Communicating with patients with low health …...Communicating with patients with low health...
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Communicatingwithpatientswithlowhealthliteracyinprimarycare
GillRowlandsInstituteforHealthandSociety,NewcastleUniversityInstituteforPublicHealth,AarhusUniversity,Denmark
May2017
Thispresentation
• Whatishealthliteracy• Whyisitimportant:health,illness,lifestyle,costs• TheimportanceofGeneralPractice• Improvinghealthliteracy• BuildinghealthliteracyskillsinGeneralPractice• Discussion/nextsteps
Whatishealthliteracy?• Thepersonalcharacteristicsandsocialresourcesneededforindividualsandcommunitiestoaccess,understand,appraiseanduseinformationandservicestomakedecisionsabouthealth1
• Thehealthliteracyabilities,skillsandpracticesofagroup,whichcanbeusedasaresourceforgroupmemberstoseek,understandandusehealthinformationtohelpmanagetheirownhealthandmakeinformedchoices2
• Thedegreetowhichindividualsandgroupscanobtain,process,understand,evaluate,andactoninformationneededtomakepublichealthdecisionsthatbenefitthecommunity3
1.WorldHealthOrganization,RegionalOfficeforSouth-EastAsia.2015. 2.EdwardsMetal.2013.3.FreedmanDAetal.2009.
HLS-EUCONCEPTUALMODEL
Individual level Population level
Knowledge, skills,
motivation &
confidence
AccessUnderstand
Appraise
Apply
Cure and care
Health promotion
Disease prevention
Literacies
Resources, opportunities & structures
Life course
Health behavior
Health outcomes
Health service
use
Health costs
Health information
HLS
Participa-tion
Empowerment
Sustain-abilityEquity
Psyc
hoso
cial
, phy
sica
l and
mat
eria
l fac
tors
SorensenKetal:Healthliteracyandpublichealth:Asystematicreviewandintegrationofdefinitionsandmodels,BMCPublichealth,2012
Whyishealthliteracyimportant?
Healthliteracyandhealth
10,8 10,8 15,2 17,7 24,134,0 35,2
43,818,6 25,132,7
40,243,7
42,4 42,037,4
31,435,9
35,331,4
25,918,7 19,4 16,1
26,422,4
14,7 9,3 5,6 4,4 2,82,2 0,7 0,5 0,7 0,1
0
10
20
30
40
50
60
70
80
90
100
<15 15-20 20-25 25-30 30-35 35-40 40-45 45-50
Percentages of Categories of
Self-assessedHealth Status
Grouped Scores of Comprehensive Health Literacy Index
Very bad
Bad
Fair
Good
Very good
<15[N=102]|15-20[N=259]|20-25[N=600]|25-30[N=1348]|30-35[N=2185]|35-40[N=1531]|40-45[N=1048]|45-50[N=704]|TOTAL[N=7777]
HLS-EU Consortium, 2012.
HealthliteracyandillnessPeoplewithlowerhealthliteracy:• Dieearlier1
• Finditmoredifficulttotaketheirmedicationasinstructed2
• Aremorelikelytohaveoneormorelong-termconditions(LTCs)3
• LTCsmorelikelytobelimiting3
• Arelesslikelytoengagewithdiseasepreventione.g.cancerscreening,immunisation2
1.BostockSetal,2012.2.BerkmanNDetal,2011.3.HLS-EUConsortium,2012.
Associationbetweenadverselifestylechoicesandmortality
BuckDetal.2012
ChangeininequalitiesinmultiplelifestyleriskfactorsintheUK2003to2008
BuckDetal.2012
*p<0.05
ChangeinlifestylebyeducationandgenderinUK2003to2008
2003 2008 Relativechange PvalueMen
Oddsratio:noqualificationsvshighereducation
1.25 1.61 1.29 0.03
Relativeindexofinequality
1.25 1.66 1.34 0.05
Women
Oddsratio:noqualificationsvshighereducation
1.51 2.07 1.37 0.003
Relativeindexofinequality
1.56 2.26 1.44 0.006
BuckDetal.2012
CostoflowHealthLiteracytothehealthservice
“…atthehealthsystemlevel,theadditionalcostsoflimitedHealthLiteracyrangefrom3to5%ofthetotalhealthcarecost
peryear.”
IfthisistrueinAustraliatheseadditionalcostsin2014to2015were
A$3.6bn– £6.0bn
Imagereproducedwithkindpermissionfromwpclipart.com
EichlerKetal,2009.
Prevalence:derivinghealthliteracylevelsinEngland
Rowlandsetal.2015
Example:BowelCancerScreeningTestinstructionsNationalQualificationslevel:Literacylevel1/Numeracylevel1KeyStageSkillEquivalentAgesLiteracy11-14years,Numeracy11-14years
FiveKeyHealthAreas64MaterialsAnalysedandRated
NQFlevel
Keystageequivalent
AtthisLITERACYlevelanadultunderstands
Entrylevel1
5-7years Shorttextswithrepeatedlanguagepatternsonfamiliartopics
Entrylevel2
7-9years Shortstraightforwardtextsonfamiliartopicsandfromfamiliarsources
Entrylevel3
9-11years ShortstraightforwardtextsonfamiliartopicsaccuratelyandindependentlyInformationfromeverydaysources
Level1 11-14years
ShortstraightforwardtextsofvaryinglengthonavarietyoftopicsaccuratelyandIndependently
Level2 14-16years
ArangeoftextsofvaryingcomplexityaccuratelyandindependentlyInformationofvaryinglengthanddetail
Materiallevel
Population level
SkillsQualificationFrameworkLiteracy
NQFlevel
Keystageequivalent
AtthisNUMERACYlevelanadultunderstands
Entrylevel1
5-7years Numbersandsymbolsina simpleformat
Entrylevel2
7-9years Numbers,symbols,simplediagramsandchartsinasimpleformat
Entrylevel3
9-11years Numbers,symbols,diagramsandchartsusedfordifferentpurposesandindifferentways
Level1 11-14years
Straightforwardmathematicalinformation,can independentlyselectrelevantinformation
Level2 14-16years
Mathematicalinformationusedfordifferentpurposes, canindependentlyselectandcomparerelevantinformationfromavarietyofsources
Materiallevel
Population level
SkillsQualificationFrameworkNumeracy
Nationalandregionalpicture:%ofadultsaged16-65yearsforwhomhealthinformationistoocomplex
52
35
3538
40
41
4444
46
Nationalaverage43%
Text(literacy)componentofhealthmaterials
Nationalandregionalpicture:%ofadultsaged16-65yearsforwhomhealthinformationistoocomplex
66
55
54
55
59
60
6062
64
Nationalaverage61%
Text(literacy)ANDNumeracycomponentofhealthmaterials
Gender Age Ethnicity
Birthplace Firstlanguage Qualifications
Employmentstatus Jobgrade Income
HomeownerArea
deprivationlevel
Demographiccharacteristicsofthoseathighestriskofbeingbelowthehealthliteracythreshold
Male(literacy)Female
(numeracy)Aged45+ BME
BornoutsideoftheUK
Englishnotfirstlanguage
Belowexpectedby
age16
Unemployed Lowestjobgrade
Incomelessthan£10,000
Notahomeowner
Top5mostdeprivedareas
Notstatisticallysignificantwhenallfactorsconsideredtogether
Populationportraits:literacyandnumeracyLowerjobstatus:supervisory,routine,unemployed53%ofpopulation=18millionpeopleHealthmaterialtoocomplexfor74%ofthisgroup
Higherjobstatus:managerial,intermediate47%ofpopulation=16millionpeopleHealthmaterialtoocomplexfor24%ofthisgroup
WhyGeneralPracticeisimportantinhealthliteracy• Holisticcare• Primarycareledservice• Individualandfamilycare• Basedincommunities• Longitudinalcare
GPs
Australiansusinghealthservicesannually
Dentists Medicalspecialists
RACGPwebsiteaccessedMay2017
WhatdoGPsintrainingknowabouthealthliteracy?• Cross-sectionalstudy:onlinesurvey• 800GPtraineesinvitedbyemail• Datacollection:January– March2014• Instrument:48items;
• 7Knowledge• 11Attitudes• 13Skills
• Responserate:27%
GroeneORetal,2017(acceptedforpublication)
Knowledge%correctanswers
74.7overestimatenumeracy
17%overestimatereadingage
0102030405060708090100
Attitudes %positiveattitudes
0102030405060708090
100
Skills%goodorexcellent
0102030405060708090
• Familiaritywiththeconceptofhealthliteracythroughunder- orpost-graduatetrainingwasassociatedwith
• AsignificantlyhigherproportionofGPtraineesself-ratingtheirskillsasgoodorexcellent(p<0.001)
• Anincreasedproportionoftraineeswithskillsself-ratedasgoodorexcellent
Healthliteracyisabalancebetweentheskillsofthepatient/family/communityandtheenvironmentinwhichtheylive(healthsystems,educationsystems,socialcaresystemsetc.)
ParkerR,2009.
Healthliteracyinterventionswithinclinicalsettings• Systematicreview1
• 23single-strategyand27mixed-strategyfairorgood-qualitystudies.
• Moderateevidenceofimpact• Healthserviceuse• Improvedhealthoutcomes(principallyinDiabetes).
Berkmanetal2011
• Threestudiesinvolvedimprovingphysicianskills• Allshowedpositiveoutcomes
• Colorectalcancerscreening• Increasedpatientself-efficacyforweightloss• Improvedmedicationadherence
• Studiesshouldincludeexplorationoftheactivecomponentsofinterventions
HealthliteracytraininginGeneralPractice
Workshopaimsandobjectives• Toincreaseknowledgeofwhathealthliteracyisandwhyitisimportant;
• Toraiseawarenessofhowhavinglowhealthliteracyimpactsonindividuals’everydaylivesandtheservicesthatthesupportthem;
• Toincreaseawarenessofthetoolsandtechniquesthatcansupportpeoplewithlowhealthliteracyandpromotehealthliteracyinpractice;
• Toraiseawarenessoftheresourcesandinformationavailabletosupportyouinpromotinghealthliteracy.
Whoarepatientswithlowhealthliteracy?
• “Heartsink”;• Patientswhodonotattendappointments(DNA);
• Theoneswhodon’t“comply”;• Regulars.
BUTNOTSTUPID• “SpikyProfiles”;• ComplexStrategies.
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Howhasitimpactedonyourpractice?
Thinkofexamplesofwhenyoumayhaveencounteredorhavehadtotakeintoaccountlow
healthliteracyissueswithinyourrole.
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HealthLiteracycutsacrosskeydomains
• Patient–centredcare- E.g.informedconsent,shareddecisionmaking• PublicHealth/HealthInequalities- E.g.healthyeating,physicalactivitymessages
• TreatmentandAdherence- E.g.howtoexplainsymptomsandrisks,takingmedication
• PersonalandPublicInvolvement(PPI)- E.g.respondingtoservicereconfiguration
Imagereproducedwithkindpermissionfromwpclipart.com
Informationdesignprinciples• Short familiar words and short sentences• Short headings that stand out• Type as large as possible• Leave ‘white space’• Use bullets for lists• Be conversational• Use the ‘active voice’• Use non-justified text• Use bold lower case for emphasis• Pictures and graphs don’t necessarily help
Raynor DK, 2009.
SimplifyinginformationActivity1
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Fivetipsformakingiteasy
1. Teach-back
2. Chunkandcheck
3. Usepictures
4. Usesimplelanguage
5. Routinelyaskpeopleiftheywouldlikehelp
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UsingTeach-backActivity2
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Whatnext?Whatareyougoingtodoaftertoday– onethingyou
willchange?
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GPPop-upstudy:feasibilitystudy
• Whathavewedonesofar?• DevelopedahealthliteracytrainingcourseforGPsandpracticestaff
• Developasystemtogenerateautomatic‘pop-up’alertswhenthenotesofapatientatriskoflowhealthliteracyareaccessed
• Obtainedfundingforafeasibilitystudy
• Whatdowewanttodointhisstudy• Combinetheseintoanintervention• SeewhetherthishasanimpactonGPpractice– specificallyGP:patientcommunication– forpatientsseeingtheirGPorpracticenurseforLong-TermConditionreviews
• Likertscale(0to10)• 6patientsperparticipatingGPorpracticenursebeforeinterventionandadifferent6patientsafterwards
• OutcomeisaverageT2scoreminusT1score• Secondarymeasures
• patientratingofdifferentaspectsofGP/nursecommunication• Co-variates:SDH– age,gender,income,ethnicity,single-itemhealthliteracyscreeningquestion
• Post-interventionfocusgroupswithcliniciansandpatients• Gatherinformationtofurtherdeveloptheinterventionsoitcanbetestedinafuturedefinitiverandomised-controlledtrial
MRCcomplexinterventiondevelopmentcycle
MRCcomplexinterventiondevelopmentcycle
Communicatingwithpatientswithlowhealthliteracyinprimarycare:summary• Lowhealthliteracyisimportantbecauseit
• Isprevalent• Impactsonhealth,illness,healthservicecosts
• GPsarekeyinsupportingpatientswithlowerskills• TrainingimprovesGPknowledge,skillsandattitudes
• Weneedmoreproperlydesignedandevaluatedinterventions
• Wehavedevelopedonesuchintervention,andarestartingtheevaluationprocess
Discussion
• WhatrolesdoesGeneralPracticehaveinhealthliteracy?Canwehelpthrough
• Buildingourownskills?• Buildingstaffskills?• Supportingthedevelopmentofpatient,communityandpublichealthliteracy?
• Whatcanwedotomakeadifference?• Howcanwemeasurethedifferencewemake?
Thankyou!GillRowlands
InstituteforHealthandSociety,NewcastleUniversityInstituteforPublicHealth,AarhusUniversity,Denmark