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Kirsten McCaffery | Improving health literacy: what's the evidence?
 

Kirsten McCaffery | Improving health literacy: what's the evidence?

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Dr Kirsten McCaffery, Senior Research Fellow, School of Public Health, University of Sydney spoke to the HARC network in April 2010 to help us consider how to improve healthcare delivery for people ...

Dr Kirsten McCaffery, Senior Research Fellow, School of Public Health, University of Sydney spoke to the HARC network in April 2010 to help us consider how to improve healthcare delivery for people with low health literacy.

HARC stands for the Hospital Alliance for Research Collaboration. HARC is a collaborative network of researchers, health managers, clinicians and policy makers based in NSW, Australia managed by the Sax Institute.

HARC Forums bring members of the HARC network together to discuss the latest research and analysis about important issues facing our hospitals.

For more information visit saxinstitute.org.au.

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    Kirsten McCaffery | Improving health literacy: what's the evidence? Kirsten McCaffery | Improving health literacy: what's the evidence? Presentation Transcript

    • IMPROVING HEALTH LITERACY: What is the evidence ? Kirsten McCaffery PhD kirsten.mccaffery@sydney.edu.auSYDNEY MEDICAL SCHOOL Screening and Test Evaluation Program (STEP) Centre for Medical Psychology and Evidence-based Decision Making (CeMPED)
    • IMPROVING HEALTH LITERACY Substantial research linking low health literacy with poor health Intervention health literacy research is less well developed 3 systematic reviews of health literacy interventions but findings mixed (Pignone JGIM 2005, Coulter & Ellins BMJ 2007, Clement et al PEC 2009) However, there IS evidence to guide policy and practice now Evidence from low literacy and general population samples
    • IMPROVING HEALTH LITERACYTwo key areas for evidence-based action:1. To improve health communication2. To support patient involvement
    • IMPROVING HEALTH LITERACYTwo key areas for evidence-based action:1. To improve health communication2. To support patient involvement
    • IMPROVING HEALTH LITERACYThere is good quality evidence to support strategies to improve : a. Written health information – use plain language guides b. Prescription drug labels – use precise instructions c. Verbal communication – use ‘teach back’ method d. Risk communication
    • IMPROVING HEALTH LITERACYThere is good quality evidence to support strategies to improve : a. Written health information – use plain language guides b. Prescription drug labels – use precise instructions c. Verbal communication – use ‘teach back’ method d. Risk communication
    • RISK COMMUNICATION Use natural frequencies 5 out of 100women will require additional treatment Gigerenzer et al 1995, Feldman-Stewart et al 2000, Fagerlin et al review 2007
    • RISK COMMUNICATION Of 100 women who have surgery ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●5 out of 100 womenwill require additional treatment Gigerenzer et al 1995, Feldman-Stewart et al 2000, Fagerlin et al review 2007
    • RISK COMMUNICATION Of 100 women who 20% less women will have surgery required additional treatment 5% of women will ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● NOT required additional ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● treatment ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●5 out of 100 womenwill require additional treatment Gigerenzer et al 1995, Feldman-Stewart et al 2000, Fagerlin et al review 2007
    • RISK COMMUNICATION Of 100 women who 20% less women will have surgery required additional treatment 5% of women will ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● NOT required additional ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● treatment ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● OR ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● 100 90 80 70 60 50 40 305 out of 100 women 20 10 0will require additional treatment Gigerenzer et al 1995, Feldman-Stewart et al 2000, Fagerlin et al review 2007
    • RISK COMMUNICATIONMedical risk training for low and high SES consumersWoloshin et al Annals Intern Med 2007 Education package to improve understanding of risk messages in the media and health statistics 2 RCTs among low and high SES consumers Medical risk primer vs general health booklet (control) Examined impact using knowledge test
    • RISK COMMUNICATIONImpact of the primer on understandingPatient group Control gp Risk Primer % Difference Significance ‘pass rate’ ‘pass rate’ (95% CIs) Pass ≥ 75 / 100 correct
    • RISK COMMUNICATIONImpact of the primer on understandingPatient group Control gp Risk Primer % Difference Significance ‘pass rate’ ‘pass rate’ (95% CIs)Low SES 26% 44% 18% p<0.01n= 221 (8-28%) Pass ≥ 75 / 100 correct
    • RISK COMMUNICATIONImpact of the primer on understandingPatient group Control gp Risk Primer % Difference Significance ‘pass rate’ ‘pass rate’ (95% CIs)Low SES 26% 44% 18% p<0.01n= 221 (8-28%)High SES 56% 74% 18% p<0.001n=334 (5-31%) Pass ≥ 75 / 100 correct
    • RISK COMMUNICATIONImpact of the primer on understandingPatient group Control gp Risk Primer % Difference Significance ‘pass rate’ ‘pass rate’ (95% CIs)Low SES 26% 44% 18% p<0.01n= 221 (8-28%)High SES 56% 74% 18% p<0.001n=334 (5-31%) Pass ≥ 75 / 100 correct
    • RISK COMMUNICATIONImpact of the primer on understandingPatient group Control gp Risk Primer % Difference Significance ‘pass rate’ ‘pass rate’ (95% CIs)Low SES 26% 44% 18% p<0.01n= 221 (8-28%)High SES 56% 74% 18% p<0.001n=334 (5-31%) Pass ≥ 75 / 100 correct Interest in medical statistics significantly increased in both groups Low SES = + 8 points (p=0.004) High SES = + 6 points (p=0.004)
    • IMPROVING HEALTH LITERACYTwo key areas for evidence based action:1. To improve health communication2. To support patient involvement • Broader definition of health literacy (asset) • Fits within model of Patient Centred Care and Shared Decision Making • Highlighted in National Health Hospital Reform Commission Report
    • IMPROVING HEALTH LITERACYEffective tools are available to support patient involvement and engagement in healthcare.2 main types: a. Patient Decision Aids b. Intervention to promote question asking (Question Prompt Lists (QPL) / patient coaching)
    • PATIENT DECISION AIDSWhat are patient decision aids? Information designed to help patients make an informed choice consistent with their preferences Booklet / video/ audio / web-based form Include evidence based information on options and outcomes Exercises to help patients clarify values
    • PATIENT DECISION AIDSPatient decision aids are very effective.Systematic review of 55 DA trials showed DAs:  Improve patient knowledge and understanding of risks and benefits  Increase realistic expectations of outcomes  Reduce uncertainty in decision making  Increase consistency between patients’ values and choice  Without increasing in patient anxiety
    • PATIENT DECISION AIDSIn some circumstances decision aids: Increase adherence Reduce unnecessary testing/ medical procedures Increase quality of life (O’Connor et al. Cochrane Review 2009)
    • QUESTION ASKING INTERVENTIONSWhat are Question Asking Interventions?Interventions to encourage patients to ask questions and directthe content of the consultation towards their needs andconcerns
    • QUESTION ASKING INTERVENTIONSWhat are Question Asking Interventions?Interventions to encourage patients to ask questions and directthe content of the consultation towards their needs andconcerns
    • QUESTION ASKING INTERVENTIONSKinnersley et al Cochrane review (2007)Question Asking Interventions Increased question asking Increased patient satisfaction (small increase) No increase in anxiety No increase in consultation lengthIn some studies QPLs Enabled participants to raise more ‘sensitive’ issues during the consultation (Clayton et al 2007)
    • INVOLVING LOW LITERACY PATIENTS Excellent evidence that DAs and QPLs support patient involvement and improve health decisions But very little research with low literacy and low education groups These groups are least involved in healthcare, most difficult to get to participate, form large % patient population However, we recently completed a RCT ‘lower literacy’ DA among adults with low education
    • FOBT SCREENING LOWER LITERACY DAMcCaffery et al NHMRC project grant, Sian Smith et al PhD. [Full project team: KMcCaffery, S Smith, L Trevena, A Barratt, J Simpson, D Nutbeam]
    • Trial design Community sample: adults 55-64 years n= 585 Lower education levels* Control: Decision Aid Govt screening booklet FOBT screening kit FOBT screening kit Knowledge Informed choice 2 weeks* No formal educ Involvement in decision makingqualifications, intermediate Psychosocial outcomesschool certificate, technical/trade qualification Screening behaviour 3 months (FOBT completion)
    • Low education/ literacy DA trial: results DA increased adequate knowledge by 38% (56% DAs vs control 18%) DA increased in informed choice by 22% (adequate knowledge, choice consistent with attitudes 34% DA vs 12% control) DA increased preferences for shared decision making (P=0.04) No difference in uncertainty in decision making and anxiety - low in both groups Acceptability of DA high (>90%) (Smith et al BMJ under review)
    • CONCLUSIONS Possible to design DAs to help low education / low health literacy consumers make informed choices Even though this involves communicating complicated medical information More research supporting patient involvement in low health literacy groups Although field is rapidly developing, evidence available to support action now:  Written health communication  Prescription drug labels  Verbal communication  Risk communication  Supporting patient involvement
    • Goal for Public Health & MedicinePatient skills Evidence + +Health system CLOSE THE GAP Practice Particular thanks to: Sian Smith
    • EFFECTIVE HEALTH COMMUNICATIONPrescription drug labels US study of 400 native English speaking primary care patients, lower SES.  50% misunderstood commonly used prescription labels (Davies et al Archives 2006) Understanding improved 53% - 89% correct, if instructions are precise and explicit (Davies et al JGIM 2008) E.g.  ‘Take at 6am and 6pm’ or  ‘take 1 with breakfast and 1 with supper’ NOT ‘take twice daily’ or ‘take every 12 hours’
    • CONSUMERS / PATIENT NEEDSSo why does SDM matter?: Consumers want more health information and involvement in health decisions European survey of over 8,000 consumers (Coulter BJC 2003)  Over 70% of those surveyed wanted ‘shared decision making’ In Australia our own work has reported similar high levels of interest in SDM in breast treatment and testing decisions (Davey, Barratt et al 2002)
    • IMPROVING HEALTH LITERACYThere is good quality evidence to support strategies to improve : a. Written health information – use plain language guides b. Prescription drug labels – use precise instructions c. Verbal communication – use ‘teach back’ method d. Risk communication – natural frequencies
    • RISK COMMUNICATION Key topics Risk of what? How big is the risk? Does the risk information reasonably apply to you? How does this compare to other risks? Things you should do to better understand risk…..
    • Trials of cancer screening decision aids (DAs) Screening Countr Study population and Description Primary % Adeq % Screened % Informed choice context and y recruitment outcomes knowldge DA vs Control DA vs Control author(s) measured DA vs (difference) (difference) Control (diff)FOBT screening Aus Men and women aged DA tailored for adults with lower Knowledge 56 vs 19 59 vs 75 34 vs 12for bowel cancer between 55-64 years with education and literacy with Informed (38) ** (-16) ** (22) **(Smith, et al. lower education levels government information booklet choice2009) Involvement in decisionMammog Aus Women aged 70 years or DA with usual care information Knowledge 77 vs 57 6 vs 7 74 vs 49screening for older , regularly (leaflet developed for breast Informed (20) ** (-1) (25)**breast cancer participated in cancer screening service). choice mammography screening.(Mathieu, et al. Participation2007) in screeningFOBT screening Aus Adults aged between 45- DA against standard government Knowledge 21 vs 6 5 vs 7 10 vs 2for bowel cancer 74 yrs at GP practice information booklet. Informed (15)** (-2) (8)**(Trevena et al choice2008)FOBT and US Adults aged 65 years and 2 DAs (one relative risk info and Screening 71 vs 54 Intentions N/Aflexible sig for older visiting their primary the other with absolute risk infor) interest and (17)** Control: 59;CRC (Wolf et al care doctor against control message. intentions2000) Rel risk DA: 67; Abs risk DA: 63FOBT, flex sig, US Adults aged 50 years and Compared DA based on multi- Decisional N/A 49 vs 52 N/Abarium en, older, visiting their primarycriteria decision-making theory conflict (-3)colonos for care doctor with a simple educational ScreeningCRC (Dolan et al intervention. intentions and2002) behaviourFOBT and US Adults aged between 50- Educational video about bowel Screening N/A 37 vs 23 N/AFleixble sig 75 years from primary screening with video on behaviour (14)**(Pignone et al care. automobile safety (control group).2000)