Assessment of Healthcare Facilities for the Promotion of Health Literacy - A Feasibility Study

Background

The term health literacy, in addition to basic literacy, refers to a range of skills that people need to acquire [1, 2, 3, 4, 5, 6], understand and evaluate health information and make informed decisions that are consistent with their needs, wishes and values [1, 2, 7, 8, 9]. The model of health literacy is relatively new; particularly in the German-speaking area it has not yet been attached the importance required to achieve the goal of empowering all people to become health-literate citizens [10]. Nevertheless, health literacy is considered a so-called soft skill of the 21st century [11]. It is based on the premise that informed citizens can and want to adequately access information in order to make relevant decisions for themselves. According to the European Health Literacy Survey model [2], this applies to all areas of life and throughout the course of life in the fields of health promotion, disease prevention and health care in the case of an existing disease. As in many - especially European - countries, the promotion of health literacy is a central concern of health policy in Austria. In the current government program (2013-2018), the third of the ten framework health goals is "strengthening the health literacy of the population". All people and sections of the population should be ensured low-threshold access to the information and the health care system. Particular focus is placed on the needs of disadvantaged groups (www.gesundheitsziele- oesterreich.at) In this context, for example, health care facilities such as hospitals, care facilities or outpatient clinics are called upon to shape health-promoting conditions at the organizational level. The term health literacy environment [5] has been developed for this purpose. This comprises the importance and comprehensibility of written information systems such as signs and words and verbal information sharing, as they are used for orientation in health organizations. Information systems should help people find their bearings and the right direction [12]. In the context of health, information systems are understood to be guidance and orientation systems containing health-related information. This must be found quickly and easily and understood and applied correctly. Reliable orientation through rapid comprehension of printed characters, words and letters is of great importance everywhere [3], because when people do not get their bearings in an unknown environment, feelings of insecurity, anger, helplessness or even fear arise [4]. In situations that are stressful, such as those involving one's own illnesses or emergencies, or worrying about sick relatives, these feelings of helplessness and anxiety can be amplified many times over. It can even lead to a loss of confidence in the health care facilities, or at least to very negative memories [13]. If people miss out on appointments due to poor orientation, if delays occur and planned examinations have to be postponed, the productivity and effectiveness of the institution are affected and the smooth flow of care can be hindered [11]. As early as the 1990s, planning projects in Canada showed that approximately 800 hours were spent a year in an 800-bed hospital to describe ways and provide orientation to patients, visitors, and other disoriented people [14]. This was confirmed and extended by relevant information from Germany in 2016. Schlüter [4] concludes in his analysis that 100 of a total of 1000 employees spend about 15 minutes per day only to provide directions because the existing information systems are not sufficiently clear to understand. This causes work interruptions and disturbs the general procedures so much that resulting costs in the amount of 300 euros per bed / year arise. In addition - in this calculation model - increased personnel costs amounting to about 80,000 euros arise. The cost of developing and implementing an efficient information system could reduce these costs by a third and pay for itself after three years [4]. A carefully planned, well thought-out guidance and orientation system not only contributes to the image of a healthcare facility, but also helps to reduce costs [11]. Requirements for a guidance and orientation system include seven key criteria [4]. Firstly, they refer to integrity - which means that the external and internal architecture, the appearance in all media, is consistent, and the mission statement in this regard is supported and lived by all colleagues. Secondly - the intuitiveness - this shows the intuitive comprehensibility by logical adaptation to spatial conditions and structures. Thirdly, it requires a reduction, that is, a minimum amount of information at maximum information content. The value, as a fourth criterion, addresses a suitable selection of durable materials, the high-quality finishing and the transparent positioning. Fifthly, guidance and orientation systems should be economically viable, that is, a standardization with a logical structure, with a limited set of signs that – as a sixth criterion - are consistent and complete from first contact to destination. Finally, accessibility as a last and seventh criterion is essential in order to provide quick, low-threshold and safe orientation to as many and as diverse people as possible [4]. Often, however, this subject only gets attention after repeated complaints in connection with the signage, or due to high stress loads of employees with regard to giving information for guidance. For guidance systems in healthcare facilities are often inconsistent and their comprehensibility requires a high level of education [3]. The authors carried out a feasibility study on "health- competence-friendly" environment in 10 hospitals in Spain. The aim of the study was to find out which factors inhibit or promote orientation in hospitals. The results show that the signage was perceived as hidden and badly positioned. Finding the goal-oriented path within the hospital proved difficult and confusing. The signs were inconsistent, in scientific language and without any special explanations. Positive reviews were given to the personal contacts with Security Personnel or other employees. Overall, the mean for all hospitals was 3.9 (= somewhat difficult to orient) in the 6-step scale. In her dissertation Seumenicht [15] deals with the analysis and evaluation of guidance systems in public space. Supplying sufficient information, especially in healthcare facilities, is a challenge. Intuitive orientation of visitors within hospitals is becoming more difficult with increasing complexity. This is also the conclusion of the editorial work of Candussi, Fröhlich [16], which confirms that health-related information is often designed at a high level and requires a corresponding high level of education [16]. In hospitals, in addition to orientation difficulties, people experience feelings of anxiety due to their health situation. In addition to good and understandable signs and pictograms it is, therefore, important to establish specially trained staff to provide appropriate verbal information [15].

In a survey study (n = 100) in the United Arab Emirates, it was found that symbols with health-specific content are less well recognized than general pictograms that are used in everyday life. However, the higher the level of education and the younger the participants, the better the comprehensibility of the presented symbols and pictograms was rated [17]. This leads to the conclusion that guidance and orientation systems are more likely to be understood by younger people who have undergone longer education. In Austria, apart from a small preliminary study [18], no research paper has been published in which the health-competence friendliness of hospitals was assessed by means of a specific assessment. In this small study, 15 health care facilities were assessed. Once more the lack of uniformity and, to a large extent, insufficiently understandable information and guidance systems were confirmed. Assessment tools to measure health literacy support relate to the ability to read and understand specific information in buildings for easy, individual orientation. A self-assessment tool has been developed as part of the European Health Literacy Survey (HLS-EU Survey) 2009- 2012. Emphasis is placed on the intelligibility of the language used and the uniformity or existence of a guidance system for the blind [19]. Another building assessment tool is "The Health Literacy Environment Activity Packet First Impression & Walking Interview" developed by Rudd [5], which was used in this study. The aim of the present feasibility study is to use a specific assessment to analyze different healthcare facilities in terms of how comprehensible and transparent their information and guidance systems are for individual orientation. In addition, the practicability and user- friendliness of the applied assessment is tested.

Ethical Reflection

Compliance with the principles of ethical research according to the Belmont Report or the Helsinki Declaration (http://www.hhs.gov/ohrp/) has been ensured by a sensitive inspection mode that was neither noticeable nor disturbing. The focus of the assessing persons was exclusively on the orientation and guidance systems of the buildings and no other people were addressed except for appointed respondents. The inspected healthcare organizations were pseudonymized for the entire analysis in order not to be able to draw any conclusions about the specific places.

The Survey Instrument

The survey instrument "First Impressions & Walking Interview" [5] is divided into two parts. The first part refers to the first impression provided by the assessed healthcare organization on the Internet, by telephone contact and in the immediate external environment of the building, especially on the way to the entrance of the building. The second part "Walking Interview" refers to the assessment of different areas within the building (Table1). The first focus is the main entrance. Here, the design of the entrance area should be assessed, the general orientation possibilities and the visibility and comprehensibility of the information. The second focus is on finding directions / support. The general placement of the information desk is assessed. When asking for the way to a particular institute or ward, the informing person is judged on the type, manner and intelligibility of the information received. The aim is to note, which impression regarding verbal information is created in general. The third focus is orientation - the way to a specific target. The design of the way with regard to signage, uniformity of the guidance system as well as the visibility, positioning and comprehensibility of signs / writing / pictograms are examined. The next focus is the observation of the target. It is estimated to what extent the process of further registration is clearly visible and understandable and whether features for wellbeing have been created. Finally, a general reflection on the entire inspection of the building is carried out. All the impressions gained are exchanged and transcribed in the form of minutes.

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First Main Category: Observation at the Entry Point or Lobby

In the main category "Entrance area" 4 subcategories could be worked out, whereby 2 of them were assigned a further subcategory in order to be able to present the results more precisely and specifically. In the first subcategory of facilities, infrastructure, equipment, the healthcare institutions were considered to

Second Main Category: Instructions / Seeking Help / Directions

The main category "Instructions / support" could only be divided into 3 subcategories. In the first subcategory of facilities, equipment mainly the presence, but also the labeling of information switches, where the desired information could be obtained, was described (mentioned 13 times). Only twice was the insufficient labeling of the information office criticized (Table 2). The second subcategory first contact, atmosphere contains the subcategory "Giving information, giving directions", in which the quality of the information transfer was assessed. The 23 positive ratings describe a friendly, helpful and attentive appearance of the respondent, who understandably describes the way to the desired destination (mentioned 4 times). A negative mention was made of non-continuous presence of the respondent or an answer spoken too fast (altogether 16 negative mentions). The third subcategory of accessibility describes both physical and language barriers. The 5 of the total of 6 negative mentions refer to an inappropriate height of the information desk for wheelchair users, which makes it difficult to establish contact. The sixth negative mention describes a possible language barrier due to information provided in dialect, which requires special language skills. The 3 positive mentions include well-accessible information desks (mentioned twice) and staff members who give verbal or non-verbal information by showing (mentioned once). In summary, it can be said that the verbal transmission of information is mostly experienced as friendly and helpful. The optical orientation systems, however, are often confusing and designed too small, not mounted visibly and also require literacy in the German language.

Third Main Category: Orientation - The Way to a Specific Destination / Navigation

When experiencing the atmosphere as the first defined subcategory of the main category "Orientation", "Lighting and the lighting conditions" play a major role with 9 + / 19 - mentions (total of 12 mentions 5 + / 7- mentions) (Table 2); they constitute a separate subcategory within the category atmosphere. In addition, the color scheme (a total of six mentions) was particularly highlighted with "the corridors seem bleak: lack of warm or intense color concept" and the room size (a total of 5 mentions), "wide, enough space, pleasant atmosphere". This subcategory also describes the decoration, the design and the overall impression of the corridors, which altogether create a rather negative image. When examining the second defined subcategory of accessibility in the corridor (18 + / 19 - mentions) and in the lift (12 + / 9 - mentions), the main focus is on walking disability (a total of 42 mentions). Remarkable is the observation of the door systems with a total of 12 mentions, whereby on the one hand it is determined that these systems have a negative influence on barrier-free movement, "the door opens quickly to the outside, which can even be dangerous for wheelchair users". In the lift, the presence of audible signals is perceived as positive for the visually impaired (total of 5 mentions). The strong dominance of the German language is also recorded as a barrier (6 mentions). The third sub-category Facilities-infrastructure- equipment (7 + / 2- mentions) covers seating facilities, the presence of plants and the possibility to get snacks. This category can be clearly rated as positive. The heart of the analysis is the evaluation of the fourth subcategory Information and guidance systems. Like the second sub-category accessibility, this category was examined separately in the corridor (36 + / 35- mentions) and in the lift / elevator (3 + / 8-mentions). A total of 19 positive assessments were made in terms of visibility and efficiency of signage, for example: clear, noticeable, adequate, consistent, helpful, purpose-oriented, repetitive, clear, etc.; seven negative reviews:" changing, not uniform, confusing, not immediately visible etc."It seems particularly relevant where the signs and other guidance systems are placed (9 + / 7- mentions): "signs at eye level "or sign from the ceiling:" not immediately noticeable ". Of course, an adequate font size is supportive (6 positive answers). Color markings are seen as enrichment for orientation (5 positive mentions), which is probably because they are self-explanatory and easy to follow. Furthermore, floor markings and pictograms (3 entries) are orientation promoting. From the interviews, it can be seen that the main shortcoming of the guidance systems is the inadequate placement of the signs (7 mentions), "small signs above head height" or that they are not uniformly marked (5 mentions), "changing orientation signage, not uniform in the corridor "or also because signs are not present at all (4 mentions),"information board or site plan not available ". With regard to guidance systems in the lift, a clear definition of the direction of travel is clearly welcome: "arrows on the buttons with` I want to go`-these arrows point up or down "or "Whether the lift is going up or down, is indicated by small arrows above the lift doors. However, if you do not know that, you can lose some time”.

Fourth Main Category: Observation of the Destination

In the main category "Observation of the destination" a total of 5 subcategories was formed. In order to allow an even more precise characterization of the categories, 2 of the subcategories are each assigned a further subcategory (Table 2). The first relevant subcategory information system has the same number of positive and negative evaluations: 15 + / 15 - mentions were counted. Of the 15 negative remarks, six refer to a missing signage of the target area: "No indication of the target, found by accident". Inadequate or confusing signage was stated four times: "many ambiguous signs". Three of the mentions describe an inappropriate size of the labeling. The second relevant subcategory of First contact shows a rather negative picture. In the destination area this category was rated positive only twice and negative 7 times. In 5 mentions of the 7 it is stated that a contact was not possible because no staff was present: "information desk unoccupied". The actual contact was otherwise experienced twice positive and negative respectively. In this case it is more a question of the welcoming staff, their friendliness or dismissive reactions: "The employees greeted in a friendly way, but they did not appear to be disturbed in their work routine by the inspecting people" and "calling caregiver does not greet, does not introduce himself/herself, does not appear very cordial."If the defined subcategory "giving information and directions" is mentioned, it is rather positively recorded. 8 mentions represent the positive perceptions, whereby 2 refer to the existence of a written form of information. The others describe the verbal information transfer as uncomplicated, precise, understandable, clear, explicit or friendly: "time is taken for the conversation". 5 entries were qualified as negative, 4 of which described the lack of a written form of instruction and information: "no information regarding the procedure of registration, required documents". All in all, it can be said that verbal information is generally perceived as friendly, uncomplicated and nice, but written information is lacking. The third subcategory accessibility shows a very balanced picture: 8 positive and 8 negative mentions, two of each referring to the language barrier. This subcategory mainly identifies the needs of older people and those with disabilities, describing handrails, anti-slip floor coverings and the overall accessibility of the destination. With regard to negative issues, an adequate guidance system for the blind or deaf people is missing. Concerning language barriers, the strong dominance of the German language is noted. The fourth subcategory equipment and infrastructure can clearly be assessed positively through the presence of seating, distractions and other facilities to meet the needs of patients. Here, 19 entries are positive and only 4 negative. The fifth and final subcategory atmosphere also tends to be perceived as positive; there are 17 positive responses compared to 12 negative responses. Here the impressions and the mood are mentioned, such as inviting, comfortable, well structured or friendly. The subcategory atmosphere has "lighting" as a subcategory, whereby brightness is perceived as particularly positive (6 positive, 2 negative mentions).

Assessment of the Practicability of the Survey Instrument

Finally, the 26 assessors participated in the evaluation of the applicability / practicality of the survey tool. The assessment was made on a scale of 1 to 5. According to the school grading system 1 is considered very practicable - 5 not practicable. Furthermore, the persons were asked to justify their classification. 6 answers refer to 1 = very practicable, three more to 2, practicable. Only one person ranked the survey instrument at level 3, moderately practicable. There were no assessments at levels 4 and 5 (not practical). The justifications for the classifications referred to the clarity of the questions in the instrument and to the fact that this trains and encourages a professional view (4 mentions) and a comprehensive perspective (3 mentions). Additionally, the inspection in pairs is perceived as very beneficial (3 mentions).