Health literacy of healthcare leaders

Differences by facility type and relationship with work ability and burnout risk

Personal health literacy (HC) refers to the ability to find, understand, evaluate, and apply health information (Rathmann/László 2024a). Organizational health literacy (OHC) describes the extent to which healthcare institutions strengthen the HC of their patients and employees through measures to support them in health decisions (Dietscher/Pelikan 2023; Rathmann/László 2024a). Study results show that managers and professionals in healthcare are considered a vulnerable group with regard to mental and physical health problems (Raspe et al. 2020; Zeike et al. 2023). Physical and mental stress in health and nursing professions, as well as high demands in everyday and professional life, should be managed by strengthening OHC (Rathmann/László 2024a). Due to demographic change and the increase in chronically ill, multimorbid patients, the German healthcare system and nursing care are facing major challenges. The high workload and staffing shortages among managers and specialists will also affect patient care in the long term. To attract and retain skilled workers and thereby improve the quality of care, healthcare facilities can, in addition to improving working conditions, invest in continuing education (as defined by the German Association of Nurses and Nurses (OGK), support patients' personal responsibility, and strengthen their self-management skills.

>> This is where the OGK concept for the development of health-literate hospitals comes into play. It aims to align structures and processes with personal health literacy and to consider the health literacy of management and healthcare professionals, as well as patients and their families (Pelikan et al. 2023; Rathmann/László 2024a). The international Working Group HPH & HLO (2019) developed the SAT-OHL (Self-Assessment Tool for Organizational Health Literacy), a self-assessment tool for health-literate hospitals. Based on this tool, the OGK is strengthened along eight standards (Fig. 1).
Health-literate institutions implement measures to strengthen health literacy across all structures of the institution, involve as many stakeholders as possible in the development of health-related materials and services, train their employees in the area of health literacy, enable easy orientation and access to services and materials, strengthen health-literate communication within the institution, and promote health literacy among patients, employees, and the local population (Rathmann/László 2024e).
While many studies focus on personal health literacy in patients or the general population, the body of research on health professionals (Janson/Rathmann 2021; Schaeffer et al. 2023; Simon et al. 2022) and personal health literacy in the healthcare system has only grown in recent years. Studies show that the personal health literacy of professionals is closely linked to a greater willingness to engage in disease prevention, performance, motivation, and fewer absences due to incapacity for work (Gernert et al. 2022; Larsen et al. 2019). In addition, an online survey of nurses in home care in Germany showed that nurses with low personal GK more often have high physical demands at work and an increased risk of frequently thinking about changing careers compared to nurses with sufficient personal GK (Janson/Rathmann 2021, 2023; Rathmann/László 2024a).
Initial results from Germany, Austria, and Switzerland demonstrate that surveyed healthcare professionals highly rate their abilities in promoting health care among their patients or clients (Schaeffer et al. 2023). There is a need for improvement in the handling of digital health information and in the communication of information and knowledge to patients (Schaeffer et al. 2023).
In the field of organizational health management, numerous international and national study results are now available that report the extent of organizational health management (e.g., measured using the HLHO-10 instrument) for healthcare facilities (Bonaccorsi et al. 2020; Rathmann et al. 2020). The number of concepts, definitions, and instruments for measuring organizational health management in healthcare facilities has steadily grown in recent years – particularly in German-speaking countries (Rathmann/László 2024b, 2024c, 2024d, 2024e). Numerous toolboxes for strengthening (organizational) health management are also available in German-speaking countries (e.g., for the healthcare sector: Rathmann et al. 2021a; 2021b). A survey for integration assistance in Germany indicates that healthcare facilities reported below-average levels of OGK, with the lowest scores on the HLHO-10 scale being measured in the area of participatory development of health information (Rathmann et al. 2020). Another study from Italy with hospital managers identified significant needs in the OGK areas of "integration of OGK into quality management measures," "training of employees on OGK," and "communication" (Bonaccorsi et al. 2020). By implementing measures, healthcare facilities contribute to the development of OGK and strengthen patient autonomy, which leads to lower use of emergency rooms, fewer care episodes, and a reduced revolving door effect among patients in care (Bonaccorsi et al. 2020).
Objectives of the article
There are currently few studies available in Germany on the extent of personal and organizational GK in healthcare facilities (acute inpatient care).
The article pursues the following objectives:
1) to report results on the personal and organizational health of managers in health care facilities in Germany,
2) to evaluate differences in the OGK between the types of institutions (hospital, nursing care, integration assistance),
3) To demonstrate the relationship between personal and organizational health and the ability to work and mental health of managers in healthcare facilities.
The “EwiKo” project
In the collaborative project "Development of Health Literacy in Healthcare Facilities (EwiKo)" between AOK PLUS and Fulda University of Applied Sciences (lead: Prof. Dr. Katharina Rathmann), a concept of measures was developed to support healthcare facilities (i.e., hospitals, nursing homes, and rehabilitation assistance) on their path to becoming health-literate institutions (duration: January 1, 2020, to June 30, 2023). The project was based on the National Action Plan for Health Literacy, which calls for the healthcare system to be user-friendly and health-literate at all levels. The "EwiKo" project comprised four work packages (WP) (Fig. 3), operated at the interface between corporate health promotion and corporate health management, and holistically addressed all standards of the OGK as well as the personal health literacy of users (i.e., patients, residents, specialist and management staff) in the facilities. The goal of the "EwiKo" project was to provide institutions with user-friendly and practical support to strengthen their health care system. An overview of the user-friendly, institution-specific products developed as part of the "EwiKo" project can be found in Online Appendix 1. The "EwiKo" project was based on the SAT-OHL-HOS concept and incorporated eight "standards" or "fields of action" of the OGK.

Data basis and methodology (WP1: online survey)
As part of the "EwiKo" project, a nationwide online survey (WP1, Fig. 3) was conducted to assess the current status of occupational health promotion (OGK), the institutions' willingness to engage in prevention, and the structures of workplace health promotion in healthcare facilities within Germany. Managers and specialists with management functions from hospitals, nursing facilities, and integration assistance services in the areas of living and working participated in the survey.
The survey was conducted using a quantitative online questionnaire between March and July 2021. A total of
N = 13,160 healthcare facilities invited to the survey.
N = 621 individuals participated in the survey and completed the questionnaire in full (response rate: 4.72%). An overview of the survey instruments used and the distribution of the scales can be found in Online Appendix 3.
Of the N = 621 health care facilities, 10.01% were hospitals (N = 62), 31.41% were nursing facilities (N = 195), 49.41% were rehabilitation facilities (N = 307) and 9.21% were other facilities (N = 57).

Data analysis
Descriptive analyses were conducted using frequency analyses and bivariate analyses using cross-tabulations (Pearson's Chi-square test) with a 5% significance level (α = 0.050). Binary logistic regression models were used to analyze the associations between personal and organizational health status in relation to respondents' ability to work, as well as their mental and physical health. The regression parameters were interpreted using odds ratios (ORs) with 95TP3T confidence intervals (CIs). All statistical analyses were calculated using IBM SPSS Statistics Version 28 statistical software.
Results

In the area of personal health information, 22.9% (n = 140) of the 621 managers and professionals surveyed reported difficulties in dealing with health information (Fig. 4). The most common difficulties were evident in assessing information about health risks from the media (32.2%; n = 198), in making decisions about disease prevention based on information from the media (29.1%; n = 179), and in researching support options for mental health problems (26.8%; n = 163). Furthermore, 23.0% of respondents (n = 141) found it difficult to judge when to seek a second opinion from a medical professional. 16.4% (n = 100) of respondents rated understanding information on health promotion from the media as difficult.
50.3% (n = 276) of respondents reported a below-average level of OHC in their facility. The most common need (59.3%; n = 331) was identified as "the presence of communication standards" and the provision of "information for patients/clients via various media" (58.0%;
n = 321), in the "use of individualized health information" (53.7%; n = 296), and in the "consideration of health literacy in quality management measures" (51.8%; n = 301) (Fig. 5). Almost half (48.9%; n = 276) reported a below-average level of health literacy in the "development of health information with patient/client involvement," 42.5% (n = 233) in "making an effort to ensure clients can navigate easily," and 39.7% (n = 225) in "training staff on health literacy."
An analysis of the extent of OTC (sum index) differentiated by facility type revealed that 50.8% (n = 30) of respondents from hospitals, 46.3% (n = 88) from inpatient (elderly) care facilities, and 52.2% (n = 154) from rehabilitation facilities reported a below-average extent of OTC (Fig. 6). Even though the differences in the extent of OTC between facilities were not statistically significant, they nevertheless provided an initial indication of the need to strengthen OTC.
For managers with a low personal GK (Table 1)
The results indicated a 2.16-fold increased chance of low physical work capacity (95% CI: 1.33-3.51; p = 0.002), a 1.89-fold increased chance of low psychological work capacity (95% CI: 1.25-2.86; p = 0.002) and a 1.57-fold increased chance of an above-average burnout risk (95% CI: 1.05-2.35;
p = 0.028) compared to managers with sufficient personal GK.
Respondents from facilities with below-average levels of OGK (Table 1) had a 1.65-fold increased chance of low physical work capacity (95%-CI: 1.05-2.60; p = 0.030), a 1.82-fold increased chance of low psychological work capacity (95%-CI: 1.25-2.67; p = 0.002), and a 1.46-fold increased chance of an above-average burnout risk (95%-CI: 1.05-2.03; p = 0.027), compared to respondents from facilities with an above-average level of OGK (Table 1).
Overall, the results of the online survey in healthcare facilities clearly demonstrated that OGK should be strengthened in healthcare facilities in the areas of "communication standards," "multimedia information," and "ensuring the understanding of health information in critical situations." The results from the "EwiKo" project also demonstrated how closely OGK is associated with aspects of work ability and burnout risk among the managers surveyed.
discussion
The aim of this article was to survey personal and organizational health capacity from the perspective of managers in healthcare facilities (hospitals, nursing homes, and rehabilitation assistance) and to analyze it in relation to health indicators. The results showed 1) that one in five managers surveyed reported low personal health capacity. Regarding the extent of health capacity, 2) managers from rehabilitation assistance most frequently reported a below-average level, followed by respondents in hospitals. Item-based, the survey results indicated that the greatest need for strengthening health capacity lies in the areas of communication and the provision of information to patients/clients via various media. Finally, the results showed 3) a significant association between personal and organizational health capacity with low work capacity and an increased risk of burnout among the managers surveyed.
Building on previous studies, the present results indicated that the frequency of sufficient personal health care among managers was significantly higher at 77.1% than in the general population, which was also to be expected given the professional background of the respondents and the COVID-19 pandemic. In comparable studies, 69.9% of young healthcare professionals reported lower personal health care (Simon et al. 2022). Survey results of professionals in (outpatient) geriatric care revealed that almost 40.0% of the nursing professionals surveyed reported low personal health care (Janson/Rathmann 2021).
The managers surveyed as part of the "EwiKo" project rated the extent of health literacy in their facility as below average at 50.3%. In a comparable study in facilities for people with disabilities, more than half of the managers and specialists also rated the extent of health literacy as below average, with the lowest HLHO-10 scores in the areas of "Participatory development of health information" (Item 3) and "Use of individualized health information" (Item 4) (Rathmann et al. 2020). In a study in hospitals in Italy, the majority (65.0%) of the managers surveyed reported a below-average extent of health literacy (Bonaccorsi et al. 2020). The most frequently reported below-average extent was in the area of "Consideration of health literacy in quality management measures" (Item 2 of the HLHO-10) (Bonaccorsi et al. 2020).
With regard to the relationships between personal health and health-related indicators of the managers surveyed, it was found that respondents with low personal health had an increased risk of poor physical and mental work capacity and an above-average risk of burnout compared to respondents with sufficient personal health. Previous studies have shown that healthcare professionals are considered a vulnerable group with regard to mental and physical health problems (Raspe et al. 2020; Zeike et al. 2023). In addition, nurses in outpatient care with low personal health showed an increased risk of more frequently considering a career change (Janson/Rathmann 2021; Raspe et al. 2020). Therefore, the authors consider personal health as a personal resource for coping with work-related stress (Janson/Rathmann 2023).
The findings from the "EwiKo" project provide initial evidence for Germany that OGK can have a positive impact on the well-being of healthcare professionals through the creation of a health-literate environment. Previous studies have indicated that the extent of OGK is positively associated not only with patient outcomes but also with staff outcomes (Gernert et al. 2022; Lindert et al. 2023). In this context, it should be noted that targeted promotion of OGK within the overall concept of the facility has positive associations with the work ability and health of professionals (Farmanova et al. 2018; Lindert et al. 2023; Rathmann et al. 2022).
Conclusion
Strengthening health literacy in healthcare facilities brings benefits to the facilities, employees, and patients. Manuals and collections of methods (Rathmann/László 2024a), such as those used in the "EwiKo" project, offer support for implementing measures to strengthen health literacy in healthcare facilities. These so-called toolboxes for strengthening health literacy (for healthcare facilities: Rathmann et al. 2021a, for integration assistance: Rathmann et al. 2021b) provide field-specific practical instructions, handouts, information materials, and checklists for strengthening health literacy (see https://ewiko-gesundheitskompetenz.de/toolbox/). The toolboxes and other materials (including a tool database, self-checks, practical guidelines, and step-by-step instructions for practical use) from the “EwiKo” project can be found in online appendix 1 (https://t1p.de/mhx98).
Furthermore, strengthening occupational health and safety can build on existing methods of organizational development (Rathmann/László 2024a). Structures and processes of quality management or occupational health management should, where possible, be designed to contribute to the development and strengthening of personal, professional, and organizational health and safety (Rathmann/Münch 2023). The concept of personal and organizational health and safety should also be incorporated into training and continuing education programs for employees in educational institutions in order to a) strengthen their own health and safety and b) enable them to impart competencies in the field of health and health information—in the sense of a multiplier approach—to other target groups (e.g., in training, continuing education, and continuing education) (Rathmann/László 2024a).