Can adults with low literacy understand shared decision making questions? A qualitative investigation

Psychometric properties of the Turkish version of the Stress Scale for Nurses Providing End-of-Life Care for Children

OBJECTIVES

This study was carried out to evaluate the validity and reliability of the Stress Scale for Pediatric Nurses Performing End-of-Life Care for Children in Turkey.

METHODS

This was a methodological study conducted with 222 pediatric nurses. Data were collected using the information form for pediatric nurses and the "stress scale for nurses performing end-of-life care for children." Content and construct validity, item analysis, confirmatory factor analysis and internal consistency were used to evaluate the data. The Global Pharmaceutical Regulatory Affairs Summit checklist was followed in this study.

RESULTS

The content validity index of the scale was 0.93. Item-total score correlation values ranged from 0.594 to 0.885. The 5-factor structure of the scale was confirmed as a result of confirmatory factor analysis. Factor loads were greater than 0.30, and fit indices were greater than 0.80. The Cronbach's alpha coefficient of the Turkish version of the scale was 0.97.

SIGNIFICANCE OF RESULTS

The stress scale for nurses performing end-of-life care for children is a valid and reliable measurement tool for the Turkish sample. This scale facilitates the assessment of the stress levels of pediatric nurses who provide end-of-life care to children. Also, this scale can be used in interventional studies to improve the well-being of pediatric nurses.

Exploring individuals' perceptions and acceptability of a 'wait and see' approach for managing self-limiting illnesses: A qualitative study

OBJECTIVE

To explore individuals' perceptions and acceptability of a 'wait and see' approach, and phrases to describe this, for managing self-limiting illnesses (those that typically resolve spontaneously).

METHODS

Semi-structured interviews with a purposive sample of 30 Australians. Two researchers independently conducted a thematic analysis of interview transcripts, and all authors agreed on final themes.

RESULTS

Four themes emerged: Interpretation of what 'wait and see' meant varied and encompassed whether individuals had already sought medical care; Individuals' experiences and circumstances influenced the acceptability of a 'wait and see' approach; Symptom management was perceived as the most reassuring phrase to describe this approach; Individuals highly valued clear communication about a 'wait and see' approach and wanted a collaborative and action-oriented plan for the waiting period.

CONCLUSION

Individuals generally accepted a 'wait and see' approach, although less so for some illnesses and in some circumstances. They wanted it at least presented as an option when appropriate, with 'symptom management' as the preferred terminology. Clear communication and collaborative decision-making were valued.

PRACTICE IMPLICATIONS

When 'wait and see' is a reasonable option, clinicians should communicate this to patients, support them in decision-making, and provide a plan for the waiting period if the option is chosen.

Mixed-Method Systematic Review and Meta-Analysis of Shared Decision-Making Tools for Cancer Screening

This review aimed to synthesize evidence on the effectiveness of shared decision-making (SDM) tools for cancer screening and explored the preferences of vulnerable people and clinicians regarding the specific characteristics of the SDM tools. A mixed-method convergent segregated approach was employed, which involved an independent synthesis of quantitative and qualitative data. Articles were systematically selected and screened, resulting in the inclusion and critical appraisal of 55 studies. Results from the meta-analysis revealed that SDM tools were more effective for improving knowledge, reducing decisional conflict, and increasing screening intentions among vulnerable populations compared to non-vulnerable populations. Subgroup analyses showed minimal heterogeneity for decisional conflict outcomes measured over a six-month period. Insights from the qualitative findings revealed the complexities of clinicians' and vulnerable populations' preferences for an SDM tool in cancer screening. Vulnerable populations highly preferred SDM tools with relevant information, culturally tailored content, and appropriate communication strategies. Clinicians, on the other hand, highly preferred tools that can be easily integrated into their medical systems for efficient use and can effectively guide their practice for cancer screening while considering patients' values. Considering the complexities of patients' and clinicians' preferences in SDM tool characteristics, fostering collaboration between patients and clinicians during the creation of an SDM tool for cancer screening is essential. This collaboration may ensure effective communication about the specific tool characteristics that best support the needs and preferences of both parties.

Question prompt lists and endorsement of question-asking support patients to get the information they seek-A longitudinal qualitative study

Introduction

Question prompt lists (QPLs) have been found to support patients to ask questions and improve the information they receive from doctors. However, some QPL tools, which have been available online for almost 15 years, have little published data on their impact in real‐world settings. This study's aim was to understand patients' attitudes and experiences accessing health information and to assess the impact of introducing two generic QPLs over 3 months.

Methods

A longitudinal qualitative study consisting of three semi‐structured interviews over a three‐month period was conducted with 31 purposively selected participants, adults ≥18 years, recruited online and through social media. Participants were introduced to two different QPLs currently available online (‘Question Builder’; ‘AskShareKnow’). Inductive thematic analysis of a total of 92 semi‐structured telephone interviews was conducted during May–November 2020.

Results

Three main themes are described. (1) Participants described barriers and facilitators to accessing health information: navigating a complex health system; difficulty asking questions of their healthcare professionals and that they value doctors with good communication skills. (2) QPLs helped some participants recognize the role of question‐asking in consultations, made them feel more empowered and helped them prepare and prioritize. (3) Participants wanted QPLs to be easier to use, be accessible when needed and that question‐asking and QPLs should be normalized in medical consultations.

Conclusions

Well‐designed and easily accessible QPLs can empower people to ask questions and be more involved in decisions about their health care. Endorsement of question‐asking in consultations by healthcare professionals and providing QPL tools at the point of contact with health services will be key to realizing the potential of QPLs.

Patient or Public Contribution

This study was completed in conjunction with a reference group consisting of a consumer representative, representatives from the Australian Commission on Safety and Quality in Health Care, Healthdirect Australia Ltd., and the research team.

Responding to requests for hastened death in patients living with advanced neurologic disease

A request for hastened death can mean many things, from an emotional plea for help with unmet needs to a request for legal provision of chemically induced hastened death. Regardless of whether the clinician supports legally available hastened death, knowing how to respond to requests for hastened death is important. Responding in an empathic and open manner will strengthen the therapeutic relationship between the patient and clinician. Suggested scripts on how to respond are provided. A framework for assessing the patient's preparation at various stages in the decisional journey is suggested. Additional factors including caring for the family and involving other healthcare providers are discussed. Last, there is some exploration of ethics considerations and a summary of legal chemically induced hastened death availability internationally.

Engaging Women with Limited Health Literacy in Mammography Decision-Making: Perspectives of Patients and Primary Care Providers

BACKGROUND

Limited health literacy is a driver of cancer disparities and associated with less participation in medical decisions. Mammography screening decisions are an exemplar of where health literacy may impact decision-making and outcomes.

OBJECTIVE

To describe informational needs and shared decision-making (SDM) experiences among women ages 40-54 who have limited health literacy and primary care providers (PCPs).

DESIGN

Qualitative, in-depth interviews explored experiences with mammography counseling and SDM.

PARTICIPANTS

Women ages 40-54 with limited health literacy and no history of breast cancer or mammogram in the prior 9 months were approached before a primary care visit at a Boston academic, safety-net hospital. PCPs practicing at this site were eligible for PCP interviews.

APPROACH

Interviews were audio-recorded and transcribed verbatim. A set of deductive codes for each stakeholder group was developed based on literature and the interview guide. Inductive codes were generated during codebook development. Codes were compared within and across patient and PCP interviews to create themes relevant to mammography decision-making.

KEY RESULTS

The average age of 25 interviewed patients was 46.5; 18 identified as black, 3 as Hispanic, 2 as non-Hispanic white, and 2 had no recorded race or ethnicity. Of 20 PCPs, 15 were female; 12 had practiced for >5 years. Patients described a lack of technical (appropriate tests and what they do) and process (what happens during a mammogram visit) knowledge, viewing these as necessary for decision-making. PCPs were reluctant to engage patients with limited health literacy in SDM due to time constraints and feared that increased information might confuse patients or deter them from having mammograms. Both groups felt pre-visit education would facilitate mammography-related SDM during clinical visits.

CONCLUSION

Both patients and PCPs perceived a need for tools to relay technical and process knowledge about mammography prior to clinical encounters to address the scope of information that patients with limited health literacy desired.

Decisional Conflict During Major Medical Treatment Decision-making: a Survey Study

BACKGROUND

Both patients and surrogate decision-makers experience decisional conflict when making a major medical treatment decision with life or death implications. The relationship between health literacy and decisional conflict while making a major medical treatment decision is not understood.

OBJECTIVE

To identify the prevalence of individuals making major medical treatment decisions for themselves or someone else and to explore the relationships between decisional conflict and circumstances of the decision as well as the decision-maker.

DESIGN

Two-phase survey study: in phase 1, we screened for who made a major treatment decision; in phase 2, we asked eligible respondents about their experience making the decision.

PARTICIPANTS

Address-based random sample of 4000 Wisconsin residents; 1072 completed phase 1 and 464 completed phase 2.

MAIN MEASURES

We asked respondents about types of decisions made, the most difficult decision made, and characteristics of the decision-maker and the decision. We included the Decisional Conflict Scale and four domains of the Health Literacy Questionnaire. Open-ended questions also allowed respondents to describe their experiences.

KEY RESULTS

About 43% of respondents reported making a major medical treatment decision. Decisions about major surgery and life support were regarded as the most difficult decisions. Respondents who made the decision for a spouse/partner (β = 6.65, p = 0.012), parent (β = 9.27, p < 0.001), or someone else (β = 10.7, p < 0.001) had higher decisional conflict. Respondents who reported higher ability to actively engage with healthcare providers (β = - 5.24, p = 0.002) and to understand health information well enough to know what to do (β = - 6.12, p = 0.001) had lower decisional conflict.

CONCLUSIONS

The need to make major treatment decisions is likely to increase and making decisions on someone else's behalf appeared to be especially difficult. Improving communication to encourage patient and family engagement in the decision-making conversation, particularly for individuals with limited health literacy, may be helpful.

Patient Attitudes Toward Spoken Surveys in a Low-Income Urban Surgical Clinic

Diverse groups in urban settings demonstrate poor participation in health care and low levels of literacy. It is possible the method of health information delivery (eg, spoken vs. written) in these settings could impact health care related communication and understanding, though little is known on this topic. The objective of this study was to uncover the advantages and disadvantages of spoken survey administration in a low-income urban setting. The data for this study were collected via spoken survey with eighty patients in 9 surgery clinics at Temple University Hospital (TUH) in North Philadelphia. Survey responses were coded into various groups until categories and relationships among them emerged to produce themes relevant in demonstrating the advantages and disadvantages of spoken survey. 69% (55) of respondents preferred a spoken survey format. Of the 55 patients who preferred the spoken format, 33% (18) possessed some level of college education and 47% (26) had finished high school. Of the 23 patients who primarily spoke Spanish or another language at home, 78% (18) preferred a spoken interview format. Overall, 53% (42) of patients experienced at least 1 instance of poor understanding throughout the survey. Patients were better able to understand questions in a spoken survey compared to written ones that they had completed in the past due to the opportunity for surveyors to explain questions when needed. It is possible that question explanation is necessary in low-income urban settings due to low-literacy levels or improved feelings of survey intimacy and efficiency.

Understanding shared decision-making experience among vulnerable population: Focus group with food bank clients

Introduction

Shared decision-making (SDM) is a critical component of delivering patient-centered care. Members of vulnerable populations may play a passive role in clinical decision-making; therefore, understanding their prior decision-making experiences is a key step to engaging them in SDM.

Objective

To understand the previous healthcare experiences and current expectations of vulnerable populations on clinical decision-making regarding therapeutic options.

Methods

Clients of a local food bank were recruited to participate in focus groups. Participants were asked to share prior health decision experiences, explain difficulties they faced when making a therapeutic decision, describe features of previous satisfactory decision-making processes, share factors under consideration when choosing between treatment options, and suggest tools that would help them to communicate with healthcare providers. We used the inductive content analysis to interpret data gathered from the focus groups.

Results

Twenty-six food bank clients participated in four focus groups. All participants lived in areas of socioeconomic disadvantage. Four themes emerged: prior negative clinical decision-making experience with providers, patients preparing to engage in SDM, challenges encountered during the decision-making process, and patients' expectations of decision aids. Participants also reported they were unable to discuss therapeutic options at the time of decision-making. They also expressed financial concerns and the need for sufficiently detailed information to evaluate risks.

Conclusion

Our findings suggest the necessity of developing decision aids that would improve the engagement of vulnerable populations in the SDM process, including consideration of affordability, use of patient-friendly language, and incorporation of drug-drug and drug-food interactions information.

Exploring the Vast Choice of Question Prompt Lists Available to Health Consumers via Google: Environmental Scan

Background

There is increasing interest in shared decision making (SDM) in Australia. Question prompt lists (QPLs) support question asking by patients, a key part of SDM. QPLs have been studied in a variety of settings, and increasingly the internet provides a source of suggested questions for patients. Environmental scans have been shown to be useful in assessing the availability and quality of online SDM tools.

Objective

This study aimed to assess the number and readability of QPLs available to users via Google.com.au.

Methods

Our environmental scan used search terms derived from literature and reputable websites to search for QPLs available via Google.com.au. Following removal of duplicates from the 4000 URLs and 22 reputable sites, inclusion and exclusion criteria were applied to create a list of unique QPLs. A sample of 20 QPLs was further assessed for list length, proxy measures of quality such as a date of review, and evidence of doctor endorsement. Readability of the sample QPL instructions and QPLs themselves was assessed using Flesch Reading Ease and Flesch-Kincaid Grade Level scores.

Results

Our environmental scan identified 173 unique QPLs available to users. Lists ranged in length from 1 question to >200 questions. Of our sample, 50% (10/20) had a listed date of creation or update, and 60% (12/20) had evidence of authorship or source. Flesch-Kincaid Grade Level scores for instructions were higher than for the QPLs (grades 10.3 and 7.7, respectively). There was over a 1 grade difference between QPLs from reputable sites compared with other sites (grades 4.2 and 5.4, respectively).

Conclusions

People seeking questions to ask their doctor using Google.com.au encounter a vast number of question lists that they can use to prepare for consultations with their doctors. Markers of the quality or usefulness of various types of online QPLs, either surrogate or direct, have not yet been established, which makes it difficult to assess the value of the abundance of lists. Doctor endorsement of question asking has previously been shown to be an important factor in the effectiveness of QPLs, but information regarding this is not readily available online. Whether these diverse QPLs are endorsed by medical practitioners warrants further investigation.

Implementation of a health-literate patient decision aid for chest pain in the emergency department

OBJECTIVE

The aim of this study was to investigate the implementation of a new health-literacy-tested patient decision aid for chest pain in Emergency Department (ED) patients. Outcomes included disposition, knowledge, decisional conflict and satisfaction prior to discharge. Patient health literacy was explored as a factor that may explain disparities in sub-group analysis of all outcomes.

METHODS

A health-literacy adapted tool was deployed using a pre/post intervention design. Patients enrolled during the intervention period were given the adapted chest pain decision aid that was used in conversation with their emergency medicine physician to decide on their course of action prior to being discharged.

RESULTS

A total of 169 participants were surveyed and used in the final analysis. Patients in the usual care group were 2.6 times more likely to be admitted for chest pain than patients in the intervention group. Knowledge scores were higher in the intervention group, while no significant differences were observed in decisional conflict and patient satisfaction, or by patient health literacy level.

CONCLUSION AND PRACTICE IMPLICATIONS

Using the adapted chest pain decision tool in emergency medicine may improve knowledge and reduce admissions, while addressing known barriers to understanding related to patient health literacy.

Evaluation of the Choosing Wisely Australia 5 Questions resource and a shared decision-making preparation video: protocol for an online experiment

INTRODUCTION

Choosing Wisely, an international effort to reduce low value care worldwide, considers communication between clinicians and patients during routine clinical encounters a key mechanism for change. In Australia, Choosing Wisely has developed a 5 Questions resource to facilitate better conversations. The primary aim of this study is to evaluate the impact of the Choosing Wisely Australia 5 Questions resource and a video designed to prepare patients for question-asking and participation in shared decision-making on (a) self-efficacy to ask questions and participate in shared decision-making, (b) intention to participate in shared decision-making and (c) a range of secondary outcomes. The secondary aim of this study is to determine whether participants' health literacy modifies the effects of the interventions.

METHODS AND ANALYSIS

We will use 2×2×2 between-subjects factorial design (preparation video: yes, no × Choosing Wisely 5 Questions resource: yes, no × health literacy: adequate, inadequate). Participants will be recruited by an online market research company, presented with a hypothetical non-specific low back pain scenario, and randomised to study groups stratified by health literacy. Quantitative primary and secondary outcome data will be analysed as intention-to-treat using appropriate regression models (ie, linear regression for continuous outcomes, logistic regression for dichotomous categorical outcomes).

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the University of Sydney Human Research Ethics Committee (protocol number: 2018/965). The results from this work will be disseminated through peer-reviewed international journals, conferences and updates with collaborating public health bodies. Resources developed for this study will be made available to patients and clinicians following trial completion.

TRIAL REGISTRATION NUMBER

This trial has been registered with the Australia New Zealand Clinical Trials Registry (trial number: 376477) and the stage is Pre-results.

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.

Availability and readability of patient education materials for deprescribing: An environmental scan

AIMS

To identify and evaluate content and readability of freely available online deprescribing patient education materials (PEMs).

METHODS

Systematic review of PEMs using MEDLINE, Embase, CINAHL, PsycINFO and The Cochrane Library of Systematic Reviews from inception to 25 September 2017 to identify PEMs. Additionally, deprescribing researchers and health professionals were surveyed to identify additional materials. Known repositories of materials were searched followed by a systematic Google search (22-28 January 2018). Materials were evaluated using an approach informed by the Patient Education Material Assessment Tool and the International Patient Decision Aids Standards Inventory. Readability of text-based materials was assessed using the US-based Gunning-Fog Index and Flesch-Kincaid Grade level.

RESULTS

Forty-eight PEMs were identified. PEMs addressing deprescribing of medications for symptom control (81%) were most common. Preventative medications were rarely addressed and material (39%) focused on older people. Only 37% of PEMs provided information about both potential benefits (e.g. reducing risk of side effects) and harms (e.g. withdrawal symptoms, increased risk of disease) of deprescribing, while 40% focussed on benefits only. Readability indices indicated an average minimum reading level of Grade 12. Option Grids and Decision Aids (mean reading level below Grade 10) were most suitable for people with average literacy levels.

CONCLUSIONS

Over 1/3 of deprescribing PEMs present potential benefits and harms of deprescribing indicating most of the freely available materials are not balanced. Most PEMs are pitched above average reading levels making them inaccessible for low health literacy populations.

The CHOICE pilot project: Challenges of implementing a combined peer work and shared decision-making programme in an early intervention service

AIM

Youth participation is central to early intervention policy and quality frameworks. There is good evidence for peer support (individuals with lived experience helping other consumers) and shared decision making (involving consumers in making decisions about their own care) in adult settings. However, youth programs are rarely tested or described in detail. This report aims to fill this gap by describing a consumer focused intervention in an early intervention service.

METHODS

This paper describes the development process, intervention content and implementation challenges of the Choices about Healthcare Options Informed by Client Experiences and Expectations (CHOICE) Pilot Project. This highly novel and innovative project combined both youth peer work and youth shared decision making.

RESULTS

Eight peer workers were employed to deliver an online shared decision-making tool at a youth mental health service in New South Wales, Australia. The intervention development involved best practice principles, including international standards and elements of co-design. The implementation of the peer workforce in the service involved a number of targeted strategies designed to support this new service model. However, several implementation challenges were experienced which resulted in critical learning about how best to deliver these types of interventions.

CONCLUSIONS

Delivering peer work and shared decision making within an early intervention service is feasible, but not without challenges. Providing adequate detail about interventions and implementation strategies fills a critical gap in the literature. Understanding optimal youth involvement strategies assists others to deliver acceptable and effective services to young people who experience mental ill health.

Supporting shared decision-making for older people with multiple health and social care needs: a realist synthesis

Background

Health-care systems are increasingly moving towards more integrated approaches. Shared decision-making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; this is particularly the case for older people with complex needs.

Objectives

To provide a context-relevant understanding of how models to facilitate SDM might work for older people with multiple health and care needs and how they might be applied to integrated care models.

Design

Realist synthesis following Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards.

Participants

Twenty-four stakeholders took part in interviews.

Data sources

Electronic databases including MEDLINE (via PubMed), The Cochrane Library, Scopus, Google and Google Scholar (Google Inc., Mountain View, CA, USA). Lateral searches were also carried out. All types of evidence were included.

Review methods

Iterative stakeholder-driven, three-stage approach, involving (1) scoping of the literature and stakeholder interviews (n = 13) to develop initial programme theory/ies, (2) systematic searches for evidence to test and develop the theories and (3) validation of programme theory/ies with stakeholders (n = 11).

Results

We included 88 papers, of which 29 focused on older people or people with complex needs. We identified four theories (context–mechanism–outcome configurations) that together provide an account of what needs to be in place for SDM to work for older people with complex needs: understanding and assessing patient and carer values and capacity to access and use care; organising systems to support and prioritise SDM; supporting and preparing patients and family carers to engage in SDM; and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that create trust between those involved, allow service users to feel that they are respected and understood, and engender confidence to engage in SDM.

Limitations

There is a lack of evidence on interventions to promote SDM in older people with complex needs or on interprofessional approaches to SDM.

Conclusions

Models of SDM for older people with complex health and care needs should be conceptualised as a series of conversations that patients, and their family carers, may have with a variety of different health and care professionals. To embed SDM in practice requires a shift from a biomedical focus to a more person-centred ethos. Service providers are likely to need support, both in terms of the way services are organised and delivered and in terms of their own continuing professional development. Older people with complex needs may need support to engage in SDM. How this support is best provided needs further exploration, although face-to-face interactions and ongoing patient–professional relationships are key.

Future work

There is a need for further work to establish how organisational structures can be better aligned to meet the requirements of older people with complex needs. This includes a need to define and evaluate the contribution that different members of health and care teams can make to SDM for older people with complex health and care needs.

Study registration

This study is registered as PROSPERO CRD42016039013.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Health Literacy: Exploring Nursing Challenges to Providing Support and Understanding

BACKGROUND

As patient advocates, oncology nurses must attend to varying levels of health literacy among patients and families. However, little is known about nurses' experiences and comfort with health literacy assessment and providing health literacy support.
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OBJECTIVES

The purpose of this study is to explore nurse communication and patient health literacy.
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METHODS

A cross-sectional survey design (N = 74) was used to explore nurse communication challenges with low-literacy patients and to measure nurses' frequency of assisting with patient literacy needs, perceived degree of difficulty communicating with low-literacy populations, and perceived comfort with health literacy support.
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FINDINGS

A majority of the nurses reported communication challenges with patients who spoke English as a second language. Oncology nurses did not identify patient communication behaviors that indicated low health literacy. Nurses were least comfortable identifying low-literacy patients and assessing a patient's health literacy level. More experienced nurses reported more difficulty with low-literacy populations than less experienced nurses. Providing health literacy support to patients should be a core nursing skill.

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.

[Why and how to promote decision-making autonomy of cancer patients?]

Involvement of patients in decision-making about their health has been promoted nationally and internationally since several years. Despite this, patient (and their relatives) participation remains insufficient and one of the objectives of the current French national cancer policy (Plan cancer 2014-2019) is to give everyone the possibility to play an active role in the management of their care. This overview focuses on decision-making autonomy of cancer patients through two main questions: why and how to promote it? After a brief review of the decision-making models described in the literature in the past decades insisting on the major role of the decisional context and the dynamic character of this context, this article presents a selection of published works which aimed to respond to those 2 questions.

Key elements of optimal treatment decision-making for surgeons and older patients with colorectal or pancreatic cancer: A qualitative study

OBJECTIVE

To identify key elements of optimal treatment decision-making for surgeons and older patients with colorectal (CRC) or pancreatic cancer (PC).

METHODS

Six focus groups with different participants were performed: three with older CRC/PC patients and relatives, and three with physicians. Supplementary in-depth interviews were conducted in another seven patients. Framework analysis was used to identify key elements in decision-making.

RESULTS

23 physicians, 22 patients and 14 relatives participated. Three interacting components were revealed: preconditions, content and facilitators of decision-making. To provide optimal information about treatments' impact on an older patient's daily life, physicians should obtain an overall picture and take into account patients' frailty. Depending on patients' preferences and capacities, dividing decision-making into more sessions will be helpful and simultaneously emphasize patients' own responsibility. GPs may have a valuable contribution because of their background knowledge and supportive role.

CONCLUSION

Stakeholders identified several crucial elements in the complex surgical decision-making of older CRC/PC patients. Structured qualitative research may also be of great help in optimizing other treatment directed decision-making processes.

PRACTICE IMPLICATIONS

Surgeons should be trained in examining preconditions and useful facilitators in decision-making in older CRC/PC patients to optimize its content and to improve the quality of shared care.

Involving members of vulnerable populations in the development of patient decision aids: a mixed methods sequential explanatory study

Background

Patient decision aids aim to present evidence relevant to a health decision in understandable ways to support patients through the process of making evidence-informed, values-congruent health decisions. It is recommended that, when developing these tools, teams involve people who may ultimately use them. However, there is little empirical evidence about how best to undertake this involvement, particularly for specific populations of users such as vulnerable populations.

Methods

To describe and compare the development practices of research teams that did and did not specifically involve members of vulnerable populations in the development of patient decision aids, we conducted a secondary analysis of data from a systematic review about the development processes of patient decision aids. Then, to further explain our quantitative results, we conducted semi-structured telephone interviews with 10 teams: 6 that had specifically involved members of vulnerable populations and 4 that had not. Two independent analysts thematically coded transcribed interviews.

Results

Out of a total of 187 decision aid development projects, 30 (16%) specifically involved members of vulnerable populations. The specific involvement of members of vulnerable populations in the development process was associated with conducting informal needs assessment activities (73% vs. 40%, OR 2.96, 95% CI 1.18–7.99, P = .02) and recruiting participants through community-based organizations (40% vs. 11%, OR 3.48, 95% CI 1.23–9.83, P = .02). In interviews, all developers highlighted the importance, value and challenges of involving potential users. Interviews with developers whose projects had involved members of vulnerable populations suggested that informal needs assessment activities served to center the decision aid around users’ needs, to better avoid stigma, and to ensure that the topic truly matters to the community. Partnering with community-based organizations may facilitate relationships of trust and may also provide a non-threatening and accessible location for research activities.

Conclusions

There are a small number of key differences in the development processes for patient decision aids in which members of vulnerable populations were or were not specifically involved. Some of these practices may require additional time or resources. To address health inequities, researchers, communities and funders may need to increase awareness of these approaches and plan accordingly.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0399-8) contains supplementary material, which is available to authorized users.