Background: Health systems around the world are facing significant shifts in demographic profiles due to increasing ethnic, cultural and linguistic diversity of populations they serve. However, the provision of health care and health services in the language of the minority has been difficult and inconsistent. The concept of the health-literate organization has been developed amid growing recognition that system changes are needed to align health-care delivery with the needs, skills, and abilities of the population. Despite the recent proliferation of research on health literacy, studies of organizational health literacy are still uncommon. Objective: This dissertation addresses the concept and practical application of “organizational health literacy” in the context of an active offer of health services in French in Ontario, Canada. I attempt to answer the question “How can health literacy advance the development of health-care designs that are responsive and accessible to official language minority?” Methods: My research consists of a three-part project that used health services research methodology and has been accomplished in academic partnership with the French Language Health Services Network of Eastern Ontario. I first conducted a review both of the literature on health literacy in linguistic minorities and of the content of organizational health literacy guides. Using a practical example of an active offer of French-language services in Ontario, I applied the organizational health-literacy framework in order to examine the strategies used by health-care organizations to provide for the active offer of health services in French. My analysis focuses on health-literacy dimensions (e.g., access and navigation, communication), quality improvement characteristics (e.g., assessment, improvement actions), and also organizational-level changes (e.g., administrative strategies, direct client services, governance). A focus group of health-care administrators provided a unique insight into the planning and implementation of the active offer and organizational health literacy and associated challenges. Results: Overall, my results show that, although organizational changes may be implemented with the purpose of improving the quality of care by providing linguistically appropriate services, these changes are largely insufficient to achieve this goal. Conclusions: The concept of organizational health literacy has not yet received the attention it deserves, but its relevance is clear: Health-care organizations must be health-literate to be able to address healthcare needs of their diverse patients. There is a significant gap between where health services are and where they ought to be to satisfy the designation criteria for the active offer of services in French. The concept and the novel theoretical framework of organizational health literacy offers the potential of improving and strengthening the process of designation and planning of an active offer of health services in French.

Background: Adolescents need to develop health literacy skills to participate in making decisions about their health care. Organizational health literacy facilitates patient understanding of health information, care access, and self-management. Methods: A literature review and qualitative case study were conducted to explore adolescent health literacy within an organizational context of an adolescent scoliosis program. Results: Adolescent health literacy is more nuanced than numeracy and reading levels. Yet, little is known about how organizations (including clinicians) support adolescent health literacy. Interviews with health care professionals in a pediatric tertiary hospital related health literacy to scoliosis patient education but did not address other factors associated with adolescents’ ability to navigate health systems. Organizational documents did not adequately support healthcare professionals in promoting the health literacy of adolescent scoliosis patients. Conclusion: Organizational supports are needed to build health literacy capacity amongst adolescents receiving scoliosis care and clinicians need help to leverage the supports that are in place.

Health literacy (HL) is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low HL has been associated with poorer self-reported health status, inability to manage chronic conditions, and less use of preventive services. More research is needed to explore the relationship between HL and sugar-sweetened beverage (SSB) intake and physical activity (PA). Although numerous HL interventions are evident in the literature, those that test HL as a moderator of effectiveness are lacking. Additionally, it has been recognized that systems-level HL efforts are necessary to lessen the burden of low HL. This dissertation addresses these needs with three unique studies that took place within the rural, medically underserved southwest Virginia region. Study 1 was a secondary analysis that examined the relationship and responsiveness of the Stanford Leisure-Time Activity Categorical Item (L-Cat) and adapted Godin Leisure-Time Exercise Questionnaire (GLTEQ) and determined if baseline HL status moderated intervention effects. There was high agreement L-Cat and adapted GLTEQ for classifying individuals as meeting PA recommendations. Baseline HL status did not moderate change in L-Cat or adapted GLTEQ measures. Study 2 was a secondary analysis that determined if 6-month change in SSB intake predicted 6-month change in body mass index (BMI), weight, and quality of life (QOL), and determined if HL moderated these relationships. The regression models for weight and QOL were not significant. The BMI model was significant. Six-month change in SSB intake, experimental condition, and age were significant predictors for the BMI model. As hypothesized, HL did not moderate relationships in any models. Study 3 details a multilevel mixed-methods needs assessment and collaboratively developed organizational HL improvement plan within the Virginia Department of Health (VDH). Staff responses revealed about half reported doing well across HL domains (written communication, oral communication, self-management and empowerment, supportive systems). However, needs were observed across all domains, with most improvement needed in written communication domain. There were significant correlations between clients' HL status and their perceptions of VDHs' HL practices, indicating potential areas of improvement within VDH. / Ph. D. / Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low health literacy has been associated with poorer self-reported health status, inability to manage chronic conditions, and less use of preventive services. More research is needed to explore the relationship between health literacy and sugar-sweetened beverage intake and physical activity. Specifically, interventions that test the moderation of health literacy (i.e., how health literacy affects the strength of a relationship) are needed. Additionally, it has been recognized that systems-level health literacy efforts are necessary to lessen the burden of low health literacy. This dissertation addresses these needs within the rural, medically underserved southwest Virginia region. Study 1 aimed to test the utility of two physical activity measures (Stanford Leisure-Time Activity Categorical Item and adapted Godin Leisure-Time Exercise Questionnaire) with a population of varying health literacy status with hopes of coming closer to identifying pragmatic standardized assessment of and detection of clinically meaningful change in physical activity behaviors, and to determine if health literacy moderated this change. Study 2 expanded upon existing research that has determined that a decrease in sugar-sweetened beverage intake can result in a decrease in weight and body mass index (BMI), and improvement in quality of life (QOL) by aiming to determine if six-month change in SSB intake predicted six-month change in BMI, weight, and QOL and if health literacy moderated these relationships. Study 3 responds to national and state-wide initiatives by detailing the first use of the AHRQ Toolkit within a public health setting, Virginia Department of Health, to conduct a needs assessment and organizational health literacy improvement plan.