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

IMPROVING HEALTH LITERACY:
What is the evidence ?

Kirsten McCaffery PhD
kirsten.mccaffery@sydney.edu.au

SYDNEY 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


Two key areas for evidence-based action:

1. To improve health communication

2. To support patient involvement


There 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 100
women 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
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5 out of 100 women
will require additional
treatment Gigerenzer et al 1995, Feldman-Stewart et al

RISK COMMUNICATION

Of 100 women who 20% less women will
have surgery required additional
treatment
5% of women will
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NOT required additional
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treatment
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5 out of 100 women

RISK COMMUNICATION

Of 100 women who 20% less women will
have surgery required additional
treatment
5% of women will
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NOT required additional
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treatment
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OR
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100
90
80
70
60
50
40
30

5 out of 100 women 20
10
0


RISK COMMUNICATION

Medical risk training for low and high SES
consumers

Woloshin 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 COMMUNICATION

Impact of the primer on understanding

Patient group Control gp Risk Primer % Difference Significance
‘pass rate’ ‘pass rate’ (95% CIs)

Pass ≥ 75 / 100 correct

RISK COMMUNICATION


Low SES 26% 44% 18% p<0.01
n= 221 (8-28%)


RISK COMMUNICATION


Low SES 26% 44% 18% p<0.01
n= 221 (8-28%)
High SES 56% 74% 18% p<0.001
n=334 (5-31%)


RISK COMMUNICATION


Low SES 26% 44% 18% p<0.01
n= 221 (8-28%)
High SES 56% 74% 18% p<0.001
n=334 (5-31%)


Interest in medical statistics significantly increased in both groups
Low SES = + 8 points (p=0.004)
High SES = + 6 points (p=0.004)


Two key areas for evidence based action:

1. To improve health communication

2. 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


Effective 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 AIDS

What 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 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


In some circumstances decision aids:

 Increase adherence

 Reduce unnecessary testing/ medical procedures

 Increase quality of life

(O’Connor et al. Cochrane Review 2009)

QUESTION ASKING INTERVENTIONS

What are Question Asking Interventions?
Interventions to encourage patients to ask questions and direct
the content of the consultation towards their needs and
concerns

QUESTION ASKING INTERVENTIONS

Kinnersley et al Cochrane review (2007)

Question Asking Interventions
 Increased question asking
 Increased patient satisfaction (small increase)
 No increase in anxiety
 No increase in consultation length

In 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 DA
McCaffery et al NHMRC project grant, Sian Smith et al PhD. [Full project team: K
McCaffery, 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 making
qualifications, intermediate Psychosocial outcomes
school 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 & Medicine

Patient skills Evidence
+ +
Health system CLOSE THE GAP Practice

Particular thanks to: Sian Smith

EFFECTIVE HEALTH COMMUNICATION
Prescription 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 NEEDS

So 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)


There 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 12
for bowel cancer between 55-64 years with education and literacy with
Informed (38) ** (-16) ** (22) **
(Smith, et al. lower education levels government information booklet
choice
2009)
Involvement
in decision
Mammog Aus Women aged 70 years or DA with usual care information Knowledge 77 vs 57 6 vs 7 74 vs 49
screening for older , regularly (leaflet developed for breast
Informed (20) ** (-1) (25)**
breast cancer participated in cancer screening service).
choice
mammography screening.
(Mathieu, et al. Participation
2007) in screening
FOBT screening Aus Adults aged between 45- DA against standard government Knowledge 21 vs 6 5 vs 7 10 vs 2
for bowel cancer 74 yrs at GP practice information booklet.
Informed (15)** (-2) (8)**
(Trevena et al
choice
2008)

FOBT and US Adults aged 65 years and 2 DAs (one relative risk info and Screening 71 vs 54 Intentions N/A
flexible 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. intentions
2000) Rel risk DA: 67;
Abs risk DA: 63
FOBT, flex sig, US Adults aged 50 years and Compared DA based on multi- Decisional N/A 49 vs 52 N/A
barium en, older, visiting their primarycriteria decision-making theory conflict
(-3)
colonos for care doctor with a simple educational
Screening
CRC (Dolan et al intervention.
intentions and
2002)
behaviour

FOBT and US Adults aged between 50- Educational video about bowel Screening N/A 37 vs 23 N/A
Fleixble sig 75 years from primary screening with video on behaviour
(14)**
(Pignone et al care. automobile safety (control group).
2000)

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