medical community. # | 3.45 ± 0.66 | 4.869 | ||
| 18 − 1 We organize health lectures and free clinics in collaboration with local communities (subdistricts) and village committees. * | 3.64 ± 0.52 | <0.001 | ||
| 18 − 2 I participate in health lectures and free clinics organized by primary care organizations in cooperation with local communities (subdistricts) and village committees. # | 3.42 ± 0.65 | 4.840 | ||
| Average Score per Item | 3.68 ± 0.50 | 3.41 ± 0.67 | 8.819 | <0.001 |
| Total Score of the Scale | 65.81 ± 6.77 | 59.97 ± 10.01 | 8.819 | <0.001 |
| Average Item Score for “Leadership and Management” Dimension | 3.67 ± 0.52 | 3.45 ± 0.62 | 6.572 | <0.001 |
| Average Item Score for “Workforce” Dimension | 3.72 ± 0.46 | 3.45 ± 0.60 | 9.301 | <0.001 |
| Average Item Score for “Access and Navigation” Dimension | 3.71 ± 0.47 | 3.41 ± 0.68 | 12.357 | <0.001 |
| Average Item Score for “Communication” Dimension | 3.68 ± 0.50 | 3.38 ± 0.69 | 12.336 | <0.001 |
| Average Item Score for “Consumers Involvement” Dimension | 3.60 ± 0.54 | 3.35 ± 0.72 | 8.455 | <0.001 |
| Average Item Score for “External Cooperation” Dimension | 3.68 ± 0.51 | 3.43 ± 0.66 | 8.840 | <0.001 |
Note: 1.* indicates the Client Version; # indicates the Provider Version
Validation of the PCO-OHL scales for clients and healthcare providers (Phase II)
Content validity
Content validity was assessed by five experts. The I-CVI for both versions ranged from 0.800 to 1.000. The S-CVI/Ave was 0.956 for the provider version and 0.944 for the client version, indicating adequate content validity for both instruments.
Reliability analysis
The reliability assessment was conducted across 11 primary healthcare centers located in Zhejiang Province (eastern China, n = 6) and Guizhou Province (western China, n = 5), including 5 urban and 6 rural institutions. Facility sizes ranged from 800 to 12,100 m², with 6 centers providing inpatient services (16–227 beds), and staff numbers ranging from 50 to 160 (Table 4).
Table 4.
General information and PCO-OHL scales of surveyed community health centers (n = 11)
| Facility ID | Province | Building Area (m²) | Inpatient Beds | Staff Size | PCO-OHL Scales for Healthcare Providers | PCO-OHL Scales for Clients |
|---|---|---|---|---|---|---|
| A | Zhejiang(urban) | 10,999 | No | ~ 100 | 62.72 | 62.33 |
| B | Zhejiang(urban) | 1980 | No | ~ 50 | 66.64 | 62.55 |
| C | Zhejiang(urban) | 3250 | No | ~ 80 | 69.48 | 61.97 |
| D | Zhejiang(rural) | 4000 | No | ~ 60 | 66.04 | 59.80 |
| E | Zhejiang(rural) | 12,100 | Yes | ~ 160 | 62.77 | 61.79 |
| F | Zhejiang(rural) | 4473 | Yes | ~ 80 | 64.35 | 60.50 |
| G | Guizhou(urban) | 3800 | Yes | ~ 60 | 66.88 | 65.17 |
| H | Guizhou(urban) | 1550 | Yes | ~ 60 | 71.04 | 55.67 |
| I | Guizhou(rural) | 1927 | No | ~ 60 | 68.73 | 58.33 |
| J | Guizhou(rural) | 6000 | Yes | ~ 120 | 65.12 | 57.42 |
| K | Guizhou(rural) | 800 | Yes | ~ 40 | 68.37 | 64.83 |
For the provider version, 364 questionnaires were distributed and 348 valid responses were received (response rate: 95.6%). Respondents had a mean age of 34.1 years (SD = 8.5, range: 20–64), and 74.1% were female. Among them, 67.8% held a bachelor’s degree or higher, and 54.6% had junior-level professional titles (Table 5).
Table 5.
Sociodemographic characteristics of healthcare providers (n = 348)
| Category | Frequency proportion (%) | |
|---|---|---|
| Age | <25 | 57 (16.4%) |
| 25 ~ 29 | 66 (19.0%) | |
| 30 ~ 34 | 73 (21.0%) | |
| 35 ~ 39 | 63 (18.1%) | |
| ≥ 40 | 89 (25.6%) | |
| Gender | Male | 90 (25.9%) |
| Female | 258 (74.1%) | |
| Years of Work Experience | ≤ 5 | 114 (32.8%) |
| 6 ~ 10 | 90 (25.9%) | |
| 11 ~ 15 | 57 (16.4%) | |
| 16 ~ 20 | 44 (12.6%) | |
| >20 | 43(12.4%) | |
| Educational Level | Secondary Vocational Education | 11 (3.2%) |
| Junior College Diploma | 101 (29.0%) | |
| Bachelor’s Degree | 231 (66.4%) | |
| Master’s Degree and Above | 5 (1.4%) | |
| Professional Title | Junior | 190 (54.6%) |
| Intermediate | 124 (35.6%) | |
| Associate Senior | 29 (8.3%) | |
| Senior | 5 (1.4%) | |
| Position | Nurse | 130 (37.4%) |
| Doctor | 135 (38.8%) | |
| Medical Technician | 54 (15.5%) | |
| Manager | 29 (8.3%) | |
For the client version, 354 questionnaires were distributed and 326 valid responses were collected (response rate: 92.1%). Respondents had a mean age of 41.2 years (SD = 16.7), with 45.1% male. A total of 57.7% resided in urban areas, and 43.6% reported a monthly household income between 5,001 and 10,000 CNY (Table 6).
Table 6.
Sociodemographic characteristics of clients (n = 326)
| Category | Frequency proportion (%) | |
|---|---|---|
| Age | 18 ~ 24 | 53 (16.3%) |
| 25 ~ 34 | 74 (22.7%) | |
| 35 ~ 44 | 73 (22.4%) | |
| 45 ~ 54 | 54 (16.6%) | |
| 55 ~ 64 | 36 (11.0%) | |
| ≥ 65 | 36 (11.0%) | |
| Gender | Male | 147 (45.1%) |
| Female | 179 (54.9%) | |
| Educational Level | Elementary or Below | 57 (17.5%) |
| Junior High | 63 (19.3%) | |
| Vocational/High School | 128 (39.2%) | |
| College or Above | 78 (23.9%) | |
| Marital Status | Married | 190 (58.3%) |
| Unmarried/Divorced/Widowed | 136 (41.7%) | |
| Residence | Rural | 138 (42.3%) |
| Urban | 188 (57.7%) | |
| Healthcare Coverage | Urban Employee Medical Insurance | 156 (47.9%) |
| Urban and Rural Resident Medical Insurance | 153 (46.9%) | |
| New Rural Cooperative Medical System | 3 (0.9%) | |
| Other (e.g., Commercial Health Insurance) | 14 (4.3%) | |
| Family Average Monthly Income | <2000 | 44 (13.5%) |
| 2001–5000 | 101 (31.0%) | |
| 5001–10,000 | 142 (43.6%) | |
| 10,001–20,000 | 36 (11.0%) | |
| >20,000 | 3 (0.9%) | |
Internal consistency was high for both versions. The Cronbach’s alpha was 0.926 for the client version and 0.889 for the provider version. Test–retest reliability, assessed using the ICC with a 2-week interval, was 0.772 for the client version and 0.895 for the provider version, demonstrating good reliability.
Comparative analysis of the PCO-OHL scales for clients and healthcare providers
The survey results showed that the mean total PCO-OHL score reported by healthcare providers from 11 institutions was 65.81 ± 6.77, while the mean score reported by clients was 59.97 ± 10.01. The difference between the two groups was statistically significant (P < 0.001). In addition, significant differences (P < 0.001) were observed for all corresponding items between the client and provider versions (Table 3). These findings support meaningful cross-group comparisons and demonstrate the added value of incorporating both provider and client perspectives in assessing OHL.
To further explore item-level perceptions across respondent groups, a scatter plot was generated (Fig. 2). The mean score of healthcare providers for each item was plotted on the x-axis, and the mean score of clients for each item was plotted on the y-axis. The vertical and horizontal reference lines represent the overall mean item scores of providers and clients, respectively, dividing the plot into four quadrants. The axes were scaled according to the observed data range (approximately 3.27–3.55 for clients and 3.58–3.73 for providers) to enhance visualization of item-level variation.
Fig. 2.
Scatter plot of item-level mean scores reported by clients and healthcare providers. Each point represents one item of the PCO-OHL scale. The vertical and horizontal reference lines indicate the overall mean item scores across all items for clients and healthcare providers, respectively
All items received relatively high ratings from both groups, with provider scores generally higher than client scores, indicating broadly consistent but not identical perceptions of organizational health literacy performance. The quadrant classification was used as a descriptive visualization approach to illustrate patterns of alignment and variation between the two respondent groups.
(1) Quadrant I (High Alignment–High Scores): Five items (Q3, Q4, Q8, Q9, Q16) received high ratings from both providers and clients, indicating consistent recognition of relatively strong organizational performance in these areas. (2) Quadrant III (High Alignment–Low Scores): Seven items (Q6, Q10, Q11, Q12, Q13, Q14, Q15) received comparatively lower ratings from both groups, suggesting shared perceptions of areas that may benefit from improvement. (3) Quadrant II (Higher Provider Scores): Two items (Q5, Q7) were rated higher by healthcare providers than by clients, indicating aspects of organizational practice that were viewed more positively by providers than by service users.
(4) Quadrant IV (Higher Client Scores): Four items (Q1, Q2, Q17, Q18) received higher ratings from clients than from providers, indicating areas where users reported relatively more favorable experiences than reflected in provider self-assessment.
Items located near the intersection of the axes (e.g., Q2) reflect similar evaluations by both respondent groups, whereas items positioned further from the center (e.g., Q12) indicate relatively lower ratings by both groups rather than substantial disagreement. Overall, the visual distribution of item scores illustrates areas of convergence as well as differences in perceived strengths of organizational performance between providers and clients, supporting the relevance of a dual-perspective approach for capturing both organizational practices and user experiences. The scatter plot is intended to identify patterns that may warrant further investigation rather than to determine modification or removal of individual items.
Discussion and limitations
Discussion
This study seeks to contribute to the conceptualization and measurement of OHL in primary care settings in two key ways. First, it introduces an OHL assessment tool specifically designed for PCOs that incorporates perspectives from both the supply side, represented by healthcare providers, and the demand side, represented by clients. Although existing instruments have improved our understanding of institutional operations or patient experiences, most adopt a single-perspective approach [19–22, 24]. This limits their ability to evaluate how well services align with users’ real-world needs. A comprehensive assessment of both provider practices and patient experiences is essential for determining whether organizational strategies successfully deliver health information and services that are accessible, understandable, and actionable [27–29]. By integrating these complementary viewpoints, the PCO-OHL Scales provide a more balanced and contextually grounded approach to assessing OHL in routine primary care delivery. The visual comparison of item-level scores further illustrates the value of incorporating both provider and client perspectives, as it helps identify areas where perceptions of organizational performance may differ between the two groups.
Second, this study extends the theoretical scope of OHL measurement by introducing External Cooperation as an independent dimension. While the Health Literacy Review Framework developed by the New Zealand Ministry of Health (2015) served as the conceptual foundation [25], previous research has highlighted interorganizational collaboration as a key element of OHL [30]. This includes partnerships with hospitals, community organizations, and local agencies. In the context of Chinese PCOs, such collaboration is commonly reflected in referral mechanisms and shared service provision with higher-level hospitals [31, 32], as well as joint health management initiatives conducted in collaboration with community organizations and subdistrict offices [33, 34]. By formally incorporating External Cooperation as a dimension of OHL, this study emphasizes that organizational responsiveness is shaped not only by internal practices but also by the broader network of relationships that facilitate health promotion at the community level.
The development of the PCO-OHL Scales followed a rigorous, multi-step process grounded in both theoretical frameworks and empirical data. A preliminary item pool was constructed through literature review, qualitative interviews, and field observations to ensure contextual relevance. This pool was reviewed and refined through expert panel discussions and two rounds of Delphi consultation, resulting in the development of a Parent Version. To capture both provider and client perspectives, the Parent Version was subsequently adapted into two parallel versions through further expert review and pilot testing, ensuring conceptual equivalence and clarity of expression. Psychometric evaluation based on formal survey data demonstrated strong internal consistency (Cronbach’s α > 0.8) and high content validity, with item-level CVIs ranging from 0.800 to 1.000 and scale-level CVIs of 0.956 for providers and 0.944 for clients. These results support the reliability, validity, and contextual applicability of the PCO-OHL Scales for dual-perspective assessment in primary care settings.
The PCO-OHL Scales are designed for both cross-sectional assessment and longitudinal monitoring. The scale can be administered either as a one-time assessment to provide a snapshot of organizational health literacy performance or periodically to monitor improvements over time as part of quality improvement initiatives. Within primary care organizations, the provider version may be completed by healthcare professionals involved in patient care, health education, or service management, while the client version can be administered to individuals receiving services through paper-based or electronic questionnaires, with brief assistance provided when necessary to facilitate comprehension.
In summary, the dual-perspective structure, expanded theoretical framework, and demonstrated psychometric strength of the PCO-OHL Scales represent a meaningful advancement in the assessment of health literacy responsiveness in primary care. The tool offers a theoretically grounded and practically applicable method for organizations seeking to evaluate and improve their health literacy performance in a way that reflects both provider intentions and client experiences.
Limitations
This study has several limitations that should be acknowledged. First, the development and validation of the PCO-OHL Scales were carried out in PCOs from only two provinces in eastern and western China, which may restrict the representativeness of the findings. Future studies should examine the applicability and adaptability of the scales in more diverse geographic and healthcare contexts. Additionally, because the scale was developed based on an internationally recognized conceptual framework for organizational health literacy, it may have potential applicability in other healthcare systems; however, cross-cultural adaptation and validation studies are needed before use in different national contexts.
Second, the use of convenience sampling may have introduced selection bias, thereby limiting the generalizability of the results. Nevertheless, the inclusion of participants from PCOs in both urban and rural areas, with diverse backgrounds in age, education, job type, and years of experience, provides some evidence that the scale was broadly understandable and acceptable.
Third, the newly developed scale was not compared with existing OHL measurement instruments, which limits the assessment of its criterion-related validity. Future research is needed to evaluate its performance in comparison with established measures.
Fourth, analyses using the scatter plot and quadrant classification provide only a simplified visualization of item-level agreement and discrepancy between clients and healthcare providers. Although useful for descriptive purposes, this approach offers limited insight into the magnitude of differences.
Finally, the present study did not assess structural validity, as the primary focus was on developing a conceptually grounded and content-valid instrument supported by a theoretical framework. While this phase prioritized establishing content validity and reliability, future research with larger and more diverse samples is required to evaluate the structural validity of the scales through factor analysis.
Conclusion
The PCO-OHL Scales developed in this study adopt a dual-perspective approach, incorporating views from both clients and healthcare providers. The scale is a four-point Likert instrument consisting of 18 items across six dimensions. Higher scores indicate higher levels of OHL. The use of this scale can help identify perceptual gaps and guide targeted quality improvement in PCOs.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Acknowledgements
The authors thank all the participants who participated in this study.
Author contributions
WQC, XP, and LHS contributed equally to this work. WQC conceived the study, conducted the investigation, curated the data, administered the project, and drafted and revised the manuscript. XP developed the methodology, validated the findings, and drafted and revised the manuscript. LHS contributed to the study conception, investigation, formal analysis, validation, and revision of the manuscript. YLW performed formal analysis and contributed to drafting and revising the manuscript. RG conducted the investigation, curated the data, and drafted the manuscript. YFW and ZYZ contributed to the investigation, data curation, and revision of the manuscript. FY, HPX, and YXW carried out formal analysis, data curation, and revised the manuscript. All authors discussed the results and approved the final version of the manuscript. ZQM contributed to the critical revision of the manuscript. YGT supervised the study, contributed to methodology and funding acquisition, and revised the manuscript. ZQM and YGT are co-corresponding authors, with YGT designated as the primary corresponding author.
Funding
This project was supported by the 2023 Ministry of Education Humanities and Social Sciences Research Planning Fund of China (23YJAZH136).
Data availability
The data used in the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
All methods were performed in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Hangzhou Normal University (reference number: 2024098). All participants completed the written informed consent before participating in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Wenqian Cheng, Xiang Pan and Lihua Sun: co-first authorship. Zhiqiong Meng and Yingge Tong: co-corresponding authorship.
Contributor Information
Zhiqiong Meng, Email: 18377619879@163.com.
Yingge Tong, Email: 20120067@hznu.edu.cn.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data used in the current study are available from the corresponding author upon reasonable request.