An integrative literature review examining twenty-two studies published between 2014 and 2022 reveals that healthcare organizations seeking to become health-literate rely on four core pillars: diagnostic assessment, communication simplification, workforce training, and community engagement, while confronting major obstacles from leadership disengagement and resource deficits. Conducted across eight international research databases, the synthesis evaluated how health systems plan and execute structured interventions to improve institutional responsiveness. Rather than treating health literacy solely as an individual patient responsibility, the analyzed evidence shows that healthcare facilities increasingly test organizational actions designed to modify institutional environments, operations, and service pathways. However, the operationalization of organizational health literacy remains uneven across healthcare settings. Half of the reviewed interventions were hindered by limited leadership buy-in and resource shortages, demonstrating that sustainable transformation requires systemic commitment rather than isolated administrative adjustments across routine clinical practice. According to the synthesized evidence, establishing responsive institutional structures is essential for facilitating access to health services and improving patient outcomes.

The conceptual foundation of the reviewed research reflects a shift away from viewing health literacy merely as an individual capability toward recognizing it as a systemic institutional responsibility. Historically, health literacy has focused on an individual’s capacity to access, understand, evaluate, and apply information necessary for self-care and appropriate health service navigation. When people experience limited capacity in these competencies, documented consequences include inadequate self-care, increased hospitalization rates, and higher overall healthcare costs. The reviewed literature emphasizes that developing these competencies does not rely solely on individuals, but requires healthcare organizations to actively reduce informational demands. Within this theoretical framework, organizational health literacy represents an institution’s strategic capacity, leadership framework, and policy commitment to foster an accessible environment. Health-literate organizations embody the practical operationalization of this capacity, translating high-level principles into governance, communication, and service delivery actions that systematically dismantle health literacy barriers for patients, families, and surrounding communities.

To capture how healthcare institutions operationalize these principles, the authors conducted an integrative review following an established six-stage methodology encompassing research question definition, eligibility determination, literature categorization, study appraisal, data interpretation, and thematic synthesis. Guided by an extended Population, Interest, and Context framework, the investigation examined planned or implemented initiatives across hospitals, primary care organizations, and community healthcare networks without geographic or temporal limits. A literature search conducted in June 2024 across eight bibliographic databases—MEDLINE via PubMed, Web of Science, Embase, Scopus, CINAHL, Cochrane Library, SciELO, and LILACS via the Virtual Health Library—initially captured 1,049 citations. Using the Rayyan screening platform, two independent investigators reviewed titles, abstracts, and full texts, resolving disagreements through structured deliberation and third-party adjudication. Thirty-two candidate publications were excluded during final full-text screening, including eight papers that were inaccessible through the CAPES Portal institutional subscription, ultimately yielding a finalized sample of twenty-two empirical studies for detailed data extraction.

The final corpus of twenty-two studies spanned publication years from 2014 through 2022, displaying a marked acceleration in research output during the latter half of the period. One study appeared in 2014, two in 2017, five in 2019, five in 2020, four in 2021, and five in 2022. The methodological approaches employed across these investigations were varied, with eight relying on qualitative or quantitative designs, six utilizing mixed-methods frameworks, four executing implementation studies, four presenting case studies, and others conducting interventions, quality improvement plans, longitudinal analyses, institutional evaluations, or pilot co-design projects. Geographic distribution exhibited an intense regional concentration, with six investigations conducted in the United States, four in Denmark, three in Germany, three in Australia, two in Switzerland, and one each in Mexico, Italy, Saudi Arabia, and an Ireland-Netherlands initiative. The study samples frequently engaged both healthcare professionals and patient populations, while a smaller subset recruited administrative personnel and executive managers across acute hospital facilities and ambulatory healthcare settings.

Qualitative synthesis across the analyzed literature identified four recurring thematic axes of institutional action, led by initial diagnostic assessment and the simplification of organizational communication. Most included studies commenced intervention planning by executing structured diagnostic self-assessments to detect existing gaps, establish baseline institutional capabilities, and evaluate how clinical staff and service users perceived health literacy needs. Investigators widely utilized established measurement instruments, including the Health Literate Health Care Organization 10-item questionnaire, the Organisational Health Literacy Responsiveness tool, hospital-specific standards such as the SAT-OHL-Hos, primary care adaptations, and the AHRQ Universal Precautions Toolkit. Building upon these baseline assessments, institutions pursued the second thematic axis by redesigning educational materials and interpersonal communication pathways. Healthcare organizations integrated textual simplification tools, plain-language formatting, audiovisual media, and restructured clinical navigation protocols. These adjustments aimed to minimize cognitive demands on patients, ensuring that written instructions, clinical signage, and institutional care pathways were understandable, navigable, and actionable for service users navigating complex clinical environments.

The remaining two thematic axes centered on internal workforce capacity building and the external engagement of community members through participatory co-design. Under the workforce development axis, healthcare institutions established structured training initiatives targeting clinical professionals, managerial leaders, and administrative support personnel. These educational interventions sought to cultivate interpersonal communication proficiencies, including teach-back verification techniques, while fostering organizational awareness of systemic health literacy barriers. Simultaneously, the fourth axis mobilized service users, patients, and local community groups through collaborative co-design methodologies. By incorporating participatory instruments and shared decision-making platforms, healthcare organizations engaged end-users to identify local care priorities and co-produce responsive institutional interventions. The authors observed that these four axes operated not as isolated administrative tasks, but as interdependent elements of a broader organizational change strategy. Combining pre-implementation diagnostic mapping with targeted staff instruction, material simplification, and community co-creation allowed healthcare facilities to foster responsive organizational environments capable of addressing diverse health literacy demands.

When mapped against the ten attributes of a health-literate organization formulated by Brach and colleagues, the reviewed studies demonstrated widespread alignment but pronounced operational unevenness. While all ten attributes were documented across the aggregate research, no single study fulfilled all ten simultaneously, and no attribute appeared universally across all twenty-two publications. The most frequently operationalized attributes were interpersonal communication strategies confirming patient comprehension at all contact points and mechanisms providing navigation assistance, each identified in seventeen studies, or seventy-seven percent. Additionally, fifteen publications, or sixty-eight percent, documented leadership that incorporated health literacy into institutional mission and operations. Conversely, other organizational attributes received far less empirical attention. Workforce preparation and monitoring appeared in only eight studies, while explicit communication regarding healthcare costs and insurance coverage, along with structured protocols for high-risk situations like medication management and care transitions, were documented in only two studies each, representing nine percent of the literature.

Evaluating the studies through the organizational barriers and facilitators framework developed by Farmanova and colleagues highlighted operational bottlenecks that impede institutional progress. Insufficient leadership buy-in and lack of resources emerged as the most pervasive obstacles, each documented in eleven studies, or fifty percent of the reviewed literature. Time constraints constituted the next most prevalent challenge, reported across nine publications, or 40.9 percent of the sample, frequently constraining the execution of staff training and material redesign. Six studies highlighted the absence of institutional policies and protocols, which undermined the long-term sustainability of implemented practices. Less frequently reported hurdles included ambiguous staff responsibilities and complex evaluation tools in three studies each, and the perception that becoming health-literate lacked organizational advantage in two studies. Nevertheless, specific interventions, such as those employing participatory workshops or collaborative co-design, demonstrated that systematic self-assessment and stakeholder engagement could effectively mitigate leadership hesitation and bolster staff confidence across participating healthcare services.

From an implementation science perspective, the authors analyzed these empirical findings through the Consolidated Framework for Implementation Research, mapping identified barriers to domains such as inner setting characteristics, individual attributes, and implementation processes. This analytical framework reinforces that establishing a health-literate organization requires systemic transformation rather than isolated technical adjustments, necessitating alignment between organizational readiness, administrative culture, and ongoing evaluation. Furthermore, while participatory co-design has gained prominence as an implementation strategy, the authors emphasized critical distinctions regarding its verified effectiveness. Although co-design initiatives demonstrated feasibility, stakeholder acceptability, and contextual relevance in reviewed studies, existing investigations lack controlled comparative designs. Consequently, the available literature does not substantiate whether co-designed interventions deliver superior measurable clinical outcomes, equity enhancements, or long-term operational sustainability compared to traditional professionally led approaches. Future research requires longitudinal trials, validated outcome metrics, and multi-level assessments spanning clinical parameters, patient experiences, and organizational capacities to determine the added value of collaborative design models across diverse healthcare systems.

The review concluded with an examination of methodological limitations and notable geographic disparities that current organizational health literacy literature must resolve. Methodologically, the review did not execute formal risk-of-bias assessments or quality appraisals, nor did it compute statistical inter-rater agreement coefficients like Cohen’s kappa during dual screening. Furthermore, the exclusion of paywalled literature inaccessible via institutional portal subscriptions, including eight candidate papers, presents potential selection bias alongside high heterogeneity in study designs. Geographically, the complete absence of studies from South America underscores a pronounced global imbalance, potentially driven by linguistic variations, regional indexing differences, publication practices, or uneven research funding distribution. Because evidence derived primarily from European and North American systems cannot be uncritically generalized to resource-constrained or culturally diverse environments, the authors urge future investigators to develop context-sensitive frameworks in underrepresented regions. Healthcare organizations pursuing health literacy must move beyond piecemeal communication edits toward institutionalized policies, protected administrative resources, committed leadership, and continuous evaluation across all operational levels.

Subject of Research: Institutional strategies and barriers in developing organizational health literacy

Article Title: An integrative review on the development of health literate organizations

Article References: Ferreira, F. V., Brasil, V. V., Moraes, K. L., & de Carvalho Sampaio, H. A. (2026). An integrative review on the development of health literate organizations. Discover Public Health, 23(1), Article 1713. https://doi.org/10.1186/s12982-026-03132-1

Image Credits: AI Generated

DOI: 10.1186/s12982-026-03132-1

Keywords: organizational health literacy, health literate organizations, integrative review, healthcare communication, implementation science, patient engagement, co-design, health systems, integrative, review, development, health