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.

Imagereproducedwithkindpermissionfromwpclipart.com

Howhasitimpactedonyourpractice?

Thinkofexamplesofwhenyoumayhaveencounteredorhavehadtotakeintoaccountlow

healthliteracyissueswithinyourrole.

Imagereproducedwithkindpermissionfromwpclipart.com

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

Imagereproducedwithkindpermissionfromwpclipart.com

Fivetipsformakingiteasy

1. Teach-back

2. Chunkandcheck

3. Usepictures

4. Usesimplelanguage

5. Routinelyaskpeopleiftheywouldlikehelp

Imagereproducedwithkindpermissionfromwpclipart.com

UsingTeach-backActivity2

Imagereproducedwithkindpermissionfromwpclipart.com

Whatnext?Whatareyougoingtodoaftertoday– onethingyou

willchange?

Imagereproducedwithkindpermissionfromwpclipart.com

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

May2017gill.rowlands@newcastle.ac.uk