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Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia)



The need for healthcare strengthening to enhance equity is critical, requiring systematic approaches that focus on those experiencing lesser access and outcomes. This project developed and tested the Ophelia (OPtimising HEalth LIteracy and Access) approach for co-design of interventions to improve health literacy and equity of access. Eight principles guided this development: Outcomes focused; Equity driven, Needs diagnosis, Co-design, Driven by local wisdom, Sustainable, Responsive and Systematically applied. We report the application of the Ophelia process where proof-of-concept was defined as successful application of the principles.


Nine sites were briefed on the aims of the project around health literacy, co-design and quality improvement. The sites were rural/metropolitan, small/large hospitals, community health centres or municipalities. Each site identified their own priorities for improvement; collected health literacy data using the Health Literacy Questionnaire (HLQ) within the identified priority groups; engaged staff in co-design workshops to generate ideas for improvement; developed program-logic models; and implemented their projects using Plan-Do-Study-Act (PDSA) cycles. Evaluation included assessment of impacts on organisations, practitioners and service users, and whether the principles were applied.


Sites undertook co-design workshops involving discussion of service user needs informed by HLQ (n = 813) and interview data. Sites generated between 21 and 78 intervention ideas and then planned their selected interventions through program-logic models. Sites successfully implemented interventions and refined them progressively with PDSA cycles. Interventions generally involved one of four pathways: development of clinician skills and resources for health literacy, engagement of community volunteers to disseminate health promotion messages, direct impact on consumers’ health literacy, and redesign of existing services. Evidence of application of the principles was found in all sites.


The Ophelia approach guided identification of health literacy issues at each participating site and the development and implementation of locally appropriate solutions. The eight principles provided a framework that allowed flexible application of the Ophelia approach and generation of a diverse set of interventions. Changes were observed at organisational, staff, and community member levels. The Ophelia approach can be used to generate health service improvements that enhance health outcomes and address inequity of access to healthcare.

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The recent transition from the Millennium to the Sustainable Development Goals has led to a renewed global focus on health and equity [1, 2]. Yet despite increased spending on healthcare, the burden of non-communicable disease continues to grow [3] and socioeconomic gradients in health continue to widen [4, 5]. Appropriate responses will require new systematic approaches that address persisting inequalities and are built upon detailed knowledge of local populations. Interventions developed in one population or setting may not be relevant in other settings, and it may be difficult to embed interventions within a service if they do not fit the needs of the population group or take local contexts into account [6, 7].

Health literacy is a multi-dimensional concept, described by the World Health Organisation as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” [8]. Information about the health literacy of people in a community can offer health and community organisations insight into the challenges people experience when trying to access and engage with their services.

The Health Literacy Questionnaire (HLQ) is a measure of health literacy designed to capture and measure all aspects of the concept. The HLQ comprises nine separate scales, each describing a different aspect of health literacy. People’s scores on each scale reflect both their personal health literacy abilities and the experiences they have had as they attempt to engage with health information and health services [9]. The nine scales are: 1) Feeling understood and supported by healthcare providers; 2) Having sufficient information to manage my health; 3) Actively managing my health; 4) Social support for health; 5) Appraisal of health information; 6) Ability to actively engage with healthcare providers; 7) Navigating the healthcare system; 8) Ability to find good health information; and 9) Understand health information well enough to know what to do. In combination, these scales provide a profile of a person’s health literacy strengths and needs. The HLQ has been shown to have strong measurement properties in a number of different settings [912].

Scores on the nine scales are not combined, rather profiles showing the areas of strength and needs across the nine scales are produced. The HLQ thus provides a mapping of health literacy needs for individuals and groups of individuals. This, in turn, informs an approach to health system strengthening through a) optimising the health literacy of individuals and, b) optimising the health literacy responsiveness of organisations. This approach, called Ophelia (OPtimising HEalth LIterAcy and Access) [7] includes three key phases as shown in Fig. 1. Phase 1 involves undertaking a health literacy needs assessment on a representative cross-section of people associated with a service or sector. The results of this assessment are then presented to stakeholders for discussion and generation of ideas for service or practice strengthening. In Phase 2, a program logic model is constructed, and processes and resources to support implementation of interventions are developed and refined using quality improvement cycles. In Phase 3, continuous quality improvement processes are applied to implement, refine and evaluate the intervention.

Fig. 1
figure 1

Phases of the Ophelia approach

The theoretical underpinnings of the Ophelia approach are described in the protocol for a large multi-centred partnership project conducted in Victoria, Australia (hereafter called Ophelia Victoria) [7]. The partnership was co-designed by academic teams from two Universities, three sections within the state government Department of Health and Human Services and nine health service sites across Victoria.

The overall aim of Ophelia Victoria was to develop and test a structured approach that organisations can use to enhance equitable engagement of consumers in health and health care. There was considerable variation in both the context in which development and testing occurred (i.e., type of partnering organisation) and in the nature of the potential interventions (i.e., from health promotion, to clinical services, to organisational policy). This variability required that testing of the Ophelia approach be applied with considerable flexibility. As such, a set of predefined principles were established to guide the project’s operationalisation (Table 1). In this paper, we report the application of the Ophelia process in a proof-of-concept study. Proof-of-concept was defined as successful application of the eight underlying principles to achieve the development of health literacy-informed interventions with the potential to impact on health and equity outcomes.

Table 1 The Ophelia (OPtimising HEalth LIteracy and Access) principles that guide the aims, development and implementation of structured interventions to improve health and equity outcomes in communities


Participating sites

Expressions of interest to participate in the project were sought from service organisations providing Home and Community Care (HACC) services, Hospital Admission Risk Programs (HARP) or community nursing and other chronic disease services [7]. Eight organisations were recruited with one large organisation subsequently separating into two program areas, resulting in nine participating sites. Details of participating organisations are shown in Table 2, including a brief description of services relevant to this project. Each site was required to establish their own project team to lead activities at their site and to liaise with the academic research team. Approval to conduct the study was obtained from three of the participating sites with their own ethics committees, while the remaining six sites accepted approval from the Deakin University Human Research Ethics Committee. Written informed consent was obtained from all participants for all phases of the study, including clients and practitioners.

Table 2 Description of each participating service organisation

Measurement of health literacy

The Health Literacy Questionnaire (HLQ) was designed using a grounded, validity-driven approach and initially tested in diverse samples of individuals in Australian communities where it was shown to have strong construct validity, reliability and acceptability to clients and clinicians [9, 13]. It can be self-administrated or administered in an interview, ensuring inclusion of people who cannot read or have other difficulties with self-administration. The HLQ contains 44 questions across nine separate scales (see background). Response options for each scale were determined by the content and nature of the items. For scales 1–5 four-point ordinal response options are used (Strongly Disagree, Disagree, Agree and Strongly Agree), while for scales 6–9 five-point ordinal response options are used (Cannot Do, Very Difficult, Quite Difficult, Quite Easy and Very Easy). The psychometric properties of the HLQ were tested in the current study sample [13]. All HLQ scales were found to have strong construct validity, be homogenous, and with good to excellent composite reliability ranging from 0.80 to 0.89. With a small number of exceptions, strict measurement invariance was seen across the participating organisations and the gender, language, age and educational level of respondents [13].

Application of the Ophelia process

In Phase 1 of the Ophelia process, each site was asked to define a broad aim for their project and identify a priority group where health literacy was thought to contribute to inequitable service access or poor health outcomes. Staff at each site then undertook a needs assessment of a representative sample of clients in their target group by collecting HLQ and demographic data [10]. The researchers also conducted semi-structured interviews with up to three participants, randomly sampled from within tertiles of HLQ scale scores. The interviews explored the thinking underlying participants’ responses to the HLQ (see Additional file 1: Phase one interviews for semi-structured interview template). Participants with higher and lower scale scores were selected in order to capture individual health literacy strengths and areas of need. Data from these interviews were used to support interpretation of the HLQ and to provide context and narrative for case studies that were used in presenting the data.

Cluster analysis of HLQ scores, within each site, was used to identify subgroups of people with health literacy profiles that were similar within each subgroup, yet distinct from other subgroups (see below for specific statistical procedure). Short vignettes (narratives) were written to represent a typical person within each subgroup. Three-hour workshops were held at each site with healthcare practitioners and managers who were familiar with the target group, the service culture, and the context within which each service operated. Each workshop was facilitated by a member of the research team and observed by others for training purposes. A co-design approach was used, whereby participants collectively raised and discussed ideas about strategies that they currently use, or could use, to support the persons described in the narratives. Workshop participants were encouraged to consider solutions at the individual client-level first, and then solutions at the organisation level. The ideas generated from these workshops provided a pool of potential solutions to the priority health issues identified at the start of the project.

In Phase 2, based on their overall project aims and the solution ideas generated in the workshops, sites were supported to develop a program logic model to describe the service improvements they wished to undertake. The program logic model presented the elements of the intervention and aligned these with desired changes to their target group’s health literacy. A rapid literature review for evidence to support the selected interventions was also conducted. Based on their program logic model and relevant evidence, sites then developed detailed implementation and evaluation plans. The template for these plans is shown as additional data (see ‘Additional file 2: Implementation plan template’). A workshop was held at this point, facilitated by the research team, in which project team members from the nine participating sites came together to share and refine their intervention ideas. Over 2–3 months, Plan Do Study Act (PDSA) quality improvement cycles were used to develop and refine materials and processes in preparation for implementation of the selected interventions. A second workshop was held so that organisations could discuss, compare and further refine their findings from this pre-testing and development phase.

In Phase 3, interventions were implemented over a period of up to 6 months, with evaluation of the interventions occurring in accordance with the Ophelia protocol [7]. Evaluation of each intervention involved collection of qualitative and quantitative data using convenience sampling in most cases. For quantitative data, five sites administered between two to three HLQ scales to intervention participants before and after delivery of the intervention. Several of these sites also selected one HLQ scale in which they hypothesised no change would occur (comparison scale). One site also administered a diabetes knowledge questionnaire to participants before and after the intervention [14]. Other quantitative data included rates of participation and uptake of the intervention where relevant. Qualitative data collection included focus groups with practitioners who were involved in delivery of interventions, and semi-structured interviews with convenience samples of participating clients and volunteers. The interviews sought to uncover the impact of the interventions on individuals and their health literacy and/or other mechanisms by which the intervention might achieve impacts (see Additional file 3 for templates for client, volunteer and practitioner interviews). Case studies of individual clients were also collected from two sites for evaluation purposes. Phase 3 of the Ophelia process also sought to embed interventions into existing organisational processes and service delivery.

Data analysis

Data were analysed using SPSS Version 22 [15] and Stata Version 13 [16]. In Phase 1, hierarchical cluster analysis was undertaken using Ward’s method for linkage as previously described [7]. Cluster analysis data were presented as means (SD) for each of the scale scores in each of the clusters. In Phase 3, the magnitude of pre-post change in HLQ scales was assessed using Cohen’s d effect size with 95% confidence intervals [17]. Participation and uptake rates were presented as numbers and percentages. For interview findings, data were thematically analysed using NVivo 10 [18]. The interview questions were utilised as starting points and data from the transcripts were coded into these initial themes. These initial themes were represented as “parent nodes" within NVivo. Once all relevant data from the transcripts were coded into the parent nodes, “child nodes” were created to represent any sub themes that emerged during further analysis. The sequence of coding followed the general structure outlined by Saldaña [19] and while a number of the coding methods that he described were used, the dominant methods were process and causal coding. Demographic data for Phases 1 and 3 were presented as means and SD for continuous data and proportions for categorical data.


Phase 1

The target groups and project aims selected by each of the participating organisations are shown in Table 3. In line with the type of client routinely seen by the organisations, most target groups included older clients with chronic conditions. Project aims for each site focused on improving clients’ health through mechanisms such as enhancing existing client or community members’ ability to self-manage their health, understand health information, or engage more effectively with healthcare providers.

A detailed description of the overall client sample (n = 813) from the needs assessment has been reported elsewhere [10]. Briefly, the mean age of clients was 72.1 (range 19–99) years. Females comprised 63% of the sample, 48% had not completed secondary education, and 96% reported at least one existing health condition. Key findings from each organisation’s needs assessment are shown in Table 3. The needs assessment identified lower health literacy for many clients, with cluster analysis revealing between 8 and 15 subgroups with different health literacy profiles at each site. Between 4 and 6 narratives describing a range of these subgroups were written for each site (n = 41 narratives in total). An example of one health literacy profile, demographic data and its narrative is shown in Fig. 2.

Table 3 Findings from site-level needs assessment, overview of interventions developed in response to needs assessment, and the focus of each intervention
Fig. 2
figure 2

Example of a narrative (vignette) derived from cluster analysis and related health literacy* and demographic data

Co-design workshops at each site were attended by between 6 and 24 participants comprising allied health and nursing practitioners with a range of clinical experience, program managers and team leaders and, in two cases, administrative staff. From these workshops, a total of 315 intervention elements were generated (mean number of ideas for each site 40, range 21 – 78). While some intervention ideas were unique to a single vignette, in many cases ideas spanned more than one vignette. In these cases, the ideas incorporated elements specific to the needs of the person described in that vignette. For example, an intervention idea to use volunteers in delivery of health messages was considered at one site to be a potential idea for three vignettes, but clinicians recognised that the method of delivery would need to vary according to the diversity of needs presented in the vignettes.

Phase 2

From the pool of ideas generated during the co-design workshops, project team members at each site selected ideas that they considered could be used to achieve their project aims. Eight sites combined ideas to develop a single activity comprising a number of components while one site applied two entirely different interventions in different program areas. Program logic models were co-designed with each site. Figure 3 shows an example of a program logic model from Site #1.

Fig. 3
figure 3

Example of a program logic model for training community members of a national women’s organisation as health mentors for elderly clients to reduce falls and decrease social isolation

The interventions that were determined from the program logic models varied in their design, approach and hypothesised mechanism of effect. An overview of interventions is shown in Table 3. Multiple intervention ideas arose in the workshops, and selection of the final ideas was driven by factors such as available resources, proximity of the intervention to the proposed outcomes, and endorsement of the intervention among staff at each site.

Interventions, shown in detail in Table 4, aimed to either improve clients’ health literacy directly or reorientate the organisation’s services and processes to make health information or services more accessible to people with diverse health literacy strengths and limitations. Overall, four distinct pathways were identified across the sites:

  • three interventions targeted clinicians through provision of skills training and resources to support them to respond to a range of health literacy strengths and limitations in working to build clients’ capacity to self-manage their long term condition (sites 3, 8 and 9);

  • two interventions utilised community volunteers to act as local health mentors and so build community members’ capacity to achieve better health outcomes (sites 1 and 4);

  • three interventions aimed to directly improve clients’ health literacy through providing clients with resources or targeted training (sites 2, 5 and 7); and

  • two interventions focused on redesigning existing service procedures to improve access to services for people with different health literacy strengths and limitations (sites 6 and 7).

In six of the nine sites, the aims of the final selected intervention aligned closely with the initial project aims. Differences were seen in the remaining three sites where initial project aims were less specific, with the final aim for these sites focused on specific client or organisational needs identified during the needs assessment and co-design workshops.

Rapid literature reviews for each intervention identified existing resources that were then used by two sites as the basis for developing client education materials to support their interventions, and in another case, highlighted useful strategies for engaging and training volunteers as heath mentors. Each site’s implementation and evaluation plan provided detail about the steps, processes and materials needed to apply their intervention, and the indicators required to evaluate its effectiveness. Approaches to measurement of short to medium outcomes, and where possible, long-term outcomes are detailed in Table 4. Evaluation of longer term outcomes was not possible given the relatively short time frame for implementation, but the program logic models identified shorter and medium-term outcomes as important intermediate achievements in producing longer term outcomes.

Table 4 Expected outcomes, evaluation activities and results for each of the 9 sites participating in Ophelia Victoria

Sites each undertook between one and three PDSA quality cycles to refine processes and materials. In most cases the refinements made were small. For example, one site developed prompts to remind clinicians to use teach-back, while another identified the need to develop locally-based training videos and filmed these themselves using hand held devices. A third site decided to limit the scope of their intervention by initially delivering it within group-based programs, with plans to extend it to home-based clients at a later stage.

Phase 3

Evaluation findings for each of the interventions tested are shown in Table 5. Across the nine sites, 228 clients (range 5 – 70) and 22 volunteers (range 8 – 14) participated in evaluation activities including completing pre-post HLQ scales, interviews or focus groups. Forty-two staff (range 4 – 10) involved in delivery of the interventions were also interviewed.

As shown in Table 5, all evaluations used a quasi-experimental (pre-post) design, with five of the nine sites utilising a mixed-methods approach. Qualitative data, obtained through interviews and focus groups with 92 clients and volunteers (range 5 – 26 across sites) and 43 clinicians (range 3 – 10) showed small, but positive impacts for clients, volunteers and clinicians, indicating that for the most part, shorter-term outcomes from the site program logic models were achievable. In the seven sites that also undertook quantitative analysis, findings supported qualitative data to varying degrees. Effect sizes (ES) for individual HLQ scales was nil/minimal (ES 0.02, 95% CI −0.41, 0.45) in two sites, moderate in two sites, and moderate/large in one site (ES 0.92, 96% CI −0.13, 1.94). Where comparison HLQ scales were used (i.e. a scale where no change was expected), small or no changes were observed.

For the three sites with interventions directly targeting health personnel, the interviewed staff reported increased awareness and responsiveness to clients’ health literacy-related needs and improved clinician-client rapport, particularly where teach-back [20] was used. For these interventions, two sites administered selected HLQ scales to participating clients, with no/small improvements seen. For the two sites with interventions that trained volunteers to act as health mentors, the volunteers themselves reported increased confidence to support others and a sense of feeling useful. In both cases, clients or community members receiving these interventions reported positive changes in behaviour. Small, moderate and large improvements were seen for selected HLQ scales in both sites. Three sites developed interventions directly targeting clients’ health literacy through providing resources or education. Findings from these sites were mixed. Some clients and clinicians reported that resources were not relevant to their needs, while others indicated they were useful. Only one site (site #5) evaluated changes in selected HLQ scales, observing moderate improvements. For the two interventions in which existing service procedures were redesigned to improve access to services, evaluation data were limited. However, qualitative findings for these two sites indicated that the process of redesign was feasible and appropriate.

Evidence for operationalisation of the eight Ophelia principles was explored across the nine sites (see Table 5) and evidence was present for each. Being outcomes focused (principle 1 [P1]) was part of the initial process of engagement and a primary aim for sites. This was reinforced through the use of program logic models. Each site was equity driven in that all sites formally considered which clients may not be receiving the full range of services or not achieving optimal health outcomes [P2]. The workshops to generate intervention ideas drew on the local wisdom of local stakeholders [P3, P5] ensuring co-design took place. The use of the HLQ to inform the vignettes ensured sites focused on local health literacy needs [P4, P7]. Organisations generated intervention ideas that ranged from those directed at individuals through to the engagement of external agencies, i.e., ideas were generated and applied, where relevant, across all levels of organisations [P8]. For some organisations the Ophelia improvement processes have been continued to ensure their interventions remain relevant and effective [P6] however longer term follow-up is required to confirm sustainability of the interventions developed during the project.

Table 5 Evidence for application of the Ophelia principles


We have described a systematic process designed to enable health services to identify and respond to the health literacy strengths and needs of their clients. Nine different sites were able to collect health literacy data, take part in co-design workshops, use program logic models, apply quality improvement cycles, and then implement and evaluate innovative interventions. The evaluation data indicate that the Ophelia process is a feasible approach by which organisations can develop tailored responses to the health literacy needs of their clients. While quantitative impacts were generally small, consistent positive findings from qualitative data indicated that service redesign occurred and some short-term outcomes for selected interventions were achievable. Impacts upon HLQ scale scores were less consistent, which may be related to the short time frame available for implementation of interventions.

In examining the program logic models and hierarchies of short, medium and long-term outcomes identified by the sites, it is possible to build an integrative program logic of changes occurring at different levels of the health system that allow it to be more responsive to the diversity of health literacy strengths and weaknesses in the community (Fig. 4). This framework recognises that while the main focus of planning and intervention may be at one level, success or failure is dependent also on what occurs at other levels: organizational change must be manifest in practice change in personnel or engagement with new partners in the community; changes in the activities of staff must be authorised and enabled by accommodations in the organization and must produce changes in the experiences of clients and so on. While it is possible for the primary focus to be on any of the levels indicated, planning, activities and monitoring at other levels are required to enable these changes to occur.

Fig. 4
figure 4

An integrated framework for health literacy interventions

In considering the impact of the different interventions, it is also necessary to consider the degree of newness that the intervention introduced to existing practice in the organization. In general, the interventions that utilised community volunteers and those that attempted to directly improve the health literacy of clients involved a greater change from normal practice, than did the interventions focused on skills of health personnel or on changing organizational processes. For example, the interventions to develop skills of health personnel occurred in programs where staff already had a clear role and a high level of skill in health education. In these contexts, the intervention may best be considered as a quality improvement activity, and/or an activity for skill development of new staff. However, it may be just as appropriate to improve relevant knowledge and skills in those organizations where staff have lower levels of commitment to high quality client education.

While the size size and composition of the samples included in the evaluation do not allow us to generalize broadly, those interventions which focused on community engagement and directly changing the health literacy of clients were more likely to lead to moderate to large changes in the targeted HLQ scales. This cannot be taken to mean, however, that those interventions are always to be preferred. As noted they tended to be more novel in terms of engaging new target groups in new ways to improve access and equity. Generally, they were also more labour intensive and probably more expensive interventions. Furthermore, interventions that focus on staff skills and organizational change are likely to have a broader impact for all users of an organization’s services.

This is one of very few studies that have shown improvements in scores on any standardized health literacy measure. The largest systematic review of health literacy studies ever conducted by the US Institute of Medicine [21] did not look at changes in health literacy scores as an outcome but rather focused on other outcomes for people with limited health literacy (e.g., knowledge, behaviour change). A review by Taggart et al. identified many changes that were classified as broadly health literacy changes but which were mostly changes in knowledge or management of specific diseases, changes in self-efficacy for target behaviours, or changes in behavioural intent related to stages of change in target behaviours [22]. Some studies focusing on health literacy for mental health [23] and oral health [24] have demonstrated changes in knowledge or attitudes, and a study of consultation skills training demonstrated improvements in interactive health literacy [25]. The improvements shown in this present study may be a result of greater sensitivity of the HLQ compared with other scales used in clinical settings, due to the broader range of concepts that it measures and the provision of scores for each independent scale.

This study has also demonstrated that sites were able to select scales likely to change based on the program logic of their interventions. Participating organizations demonstrated some success in selecting a limited number of scales in order to assess health-literacy-related intermediate outcomes while using a comparison scale that was not expected to change.

In this study, proof-of-concept was defined as successful application of the eight underlying principles to achieve the development of health literacy-informed interventions to impact on health and equity outcomes. Evidence indicating that the Ophelia approach was applied with fidelity is shown in Table 5. Overall, the Ophelia principles were operationalised at many levels of the project across all sites.

This proof-of-concept study of the Ophelia approach aimed to generate data to develop, improve and apply health literacy interventions in real world settings. Although further analysis is required to identify the determinants of successful implementation, at the organisational level, one determinant appeared to be the early establishment of a clearly defined project objective. Another determinant may be having ‘flexible’ interventions that can respond to different needs of clients, to changes in the organisation, or to feedback from clinicians. This flexibility is essential if quality improvement cycles are to be effective, and may be an important characteristic of ‘responsive’ health literacy interventions. Finally, having a suite of activities rather than one fixed intervention seemed to be an important determinant, possibly because it allowed clinicians to use their own discretion in tailoring what they do for individuals or groups of service users.

An important strength of this study is the application of a co-design process that emphasised participatory design of interventions through genuine engagement of practitioners and managers from across prevention and care pathways. Great care was taken to elicit and utilize their expertise and local knowledge, with the vignettes providing an effective vehicle for this in the co-design workshops. As intended, the workshops generated locally relevant, and for the most part, implementable interventions. The co-design approach specifically sought to assign increasing ownership and responsibility of the application of the intervention to sites. The intensive engagement of local personnel in all stages was, however, time consuming for some stakeholders due to the number of steps requiring feedback and local decision-making. There was also a risk of losing the overall focus in attending to details at each step. The Ophelia process sought to maintain a balance between these elements, and program fidelity was reasonably achieved according to the utilisation of Ophelia principles.

An important marker of success was the retention of all nine sites throughout the entire study period. Almost all sites and project teams experienced project team-related or organisational change, with only four of the sites retaining the original project team members over the three years of the project. Two sites amalgamated with other services, and two sites underwent major organisational re-structuring. Despite this, all sites continued active participation in the study, and in most cases expressed a sense of ownership of ‘their’ intervention and a desire to generate their intended objectives and complete the project. The observation that interventions were readily taken up within organisations even in the context of time pressures and financial constraints experienced by most health services suggests they were acceptable to front line providers and their managers (data not shown).

Limitations of the study include the relatively short time-frame of the project, which meant that the longer-term impacts of interventions were not able to be assessed. Nevertheless, short-term outcomes described in the logic models for all sites were met, suggesting accuracy in the thinking that occurred about the mechanisms by which each intervention worked. Small sample sizes for phase 3 mean that in most cases, quantitative data analyses are only indicative. As this was a feasibility study, and we were not seeking to formally test hypotheses, we used effect sizes with 95% confidence intervals. Generally, the confidence intervals were wide (reflecting the small sample sizes and the variable responses of individuals tested). Nonetheless, some interventions generated moderate mean effects at the individual level alongside clear indications of clinician and organisation change. It is important to note that the client-level pre-post changes are potentially influenced by a range of biases, and there were no control groups. While the application of a ‘comparison’ HLQ scale (where no change was expected) generally provided some evidence the interventions generated intended effects, future formal evaluations will be greatly strengthened through more comprehensive evaluation designs. A further potential limitation is the generalisability of the Ophelia approach in other settings and countries. Of note, the approach is currently being applied in a diverse range of healthcare services and communities in the UK, Thailand and Norway, where community members contribute significantly to the co-design approach.


The Ophelia process was successfully applied across nine sites with evidence of successful generation of a wide range of health literacy interventions directly related to organisations’ priorities. Proof-of-concept was evidenced through successful application of eight a priori principles. The co-design elements, with a wide range of stakeholders across disparate organisations, generated locally relevant and fit-for-purpose interventions that were implementable and achieved outcomes at four key levels, including organisational level process improvements, improvements in staff knowledge and skills, improvements in community engagement, and direct improvements in client outcomes and equity.



Effect size


Home and Community Care


Health Literacy Questionnaire


Optimising health literacy and access


Plan, Do, Study, Act


  1. World Health Organization. Sustainable development and health equity. Available at: Accessed 1 Oct 2016.

  2. Tangcharoensathien V, Mills A, Palu T. Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals. BMC Med. 2015;13(1):1–5.

    Article  Google Scholar 

  3. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries: a systematic analysis for the Global Burden of Disease Study. Lancet. 2013;386(9995):743–800.

  4. Elgar FJ, Pförtner T-K, Moor I, De Clercq B, Stevens GWJM, Currie C. Socioeconomic inequalities in adolescent health: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study. The Lancet. 2015;385(9982):2088–95.

  5. Singh G, Gopal K, et al. Increasing area deprivation and socioeconomic inequalities in heart disease, stroke, and cardiovascular disease mortality among working Age populations, United States, 1969–2011. Int J MCH AIDS. 2015;3(2):119–13.

    PubMed  PubMed Central  Google Scholar 

  6. Hawe P. Minimal, negligible and negligent interventions. Soc Sci Med. 2015;138:265–8.

    Article  PubMed  Google Scholar 

  7. Batterham R, Buchbinder R, Beauchamp A, Dodson S, Elsworth G, Osborne R. The OPtimising HEalth LIterAcy (Ophelia) process: study protocol for using health literacy profiling and community engagement to create and implement health reform. BMC Public Health. 2014;14:694.

    Article  PubMed  PubMed Central  Google Scholar 

  8. World Health Organization. Health promotion glossary. Health Promot Int. 1998;13(4):349–64.

    Article  Google Scholar 

  9. Osborne RH, Batterham RW, Elsworth GR, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health. 2013;13:658.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Beauchamp A, Buchbinder R, Dodson S, Batterham RW, Elsworth GR, McPhee C, et al. Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ). BMC Public Health. 2015;15(1):1–13.

    Article  CAS  Google Scholar 

  11. Bo A, Friis K, Osborne R, Maindal H. National indicators of health literacy: ability to understand health information and to engage actively with healthcare providers - a population-based survey among Danish adults. BMC Public Health. 2014;14:1095.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Friis K, Lasgaard M, Osborne RH, Maindal HT. Gaps in understanding health and engagement with healthcare providers across common long-term conditions: a population survey of health literacy in 29 473 Danish citizens. BMJ Open. 2016;6(1):e009627. doi:10.1136/bmjopen-2015-009627.

  13. Elsworth GE, Beauchamp A, Osborne RH. Measuring health literacy in community agencies: a Bayesian study of the factor structure and measurement invariance of the Health Literacy Questionnaire (HLQ). BMC Health Serv Res. 2016;16:508.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Eigenmann CA, Skinner T, Colagiuri R. Development and validation of a diabetes knowledge questionnaire. Pract Diabetes Int. 2011;28(4):166–70d.

    Article  Google Scholar 

  15. IBM Corp. Released 2012. IBM SPSS Statistics for Windows VA, NY: IBM Corp.

  16. StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP

  17. Cohen J. Statistical power analysis for behavioral sciences (revised ed.). New York: Academic; 1977

  18. QSR International Pty Ltd..NVivo qualitative data analysis software, Verson 10. Version 10 ed: QSR International Pty Ltd.; 2012.

  19. Saldaña J. The coding manual for qualitative researchers (2nd Ed). 2nd ed. London: Sage Publications Ltd; 2013.

    Google Scholar 

  20. Jager AJ, Wynia MK. Who gets a teach-back? patient-reported incidence of experiencing a teach-back. J Health Commun. 2012;17(sup3):294–302.

    Article  PubMed  Google Scholar 

  21. Berkman N, Sheridan S, Donahue K, Halpern D, Viera A, Crotty K, et al. Health literacy interventions and outcomes: an updated systematic review. Evid Rep Technol Assess. 2011;199

  22. Taggart J, Williams A, Dennis S, Newall A, Shortus T, Zwar N, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract. 2012;13:49.

    Article  PubMed  PubMed Central  Google Scholar 

  23. McLuckie A, Kutcher S, Wei Y, Weaver C. Sustained improvements in students’ mental health literacy with use of a mental health curriculum in Canadian schools. BMC Psychiatry. 2014;14:379.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hjertstedt J, Barnes SL, Sjostedt JM. Investigating the impact of a community-based geriatric dentistry rotation on oral health literacy and oral hygiene of older adults. Gerodontology. 2014;31(4):296–307.

    Article  PubMed  Google Scholar 

  25. Smith PD, Martin B, Chewning B, Hafez S, Leege E, Renken J, et al. Improving Healthcare Communication for Caregivers: A Pilot Study. Gerontol Geriatr Educ. 2016. [Epub ahead of print].

  26. Allen K, Zoellner J, Motley M, P E. Understanding the internal and external validity of health literacy interventions: A systematic literature review using the RE-AIM framework. J Health Commun. 2011;16(Suppl 3):55-72.

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The authors wish to thank Jayne Power, Sylvia Barry, Kirsten Phillip, and Silvana Cavalli from the Victorian Department of Health and Human Services, and Melanie Hawkins from Deakin University. We also wish to thank staff from the healthcare organisations participating in this study for their commitment and support for the study.


The project was funded by a peer-reviewed nationally competitive Australian Research Council (ARC) Linkage Project grant, with partnership funding from the Victorian Department of Health and Human Services (DHHS), Deakin University and Monash University. Richard Osborne was funded in part through a National Health and Medical Research Council (NHMRC) Senior Research Fellowship #APP1059122. Rachelle Buchbinder was funded in part through an NHMRC Practitioner Fellowship #APP606429. Alison Beauchamp was funded through an ARC Linkage Industry Fellowship. Staff employed at each of the funding partners (Deakin University, Monash University, and DHHS) contributed to the overall design of the study, collection of data, interpretation of results and the final draft of the manuscript.

Availability of data and materials

The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Authors’ contributions

AB managed the study, led the data collection, statistical analysis and writing of all drafts. The overall study design was devised by RWB, RHO, RB, JJ and GE, and operationalized by AB, SD, RWB, BA and RHO. RHO and RWB provided ongoing guidance, contributed extensively to initial drafts and interpretation of results. RB provided ongoing guidance and all authors contributed to the second and subsequent drafts including interpretation of the results. AB, SD, and RHO were active in recruitment, selection and orientation of sites, and the provision of training to staff. AB and CM provided support for data collection. CM and RWB conducted NVIVO data analysis. All authors approved the final draft.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Written consent was obtained from all participants for publication.

Ethics approval and consent to participate

Approval to conduct the study was obtained from the following ethics committees: Deakin University (reference 2012–295); Barwon Health (reference 13/28), Eastern Health (reference LR84/1213) and Royal District Nursing Service (reference 138). Written informed consent was obtained from all participants for all phases of the study, including clients and practitioners.

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Corresponding author

Correspondence to Alison Beauchamp.

Additional files

Additional file 1:

Phase one interviews.pdf (template for client interviews used to inform development of vignettes). (PDF 348 kb)

Additional file 2:

Implementation plan template.pdf (template for implementation and evaluation plans used in Phase two of the Ophelia process). (PDF 346 kb)

Additional file 3:

Phase three interviews.pdf (template for client, volunteer and practitioner interviews conducted in phase three). (PDF 382 kb)

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Beauchamp, A., Batterham, R.W., Dodson, S. et al. Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia). BMC Public Health 17, 230 (2017).

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