Table 5 Evidence for application of the Ophelia principles

1. Outcomes focused

Phase 1: establishing project aims that were focused on improving health outcomes either in vulnerable clients or that took a population-based approach to selection of the target group;

Phase 2: use of program logic models, which by their nature are outcomes focused,

Phase 3: ensuring these logic models were used as the basis of implementation and evaluation plans and that evaluation measures captured these outcomes where possible.

Most sites had some difficulty defining a specific target group at the start and narrowed their focus during the project. Tools were developed during the project to assist selection of a focus.

2. Equity driven

Design process deliberately focused on clients who may not be receiving the full range of services or not achieving the full range of outcomes. Examples include:

• embedding brief interactive health literacy screening into a service’s assessment process to identify all clients experiencing difficulty engaging with health providers,

• developing a process that enables low-income clients to access a primary health service.

While not directed to do so, many sites incorporated elements that made them available to disadvantaged groups as well as to core client groups. The process steered clinician’s thoughts towards equity including through use of vignettes that focused on how the health literacy profile could cause people to miss out.

There can be difficulties ensuring an adequate number of responses to the HLQ from people most at risk, especially people who have very little engagement with health services. Collaborative and outreach projects to collect data from high risk groups in community settings may be a useful supplement.

3. Co-design approach

Co-design was inherent in all activities; from data collection and interpretation, to development and pilot-testing of intervention plans, through to conducting evaluation activities. In Phase 1, the process of engaging clinicians in ‘their’ data and interventions may have been enhanced by the use of narratives. This approach to presenting data was very engaging for clinicians and managers, generating multiple intervention ideas.

The researchers probably underestimated the time, training and support required for sites to work through all stages of the project. Many tools and exemplars have been developed to assist future users.

4. Needs-diagnostic approach

Health literacy and demographic data were collected from a pre-defined target group in whom health literacy was thought to contribute to inequitable service access or poor health outcomes. Collection of health literacy data using a comprehensive and robust measurement tool, designed for this purpose, supported this process. The multidimensional tool allowed identification of different profiles of strength and weakness rather than just single health literacy scores.

Potential contextual or other barriers to access should be considered in detail at the outset so that additional questions (other than health literacy) can be included in needs assessment.

5. Driven by local wisdom

The co-design workshops allowed local clinicians and managers to draw on their knowledge and provide intervention ideas in response to needs identified from the local data collection. Interventions were: tailored to local context (such as the outreach nature of interventions from rural organisations); took existing organisational processes into account (e.g. formalising the case-management role of community nurses), and; utilised existing resources (e.g. using volunteers already in place).

During implementation of the interventions, use of quality improvement cycles allowed clinicians to refine and further tailor the intervention according to their local knowledge. Design of intervention evaluation was also driven by local knowledge, with project teams determining the most appropriate indicators for their client or community group.

Allowing time in the co-design workshops for detailed discussion of the issues raised within the vignettes is essential if solutions are to be responsive. At all stages of the process, involving the people who know the client group and who will be delivering the intervention is also essential.

Ophelia principle

Evidence of application

Limits, difficulties, lessons learned

6. Sustainable

Since completion of the study, several sites have commenced using existing organisational quality improvement processes to ensure their interventions remain relevant and effective. For some sites, interventions are seen as stepping-stones to broader objectives with plans to use small interventions at one level to build up over time to achieve organisational priorities and objectives. For example, the intervention to develop a client access point between dental and primary health services will be used as the basis for developing an organisational policy on service access within 5 years.

Having management visibly support the project from the start helped ensure continuity of the intervention at some sites. External factors (such as changes to the chronic disease funding model) influenced sustainability.

7. Responsiveness

Responsiveness was considered in terms of how the organizations responded to health literacy diversity and other unique needs in the target population. It was most clearly demonstrated through use of cluster analysis to capture the diverse range of health literacy profiles. In relation to diversity in the delivery of interventions, three sites selected similar activities (teach-back and learning styles assessment). However, these interventions were applied to achieve different outcomes. Any large or diverse organisation seeking to apply the Ophelia process will need to consider that health literacy will vary considerably between clients, and apply the process accordingly. For example, organisations with different cultural groups using their services may need to collect sufficient needs assessment data to ensure that diversity is adequately captured, and then will need to tailor interventions to these different groups’ needs, or in some cases, develop specific interventions.

More recent Ophelia projects have conducted co-design workshops with consumers or community members, separate to those held with clinicians, but using the same vignettes. This ensures consumers’ perspectives are included. More than one workshop may be needed if there is important cultural or other diversity in the target group.

8. Systematically applied

We have previously identified that health literacy is a potential barrier at multiple access points within a service [7]. Health literacy interventions are therefore required at all levels of client engagement [26]. In this study, interventions focused on multiple levels including:

• directly targeted at improving individual client’s skills,

• enabling clinicians to respond appropriately to health literacy needs (existing clients, clients who approach the service, community outreach),

• changes in organisational processes,

• engagement with external agencies

Several interventions encompassed more than one level.

Using these 4 levels to categorise the intervention ideas helps to demonstrate how an intervention can be refined to encompass more than one level. Some recent Ophelia projects have also incorporated a further workshop to discuss and select interventions; these workshops can include representatives from external agencies and funding bodies.