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Adequately responding to the needs of patients requires good communication skills of healthcare professionals within healthcare organizations. The PIKoG project (As made for us \u2013 Improving professional health literacy in hospitals) aimed at improving professional health literacy by implementing participatory health literacy training and supporting measures in a hospital setting. This study aimed to analyze processes supporting and hindering the implementation of the complex intervention.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>A mixed-methods study was conducted, including focus group interviews and a paper-pencil survey with healthcare professionals. Data was combined and analyzed using categories derived from the Medical Research Council\u2019s guidance on process evaluation: (1) Implementation, (2) Mechanisms of impact, and (3) Context. Interview data were analyzed using structured qualitative content analysis according to Kuckartz. Survey data were analyzed descriptively.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>One of three on-site, full-day health literacy training sessions was offered weekly. Supporting measures were implemented step by step over the course of a year. Both the training and the supporting measures were rated positively overall, but they could not be effectively integrated into daily routines. The COVID-19 pandemic as well as resource constraints adversely affected implementation by altering workflows, increasing stress levels and shifting priorities. The participatory approach and individual change agents fostered the implementation of the complex intervention. Nurses were reached the most, while physicians engaged least in the interventions. Adaptations during the implementation increased the use of the implemented measures and gave rise to ideas for future improvements.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>The study highlights the challenges involved in implementing a complex intervention supporting professional health literacy in an organization and stresses the importance of considering available resources, recruiting opinion leaders, and being responsive to the needs of different groups. While the participatory co-design development approach was found to be valuable, it does not guarantee successful organizational change in times when hospitals face multiple challenges. Subsequent studies should therefore focus on investigating the capacities of healthcare organizations for organization-wide improvement processes and identify how healthcare organizations can be innovative and patient-centered even in the presence of extremely difficult contextual conditions.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Trial registration<\/jats:title>\n            <jats:p>DRKS00019830, since 16th of April 2020.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1186\/s12913-025-12679-9","type":"journal-article","created":{"date-parts":[[2025,4,15]],"date-time":"2025-04-15T19:40:51Z","timestamp":1744746051000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Process evaluation of a co-design and implementation study to improve professional health literacy in a regional care hospital (PIKoG): a mixed-methods study"],"prefix":"10.1186","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4315-1816","authenticated-orcid":false,"given":"Johanna Sophie","family":"Lubasch","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4482-9119","authenticated-orcid":false,"given":"Hannah","family":"Nordmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6174-4909","authenticated-orcid":false,"given":"Mona","family":"Voigt-Barbarowicz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8272-0399","authenticated-orcid":false,"given":"Sonia","family":"Lippke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4663-1882","authenticated-orcid":false,"given":"Christina","family":"Derksen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4197-6048","authenticated-orcid":false,"given":"Anna Levke","family":"Br\u00fctt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8628-7166","authenticated-orcid":false,"given":"Lena","family":"Ansmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,4,15]]},"reference":[{"key":"12679_CR1","doi-asserted-by":"publisher","unstructured":"DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. 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