working with tafe and adults with lower literacy...the university of sydney page 1 working with tafe...

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

dmus5397@uni.sydney.edu.au

@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

The University of Sydney Page 39

Danielle M Muscat

dmus5397@uni.sydney.edu.au

@Dmuscat92