Improving Organizational Health Literacy in Extracurricular Youth Work Settings

Abstract

Although most health literacy (HL) interventions in Europe focus on the enhancement of individual competences and primarily address health care, this article describes a novel approach to improving the HL friendliness of extracurricular youth work in Austria. Accordingly, the “Vienna Concept of Health-Literate Hospitals and Healthcare Organizations (V-HLO)” was transferred to extracurricular youth work for the first time. This article first gives a concise overview of the project, then outlines the interaction between the project development and the evaluation, and finally summarizes the main project outcomes and results. The project outcomes and the results indicate that the concept of organizational HL, in particular the V-HLO, could be transferred from the health care setting to the extracurricular youth work setting; yet data indicate that different priorities are relevant and different tools are needed. Although quality management is an important partner to implement the V-HLO in hospitals, more informal and flexible structures are required for an extracurricular youth work setting. The successful transfer of the V-HLO to the extracurricular youth work setting illustrates that the V-HLO has potential in varied settings beyond health care. [Health Literacy Research and Practice. 2017;1(4):e233–e238.]

Childhood and adolescence are the most rapid phases of human development. In these life phases, essential development processes take place and health-related behaviors and skills are acquired (McDaid, 2016; Wolf et al., 2009). Health behavior theory indicates that health literacy (HL) starts developing during childhood and adolescence and that this phase of life is particularly sensitive for adapting health behaviors and can have a great effect on the risk for developing chronic diseases in adulthood (O'Connel, Baoat, & Warner, 2009). Developing HL skills early in life can provide an important foundation for building up HL in later life (Bröder et al., 2017; Manganello, 2008; McDaid, 2016; Okan, Bröder, Pinheiro, & Bauer, 2017; Zamora et al., 2015).

Based on Parker's (2009) relational understanding of HL, HL aligns the individual skills and abilities of those requiring health information and services with the demands and complexities of information and services. Therefore, HL can be enhanced by improving personal abilities through education and training and/or by decreasing situational demands by refining accessibility, understandability, and usability of systems, services, and materials. Considering the latter, a HL-friendly environment makes it “easier for people to navigate, understand, and use information and services to take care of their health” (Brach et al., 2012). As adolescents are particularly sensitive to environmental influences such as family, peer groups, school, neighborhood, and social settings (Mulye et al., 2009), a HL-friendly environment can be very influential to support their development of HL. One setting relevant to adolescents is extracurricular youth work settings. To make these settings more health literate and improve their health responsibility it is important to reduce the organizational demands and provide a system that is easy to navigate, understand, and use.

Building upon the “10 Attributes of Health Literate Health Care Organizations” (Brach et al., 2012), the “Vienna Concept of Health-Literate Hospitals and Healthcare Organizations (V-HLO)” (Dietscher & Pelikan, 2017; Pelikan & Dietscher, 2015) considers the necessity of developing organizational capacities, structures, and processes for HL as a relevant precondition for sustainable implementation (Dietscher & Pelikan, 2017). To recognize a HL-friendly hospital, a self-assessment tool comprised of 9 standards, 22 substandards, and 160 items was developed and piloted at nine Austrian hospitals (Dietscher, Lorenc, & Pelikan, 2015).

The project, “Health Literate Extracurricular Youth Work Settings,” followed this approach. The goal was to improve the organizational HL of extracurricular youth work in Austria. It intended to transfer the V-HLO to these settings by (1) developing an appropriate guideline for organizational change in a participatory process with youth workers, (2) developing a self-assessment tool to measure the HL friendliness of the extracurricular youth work settings (Brach et al., 2012), and (3) planning and implementing HL practice projects based on these guidelines. This article presents the methods that have been applied for transferring the V-HLO to the extracurricular youth work and the major results from the evaluation. These methods could be useful for practitioners aiming at transferring the approach of health literate organizations beyond the health care setting.

Health Literate Extracurricular Youth Work Settings: Project Description

From the end of 2014 to mid-2017, the project took place within professional open youth work and youth information centers in three federal states of Austria (Styria, Tyrol, and Salzburg). Although professional open youth work provides social work, education, cultural work, and health promotion, youth information centers offer youth-appropriate information processing and dissemination on many issues including health. Throughout Austria, there are over 600 professional open youth work locations and about 28 youth information centers. Following the requirements of the project funder, three large providers of professional open youth work locations and three youth information centers participated in the project (two youth work settings per federal state). The project structure consisted of a project team, an advisory board, including nationally renowned experts in health promotion and HL research and practice that offered consultancy to the project team, and an external evaluation team. The main target group was youth workers.

During the project kick-off events in the three federal states, the evaluation team took an active role by introducing the concept of HL with a specific focus on organizational HL. Besides youth workers, especially those that had an active role in the project, relevant stakeholders from politics, local authorities, and research attended these kick-off events. Kick-off events were comprised of presentations on the Austrian youth strategy, the concept of organizational HL, and possible points of reference for extracurricular youth work, as well as a description of the project and evaluation design. After the kick-off events, a total of 30 workshops were organized. The kick-off events lasted 2 hours, and the workshops took 4 to 6 hours. The first part of the workshops introduced and discussed the concept of organizational HL, especially the V-HLO, and health topics that had been defined as relevant by youth workers. Based on the V-HLO, the second part of the workshops was specifically dedicated to developing guidelines for HL-friendly extracurricular youth work. These guidelines were then used as basis for the development of a self-assessment tool to measure how easy youth workers and youth can navigate, understand, and use information and services to take care of their health and practice projects to implement the guidelines. In total, 6 to 15 youth workers per federal state participated in the project.

Method

The external evaluation was a major prerequisite of the project funder with the aim to evaluate the process and the outcomes. The purpose of the evaluation was to take an active role in introducing the concept of HL and creating feedback loops with the project team regarding the development of the guidelines, the practice projects, and the self-assessment tool. A qualitative approach was chosen, including thematic analysis of the project documents (for example, meeting and workshop minutes and open feedback questions.

The evaluation of the outcomes followed the major goals of the project, which include (1) reflecting on the dimensions that are relevant for extracurricular youth work to be/become a HL-friendly setting and developing guidelines based on this reflection; (2) implementing practice projects based on the developed dimensions for HL-friendly extracurricular youth work; and (3) developing ways to monitor and assess the HL friendliness of extracurricular youth work.

Accordingly, a summative evaluation was applied to explore whether goals were met (Stockmann, 2007). This was done via a descriptive (comparative) analysis of youth workers' answers to the feedback questionnaires for the workshops, and of participation structures in the workshops. This mixed methods design (Patton, 2002) was considered the most suitable data collection method as it allowed for exploring perceptions of different stakeholders (members of the project team, the advisory board, and youth workers) as well as investigating whether previously defined project goals had been achieved.

The advisory board approved the evaluation concept during its first meeting. Interim outcomes of the evaluation and progress of the project were discussed 1 to 2 times per year during advisory board meetings. The authors confirm that all personal identifiers have been removed or disguised so that people are not identifiable through the details of the story.

Results

Transferring the V-HLO: Guidelines for HL-Friendly Extracurricular Youth Work

The V-HLO has nine standards representing different dimensions of organizational HL. During the process of developing the guidelines for HL-friendly extracurricular youth work, they also proved suitable to this setting (Table 1). One difference is that youth workers extended the original wording by short slogans (“develop materials and services in participation with adolescents,” “adolescents know what they need”). According to the project leader, these slogans were required to make the nine dimensions more “tangible” for youth workers. Moreover, the evaluation showed that youth workers compiled short descriptions for each dimension outlining its particular meaning for their setting. In dimension 2, youth workers from the professional group specified that their organizations recognize them as experts on their own lives.

Table 1.

Guidelines for Health Literate Extracurricular Youth Work Settings

Standard or Dimension	V-HLO Standards (Dietscher & Pelikan, 2017)	Dimension of the Extracurricular Guideline (bOJA, bÖJI 2016)
1	Establish management policy and organizational structures of health literacy	Establish management policy and organizational structures of health literacy (embedding health literacy in the organization)
2	Develop materials and services in participation with relevant stakeholders	Develop materials and services in participation with adolescents (adolescents know what they need)
3	Qualify staff for health-literate communication with patients	Qualify staff for health-literate communication with adolescents (qualified in health)
4	Provide a supportive environment (health-literate navigation and access)	Provide a supportive environment (health-literate navigation and access). Health literacy for all
5	Apply health literacy principles in routine communication with patients	Apply health literacy principles in routine communication with adolescents (making health attractive)
6	Improve the health literacy of patients and significant others	Improve the health literacy of adolescents and significant others (health takes many forms)
7	Improve the health literacy of staff	Improve the health literacy of staff (promoting staff health)
8	Contribute to health literacy in the region	Contribute to health literacy in the region (establishing healthy regions)
9	Share experience and be a role model	Share experience and be a role model (together for health)

Note. bOJA = Bundesweites Netzwerk Offene Jugendarbeit (Centre of Competence for Open Youth Work in Austria); bÖJI = Bundesnetzwerk Österreichische Jugendinfos (Austrian Youth Information Center); V-HLO = Vienna Concept of Health-Literate Hospitals and Healthcare Organizations.

Putting the Guidelines into Practice

To make the guidelines for HL-friendly extracurricular youth work applicable to practice, the external evaluation and the project team developed a self-assessment tool (http://www.boja.at/news/newsarchiv/newsarchiv/beitrag/check-gesundheitskompetenz/). It enables youth workers to assess the HL of their organization and to identify possible needs for improvement as a basis for future projects. The self-assessment revealed that in all participating settings, dimension 8 (“contribute to health literacy in the region—establishing healthy regions”) needed improvement. In two federal states each, dimension 2 (“develop materials and services in participation with adolescents—adolescents know what they need”), dimension 5 (“apply health literacy principles in routine communication with adolescents—making health attractive”), and dimension 7 (“improve the health literacy of staff—promoting staff health”) were all considered relevant. Dimension 6 (“improve the health literacy of adolescents and significant others—health takes many forms”) and dimension 9 (“share experience and be a role model—together for health”) were mentioned only once, whereas dimensions 1, 3, and 4 were not specifically highlighted (Table 2).

Table 2.

Dimensions with Specific Need for Improvement According to Pilot Self-Assessment of Organizational Health Literacy in Extracurricular Youth Work Settings in Three Austrian Federal States

Dimension of the Extracurricular Guideline (bOJA, bÖJI 2016)	Federal State
	Styria	Tyrol	Salzburg
1. Establish management policy and organizational structures of health literacy (embedding health literacy in the organization)
2. Develop materials and services in participation with adolescents (adolescents know what they need)		X	X
3. Qualify staff for health-literate communication with adolescents (qualified in health)
4. Provide a supportive environment (health-literate navigation and access). Health literacy for all
5. Apply health literacy principles in routine communication with adolescents (making health attractive)		X	X
6. Improve the health literacy of adolescents and significant others (health takes many forms)			X
7. Improve the health literacy of staff (promoting staff health)	X		X
8. Contribute to health literacy in the region (establishing healthy regions)	X	X	X
9. Share experience and be a role model (together for health)		X

Note. bOJA = Bundesweites Netzwerk Offene Jugendarbeit (Centre of Competence for Open Youth Work in Austria); bÖJI = Bundesnetzwerk Österreichische Jugendinfos (Austrian Youth Information Center); X = Improvement needed in this area.

Accordingly, youth workers developed good practice projects that built on selected dimensions of the guidelines. One of the projects, the “Healthy BoXXX” (https://www.youtube.com/watch?v=xvUBH78zGHs), comprises a mobile box that aims to provide easy-to-understand health information. The box can be used by youth workers in their daily work and is flexible for use at different locations. A card game seeking to improve health knowledge (“Hopssmoothie, Tindergarden and Discojumping [The Game for Your Health]) invented by youth workers was also integrated into the “Healthy BoXXX,” which demonstrates the exchange and cooperation between initiatives that resulted from the project.

Discussion and Conclusion

Adolescents constitute an important target group for HL interventions and research because essential health-related behaviors and skills are formed at this age (McDaid, 2016; Wolf et al., 2009). HL interventions can help promote personal health and well-being for children and adolescents, as well as ameliorate future health risks (Bröder et al., 2017). In line with current concepts of HL, it is not only important to focus on individual skills and capacities but also on the HL friendliness of environments such as organizations and systems (Parker, 2009).

Although most HL interventions in Europe focus on the enhancement of individual competencies (i.e., self-management and health knowledge) (Heijmans et al., 2015) and primarily address the health care sector, this article describes a novel approach to improving the HL friendliness of extracurricular youth work. The results of the evaluation show that the V-HLO (Dietscher & Pelikan, 2017; Pelikan & Dietscher, 2015) was successfully transferred to extracurricular youth work settings for the first time. Through developing guidelines for health literate extracurricular youth work in Austria, characteristics were defined that constitute their HL friendliness. Resulting adjustments become especially apparent in the wording. Although quality management is an important partner to implement the V-HLO in hospitals, structures that are more informal are required for youth work. Moreover, the self-assessment tool and the practice projects can contribute to its sustainability.

Future HL research could investigate how the guidelines are applied in other federal states of Austria, how the self-assessment tool is used in practice, and how the practice projects can be transferred to other settings. More generally, the transferability of the V-HLO to settings beyond hospitals, health care, and extracurricular youth work, as well as experiences with organizational HL on an international level can be explored.