The University of Sydney Page 1
Working with TAFE
and adults with
lower literacy
Healthdirect Australia’s Information Partner Forum
Friday 11th November, 2016
Presented by
Danielle Muscat Faculty of Medicine, School of Public Health
@Dmuscat92
The University of Sydney Page 2
Research Team Project Linkage Partners
Danielle Muscat
Suzanne Morony
Don Nutbeam
Heather Shepherd
Andrew Hayen
Sian Smith
Haryana Dhillon
Lyndal Trevena
Karen Luxford
Kirsten McCaffery
University of Sydney
TAFE Social Inclusion and
Vocational Access Unit
NSW Clinical Excellence
Commission
NSW Health
National Prescribing Service
University of NSW
University of Southampton
World Education Boston, US
The University of Sydney Page 3
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 4
‘Living Literacy’ Research Program
Program designed to:
1. Increase health literacy & shared decision-making and
2. Improve language, literacy and numeracy skills
…for adults attending basic adult education.
– Native English speakers (including those receiving
unemployment benefits)
– (Recent) migrants with poor English language skills
The University of Sydney Page 5
Program Overview
UK program adapted by adult education experts at
TAFE to develop a pilot Australian version (2011-12)
18 week program 2 x 3 hours sessions per week
Following pilot, program amended and reviewed by
NSW Health, NSW CEC, NPS and University of Sydney
The University of Sydney Page 6
Course content
BEING HEALTHY
Teacher manual 1
STAYING HEALTHY
Teacher manual 2
1.1 Taking temperature* 2.1 Getting involved
1.2 Checking medicine labels* 2.2 Food groups
1.3 Prescriptions 2.3 Food labels *
1.4 Dosage and timing 2.4 Nutritional information*
1.5 Health workers 2.5 Food temperature safety
1.6 Telling your doctor what is wrong* 2.6 Food date safety
1.7 Talking to your doctor* 2.7 What is a serve?*
1.8 Answering your doctor’s questions* 2.8 Budgeting
1.9 Immunisation and health screening 2.9 Understanding a diet
1.10 Asking questions* 2.10 Drinking enough fluids
1.11 Shared decision-making* 2.11 Heart Rate and Pulse
1.12 Completing medical forms 2.12 Being Active
1.13 Emergency services 2.13 Watch First Aid demonstrations
1.14 Advice from pharmacist 2.14 Follow written instructions
1.15 Saving lives 2.15 Talking on the telephone
1.16 Follow emergency instructions Revision / Goal setting
The University of Sydney Page 7
The role of HealthDirect
The University of Sydney Page 8
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 9
What is shared decision-making?
“...a partnership between professional and patient, in which each
contributes equally to decisions about treatment or care.”
(Tattersall & Butow, 2005)
The University of Sydney Page 10
Shared decision-makingInvolvement of
doctor and patient in all phases of decision-making
Information exchange in both directions and by
both parties
Consideration of treatment options (including risks and benefits)
Agreement on the treatment to implement
• Now considered a marker of
high-quality healthcare
• Endorsed by national and
international quality standards
The University of Sydney Page 11
Shared decision making and health literacy
– Shared decision making skills:
– are an important aspect of health literacy
– allow consumers/patients to have greater
autonomy and control over healthcare decisions.
Functional health literacy
Communicative health literacy
Critical health literacy
The University of Sydney Page 12
Shared decision making program overview
• Aimed to develop learners’ self-efficacy and understanding of:
(a) the right to participate in healthcare decision-making
(b) shared decision-making concepts and terminology
(c) risk and benefit information
(d) values and preferences in SDM
(d) tools to facilitate shared decision making (AskShareKnow)
http://www.askshareknow.com.au/
The University of Sydney Page 13
Shared decision making program overview
The University of Sydney Page 14
Shared decision making program overview
The University of Sydney Page 15
Shared decision making program overview
The University of Sydney Page 16
Shared decision making program overview
The University of Sydney Page 17
Cluster-randomised controlled trial design
23 NSW adult education centres
ACSF Level 2 Literacy Classes
Standard Language Literacy and
Numeracy program
(15 classes)
Pre-assessment
Immediate post-assessment*
2 month qualitative follow-up
New health literacy program
including SDM
(14 classes)
Professor Kirsten McCaffery
ARC Linkage Grant (CIA: 130100480)
n=308
* Quantitative analyses adjusting for clustering
6 month follow-up*
The University of Sydney Page 18
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 19
Participants
Demographic information and baseline health literacy
Overall Health literacy Standard LLN
N M (SD) or % N M (SD) or % N M (SD) or %
Demographic information
Age
Mean (SD) 303 46.3 (14.8) 166 44.9 (14.0) 137 48.0 (15.5)
Gender
Female 303 72% 165 69% 138 77%
Region (metropolitan/regional)
Metropolitan 308 65% 167 67% 141 63%
Language spoken at home
English 278 40% 147 33% 131 47%
Longstanding illness/disability
Yes 289 65% 161 70% 128 9%
The University of Sydney Page 20
Participant Health Literacy: Newest Vital Sign
− 79% of participants < 3
questions correct
Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt
DA, Pignone MP, Mockbee J, Hale FA. Quick
assessment of literacy in primary care: the newest
vital sign. Ann Fam Med. 2005;3:514–22.
1. If you eat the entire container,
how many calories will you eat?
5. Pretend that you are allergic to
the following substances: penicillin,
peanuts, latex gloves, and bee
stings.
Is it safe for you to eat this ice
cream?
The University of Sydney Page 21
Participant Health Literacy: Single Item Literacy Screener
– “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”
– 80% of participants = sometimes, often, always
Morris NS, MacLean CD, Chew LD, Littenberg B. The Single Item Literacy Screener: evaluation of a brief instrument to identify limited
reading ability. BMC Fam Pract. 2006;7:21.
The University of Sydney Page 22
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 23
Outcomes: Decision-making preferences
– Decision-making preferences (Control Preferences Scale)
– ~ 78% of participants in both groups indicated a patient-involved decision making preference
Control Preferences Scale
The University of Sydney Page 24
Outcome: AskShareKnow Recall
Table 4
AskShareKnow question recall and use at immediate and 6-month follow-up (Intervention group only)
Recall Use
Immediate post
(N=109)
6 months post
(N=84)
6 months post
(N=73)
n (%) n (%) n (%)
Q1: What are my options? 84 (77) 29 (35) 26 (36)
Q2: What are the benefits and harms of
those options?
72 (66) 26 (31) 25 (34)
Q3: How likely are each of those benefits
and harms to happen to me?
65 (60) 26 (31) 20 (27)
All 3 questions 59 (54) 25 (30) 20 (27)
At least 1 question 85 (78) 29 (35) 26 (36)
Shepherd et al; 47% of participants (higher-literacy) were
able to recall all 3 questions 2 weeks after consultation.
The University of Sydney Page 25
Outcome: Perceived importance of SDM concepts
– “Think about the next time you will visit your doctor. If your doctor tells you about a new test or treatment, what are 3 questions you might ask…?”
The University of Sydney Page 26
Outcome: Perceived importance of SDM concepts
0
10
20
30
40
50
60
70
80
Options Benefits andharms
Likelihood Processquestions
Perc
ent
(%
)
Concept
Health Literacy Group
Standard LLN group
*
*
*
*
* p<.001
“When is the date and where is
the place?”“Where can I make an
appointment?”
The University of Sydney Page 27
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 28
2-month qualitative follow-up methods
– Semi-structured interviews
Teachers (n=11)
Students (n=25)
– Aim: to explore the experience of teaching and learning about SDM as part of a health literacy program.
– The Framework Method was used for the management and analysis of qualitative data.
Familiarisation
Identification of a thematic framework
Indexing ChartingMapping and interpretation
The University of Sydney Page 29
Promoting empowerment
– Teachers described students as a “passive” and “disempowered” group who do not participate in decisions about their health.
“... They’re not the sort of people that would ask questions…[they] would just accept what … the doctor says.” (Teacher)
– Program thought to “challenge” students’ established belief that professionals are solely responsible for decision-making
“… actually it’s been a real eye-opener. I find. It’s been really good.”
(Student)
The University of Sydney Page 30
A new perspective on decision-making
– From an educator’s perspective, the SDM program was successful in creating awareness among students of:
a) the right to participate in decision-making
b) question-asking as a means to participation
c) the availability of test/treatment options
"…and they realised that they had rights and that they can actually question what a doctor says, and can be assertive without being
rude…they can actually ask questions". (Teacher)
The University of Sydney Page 31
A new perspective on decision-making
– Participants felt more assertive and asked more questions
– “But I do feel a lot more comfortable. Because before… you used to feel as if, oh, you’d feel stupid thinking you’re saying something silly.”
“...it gave you options, like let you know we had options and how to approach [healthcare professionals] instead of just sitting back and being told...you’ve got a voice.”
“...the doctor say maybe you needed to op, op, operation....I ask maybe can more long, more long time. I, I, I don’t want to operation to my eyes...the doctor, the doctor say that you can wait and watch”
The University of Sydney Page 32
Teaching experience
– Two teachers initially skeptical that SDM content would be too difficult and/or unengaging for students. However, students “engaged really well”.
The University of Sydney Page 33
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 34
Student challenges
1. Language
“I was able to get them to understand. But it took a little bit of work. Basically
because of that language”. (Teacher)
“What are my opi- opi-
opions?” (P203)
“What the ‘weigh’? [Pause]
You mean weigh up, more
heavy?” (P204)
“Wait is when you have to
wait. And watch is when you
watch T.V.” (P201)
“I just had to keep saying good and bad… or problems and no problems, and that sort
of… language". (Teacher)
The University of Sydney Page 35
Student Challenges
2. Computational numerical risk tasks
– Comparing frequencies with different denominators such as 10 and 100 was noted as a particular challenge.
“They did have a little… bit of difficulty understanding the concept that, um… there… if the, if their chance was one out of 10, verses one out of 100…” (Teacher)
– More complex risk expressions (e.g. relative risk; small risks [<1%]) were deliberately excluded from our program.
The University of Sydney Page 36
Student Challenges
3. The concept of likelihood
– Understanding the concept of individual likelihood/risk was a challenge for learners across all campuses
“…the whole concept of probability, certain to very unlikely…the activities were excellent, but you could have spent much more time on it”. (Teacher)
The University of Sydney Page 37
Presentation outline
01 The ‘Living Literacy’ program: development and content
02 Shared decision-making as a component of health literacy .training
03 Participants: Who are we working with?
04 Shared decision-making results: Quantitative
05 Shared decision-making results: Qualitative
06 Student challenges
07 Conclusions
The University of Sydney Page 38
Conclusions
– May not be aware of their right to participate/ be involved in healthcare decision-making or that there are test and treatment options available to them.
– Perceive SDM concepts to be important once they do and most express desire to be involved
– With appropriate support, can gain skills and tools for participation
– There are challenges:
– Language
– Numerical risk tasks
– Concept of likelihood
Top Related