. 2019 Nov 29;16(23):4812. doi: 10.3390/ijerph16234812

Table 5.

Quotes illustrating outcomes of OHL-interventions reported in Irish and Dutch healthcare settings.

Stage 1. Outcomes of the OHL-Intervention Assessment	Illustrative Quotes
Awareness of health literacy and related communication barriers (all settings).	“So it has made me stop, take off my work hat and […] look at it from a patient’s perspective. So it’s made me more aware and it’s made me very anxious to try and be part of doing something about it”. (IRL ¹, setting 1, participant 22, interview)
Written communication (settings 1, 2, and 3): - Information and structure unclear and difficult words. - Different working procedures. - No patient centred perspective.	“Well they (service users) were so clear about it. That they get far too much information, too many letters. And according to me, the letters also very often (contain) information that does not reach the customer at the right time, and contradictory messages in a letter and ehm well all sorts of things”. (NLD ², setting 2, participant 2, interview)
Navigation (settings 1 and 3): - Inconsistency in words and numbers on signage.	“I mean, if you were able to come to the hospital and walk around. It can be very confusing for people. And it’s quite a large building with a lot of different areas and no two signs are the same”. (IRL, setting 1, participant 23, follow up interview)
Oral communication (settings 1 and 2): - Information, (organisational) jargon and accents difficult to understand.	“If we use jargon, if we choose this, you also create a distance with the patient. Besides that, it is ineffective, because he does not always understand it”. (NLD, setting 2, participant 3, interview)
Website (settings 1, 3 and 4): - Fast reading out function, service users do not use scrolling or search function, unclear and long information.	“Yes, because I also know that we said in advance, everyone scrolls, when you go to the website. […] Well not really. […] I saw this with those low-literate people, nobody scrolls. Everyone thinks this is it. And then there is a lot of information underneath”. (NLD, setting 4, participant 6, interview)
Stage 2 and 3. Organisational Changes Undertaken Following Action Plan	Illustrative Quotes
Organisation wide health literacy committee established (settings 1 and 2).	“Establishing the Health Literacy Committee was a big step. And then spreading the word about it. […] And all the hospitals in our group are very interested in it as well, ehm, because people do realise that it is very difficult for patients”. (IRL, setting 1, participant 23, follow up interview)
Extra employee to facilitate the embedding of health literacy in working procedures and professionals’ practice (settings 2).	“We have at least one employee for a year, so there is also a limitation in terms of employability. Hence, we also want to see as much as possible, which tools for example, we can already use for staff and administration, to train these people and provide them with skills. So that they can continue with it independently”. (NLD, setting 2, participant 1, follow up interview)
Health literacy policy and more user-friendly checklist to assess leaflets or letters (settings 1).	“The health literacy policy for the hospital, okay? So that people have a process to follow when they are developing not only information leaflets but I suppose any kind of (patient) information”. (IRL, setting 1, participant 21, follow up interview)
Written communication (settings 1, 2, and 3): - Examples of comprehensible materials. - Adaption of systems to print user-friendly patient letters.	“Ehm, yes, they obviously cannot copy sentences, because every brochure is different. But (they can take over) the tone in which a brochure is written or the layout of a text on the website. […] So that there are a number of examples that people can continue with”. (NLD, Setting 2, Participant 5, follow up interview)
- Plain language training.	“So they did either four hours or half a day of plain English training. […] Yeah, I think I’d say 64 or 65 people at this stage that have been trained in plain English”. (IRL, setting 1, participant 21, follow up interview)
- Develop comprehensible materials and streamline information processes.	“So, what we looked at was our outpatients’ letters […] we revised those letters. Now that was a process of itself and we went, we passed them with some low literacy level groups and also high literacy level groups and we’ve kind of come back to the basics of who, what, why, where and when. Yes! So we changed about three or four letters. We have over 30 letters, okay?” (IRL, setting 1, participant 21, follow up interview)
Digital communication (websites) (settings 3 and 4): - Plain language, information reduction on webpages - Design, banners, reading function.	“When people looked at the left in the navigation structure and when they were (looking at) a condition, they did not know exactly which treatment and what examination belonged to it. In terms of image, we made some adjustments. Another font and a different color, now it is clearer what belongs together”. (NLD, setting 4, participant 6, follow up interview)
Navigation (settings 1 and 3)	“Ehm, another thing we hoped to do but we didn’t get the money this time for it was a site map. You know, a simple map with all, we have quite a big site here and a lot of different buildings”. (IRL, setting 1, participant 23, follow up interview)
Oral communication (setting 2)	“I’m sure it will come in time […] But we definitely will look at the oral communication, but we’re not there or near to it”. (IRL, setting 1, participant 21, follow up interview)

¹ Ireland is abbreviated as IRL. ² The Netherlands is abbreviated as NLD.