Equity in Communication: A Policy Template for Promoting Organizational Health Literacy
The policy template presented here provides ideas on how to promote organizational health literacy within organizations.
The work presented in this post was supported by the William and Linda Frost Fund (College of Science and Mathematics, California Polytechnic State University, San Luis Obispo), in the form of a Frost Undergraduate Student Research Award awarded to the first author (CNS).
This post presents the steps and experience used to develop the policy template mentioned in our JPHMP commentary, “The Ever-Evolving Nature of Health Literacy in Organizations: A Commentary on the 2021 JPHMP Article: ‘Updating Health Literacy for Healthy People 2030.’” The purpose of introducing the policy template was to provide organizations with further support in developing organizational health literacy. Given that diverse organizations communicate health-related information, a set of policy guidelines that could be readily adopted to promote organizational health literacy is needed. Such guidelines would enable staff to foster or expand equity within the materials disseminated by their organization. Moreover, the provided policy template gives a start which organizations could build upon in efforts to meet health promotion objectives laid out in Healthy People 2030 (or another guiding framework for health policy within in their region).
The policy template was developed through a college service-learning project, where a student created a research summary video for college students and professionals. The video summarized research on common design issues that impede use of lay educational material among patients and the public. The student created the video using skills for critically appraising lay material quality, such as those outlined in Teaching Patients with Low Literacy Skills. The activities used to create the research summary video were the basis to several activities listed in the policy template. Consistent evidence suggests service-learning is an effective teaching strategy among college students. Using the policy template could extend this high-impact teaching practice into health care and other settings (for ways to overcome potential logistical barriers, see the article by Surr et al).
Creating the Research Summary Video
For the service-learning project which occurred between June and September of 2020, a short video less than 7 minutes in duration, composed in English was created by the first author (who at the time was an undergraduate public health student). Editorial supervision was provided by the third author, who also served as the project supervisor (the third author is a faculty member trained in kinesiology and public health). The project’s aims were to: (1) create a plain language, short video summary to an article of original, peer-reviewed research focused on lay material quality, (2) engage professionals/students in activities to help them understand common design issues in lay material, and (3) prompt viewers to practice correcting the design issues presented in the video. The video was of a recorded slideshow presentation developed using PowerPoint. The steps in creating the summary video entailed reading and summarizing key points from the select, peer-reviewed research article published in 2020, as well as reviewing guidelines for slide layout and design.
Teaching Example: Graphic Summary of Research Article Main Findings
Graphics were created based on the most relevant takeaways from the research article, which highlighted areas the online articles sampled in the study were consistently lacking. The goal was to highlight the lack of suitable materials and equip the audience with the skills needed to create suitable resources and adjust existing resources for their intended audience. A bar graph was made with the free (ie, basic) subscription plan for the online tool, Infogram, which was used to highlight the top unsatisfactory subcategories in a sample of online articles reported on in the research article. The researchers used the Suitability Assessment of Materials (SAM) method to rate the suitability of online physical activity promotion articles, which were produced by a diverse set of organizations and covered a range of topics. A pie chart was also made with the Infogram software, and it broke down overall suitability levels of the sample articles, which were either unsatisfactory, satisfactory, or optimal in accordance with SAM guidelines and the interpretive nomenclature proposed by Thomas and Cardinal.
Teaching Example: Reading Grade Level Suitability
A demonstration of reading grade level reduction was performed using two blocks of text placed side by side. To emphasize the difference in readability level between the two blocks of text, words with three or more syllables were bolded in both. The audience was prompted in the video recording to pause the video and read through both versions and compare how easy it was to read each one. The Simple Measure of Gobbledygook (SMOG) reading grade level formula was used in this teaching example. The reference material for the reading grade level teaching example was obtained from the research presentation by Tse et al.
Teaching Example: Layout and Design Suitability
An interactive activity was created with Infogram, which was used to create before and after images of a mock web article. The before image of the mock article purposefully included insufficient materials in three categories: (1) graphic captions, (2) relevant graphics, and (3) summary included. The select categories were common suitability issues observed in the summarized research article and in previous research. The audience was given the definition of suitable materials and asked to brainstorm ways the mock web article could be improved. After 60 seconds, sample changes that would improve the mock web article according to the SAM were shown, then explained. Together, this and the previous teaching examples summarized modeled ways to assess and revise lay material for improved suitability.
Recording the Video Summary
Using similar methods used by Thomas and colleagues, the free access option for the online tool, Screencast-O-Matic, was used to record the slideshow presentation with audio narration. Several drafts of the video were produced until the first and third authors agreed the latest draft met guidelines for dissemination to a diverse audience of professionals and college students (eg, plain language, succinct, used a distraction-free slide layout). The video was pilot tested using an optional and anonymous online questionnaire with a small group of undergraduate college students majoring in biology, kinesiology, and public health (five day grace period, July 30-Agust 3, 2020, N = 8, 62.5% response rate). Participants unanimously felt the summary video was interesting, helpful, and clear. The human subject component of the project received Institutional Review Board approval from the first and third authors’ university. Feedback gathered in the pilot test was used to make final edits to the video (eg, correct minor errors in grammar, respond to suggestion to slow the speaking speed down).
Research results suggest that many individuals who select or design lay material do not understand factors that affect health literacy. This gap in knowledge is problematic, given the primary role of health material is to promote health literacy. Thus, the video summary project, which preceded the policy template presented in this post, was conceptualized as a means of encouraging college students and professionals to learn about common design issues affecting lay material, then resolve to address them in their own practice. Accordingly, the research summary video ends with a call to action towards that end and supplies viewers with resources in getting started. The service-learning project was educationally valuable to the first author too, having reviewed research in the area and through applying techniques for developing lay material to create the research summary video.
Subsequently, the first and third author realized that in order for training material to gain wide use in settings where they are most needed, organizational policy aligned with a public health mission is crucial. Public health policy entails “laws, regulations, actions, and decisions implemented within society in order to promote wellness and ensure that specific health goals are met.” As mentioned in the companion article to this post, research strategies to develop organizational health literacy policy are not new, yet dissemination of resource material with a limited ability to promote health literacy has remained common. The first author resolved to present at a professional conference on the value of the service-learning project from an undergraduate student’s perspective. The first and third author were ultimately successful in presenting on the video summary project at a 2021 professional conference focused on public health policy and practice. They devised, apriori, to use their presentation to encourage the wide adoption of service-learning experiences like that of the video summary project, including beyond the college setting. The idea for the policy template was born.
The policy template for promoting organizational health literacy was developed using the results of a reflexive thematic analysis to identify specific skills supported by the service-learning project and by reviewing the Health In All Policies framework. Both steps were performed by the first author and supervised by the third author. The Health in All Policies framework was used to further align any policy statements with the prevailing aims for public health policy.
According to Emeline Brulé, reflexive thematic analysis is an approach to analyzing qualitative data to answer research questions about individuals’ experiences, views, perceptions, and representations of a given phenomenon. In this case, the first author used reflexive thematic analysis to conceptualize what skills she had developed, grounded in the activity and experiences of the service-learning project. Specifically, the first author reviewed the software and guidelines she used throughout the process in creating the research summary video, paired with annotations she made in reflecting on specific skills she sensed she had acquired or further developed through the service-learning project. Pooling the observations from her review and reflection together generated a set of themes signifying cognitive and technical skills developed through the service-learning project. Specifically, four thematic skills were conceptualized from the data: (1) learn/grow multi-media skills, (2) learn/grow plain language communication skills, (3) learn to anticipate pitfalls in designing resource material, and (4) learn to solicit and use end-user feedback.
To elaborate, the multimedia skills were developed through practice creating a slideshow presentation, working with software to create graphics, designing an interactive activity, and creating a video summary. Plain language communication skills were practiced not only in the oral presentation of the slides, but also in developing the slides and learning to apply guidelines for font type, text size and color, page layout, etc. The student came to recognize the value of the set of presentation guidelines, namely to optimize accessibility of the presentation. Feedback from fellow research assistants working in the same lab as the first author was incorporated into the presentation, which also confirmed she had actualized competency in developing a plain language multimedia presentation for college students (ie, undergraduates). An area of future research would include soliciting feedback from professionals or graduate level students.
The list of skills supported in creating the research summary video has overlap with Erwin and Brownson’s list of required capabilities for the public health practitioner of the future. They state that “the public health practitioner of the future will require new skills, knowledge, and abilities, as well as new ways of conceptualizing, to successfully attend to the many forces of change affecting her or his practice environment.” One skill that they mention is communication, specifically sifting noise from substance, and they note the need for new approaches to curriculum design for those in academics. This echoes the need for policy development to train health students and officials in creating suitable materials.
The article by Erwin and Brownson also calls for new ways of conceptualizing health information. With all the emerging technology available to consumers, people are receiving their health material using various new online platforms (eg, social media platforms), but Erwin and Brownson note that changing the platform that health material is accessed by does not mean that there is any better communication currently available. The statements within the provided policy template can be adopted as part of a broader policy initiative supporting the creation of quality resource materials across current and new communication channels and methods. Specifically, the provided policy template supports training of health students and current professionals to address quality resource issues in their practice or line of work.
Creating the Policy Template and Concluding Thoughts
The first author reviewed a document on Health in All Policies and a document on ways to compose policy statements, both of which guided how the policy statements were written within the planned policy template for promoting organizational health literacy. These aforementioned steps were taken to ensure the syntax used in the eventual policy template would provide a basis for lasting impact and health improvement across populations. Visually, the policy template presents as a table (see Table 1). Each row contains an activity, policy which would create institutional support for the activity, which key element of the Health in All Policies framework the activity and policy statement aligns with, and ends with a next step to ensure the activity experience can support organizational health literacy. Categories within the Health in All Polices framework are not mutually exclusive, and the reader may see that an activity and/or policy statement presented in the policy template aligns with multiple key elements in the Health in All Policies framework.
Given organizational health literacy focuses on ability of staff to ensure health communications made by the organization are equitable, the activities in the policy template should help students and professionals practice creating quality resource materials that are equitable. Moreover, they could promote a value for being aware of, or locating ways, an organization may fall short of meeting standards for lay communication, which the organizational health literacy definition advanced in Healthy People 2030 represents.
|Activity||Supporting policy||Health in All Policies connection||Building capacity: Prompts for dialogue and action|
|Define suitability; create and revise a mock article.||Health students must learn about the importance of suitability and practice creating suitable materials.||Promote health, equity, and sustainability.||1. After revision of the mock article, refer back to the suitability definition and assess any improvements in the article.|
|Employees watch a summary video or read a summary article on suitability issues that affect the health field.||Provide time and compensation for employees to learn about suitability issues.||Create structural or procedural change.||2. Prompt employees to think about how they might address suitability issues in their workplace.|
|Find an online consent form, and revise it to be more suitable. Design a survey to get feedback on the revisions from community members.||Health students must be comfortable revising diverse forms of health materials and soliciting feedback from community members.||Engage stakeholders.||3. Discuss why it is important that this material be well suited to its intended audience.|
|Read through Ch. 4 of Teaching Patients with Low Literacy Skills, which includes the SAM coding form.||Health students will be familiar with the SAM coding form to assess suitability of materials.||Promote health, equity, and sustainability.||4. Discuss what are some components of the SAM coding form that were surprising or that students had not thought of before.|
|Pick a health topic and create a brief mock article. Include context before each paragraph.
|Health students must have practice writing a suitable article.||Promote health, equity, and sustainability.||5. Refer to the definition of suitability. Discuss how the addition of context before each paragraph improves the suitability of the article.|
|Interns in secondary school or college are trained to evaluate the suitability of material used at their site of internship.||Student interns must be previously trained in suitable material evaluation and must apply this training to their workplace internship.||Support intersectoral collaboration.||6. Reflect on how an increase in suitable materials created by the place of internship might improve health equity and/or outcomes.|
|The policy statements presented in this table focus on helping students and professionals practice creating quality resource material. The first column lists activities that aim to train individuals in suitable content creation. The second column presents policy statements that could provide the basis for a policy template or outline that could be adopted by groups, and the third column identifies a key element of the Health in All Policies approach that is supported by the policy statements. The last column contains suggestions for the activities.|
To learn more, read our article, The Ever-Evolving Nature of Health Literacy in Organizations: A Commentary on the 2021 JPHMP Article “Updating Health Literacy for Healthy People 2030” in the Journal of Public Health Management and Practice.
Caroline Smith is currently an undergraduate student at California Polytechnic State University, San Luis Obispo, USA, studying Public Health. Her research experience is in health communication and knowledge translation. Her future career interests include working in health care and with vulnerable populations to decrease health disparities.
Paul Gorczynski, PhD, HCPC, CPsychol, AFBPsS, is a Senior Lecturer at the University of Greenwich and a Chartered and Practitioner Psychologist. His research examines mental health promotion programs in clinical, educational, and sporting environments. He has consulted for major sporting organizations and governments on mental health literacy and LGBTQI+ mental health service use.
Jafrā D. Thomas, PhD, MPH, MA, serves as an Assistant Professor at the California Polytechnic State University, San Luis Obispo, USA (College of Science and Mathematics, Department of Kinesiology and Public Health). Through a research focus on knowledge translation, he aims to promote equity in health and physical activity promotion.