title: The health literate health care organization 10 item questionnaire (HLHO-10): development and validation.
abstract: BACKGROUND
  While research on individual health literacy is steadily increasing, less attention has been paid to the context of care that may help to increase the patient's ability to navigate health care or to compensate for their limited health literacy. In 2012, Brach et al. introduced the concept of health literate health care organizations (HLHOs) to describe the organizational context of care. This paper presents our effort in developing and validating an HLHO instrument.
  
  
  METHODS
  Ten items were developed to represent the ten attributes of HLHO (HLHO-10) based on a literature review, an expert workshop, a focus group discussion, and qualitative interviews. The instrument was applied in a key informant survey in 51 German hospitals as part of a larger study on patient information and training needs (PIAT-study). Item properties were analyzed and a confirmatory factor analysis (CFA) was conducted to test the instrument's unidimensionality. To investigate the instrument's predictive validity, a multilevel analysis was performed that used the HLHO-10 score to predict the adequacy of information provided to 1,224 newly-diagnosed breast cancer patients treated at the sample hospitals.
  
  
  RESULTS
  Cronbach's α of the resulting scale was 0.89. CFA verified the one-factor structure after allowing for the correlation for four pairs of error terms. In the multilevel model, HLHO-10 significantly predicted the adequacy of information as perceived by patients.
  
  
  CONCLUSIONS
  The instrument has satisfactory reliability and validity. It provides a useful tool to assess the degree to which health care organizations help patients to navigate, understand, and use information and services. Further validation should include participant observation in health care organizations and a sample that is not limited to breast cancer care.
authors: Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupener Strasse 129, Cologne, 50933, Germany. christoph.kowalski@uk-koeln.de.|German Cancer Society, Kuno-Fischer-Straße 8, 14057, Berlin, Germany. christoph.kowalski@uk-koeln.de.
authors: Christoph
authors: C
authors: Kowalski
authors: Department of Health Management and Policy, The University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, MI, 48109-2029, USA. sylee@umich.edu.
authors: Shoou-Yih D
authors: SY
authors: Lee
authors: Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupener Strasse 129, Cologne, 50933, Germany. anna.schmidt@uk-koeln.de.
authors: Anna
authors: A
authors: Schmidt
authors: German Cancer Society, Kuno-Fischer-Straße 8, 14057, Berlin, Germany. wesselmann@krebsgesellschaft.de.
authors: Simone
authors: S
authors: Wesselmann
authors: University of Education Freiburg, Kunzenweg 21, 79117, Freiburg, Germany. markus.wirtz@ph-freiburg.de.
authors: Markus A
authors: MA
authors: Wirtz
authors: Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupener Strasse 129, Cologne, 50933, Germany. holger.pfaff@uk-koeln.de.
authors: Holger
authors: H
authors: Pfaff
authors: Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne, Eupener Strasse 129, Cologne, 50933, Germany. Nicole.ernstmann@uk-koeln.de.
authors: Nicole
authors: N
authors: Ernstmann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000628:therapy*; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005163:Factor Analysis, Statistical; D005260:Female; D005858:Germany; D057220:Health Literacy / Q000458:organization & administration*; D006801:Humans; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D016730:Program Development; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D055815:Young Adult
references: JAMA. 2011 Apr 27;305(16):1695-701
references: 21521851
references: Patient Educ Couns. 2009 Jun;75(3):321-7
references: 19395223
references: Health Aff (Millwood). 2012 Feb;31(2):434-43
references: 22262723
references: Patient Educ Couns. 1999 Sep;38(1):33-42
references: 14528569
references: J Gen Intern Med. 2008 May;23(5):561-6
references: 18335281
references: Patient Educ Couns. 2010 Dec;81 Suppl:S34-40
references: 21074963
references: Fam Med. 1991 Aug;23(6):433-5
references: 1936717
references: Patient Educ Couns. 1998 Jan;33(1):25-37
references: 9481346
references: Nurs Outlook. 2011 Mar-Apr;59(2):85-94
references: 21402204
references: Soc Sci Med. 2008 Apr;66(8):1809-16
references: 18295949
references: J Gen Intern Med. 1995 Oct;10(10):537-41
references: 8576769
references: J Gen Intern Med. 2004 Dec;19(12):1228-39
references: 15610334
references: Psychol Methods. 2002 Jun;7(2):147-77
references: 12090408
references: Implement Sci. 2009 Oct 19;4:67
references: 19840381
references: Fam Med. 2004 Sep;36(8):588-94
references: 15343421
references: Acad Emerg Med. 1996 Mar;3(3):264-70
references: 8673784
references: Arch Intern Med. 2003 Jan 13;163(1):83-90
references: 12523921
references: J Health Commun. 2011;16 Suppl 3:308-21
references: 21951260
references: N Engl J Med. 2010 Dec 9;363(24):2283-5
references: 21142532
references: Soc Sci Med. 2008 Dec;67(12):2072-8
references: 18952344
references: Health Care Manage Rev. 2013 Oct-Dec;38(4):295-305
references: 22936002
references: Med Care Res Rev. 2008 Jun;65(3):259-99
references: 18089769
references: J Gen Intern Med. 2006 Aug;21(8):878-83
references: 16881951
references: Support Care Cancer. 2012 Sep;20(9):2167-76
references: 22081119
references: JAMA. 2010 Jul 7;304(1):76-84
references: 20606152
references: BMC Health Serv Res. 2012 Jan 26;12:22
references: 22280514
references: BMC Public Health. 2012 Jan 25;12:80
references: 22276600