Qualitative insights into the experience of teaching shared decision making within adult education health literacy programmes for lower-literacy learners

Is there a need for change in cancer survivorship care? A qualitative exploration of survivor experiences and needs at the Sydney Cancer Survivorship Centre Clinic

PURPOSE

Effective cancer survivorship care is contingent on a comprehensive understanding and management of the dynamic needs of cancer survivors. The Sydney Cancer Survivorship Centre (SCSC) clinic established a holistic, multidisciplinary model of survivorship care. We aimed to explore survivors' experiences and perceptions of the clinic, and to identify their unmet needs.

METHODS

Semi-structured focus groups (FGs) involving participants recruited from the SCSC clinic were conducted by an experienced facilitator and observer using a guide covering: survivor perceptions of first SCSC clinic visit, services accessed, ongoing unmet needs, and how needs changed over time. FGs were audio-recorded and transcribed. Interpretive description using a Framework approach was undertaken and participant characteristics summarised descriptively.

RESULTS

Eight FGs were conducted involving a total of 26 participants (mean age: 60), most were female (n = 20), born in Australia (n = 14), and with breast cancer diagnoses (n = 16). Four overarching themes were identified: (i) perceptions of the SCSC clinic; (ii) patient-centred care; (iii) adjustment to illness; and (iv) external supports and resources. Participants valued the centralisation of multidisciplinary survivorship care at the SCSC clinic, which helped their recovery. Mitigating ongoing treatment sequelae, reassurance of good-health, normalisation of survivorship experiences, and handling caregiver stress represent some needs identified.

CONCLUSIONS

The SCSC clinic offers holistic, specialised care and reassurance to cancer survivors. Adjustment to the survivorship journey, inter-survivor shared experiences, and management of physical treatment sequelae were perceived as important in their recovery. Managing survivor needs is integral to improving long-term survivorship care.

Finding Your Way - A shared decision making resource developed by and for Aboriginal people in Australia: Perceived acceptability, usability, and feasibility

BACKGROUND

Finding Your Way is a culturally adapted shared decision making (SDM) resource for Aboriginal (First Nations) people of Australia. It integrates the Eight Ways of Aboriginal Learning (8 Ways) and was created by Aboriginal health workers and community members in New South Wales (NSW), Australia.

OBJECTIVE

To explore the perceived acceptability, usability, and feasibility of Finding Your Way as a SDM resource for Aboriginal people making health and wellbeing decisions.

METHODS

The web-based resources were disseminated using social media, professional networks, publications, and the 'Koori grapevine'. Thirteen 'champions' also promoted the resources. An online questionnaire was available on the website for three months. Framework analysis determined early indications of its acceptability, usability, and feasibility. Web and social media analytics were also analysed. Partnership with and leadership by Aboriginal people was integrated at all phases of the project.

RESULTS

The main landing page was accessed 5219 times by 4259 users. 132 users completed the questionnaire. The non-linear and visual aspects of the resources 'speak to mob' and identified with Aboriginal culture. The inclusion of social and emotional well-being, and the holistic approach were well received by the small number of users who opted to provide feedback. They suggested that non-digital formats and guidance on the resources are required to support use in clinical practice.

CONCLUSION

The 8 Ways enabled the development of a culturally safe SDM resource for Aboriginal people, which was well received by users who took the time to provide feedback after a brief dissemination process. Additional accessible formats, practice guides and training are required to support uptake in clinical practice.

PRACTICE IMPLICATIONS

Finding Your Way could be used to help improve experiences, health literacy, decision making quality and outcomes of healthcare for Aboriginal Australians.

Determining the Development Strategy and Suited Adoption Paths for the Core Competence of Shared Decision-Making Tasks through the SAA-NRM Approach

Shared decision making (SDM) is an interactive process that involves patients and their healthcare professionals reaching joint decisions about medical care through negotiation. As the initiators of medical decision-making in daily routine, physicians should be aware of and concerned about the SDM process. Thus, professional competency development for SDM has become increasingly critical for physicians' training. Therefore, this study investigates the professional competency and the important competency development aspects/criteria of SDM tasks through expert interviews and literature research. The study adopts the SAA (satisfaction-attention analysis) method to assess the status of competency development aspects/criteria and determine the NRM (network relation map) based on the DEMATEL (decision-making trial and evaluation laboratory) technique. The results demonstrate that the CE (concept and evaluation) aspect is the dominant aspect, and the CR (communication and relationship) aspect is the aspect being dominated. The CE aspect influences the aspects of SP (skill and practice), JM (joint information and decision making) and CR, and the SP aspect affects the aspects of JM and CR. Then, the JM aspect affects the CR aspect. The study also suggests suitable adoption paths of competency development for SDM tasks using the NRM approach. It provides recommendations and strategic directions for SDM competency development and sustainable training programs.

Exploring Family Caregiver Communication Difficulties and Caregiver Quality of Life and Anxiety

BACKGROUND

When family caregivers are involved in patient care, both patients and caregivers experience better clinical outcomes. However, caregivers experience communication difficulties as they navigate a complex health care system and interact with health care providers. Research indicates that caregivers experience a communication burden that can result in topic avoidance and distress; however, little is known about how burden stemming from communication difficulties with health care providers relates to caregiving outcomes.

OBJECTIVES

To investigate how family caregiver communication difficulties with health care providers influence caregiver quality of life and anxiety.

METHODS

Data were collected in a cross-sectional online survey of 220 caregivers with communication difficulties resulting from caregiver avoidance of caregiving-related topics, inadequate reading and question-asking health literacy, and low communication self-efficacy.

RESULTS

Caregiver outcomes were not affected by reading health literacy level but did differ based on question-asking health literacy level. Adequate question-asking health literacy was associated with lower anxiety and a higher quality of life. Caregivers who avoided discussing caregiving topics reported higher anxiety and lower quality of life and caregivers with increased communication self-efficacy reported a higher quality of life.

CONCLUSION

Involvement of family caregivers in care is likely to require tailored approaches that address caregiver communication and health literacy skills. Findings from this study suggest that hospice and palliative care providers should identify and provide support for caregiver communication difficulties in order to positively influence caregiver quality of life and anxiety.

Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff

Background

There is limited evidence on how to implement shared decision-making (SDM) interventions in routine practice. We conducted a qualitative study, embedded within a 2 × 2 factorial cluster randomized controlled trial, to assess the acceptability and feasibility of two interventions for facilitating SDM about contraceptive methods in primary care and family planning clinics. The two SDM interventions comprised a patient-targeted intervention (video and prompt card) and a provider-targeted intervention (encounter decision aids and training).

Methods

Participants were clinical and administrative staff aged 18 years or older who worked in one of the 12 clinics in the intervention arm, had email access, and consented to being audio-recorded. Semi-structured telephone interviews were conducted upon completion of the trial. Audio recordings were transcribed verbatim. Data collection and thematic analysis were informed by the 14 domains of the Theoretical Domains Framework, which are relevant to the successful implementation of provider behaviour change interventions.

Results

Interviews (n = 29) indicated that the interventions were not systematically implemented in the majority of clinics. Participants felt the interventions were aligned with their role and they had confidence in their skills to use the decision aids. However, the novelty of the interventions, especially a need to modify workflows and change behavior to use them with patients, were implementation challenges. The interventions were not deeply embedded in clinic routines and their use was threatened by lack of understanding of their purpose and effect, and staff absence or turnover. Participants from clinics that had an enthusiastic study champion or team-based organizational culture found these social supports had a positive role in implementing the interventions.

Conclusions

Variation in capabilities and motivation among clinical and administrative staff, coupled with inconsistent use of the interventions in routine workflow contributed to suboptimal implementation of the interventions. Future trials may benefit by using implementation strategies that embed SDM in the organizational culture of clinical settings.

Evaluation of an Australian Health Literacy Program Delivered in Adult Education Settings

Background:

Adult education targeting health literacy (HL) may bring added value in the form of improved health.

Objective:

This study evaluated the effects of a HL program as part of an adult education curriculum for adults with low literacy and numeracy.

Methods:

This was a partial-cluster randomized controlled trial among 308 adults enrolled in basic education programs in Australia. Of the 308 participants, 141 (46%) were randomized to either the standard program (language, literacy, and numeracy [LLN]), or the HL intervention (LLN with embedded health content); the remainder (n = 167) were allocated to standard intervention programs by the education provider at the class level. The main outcomes were functional HL, self-reported confidence, patient activation, generic HL (ie, HLQ, health knowledge, and self-reported health behavior). Data were collected at baseline, immediately after, and at 6 months post-intervention.

Key Results:

Of the 308 participants, 71% had limited literacy and 60% spoke a language other than English at home. Both interventions benefited participants, with improvements from baseline to immediate follow up on individual-level functional HL (e.g., reading a thermometer; HL group 18.4% vs. standard group 7.2%; p = .001), confidence (HL group 0.34 vs. standard group 0.06; p = .014) and health literacy questionnaire (HLQ) subscales. At 6 months, improvements in confidence (p < .001) and some HLQ measures were retained. A consistent pattern of increased improvement in the HL program was observed compared to the standard program, although only some measures reached statistical significance: reading a food label (HL group 6.03/10 correct vs. standard group 5.49/10 correct; p = .022); confidence (p = .008); ability to actively manage health (HLQ) (p = .017), and health knowledge at 6 months (HL group 68% vs. standard group 60% correct, p = .052). HL participants reported being more likely to share course information and rated the program more useful to understand their health.

Conclusions:

Improving language, literacy, and numeracy generally has potential public health benefits that are retained at 6 months. Integrating health content adds further value to adult basic learning, is feasible, and potentially scalable. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S42–S57.]

Plain Language Summary:

We compared the effect of an adult education-based health literacy (HL) program versus a standard language, literacy, and numeracy program on students' HL skills and psychosocial outcomes. Although students in both trial arms improved their skills, students in the HL program had better outcomes with higher HL, greater confidence, and higher health knowledge scores at 6 months.

Skills for Shared Decision-Making: Evaluation of a Health Literacy Program for Consumers with Lower Literacy Levels

Background:

Shared decision-making (SDM) has been found to be significantly and positively associated with improved patient outcomes. For an SDM process to occur, patients require functional, communicative, and critical health literacy (HL) skills.

Objective:

This study aimed to evaluate the impact of a program to improve health literacy skills for SDM in adults with lower literacy.

Methods:

An HL program including an SDM component (HL + SDM) and teaching of the three “AskShareKnow” questions was delivered in adult basic education settings in New South Wales, Australia. The program was evaluated using a partially cluster-randomized controlled trial comparing it to standard language, literacy, and numeracy (LLN) training. We measured the effect of these programs on (1) HL skills for SDM (conceptual knowledge, graphical literacy, health numeracy), (2) types of questions considered important for health decision-making, (3) preferences for control in decision-making, and (4) decisional conflict. We also measured AskShareKnow question recall, use, and evaluation in HL + SDM participants.

Key Results:

There were 308 participants from 28 classes enrolled in the study. Most participants had limited functional HL (71%) and spoke a language other than English at home (60%). In the primary analysis, the HL + SDM program compared with the standard LLN program significantly increased conceptual knowledge (19.1% difference between groups in students achieving the competence threshold; p = .018) and health numeracy (10.9% difference; p = .032), but not graphical literacy (5.8% difference; p = .896). HL + SDM participants were significantly more likely to consider it important to ask questions that would enable SDM compared to standard LLN participants who prioritized nonmedical procedural questions (all p < .01). There was no difference in preferences for control in decision-making or in decisional conflict. Among HL + SDM participants, 79% (n = 85) correctly recalled at least one of the AskShareKnow questions immediately post-intervention, and 35% (n = 29) after 6 months.

Conclusions:

Teaching SDM content increased participants' HL skills for SDM and changed the nature of the questions they would ask health care professionals in a way that would enable shared health decisions. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S58–S74.]

Plain Language Summary:

We developed a health literacy program that included a shared decision-making (SDM) section. The program was delivered in adult basic education classes by trained educators and compared to standard language, literacy, and numeracy training. Teaching SDM content increased participants' health literacy skills for SDM and changed the nature of the questions they would ask health care professionals.

Discussions about evidence and preferences in real-life general practice consultations with older patients

OBJECTIVES

To explore how decisions are made in real-life general practice consultations with older patients (65+ years), and examine how general practitioners (GPs) communicate risk and benefit information and evidence, and integrate patient preferences.

METHODS

Secondary analysis of 20 video-recorded consultations with older patients in Australian primary healthcare settings. Consultations were analysed qualitatively using the Framework method and quantitatively using the Observer OPTION⁵ scale and the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool.

RESULTS

Overall, Observer OPTION⁵ and ACEPP scores were low, with mean total scores of 11.3 (out of 100) and 10.4 (out of 40) respectively. Together with qualitative findings, these results suggest that shared decision-making did not occur, and that healthcare options (including anticipated benefits and risks), evidence and patient preferences were rarely discussed in our sample of consultations with older people. GPs often unilaterally made treatment decisions (usually pharmacotherapy) while patients reverted to a passive decision-making role.

CONCLUSION

We observed a lack of shared decision-making in our primary care study, with little engagement of older patients in decisions about their health.

PRACTICE IMPLICATIONS

Training and support tools may be needed to enhance the capacity and self-efficacy of providers and older patients to share healthcare decisions.

Experienced barriers in shared decision-making behaviour of orthopaedic surgery residents compared with orthopaedic surgeons

INTRODUCTION

In shared decision-making (SDM), physicians encourage the patient to participate in the care process. The theory of planned behaviour describes that behaviour is dependent on intention. In its turn, intention is explained by attitude, subjective norm and perceived behavioural control. In orthopaedics, little is known about current SDM behaviour and how to promote it.The aim of the present study was to gain insight into the SDM behaviour of orthopaedic residents and supervisors by measuring levels of intention, attitudes, subjective norms and perceived behavioural control. Furthermore, we aimed to determine the predictors of intention for SDM.

METHODS

A questionnaire survey study was conducted among orthopaedic surgeons and residents working in the care of hip and knee osteoarthritis, to determine their intentions, attitudes, subjective norms and perceived behavioural control regarding SDM.

RESULTS

Of the 385 physicians approached, 71 residents and 64 orthopaedic surgeons participated. Residents and the supervisors alike had positive intentions regarding SDM. Intention for SDM behaviour was explained by attitude, subjective norm and perceived behavioural control, with perceived behavioural control having the strongest association. In residents, the intention to engage in SDM was more hampered by a lower level of perceived behavioural control than in surgeons.

CONCLUSIONS

Physicians are willing to perform SDM and consider SDM as favourable in the orthopaedic clinic. The implementation of SDM is mainly hampered by experienced barriers that they cannot control. These findings underline the importance of incorporating SDM in the curriculum of postgraduates. Possibilities for efficient SDM implementation should be explored, to overcome perceived barriers.

A Qualitative Study of the Development of Health Literacy Capacities of Participants Attending a Community-Based Cardiovascular Health Programme

Health literacy is a critical determinant of health, which can empower individuals and lead to engagement in collective health promotion action and is also a crucial component in the self-management of illness. The current study moves beyond a focus on functional health literacy and presents findings from a longitudinal qualitative (LQ) study consisting of three phases. This paper presents findings from the second phase of the study, which assessed the development of health literacy capacities of individuals attending a structured cardiovascular risk reduction programme in Ireland. The study objectives were to: explore perceptions of changes in interactions and information exchange within health consultations; identify the facilitators associated with changes in health literacy capacities; assess developments in engagement with broader contexts for health literacy capacities. A LQ study design was undertaken, which employed repeat interview methodology with 19 participants (aged 36⁻76 years) 12 weeks after beginning a structured cardiovascular risk reduction programme. Health literacy levels were assessed using the HLS-EU 47 item instrument in phase 1 (68% limited health literacy (HL), 32% adequate health literacy). A semi-structured interview guide, (informed by Sørensen's conceptual model of health literacy), was used to explore the development of health literacy and to identify changes in knowledge, attitudes and experiences over time. Thematic analysis was used, informed by aspects of Saldaña's framework for longitudinal qualitative data analysis. All participants reported having acquired increased understanding of issues relevant to their health and self-care. Participants described health literacy capacities that incorporate aspects of all levels of health literacy (functional, interactive and critical). Core themes were identified corresponding to changes in these levels: re-engagement with health information and increased understanding of risk and protective factors (changes in functional health literacy); changes in interactions with healthcare providers (HCP) (changes in interactive health literacy); enhanced psychological insights and understanding the broader determinants of health (changes in critical health literacy). Findings support the development of health literacy capacities across the functional, interactive and critical health literacy domains. Participants are capable of locating responsibility for health beyond the individual level and are making sense of knowledge within their own social contexts. Individuals, regardless of their initial health literacy levels, are capable of engaging with broader issues that can impact on their health and can be supported to develop these critical health literacy capacities.

Developing Verbal Health Literacy with Adult Learners Through Training in Shared Decision-Making

Background

Health literacy skills are often assessed in relation to written health materials; however, many important communications are in other formats, especially verbal communication with health care providers.

Objective

This qualitative study sought to examine adult learners' experiences of developing verbal health literacy skills within an Australian adult basic education program, and to explore verbal communication and shared decision-making as a constituent domain of health literacy.

Methods

We conducted a semi-structured qualitative interview study between September and November 2014 with adult learners who had participated in a single-semester health literacy program that included an integrated shared decision-making component. We analyzed interviews using the Framework method; a matrix-based approach to thematic analysis. A hybrid process of inductive and deductive coding was used to interpret raw data.

Key Results

Interviewees were 22 students from six health literacy classes and ranged in age from 18 to 74 years (mean, 48.3). The majority were women (n = 15) and born outside Australia (n = 13). Health literacy was generally limited according to the Newest Vital Sign screening tool (n = 17). The health literacy program appeared to serve two key functions. First, it stimulated awareness that patients have the right to participate in decision-making concerning their treatment and care. Second, it facilitated verbal skill development across the domains of functional (e.g., communicating symptoms), communicative (e.g., asking questions to extract information about treatment options), and critical (e.g., integrating new knowledge with preferences) health literacy.

Conclusions

Our findings support the conceptualization of health literacy as a modifiable health asset that is subject to change and improvement as a result of deliberate intervention. Results reinforce verbal health literacy as an important component of health literacy, and draw attention to the hierarchy of verbal skills needed for consumers to become more actively involved in decisions about their health. We present a revised model of health literacy based on our findings. [Health Literacy Research and Practice. 2017;1(4):e257-e268.].

Plain Language Summary

We developed a health literacy program for adults with lower literacy to help learners develop skills to talk to health care providers and share health decisions. The program was taught in Australian adult education settings. The article explores the range of health literacy skills needed for communication and decision-making in this study, and presents a model in which verbal skills are an important part of health literacy.

Qualitative insights into the experience of teaching shared decision making within adult education health literacy programmes for lower-literacy learners

Background

Enhancing health literacy can play a major role in improving healthcare and health across the globe. To build higher‐order (communicative/critical) health literacy skills among socially disadvantaged Australians, we developed a novel shared decision making (SDM) training programme for adults with lower literacy. The programme was delivered by trained educators within an adult basic education health literacy course.

Objective

To explore the experience of teaching SDM within a health literacy programme and investigate whether communicative/critical health literacy content meets learner needs and teaching and institutional objectives.

Design and participants

Qualitative interview study with 11 educators who delivered the SDM programme. Transcripts were analysed using the Framework approach; a matrix‐based method of thematic analysis.

Results

Teachers noted congruence in SDM content and the institutional commitment to learner empowerment in adult education. The SDM programme was seen to offer learners an alternative to their usual passive approach to healthcare decision making by raising awareness of the right to ask questions and consider alternative test/treatment options. Teachers valued a structured approach to training building on foundational skills, with language reinforcement and take‐home resources, but many noted the need for additional time to develop learner understanding and cover all aspects of SDM. Challenges for adult learners included SDM terminology, computational numerical risk tasks and understanding probability concepts.

Discussion and conclusions

SDM programmes can be designed in a way that both supports teachers to deliver novel health literacy content and empowers learners. Collaboration between adult education and healthcare sectors can build health literacy capacity of those most in need.