University of Groningen Improving communication in healthcare for patients with low health literacy Kaper, Marise

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Improving communication in healthcare for patients with low health literacy

Kaper, Marise

DOI:

10.33612/diss.172455932

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Publication date:

2021

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Citation for published version (APA):

Kaper, M. (2021). Improving communication in healthcare for patients with low health literacy: Building

competencies of health professionals and shifting towards health literacy friendly organizations. University

of Groningen. https://doi.org/10.33612/diss.172455932

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Processed on: 27-5-2021 PDF page: 202PDF page: 202PDF page: 202PDF page: 202

202 Marise Sarien Kaper was born on 24 November

1982 in Ede, the Netherlands. She obtained her

bachelor degree in Human Resource

Mana-gement in 2005 and her master degree in Social

Psychology at the University of Groningen in

2011. She wrote her master thesis on the dyadic

coping strategies and relationship satisfaction

of patients with Meniere’s disease and their

partners, at the Department of Health Sciences

at the University Medical Center Groningen

(UMCG).

From 2005 she has fulfilled various positions in the health care sector in the

area of human resources, teaching and training, policy, and research and as

such has developed a broad scope of working expertise. Over the years, Marise

has developed a keen interest in the health care sector, and health promotion

through effective communication and treatment by health professionals and

organizations. This interest was particularly informed by her work as a trainer

and teacher from 2009 to 2013 for the educations Dentistry of the University of

Groningen and Dental Hygiene of the Hanze University for Applied Sciences

which are both located in the UMCG.

In 2014 Marise obtained the position as a PhD-candidate affiliated with the

Department of Health Sciences at the UMCG, which allowed her to express her

interest in health promotion and communication by conducting research. Her

research resulted in this PhD-thesis on the improvement of communication

and provision of health care for patients with low health literacy, through

competency development of health professionals and transformation of

organizations. In this period, Marise also has followed many courses in the

field of research, and education.

Since 2019, Marise again has been employed as a researcher and a teacher

for the educations Dentistry and Dental Hygiene. She is responsible for the

development and implementation of education and research in the field of

behavioral sciences, health literacy, patient centered communication and

health promotion.

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203

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206 CHAPTER 2 APPENDIX 2.1

Participant characteristics

Stage 1 Stage 2

IRLa _ITA _NL _IRL _ITA _NL

Number of participants 6 6 5 3 5 5 Discipline - Physician 3 1 - Physician assistant 1 - Nurse 2 2 1 1 2 - Physiotherapist 1 1 1 1 - Occupational therapist 1 1 - Podiatrist 2 - Psychologist 1 - Social worker 1 2 - Movement therapist 1 - Activity therapist 1 - Diabetes researcher 1 - Medical consultant 1 - Speech therapist 1 Work experience (years)

0 – 10 2 1 2 1 - 1

11 – 20 - 1 1 2 5 2

> 20 4 4 2 - - 2

a _{IRL refers to Ireland, ITA refers to Italy, NL refers to the Netherlands.}

The majority of participants in all FGDs had some familiarity with health

literacy, whereas three Irish participants were already conversant with health

literacy. Most participants in Ireland and the Netherlands had received some

communication training either during their initial professional education or

their continuing professional development.

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207 CHAPTER 2 APPENDIX 2.2

Description of topic guides on focus group discussions in stage 1 and 2

Three FGDs in stage 1 involved health professionals reviewing the proposed

prototype training program. The topic guide introduced the overall training

and reviewed each workshop relating to: (1) the objective, (2) the core

components, and (3) the educational techniques. Two educational techniques

were tested. Participants assessed the comprehensibility of written materials

and took part in roleplay between a health professional and a patient with

limited health literacy.

Three FGDs in stage 2 involved newly recruited health professionals

providing feedback following the pilot training. First, we provided the pilot

training to the health professionals in each country. The duration of the

training was ten hours and involved five workshops spread over four weeks.

Second, we conducted three FGDs. The topic guide reviewed the overall

training and each specific workshop in relation to: (1) the contribution of the

training components to the training objectives, (2) the perceived effectiveness

of the educational techniques.

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208 CHAPTER 2 APPENDIX 2.3

Item-scores of Pre-post Training Questionnaire.

Questions Pre training_{Median (IQR)}d Post training_{Median (IQR) P}e

Health Literacy Knowledge b

Pre-post scale: from very poor (1) to excellent (5) 2.8 (2.3-3.4) 4.0 (3.8-4.1) .003 1. Do you understand the difference between functional, interactive and

critical health literacy? 3.0 (1.0-3.0) 4.0 (4.0-4.0) .006

2. Are you aware of what it means for patients to have low health literacy? a _{3.0 (2.0-3.8)} _{4.0 (4.0-4.5)} _.010

3. Do you know which specific health outcomes are associated with low

health literacy? a 3.0 (2.0-3.0) 4.0 (3.0-4.0) .016

4. Are you able to recognize cues that may indicate that a person has low

health literacy? a 3.5 (2.3-4.0) 4.0 (4.0-4.0) .084

Communication skills

Pre-post scale: from never (1) to always (5)

Gathering information b _{4.0 (3.4-4.2)} _{4.4 (3.9-4.5)} _.006

5. Do you ask patients open questions relating to their prior knowledge and

beliefs, main concerns and perceived barriers during their treatment? 4.0 (3.0-4.0) 4.0 (4.0-4.5) .040 6. Do you use active listening techniques to gather information? 4.0 (4.0-5.0) 5.0 (4.0-5.0) .083 7. Are you aware of cues related to non-verbal communication of patients? 4.0 (3.0-4.0) 4.0 (4.0-5.0) .024 8. Do you explore and respond to patients’ emotions? 4.0 (4.0-4.5) 4.0 (4.0-4.5) .157 9. Are you careful to express empathy with patients’ potential shame about

low health literacy issues? a 4.0 (3.0-4.0) 4.0 (4.0-4.0) .034

Providing information b _{3.2 (2.8-3.3)} _{3.6 (3.4-4.0)} _.010

10. Do you tailor your information by using plain, non-medical language? a _{4.0 (4.0-5.0)} _{4.0 (4.0-5.0)} _.157

11. How often do you limit the amount of information provided and repeat it? a _{3.0 (3.0-4.0)} _{4.0 (2.5-4.0)} _.317

12. Are you careful to speak at a pace the patient is able to follow? a _{3.0 (3.0-4.0)} _{4.0 (3.5-5.0)} _.071

13. How often do you use teach-back or show-me techniques to check

understanding of information? a 2.0 (1.0-4.0) 3.0 (3.0-4.0) .027

14. Do you show or draw pictures in addition to providing verbal

information? a 2.0 (2.0-3.5) 3.0 (2.5-4.0) .020

Shared decision-making c _{3.3 (2.7-3.8)} _{3.7 (3.3-4.0)} _.024

15. How often do you encourage patients to ask questions at different times

during the interaction? 4.0 (3.5-4.0) 4.0 (3.0-4.5) 1.000

16. Do you let the patient think about how they can best be involved in their

own treatment? 3.0 (2.0-3.5) 4.0 (3.0-4.0) .010

17. Do you involve the preferences of the patient with regard to treatment? 3.0 (1.5-5.0) 3.0 (3.0-4.5) .083

Enabling self-management c _{3.3 (3.0-4.3)} _{4.2 (3.3-4.3)} _.077

18. Do you assess barriers related to treatment compliance? 3.0 (2.0-3.5) 4.0 (3.5-4.0) .010 19. Do you formulate personalized goals and action plans together with the

patient? 4.0 (3.5-5.0) 4.0 (3.0-4.0) .157

20. Do you educate patients with limited health literacy to perform adequate

self-management behaviour? 4.0 (2.5-4.5) 4.0 (3.0-5.0) .366

a _{Items based on questionnaire of Mackert et al. [28],}b _{Number of participants: N=12,}c _{Number of} participants: N=13, d_{IQR means Interquartile range,}e_{P-values are based on the Wilcoxson signed rank} test.

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209 CHAPTER 3 APPENDIX 3

The subscales presented below were used in questionnaires on Health

literacy consultation skills before and after education. Questionnaire 1 was

provided before the training, questionnaire 2 immediately after the training

and questionnaire 3 was provided 6-12 weeks afterwards. The order of the

subscales presented is: general questions, health literacy knowledge, health

literacy consultation skills, attitude, confidence and evaluation of the training.

General questions about you and your organization (included in questionnaire 1) - What is your age in years? ………. Years

- What is your gender? Male Female - What country do you live in? Italy

Northern Ireland The Netherlands - What is the name of the organisation you

work for? ……….

- What is the highest level of completed

education? Grammar schoolHigh school or equivalent Vocational/technical school (2 year) Some college

Bachelor’s undergraduate degree Master’s postgraduate degree Professional degree

Doctoral degree Other

- What is your current position? ………. - How many years have you worked in this

position? …………. Years

- How often do you work with patients with

low health literacy? 1 – Never 2 – Rarely 3 – Occasionally 4 – Regularly 5 – Very often - Have you previously received education or

training on health literacy? 1 – Never 2 – Rarely 3 – Occasionally 4 – Regularly 5 – Very often - Have you previously received education or

training in communication? 1 – Never 2 – Rarely 3 – Occasionally 4 – Regularly 5 – Very often

- Can you indicate your learning objectives related to communicating with patients with low health literacy? ……….

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210

Knowledge of health literacy (included in questionnaire 1-3)

Please indicate how much you agree or disagree with the following questions:

Scale 1 Strongly disagree 2 Disagree Somewhat 3 disagree 4 Neither agree nor disagree 5 Somewhat agree 6 Agree Strongly 7 agree Questions

- I understand what it means for patients to have low health literacy. - I know the prevalence of low health literacy.

- I know the groups that are more likely to be low health literate. - I understand the health outcomes associated with low health literacy. - I do a good job identifying low health literate patients.

- I am good at knowing whether or not my patients understand what I tell them.

Health Literacy focused Communication skills (included in questionnaire 1-3) Indicate how frequently you use each technique when working with patients; on a scale from Never (1) to Every time (7).

Scale 1

Never Rarely2 Occasionally3 Sometimes4 Frequently5 Usually6 Every 7 time Questions

Gathering information

- Ask open questions

- Use active listening techniques to gather information - Observe cues related to non-verbal communication - Create a shame-free environment

Providing information

- Speaking slowly

- Using plain, non-medical language - Show or draw pictures

- Limit the amount of information provided and repeat it

- Use the teach-back or show-me techniques (the patients explains the information in his own words to check understanding).

Shared decision making

- Convey awareness among patients that a choice exists in health care or treatment. - Inform patients about health care or treatment options in more detail.

- Support patients to explore ‘what matters most to them’ after informing them on health care or treatment options.

- Train patients to participate in shared decision making.

Enabling self-management

- Assess barriers and facilitators relating to treatment compliance. - Involve the patient in formulating personalized goals and action plans. - Train patients to perform adequate self-management behaviour.

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211

Attitude: Your opinion on using health literacy strategies (included in questionnaire 1-3) Health literacy strategies are defined as the communication and teaching strategies that have been described as effective with low health literacy patients. These include, plain language communication, which is the avoidance of medical jargon, and Teach-Back, which is a teaching strategy that has the patient teach back to the provider the information just presented to them and also include strategies related to shared decision making and promoting self-management. Please read each question and circle the answer that best reflects your opinion on the use of health literacy strategies in clinical practice. Choose only one answer.

Questions Scale

- My use of health literacy strategies with patients will result in patients having a better understanding of their illness and its treatment.

1

Likely 2 3 4 5 6 Unlikely7

- Improved patient understanding will

improve patient outcomes. Agree1 2 3 4 5 6 Disagree7 - Use of health literacy strategies with

patients would help patients stay healthy.

1

Agree 2 3 4 5 6 Disagree7

- My use of health literacy strategies

with patients would be a… Bad idea1 2 3 4 5 6 Good idea7

Your confidence in health literacy focused communication (included in questionnaire 1-3) With respect to the following questions, please indicate your level of confidence in using your health literacy communication skills

Scale 1 Not at all confident 2 Slightly confident 3 Neutral Moderately4 confident 5 Very confident Questions

How confident are you in your ability to:

- To communicate with patients who may have low health literacy - Use instruments to identify patients with low health literacy

- Identify behaviours typically exhibited by people with low health literacy

- Judge appropriateness of written health information for patients with low health literacy - Gather information from patients with low health literacy

- Provide clear information to patients with low health literacy

- Use the teach back or show me technique to check understanding of patients with low health literacy

- Create a shame free environment for patients with low health literacy - Involve patients with low health literacy in shared decision making

- Train patients with low health literacy to participate in shared decision making - Promote self-management skills in patients with low health literacy

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212

Your evaluation of this training (part 1, used in questionnaire 2).

For each question indicate which answer applies best to you by ticking the appropriate boxes.

- Did you have a clear picture of the topics and

objectives before the start of this training? Yes Partially No - What was the balance between theory and practice

(exercises, roleplays, assignments)? Too much theory Good Too much practice - Were you sufficiently challenged by the trainer to

participate actively? Yes Sometimes No

- Did the facilitator sufficiently relate back to your

practice experience? Yes Sometimes No

- How difficult were the meetings? Difficult Good Easy - Do you think you can use the contents of this training

in your work? Yes Partially No

- How do you rate the length of this training? Too long Good Too short - How do you rate the group size of this training? Too large Good Too small - Did your supervisor pay attention to this training? Yes A little No - Have the objectives of this training been achieved

according to you? Yes Partially No

- Would you recommend this training to your

colleagues? Yes Partially No

Your evaluation of this training (part 2, used in questionnaire 2).

Please indicate how much you agree or disagree with the following questions

- The training was appropriate for my educational level and working experience. - The training increased my knowledge about health literacy

- The training increased my comfort in communicating with patients with low health literacy. - I found the roleplay descriptions to be realistic.

- I found practicing with a standardized patient useful.

- I found the feedback following my roleplay conversations useful. - I will use the suggested communication strategies in my practice

Open questions

- What did you learn in this training related to health literacy focused communication? - With which number from 1-10 would you rate the trainers?

Trainer 1 Trainer 2

- With which number from 1-10 would you rate the training in total? - Do you have any advice or suggestions related to this training?

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213 CHAPTER 4 APPENDIX 4.1

The subscales presented below were used in questionnaires on Health literacy

consultation skills before and after education. Questionnaire 1 was provided

before the training and questionnaire 2 after the training. The order of the

subscales presented is: general questions, health literacy knowledge, health

literacy consultation skills, attitude, confidence and evaluation of the training.

General questions (included in questionnaire 1)

What is your age in years? ………. years

What is your sex? Male

Female Have you previously received training on health literacy? 1 – Never

2 – Rarely 3 – Occasionally 4 – Regularly 5 – Very often How confident are you to use communication skills in

roleplays with patients? 1 – Not at all confident 2 – Slightly confident 3 – Neutral

4 – Moderately confident 5 – Very confident

Your knowledge about health literacy (included in questionnaires 1 and 2)

Please indicate how much you agree or disagree with the following questions. Choose only one answer. Scale 1 Strongly disagree 2 Disagree Somewhat 3 disagree 4 Neither agree nor disagree 5 Somewhat agree 6 Agree Strongly 7 agree Questions on Knowledge

I understand what it means for patients to have low health literacy I know the prevalence of low health literacy

I know the groups that are more likely to be low health literate I understand the health outcomes associated with low health literacy I do a good job identifying low health literate people.

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214

Your consultation skills focused on health literacy (included in questionnaires 1 and 2) The following medical consultation and teaching skills have been described as effective with patients with low health literacy. In your first and second year you practiced medical consultation skills in roleplays with simulated patients. We want to know to which extent you practiced these health literacy consultation skills in prior training. It is also possible that you never practiced the skills.

Therefore, please indicate how frequently you used the following health literacy consultation skills during roleplay conversations with simulated patients. Choose only one answer.

Scale 1

Never Rarely2 Occasio-3 nally 4 Some-times 5 Fre-quently 6 Usually Every 7 time Gathering information

Asking open questions

Use active listening techniques to gather information Observe cues related to non-verbal communication Create a shame-free environment

Providing information

Speaking slowly

Using plain, non-medical language Show or draw pictures

Limit the amount of information provided and repeat it

Use teach-back (let the patient tell information in their own words to check understanding).

Shared decision making

Make patients aware that they have a choice in health care or treatment. Inform patients about health care or treatment options in more detail.

Support patients to explore ‘what matters most to them’ after informing on treatment options. Train patients to participate in shared decision making.

Enabling self-management

Assess barriers and facilitators relating to treatment compliance. Involve the patient in formulating personalized goals and action plans. Train patients to perform adequate behaviour to manage their own health.

In the previous questions 15 to 30 you indicated how frequently you used each medical consultation skill in roleplay with simulated patients.

Which of these consultation skills do you find easy to apply in roleplay with a simulation patient? Explain your answer:

In the previous questions 15 to 30 you indicated how frequently you used each medical consultation skill in roleplay with simulated patients.

Which of these consultation skills, do you find difficult to apply in roleplay with a simulation patient? Explain your answer:

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Your opinion on using health literacy consultation skills (attitude)

Health literacy consultation skills are defined as the communication and teaching strategies that have been described as effective with low health literacy patients. These include, plain language communication, which is the avoidance of medical jargon, and Teach-Back, which is a teaching strategy that has the patient teach back to the provider the information just presented to them and also include skills related to shared decision making and promoting self-management. Please read each question and circle the answer that best reflects your opinion on the use of health literacy consultation skills. Choose only one answer.

My use of health literacy consultation skills with patients will result in patients having a better understanding of their illness and its treatment.

1

Likely 2 3 4 5 6 Unlikely7

Improved patient understanding will

improve patient outcomes. Agree1 2 3 4 5 6 Disagree7 Use of health literacy consultation skills

with patients would help patients stay healthy.

1

Agree 2 3 4 5 6 Disagree7

My use of health literacy consultation

skills with patients would be a… Bad idea1 2 3 4 5 6 Good idea7

Your confidence in using health literacy consultation skills

With respect to the following questions, please indicate your level of confidence in using health literacy consultation skills in roleplay conversations with simulation patients. Choose only one answer.

Scale 1 Not at all confident 2 Slightly confident 3 Neutral Moderately 4 confident 5 Very confident Questions

How confident are you in your ability to:

Use instruments to identify patients with low health literacy

Identify behaviors typically exhibited by people with low health literacy Gather information from patients with low health literacy

Provide clear information to patients with low health literacy

Use the teach back or show me technique to check understanding of patients with low health literacy Create a shame free environment for patients with low health literacy

Involve patients with low health literacy in shared decision making

Train patients with low health literacy to participate in shared decision making Stimulate patients with low health literacy to manage their own health

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216

Your evaluation of the health literacy consultation skills training

For each question indicate which answer applies best to you by ticking the appropriate boxes.

Have the objectives of this training been achieved

according to you? Yes Partially No

What was the balance between theory and practice

(exercises, roleplays, assignments)? Too much theory Good Too much practice Were you sufficiently challenged by the trainer to

participate actively? Yes Sometimes No

Please indicate how much you agree or disagree with the questions about the health literacy consultation skills training. Choose only one answer.

The training was tailored to my educational level. I found practicing with a simulation patient useful. I found the feedback during my roleplay conversations useful. I found the visually recording of my roleplay conversations useful. I would recommend this education program to other medical students

Open questions

What did you learn in this training related to health literacy focused communication? Do you have any advice or suggestions related to this training?

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H ab its Rat in g S ca le w ith a nc ho r p oi nt s H ab it 1 : I nv es t i n t he b eg in ni ng 1 2 3 4 5 A . S ho w fa m ili ar ity Cl in ic ia n n ee ds t o r ef er t o c ha rt co nt in ua lly t o f am ili ar iz e s el f w ith ca se o r d oe s n ot r el at e c ur re nt v isi t w ith p at ie nt ’s h ist or y o r c ha rt ( or d oe s not ev en h av e c ha rt) . Cl in ic ia n m ak es s om e r ef er en ce t o pa st v isi ts o r h ist or y, b ut f am ili ar ity w ith t he se d oe s n ot s ee m s tr on g. Cl in ic ia n i nd ica te s c le ar f am ili ar ity w ith pa tie nt ’s h ist or y/ ch ar t ( e.g ., m en tio ns r ec en t te st s p er fo rm ed o r v isi t i nf or m at io n b as ed o n pr ev io us c ha rt n ot es ). B. G re et wa rm ly G re et in g o f p at ie nt i s c ur so ry , im pe rs on al, o r n on -e xi st en t. Pa tie nt i s g re et ed i n m an ne r t ha t re cog ni ze s p at ie nt , b ut w ith ou t gr ea t w ar m th o r p er so na liz at io n. Pa tie nt i s g re et ed i n m an ne r t ha t i s p er so na l an d w ar m ( e.g ., c lin ic ia n a sk s p at ie nt h ow s /h e lik es t o b e a dd re ss ed , u se s p at ie nt ’s n am e). C. E ng ag e i n sm all tal k Th e c lin ic ia n g et s r ig ht d ow n t o bu si ne ss w ith ou t a ny a tte m pt a t s m al l ta lk ( or c ut s p at ie nt o ff c ur tly a nd ab ru pt ly , o r i f l at er i n v isi t, s ho w s onl y p as sin g in te re st) . Cl in ic ia n m ak es c ur so ry a tte m pt a t sm al l t al k ( sh ow s n o g re at i nt er es t, ke ep s d isc us sio n b rie f b ef or e m ov in g o n) . Cl in ic ia n m ake s n on -m ed ica l c om m en ts , u si ng th es e t o p ut t he p at ie nt a t e as e. D. Q ue st io n s ty le Th e c lin ic ia n t rie s t o i de nt ify t he pr ob le m (s) u si ng pr im ar ily cl os ed -en de d q ue st io ns ( st ac ca to s ty le) . Th e c lin ic ia n t rie s t o i de nt ify t he pr ob le m (s) u si ng a c om bi na tio n o f op en a nd c lo se d e nd ed q ue st io ns (p os sib ly b eg in s w ith o pe n-en de d bu t q ui ck ly r ev er ts t o c lo se d e nd ed ). Th e c lin ic ia n t rie s t o i de nt ify t he p ro bl em (s) us in g p rim ar ily o pe n-en de d q ue st io ns ( as ks qu es tio ns i n a w ay t ha t a llo w s p at ie nt t o t el l ow n s to ry w ith m in im um o f i nt er ru pt io ns o r clos ed en de d qu es tio ns ). E. E xp an sio n o f co nc er ns Th e c lin ic ia n i nt er ru pt s o r c ut s t he pa tie nt o ff i n h is/ he r a tte m pt t o ex pa nd ( is c le ar ly n ot v er y i nt er es te d) . Cl in ic ia n n ei th er c ut s t he p at ie nt off n or e xp re ss es g re at i nt er es t i n le ar ni ng m or e ( lis te ns , b ut d oe s not e nc ou ra ge e xp an sio n o r f ur th er di sc uss io n) . Th e c lin ic ia n e nc ou ra ge s t he p at ie nt t o e xp an d in d isc us si ng h is/ he r c on ce rn s ( e.g ., u si ng va rio us c on tin ue rs s uc h a s A ha, t el l m e m or e, G o o n) . F. E lic it f ul l ag en da Th e c lin ic ia n i m m ed ia te ly p ur su es th e p at ie nt ’s fi rs t c on ce rn w ith ou t a n atte m pt t o d isc ov er ot he r p os sib le co nc er ns o f t he p at ie nt s. Th e c lin ic ia n m ak es s om e re fe re nc e t o ot he r p os sib le co m pl ai nt s, o r a sk s b rie fly a bo ut th em b ef or e p ur su in g t he p at ie nt ’s fir st c om pl ai nt , o r g en er at es a n ag en da a s t he v isi t p rog re ss es Th e c lin ic ia n a tte m pt s t o e lic it t he f ul l r an ge of t he p at ie nt ’s c on ce rn s b y g en er at in g a n ag en da e ar ly i n t he v isi t ( cl in ic ia n d oe s ot he r th an s im pl y p ur su e fi rs t s ta te d co mpl ai nt ).

CHAPTER 4 APPENDIX 4.2

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H ab it 2 : E lic it p at ie nt ’s p er sp ec tiv e 1 2 3 4 5 A. P at ie nt ’s un de rs ta nd ing o f th e p ro bl em Cl in ic ia n m ake s n o a tte m pt /sh ow s n o in te re st i n u nd er st an di ng t he p at ie nt ’s pe rs pe ct ive. Cl in ic ia n s ho w s b rie f o r s up er fic ia l in te re st i n u nd er st an di ng t he p at ie nt ’s un de rs ta nd ing o f t he p ro bl em a nd br iefl y c on sid er s l ow h ea lth l ite ra cy . Cl in ic ia n s ho w s g re at i nt er es t i n e xp lo ring t he pa tie nt ’s u nd er st an di ng o f t he p ro bl em ( e.g ., as ks t he p at ie nt w ha t t he s ym pt om s me an t o hi m /h er ) a nd c on sid er s l ow h ea lth l ite ra cy : do y ou n ee d h el p t o fi ll i n f or m s? C ue s: m is se d a pp oi nt me nt s, e xc us es , i nc on sis te nt inf or m at io n. B. G oa ls f or v isi t Cl in ic ia n m ake s n o a tte m pt t o de te rm in e ( sh ow s n o i nt er es t i n) w ha t th e p at ie nt h op es t o g et o ut o f t he v isi t. Cl in ic ia n s ho w s i nt er es t i n g ett ing a br ie f s en se o f w ha t t he p at ie nt h op es to g et o ut o f t he v isi t, b ut m ov es o n qu ic kl y. Cl in ic ia n a sk s ( or r es po nd s w ith i nt er es t) ab ou t w ha t t he p at ie nt h op es t o g et o ut o f th e v isi t ( e.g ., c an b e ge ne ra l e xp ec ta tio ns o r sp ec ifi c r eq ue st s s uc h a s me ds , r ef er ra ls) . C. I m pa ct o n l ife Cl in ic ia n m ake s n o a tte m pt t o de te rm in e/ sh ow s n o i nt er es t i n h ow th e p ro bl em i s a ffe ct ing p at ie nt ’s lif es ty le . Cl in ic ia n a tte m pt s t o d et er m in e b riefl y/ sh ow s o nl y s ome i nt er es t i n h ow t he pr ob le m i s a ffe ct ing p at ie nt ’s l ife st yl e. Cl in ic ia n a tte m pt s t o d et er m in e i n d et ai l/ sh ow s g re at i nt er es t i n h ow t he p ro bl em i s affe ct ing p at ie nt ’s l ife st yl e ( w or k, fa m ily , d ai ly ac tiv iti es ). H ab it 3 : D em on st rat e e m pat hy a nd c re at es a s ha m e f re e e nv ir on m en t, t o a dd re ss p ot en tia l f ee lin gs o f s ha m e a nd /o r c on fu si on 1 2 3 4 5 A. E nc ou ra ge emo tio na l ex pr es sion Cl in ic ia n s ho w s n o i nt er es t i n p at ie nt ’s em ot io na l s ta te a nd /o r d isc ou ra ge s or c ut s o ff t he e xp re ss io n o f e m ot io n by t he p at ie nt ( sig na ls v er ba lly o r no nv er ba lly t ha t i t i s n ot o ka y t o ex pres s e m ot io ns ). Cl in ic ia n s ho w s r el at iv el y l itt le i nt er es t or e nc ou ra ge me nt f or t he p at ie nt ’s ex pr es sio n o f e m ot io n; o r a llo w s em ot io ns t o b e s ho w n b ut a ct iv el y o r su bt ly e nc ou ra ge s p at ie nt t o m ov e o n. Cl in ic ia n o pe nl y e nc ou ra ge /is r ec ep tiv e t o th e e xp re ss io n o f e m ot io n ( e.g ., t hr ou gh u se of c on tin ue rs o r a pp ro pr ia te p au se s ( sig na ls ve rb al ly o r n on ve rb al ly t ha t i t i s o ka y t o ex pr es s f ee ling s). B. A cc ept fe el in gs Cl in ic ia n m ake s n o a tte m pt t o r es po nd to /v al id at e t he p at ie nt ’s f ee ling s, o r po ss ib ly b el itt le s o r c ha lle nge s t he m (e .g ., I t’s r id ic ul ou s t o b e s o c on ce rn ed ab ou t . . . ). Cl in ic ia n b riefl y a ck no w le dge s p at ie nt ’s fe el ing s b ut m ake s n o eff or t t o i nd ica te ac ce pt an ce /v al id at io n. Cl in ic ia n m ake s c om me nt s c le ar ly i nd ica ting ac ce pt an ce /v al id at io n o f p at ie nt ’s f ee ling s ( e.g ., I’d f ee l t he s ame w ay . . . I c an s ee h ow t ha t w ou ld w or ry y ou . . . ). C. I de nt ify f ee ling s Cl in ic ia n m ake s n o a tte m pt t o i de nt ify pa tie nt ’s f ee ling s. Cl in ic ia n m ake s b rie f r ef er en ce t o pa tie nt ’s f ee ling s, b ut d oe s l itt le t o ex pl or e t he m b y i de nt ifi ca tio n o r la be lli ng. Cl in ic ia n m ake s c le ar a tte m pt t o e xp lo re pa tie nt ’s f ee ling s b y i de nt ify ing o r l ab el ling th em ( e.g ., S o h ow d oe s t ha t m ake y ou f ee l? I t se em s t o me t ha t y ou a re f ee ling q ui te a nx io us ab ou t…) D. S ho w g oo d n on -ve rb al b eh av io ur Cl in ic ia n’ s n on ve rb al b eh av io ur di sp la ys l ac k o f i nt er es t a nd /o r co nc er n a nd /o r c on ne ct io n ( e.g ., l itt le or n o e ye c on ta ct, b od y o rie nt at io n or u se o f s pa ce i na pp ro pr ia te , b or ed vo ice) . Cl in ic ia n’ s n on ve rb al b eh av io ur s ho w s ne ith er g re at i nt er es t o r d isi nt er es t (o r b eh av io ur s o ve r c ou rs e o f v isi t a re in con sis te nt ). Cl in ic ia n d isp la ys n on ve rb al b eh av io ur s t ha t ex pr es s g re at i nt er es t, c on ce rn a nd c on ne ct io n (e .g ., e ye c on ta ct, t on e o f v oi ce , a nd b od y or ie nt at io n) t hr ou gh ou t t he v isi t.

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H ab it 4 : I nv es t i n t he e nd 1 2 3 4 5 A. U se p at ie nt s fr ame o f r ef er en ce Cl in ic ia n f ra me s d ia gn os is a nd in fo rm at io n i n t er m s t ha t fi t ph ys ic ia n’ s f ra me o f r ef er en ce r at he r th an i nc or po ra ting t ho se o f t he pa tie nt . Cl in ic ia n m ake s c ur so ry a tte m pt t o fr ame d ia gn os is a nd i nf or m at io n i n te rm s o f p at ie nt ’s co nc er ns an d att em pt s to p ro vi de b rie f a nd u nd er st an da bl e in fo rm at io n o n d ia gn os es. Cl in ic ia n f ra me s d ia gn os tic a nd o th er r el ev an t in fo rm at io n i n w ay s t ha t r efl ec t p at ie nt ’s in iti al p re se nt at io n o f c on ce rn s. I nf or m at io n on d ia gn os is i s b rie f a nd u nd er st an da bl e. B. A llo w t ime t o ab sor b Cl ini ci an gi ve s inf or m at io n an d co nt in ue s o n q ui ck ly w ith g iv ing pa tie nt o pp or tu ni ty t o r ea ct (im pr es sio n i s t ha t t hi s i nf or m at io n w ill n ot b e r eme m be re d p ro pe rly o r fu lly a pp re ci at ed b y t he p at ie nt ). Cl in ic ia n p au se s b riefl y f or p at ie nt re ac tio n, b ut t he n q ui ck ly m ov es o n (le av ing t he i m pr es sio n t ha t t he p at ie nt m ay n ot h av e f ul ly a bs or be d t he inf or m at io n) . Cl in ic ia n p au se s a fte r g iv ing i nf or m at io n w ith i nt en t o f a llo w ing p at ie nt t o r ea ct t o a nd ab so rb it . C. G iv e c le ar ex pla na tio n In fo rm at io n i s s ta te d i n w ay s t ha t ar e t ec hn ica l o r a bo ve p at ie nt ’s he ad ( in di ca ting t ha t t he p at ie nt h as pr ob ab ly n ot u nd er st oo d i t f ul ly o r pr op er ly) . In fo rm at io n c on ta in s s ome j ar go n a nd is s ome w ha t d iffi cu lt t o u nd er st an d. Cl in ic ia n a tte m pt s t o p rio rit iz e in fo rm at io n a nd u si ng A sk me 3 . In fo rm at io n i s s ta te d c le ar ly ( in p la in la ng ua ge ) a nd w ith l itt le o r n o u se o f j ar go n. Cl in ic ia n p rio rit iz es i nf or m at io n r ega rd ing ca us e, s ev er ity , c on se qu en ce s u si ng A sk me 3 : 1. W ha t d o I n ee d t o k no w , 2 . W ha t d o I n ee d to d o, 3 . W hy i s i t i m po rt an t? D. O ffe r r at io na le for te st s Cl in ic ia n o ffe rs /o rd er s t es ts a nd tr ea tme nt s, g iv ing l itt le o r a ny ra tio na le f or t he se . Cl in ic ia n o nl y b riefl y e xp la in s t he ra tio na le f or t es ts a nd t re at me nt s. Cl in ic ia n f ul ly /cl ea rly e xp la in s t he r at io na le be hi nd c ur re nt, p as t, o r f ut ur e t es ts a nd tr ea tme nt s s o t ha t p at ie nt c an u nd er st an d th e s ig ni fic an ce o f t he se t o d ia gn os is a nd tr ea tm ent . E. T es t f or co m pr eh en sion Cl in ic ia n m ake s n o eff or t t o d et er m in e w he th er t he p at ie nt h as u nd er st oo d w ha t h as b ee n s ai d. Cl in ic ia n b riefl y o r i neffe ct iv el y t es ts fo r t he p at ie nt ’s c om pr eh en sio n. Cl in ic ia n effe ct iv el y t es ts f or t he p at ie nt ’s co m pr eh en sio n a nd u se s T ea ch b ac k: I w an t t o m ake s ur e I h av e e xp la in ed e ve ry th ing c le ar ly , co ul d y ou t el l me i n y ou r o w n w or ds w ha t yo u n ee d t o k no w o r d o? F. I nv ol ve i n de ci sion s Pr ov id er s ho w s n o i nt er es t i n h av ing pa tie nt ’s i nv ol ve me nt o r a ct iv el y di sc ou ra ge s/i gn or es p at ie nt ’s eff or ts t o be p ar t o f d ec isi on -m ak ing p ro ce ss. Cl in ic ia n s ho w s l itt le i nt er es t i n in vi ting t he p at ie nt ’s i nv ol ve me nt i n t he de ci sio n-m ak in g p roces s, o r re sp on ds to t he p at ie nt ’s a tte m pt s t o b e i nv ol ve d w ith r el at iv el y l itt le e nt hu sia sm . Cl in ic ia n c le ar ly e nc ou ra ge s a nd i nv ite s pa tie nt ’s i np ut i nt o t he d ec isi on -m ak ing pr oc es s, u si ng C hoi ce t al k ( do ct or m ake s pa tie nt s a w ar e t ha t t he y h av e a c hoi ce : s te p ba ck , o ffe r a nd j us tif y c hoi ce , c he ck r ea ct io n, de fe r c lo su re ) a nd O pt io n t al k ( do ct or pr ov id es b rie f u nd er st an da bl e i nf or m at io n o n tr ea tme nt o pt io ns : c he ck k no w le dg e, l ist a nd de sc rib e o pt io ns , d isc us s h ar m s a nd b en efi ts , su m m ariz e)

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G . E xp lo re p la n acc ept ab ili ty Cl in ic ia n o ffe rs r ec om m en da tio ns fo r t re at m en t w ith l itt le o r n o atte m pt s t o el ic it pa tie nt ’s ac ce pt an ce of ( w ill in gn es s o r l ik el ih oo d o f fo llo w in g) t he p la n. Cl in ic ia n m ak es b rie f a tte m pt t o de te rm in e a cc ep ta bi lit y o f t re at m en t pl an , a nd m ov es o n q ui ck ly . Cl in ic ia n e xp lo re s a cc ep ta bi lit y o f tr ea tm en t p la n, e xp re ss in g w ill in gn es s t o neg ot ia te i f n ec es sa ry , u si ng d ec isi on t al k: in vo lv e t he p at ie nt i n d ec isi on m ak in g in clu di ng s up po rt t o e xp lo re i nd iv id ua l co ns id er at io ns : F oc us a nd e lic it p re fe re nc es , ed uc at e t he p at ie nt s h ow t o d isc lo se t he ir co nc er ns , a sk q ue st io ns a nd s ta te t he ir pr ef er en ce s, m ov e t o a de ci sio n, off er rev iew H. E xp lo re ba rr ie rs Cl in ic ia n d oe s n ot a dd re ss w he th er ba rr ie rs e xi st f or i m pl em en ta tio n o f tr ea tm en t p la n. Cl in ic ia n b rie fly e xp lo re s b ar rie rs t o impl em en ta tio n o f t re at m en t pl an . Cl in ic ia n f ul ly e xp lo re s b ar rie rs t o im pl em en ta tio n o f t re at m en t p la n a nd ad he re nc e t o t he t re at m en t. En ab lin g s elf -m an ag em en t 1 . Cl in ic ia n d oe s n ot d isc us s h ow t o pr ep ar e fo r s el f-m an age me nt . Cl in ic ia n b rie fly d isc us se s h ow t o pr ep ar e fo r s el f-m an age me nt . Cl in ic ia n d isc us se s h ow t o p re pa re f or s el f-m an ag em en t ( w rit e d ow n i nf or m at io n, h ow to s ta te p re fe re nc es , c on ce rn s). En ab lin g s elf -m an ag em en t 2 . Cl in ic ia n d oe s n ot f or m ul at e a nd re al ist ic g oa ls w ith t he p at ie nt s a nd do es n ot p ro vi de c le ar i ns tr uc tio ns Cl in ic ia n b rie fly d isc us se s t o fo rm ul at e a nd r ea lis tic g oa ls w ith t he pa tie nt s a nd b rie fly p ro vi de s c le ar ins tr uc tio ns Fo rm ul at es p er so na l a nd r ea lis tic g oa ls w ith th e p at ie nt a nd p ro vi de s c le ar i ns tr uc tio ns : o C om bi ne p rio r k no w le dg e o n d ise as e w ith id en tif yi ng s tra teg ie s f or n ew b eh av io ur . o S tr en gt he n s el f-e ffi ca cy : d isc us s s el f-m on ito rin g, o ve rc om in g p ro bl em s, s ou rc es of s up po rt. En ab lin g s elf -m an ag em en t 3 . Cl in ic ia n m ak es n o e ffo rt t o de te rm in e w he th er t he p at ie nt h as un de rs to od t he i ns tr uc tio ns . Cl in ic ia n b rie fly o r i ne ffe ct iv el y t es ts fo r t he p at ie nt ’s c om pr eh en sio n o f ins tr uc tio ns . U se s t ea ch b ac k t o c he ck u nd er st an di ng o f in st ru ct io ns : a sk p at ie nt s t o t el l i ns tr uc tio ns in t he ir o w n w ord s. I. E nc ou ra ge qu es tio ns Cl in ic ia n m ak es n o a tte m pt t o s ol ic it ad di tio na l q ue st io ns f ro m p at ie nt or l ar ge ly i gn or es t he m i f m ad e un so lic ite d. Cl in ic ia n a llo w s f or a dd iti on al qu es tio ns f ro m p at ie nt , b ut d oe s not e nc ou ra ge q ue st io n a sk in g n or re sp on d t o t he m i n m uc h d et ai l. Cl in ic ia n o pe nl y e nc ou ra ge s a nd a sk s f or ad di tio na l q ue st io ns f ro m p at ie nt ( an d re sp on ds t o t he m i n a t l ea st s om e d et ai l). E. g. , w ha t q ue st io ns d o y ou h av e, i ns te ad o f do y ou h av e a ny q ue st io ns ? J. P la n f or f ol lo w up Cl in ic ia n m ak es n o r ef er en ce t o fo llo w -u p p la ns . Cl in ic ia n m ak es r ef er en ce s t o f ol lo w -up , b ut d oe s n ot m ak e s pe ci fic p la ns . Cl in ic ia n m ak es c le ar a nd s pe ci fic p la ns f or fo llo w -u p t o t he v isi t. O ve ra ll e va lu at io n: w he n y ou c on si de r y ou r r at in gs r el at in g t o t he f ou r h ab its a nd n on -v er ba l c om m un ic at io n, w hat r at in g w ou ld y ou p ro vi de f ro m 1-10 a s a n o ve ra ll e va lu at io n o f t he e nt ir e M ed ic al c on su ltat io n? Ra tin g f ro m 1 -10 Sp ec ifi c f ee db ac k o r s pe ci al i ss ue s r eg ar di ng m ed ic al c on su ltat io n: Fill in :

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221 CH

A

PT

ER 5 A

PP

EN

DI

X 5

Overview of det ailed s ear ch str at egy Step s Pu bme d Sco pu s Ci na hl Ps yc hIn fo Step 1 . Te rm s r el at in g t o “he al th l it er ac y” he alt h l ite ra cy [ti ] O R h ea lth lit er at e[ ti] O R “ H ea lth Li te ra cy /o rg ani za tio n an d ad m in is tr at io n” [M es h] A N D TI TL E “h ea lth lit er ac y” O R “ he alt h lit er at e” A N D M H “ H ea lth L ite ra cy /O G ” O R T I he alt h l ite ra cy O R h ea lth lit er at e AN D M M “ H ea lth L ite ra cy ” O R M M “M en ta l H ea lth L ite ra cy ” O R T I he al th l ite ra cy O R h ea lth l ite ra te A N D Step 2 . Te rm s r el at in g to “ he al th c ar e se tt ing ” “C om mu nit y H ea lth Se rv ices ”[ M es h] O R he alt hc ar e s ys te m *[ ti ab ] O R “ Pr im ar y H ea lth C ar e” [M es h] O R p ri m ar y ca re [ti ab ] O R “ D el iv er y of H ea lth C ar e/ or ga ni za tio n and ad m in is tr at io n” [M es h] O R o rg ani za tio n* [ti ab ] O R o rg ani za tio n* [ti ab ] OR h os pi ta l*[ ti ab ] OR in sti tu tio n* [ti ab ] TI TL E-ABS K EY o rg an iz at io n* OR or gani za tio n* O R “h ea lth ca re s ys te m *” O R “ pr im ar y c ar e” O R “ pr im ar y h ea lth ca re ” O R “ pr im ar y he alt hc ar e” O R ho sp ita l* M H “ Pr im ar y H ea lth C ar e” O R M H “ H ea lth C ar e D el iv er y+ / A M ” O R M H “ Co m m un ity H ea lth Se rv ic es ” O R M H “ Co m m un ity M en ta l H ea lth S er vi ce s+ ” O R M H “Co m m un ity H ea lth N ur si ng +” O R M H “ H om e H ea lth C ar e+ ” O R M H “P re ve nt iv e H ea lth C ar e+ ” O R T I ( o rg ani za tio n* O R o rg ani za tio n* O R h ea lth ca re s ys te m * O R p ri m ar y ca re O R p ri m ar y h ea lth c ar e O R pr im ar y h ea lth ca re O R h os pit al * O R in st itu tio n* D E “ Pu bl ic H ea lth S er vi ce s” O R D E “ Pr im ar y H ea lth C ar e” O R T I ( o rg ani za tio n* O R o rg ani za tio n* O R h ea lth ca re s ys te m * O R p ri m ar y ca re o r p ri m ar y h ea lth c ar e o r pr im ar y h ea lth ca re O R h os pi ta l* O R in st itu tio n* O R A B o rg an iz at io n* O R or ga ni za tio n* O R K W o rg an iz at io n* O R o rg an iz at io n* O R h ea lth ca re sy st em Step 3 . Se arc h t er ms re la ti ng t o “ In te r-ve nt io n-ch ar ac te r-is ti cs ” O R “ O rg ani za tio na l cu ltu re ”[ M es h] O R “O rg ani za tio na l In no va tio n” [M es h] O R “ O rg ani za tio n an d A dm in is tr at io n” [M es h] O R “P ro gr am D ev el opm en t” [M es h] O R “ Pr of ess io na l-P at ie nt R el at io ns ”[ M es h] O R “C ult ur al ly C om pe te nt C ar e” [M es h] O R p ro gr am de ve lo pm ent [ti ab ] O R pr of es si on al p at ie nt re la tio n* [ti ab ] O R c ro ss cu ltu ra l c om m un ic ati on [ti ab ] O R in te rc ult ur al co m m un ic at io n[ ti ab ] O R “p ro gr am de ve lo pm ent ” O R “ pr of es si on al pat ie nt r el at io n* ” O R “ cr os s c ult ur al co m m un ic at io n” O R “i nt er cu ltu ra l co m m un ic at io n” O R M H “ O rg an iz at io na l C ul tu re +” O R M H “ O rg an iz at io na l C ha ng e” O R M H “ Pr og ra m D ev el op m en t+ ” O R M H “ Pr of ess io na l-P at ien t R el at io ns +” O R M H “ C ul tu ra l Co m pe te nc e” O R p ro gr am de ve lo pm en t O R p ro fe ss io na l pa ti en t r el at io n* O R c ro ss c ul tu ra l co m mu ni ca tio n O R in te rc ult ur al co m mu ni ca tio n O R D E “ H ea lth C ar e D el iv er y” O R D E “ C lin ic al P ra ct ic e” O R D E “ H ea lth C ar e A cc es s” O R D E “ H ea lth C ar e Co st s” O R D E “ H ea lth C ar e R ef or m ” O R D E “ H ea lth C ar e U ti liz at io n” O R D E “ M an ag ed C ar e” O R D E “Q ua lit y of C ar e” O R D E “ Q ua lit y of Se rv ic es ” O R D E “ C lin ic al P ra ct ic e” O R D E “ C as e Co nc ep tu al iz at io n” O R D E “ H ea lth C ar e A cc es s” O R D E “ Tr ea tm en t B ar ri er s” O R D E “U ti liz at io n R ev ie w s” O R D E “ H ea lth M ain te nan ce O rg ani za tio ns ” O R D E “ O rg an iz at io na l C ha ng e” O R D E “ O rg an iz at io na l C lim at e” O R D E “ In no va tio n” O R D E “ Pr og ra m D ev el op m en t” O R D E “ Th er ap eu tic Pr oc es se s” O R p ro gr am d ev el opm en t O R p rof es si on al pa ti en t r el at io n* O R cr os s c ul tu ra l c om m un ic at io n O R in te rc ult ur al c om m un ic at io n) N um be rs re tr ie ve d p er da ta ba se 15 11 13 51 17 50 80 8

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222 CHAPTER 6 APPENDIX 6

Tables S1 – S6 including descriptive results of the perceived moderators.

Table S1. Frequency scores of moderator ‘Participant Responsiveness’ (Implementation stage 1).4

Ireland (N = 7) Netherlands (N = 13)

Moderators Agree Dis-_agree Neither _A/D1 Missing _{res ponses Agree} Dis-_agree Neither _A/D Missing _{res ponses}

Participant responsiveness

- Helps identify issues in setting that may disadvantage patients

7 - - - 11 2 -

-- Helps reduce time in dealing with accessibility issues and repeating information to patients

3 2 2 - 5 2 5 1

- Helps make improvements

in relationship with patients 4 1 2 - 7 1 4

-- Satisfied with intervention 3 3 1 - 9 - 4

-- Professional obligation 5 1 - - 6 1 6

-- Actively involved with implementation of intervention

3 3 1 - 12 - 1

-- I am not the correct person

to implement 2 3 2 - 3 8 2

-- Subjective norm -- normative

beliefs direct colleagues 2 1 1 5 - 1 4 8

-- Subjective norm -- normative

beliefs other persons 2 1 - 6 - 3 3 7

-- Subjective norm -- motivation to comply direct colleagues and managers 3

6 - 1 - 6 3 4

-- Subjective norm -- motivation

to comply other persons 3 7 - - - 9 2 1 1

- Social support 6 - 1 - 7 4 2

-- Self--efficacy 1 4 2 - 7 1 5

-- Knowledge 1 6 - - 9 2 2

-Intervention complexity

- Tool is too complicated 2 5 - - 1 10 2

-- It is too long 3 3 1 - 2 8 2 1

- I cannot answer all

questions in tool 5 2 - - 5 7 1

-- Provides practical way to

assess health literacy 7 - - - 8 1 4

-1_{Neither A/D= neither agree/disagree.}2 _{Alternative response scale: 1) most definitely not, 2) definitely} not, 3) perhaps not, perhaps, 4) definitely, 5) most definitely, recoded into disagree (most definitely not, and definitely not), agree (definitely, and most definitely) and neither agree or disagree (perhaps not, perhaps). 3_{Alternative response scale: 1) very little, 2) little, 3) not a little, not a lot, 4) a lot, 5) a great deal} recoded into disagree (very little, and little) agree (a lot, and a great deal) and neither agree or disagree (not a little, not a lot). 4_{This questionnaire was informed by: Fleuren, et. al. Towards a Measurement} Instrument for Determinants of Innovations. Int. J. Qual. Health Care, 2014, 26 (5), 501–510

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Table S2. Frequency scores of moderator ‘Facilitating Strategies’ (Implementation stage 2)3

Dis-agree Neither A/D1 Agree NA2

Missing

responses Dis-_agree Neither _A/D Agree NA Missing_responses

- Clear training/ introductory meeting - - 3 - 4 - 2 4 1 1 - Useful training/ introductory meeting - - 3 - 4 - 3 4 1 -- Sufficient training/ introductory meeting - - 3 - 4 - 2 4 1 1 - Clear protocol/ manual - - 1 - 6 3 1 4 - -- Useful protocol / manual - - 1 - 6 1 1 6 - -- Sufficient protocol / manual - - 1 - 6 3 1 4 - -- Clear feedback - - 1 - 6 - 1 4 3 -- Useful feedback - - 1 - 6 - 1 4 3 -- Detailed feedback - - 1 - 6 1 2 2 3

-1 _{Neither A/D= neither agree/disagree.}2 _{NA= if participant chose ‘not applicable’ or ‘no’ to question.}3 _This questionnaire was informed by: Schinckus, L. et. al. Assessment of implementation fidelity in diabetes self-management education programs: A systematic review. Patient Educ. Couns., 2014, 96 (1), 13–21; and Schinckus, L. Implementation fidelity questionnaire diabetes health education interventions.; 2014, UCLouvain, Belgium.

Table S3. Frequency scores of moderator ‘Participant responsiveness’ (Implementation stage 2).2

Ireland (N = 5) Netherlands (N = 8) Disagree Neither _A/D1 Agree Disagree Neither _A/D Agree

- Satisfied with content of

OHL-intervention - 1 4 2 2 4

- The OHL-intervention met my needs - 2 3 1 2 5

- Engaged in the OHL-intervention - - 5 - 1 7

- Satisfied with delivery - 1 4 1 1 6

- Used available resources (eg. staff with organisational competency relating to health literacy assessment)

- 1 4 - - 8

- Recognised the benefits of

OHL-intervention - - 5 - 1 7

- Carried out the essential activities - - 5 - - 8

- Involved beyond what was expected 1 3 1 1 3 4

1 _{Neither A/D= neither agree/disagree.}2 _{This questionnaire was informed by: Schinckus, L. et. al.} Assessment of implementation fidelity in diabetes self-management education programs: A systematic review. Patient Educ. Couns., 2014, 96 (1), 13–21; and Schinckus, L. Implementation fidelity questionnaire

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Table S4. Frequency scores of moderator ‘Intervention Complexity’ (Implementation stage 2). 3

Ireland (N = 5) Netherlands (N = 8) Dis agree Neither _A/D1 Agree NA2 Dis agree Neither _A/D Agree NA

- Familiar with content _- _- ₅ _- ₂ ₂ ₄

-- Needed training to implement the OHL-intervention

2 1 2 - 5 2 - 1

- Many components to

implement - 3 2 - 3 - 5

-- Clear descriptions - 2 3 - 2 4 2

-- Used to this kind of tool ₄ ₁ _- _- ₆ ₁ ₁

-- I had to perform components

of the tool several times 1 1 3 - 3 1 4

-- Detailed description of the tool sufficiently detailed

1 3 1 - 1 2 5

-- Many difficult goals to reach _- ₂ ₂ ₁ ₄ ₂ ₂

-- Had to work with other professionals to deliver the OHL-intervention

- - 5 - 1 - 7

-- The OHL--intervention required a lot of effort from the institution/hospital setting

1 - 4 - 1 - 7

-1 _{Neither A/D= neither agree/disagree.}2 _{NA= if participant chose ‘not applicable’ or ‘no’ to question.}3 _This questionnaire was informed by: Schinckus, L. et. al. Assessment of implementation fidelity in diabetes self-management education programs: A systematic review. Patient Educ. Couns., 2014, 96 (1), 13–21; and Schinckus, L. Implementation fidelity questionnaire diabetes health education interventions.; 2014, UCLouvain, Belgium.

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Table S5. Frequency scores of moderator ‘Quality of delivery’ (Implementation stage 2). 3

Dis-agree Neither A/D1 Agree NA2 _responsesMissing _agreeDis- Neither _A/D Agree NA Missing_responses

- The OHL-intervention would be very useful for patients

1 - 4 - - - - 7 - 1

- Knew the subject of

the OHL-intervention 1 1 3 - - 1 1 5 - 1

- Used simple words - - 4 1 - - 2 4 1 1

- Was highly motivated to deliver the OHL-intervention 1 1 3 - - - - 6 - 2 - Repeated essential information components involving patients/ clients - 1 2 2 - - 1 4 3 -- Able to answer questions during implementation involving patients/ clients 1 2 1 1 - - - 5 3 -- Lacked experience - - 5 - - 4 3 1 - -- Asked open questions during implementation involving patients/ clients - 1 2 2 - - 1 5 2 -- Had a good knowledge of health literacy and its environmental assessment 1 2 2 - - - 4 4 - -- Actively listened to patients / clients during implementation - 2 1 2 - - 1 5 2

-- Sceptical about the outcome of the

OHL-intervention 3 - 2 - - 7 1 - -

-1 _{Neither A/D= neither agree/disagree.}2 _{NA= if participant chose ‘not applicable’ or ‘no’ to question.} 3 _This questionnaire was informed by: Schinckus, L. et. al. Assessment of implementation fidelity in diabetes self-management education programs: A systematic review. Patient Educ. Couns., 2014, 96 (1), 13–21; and Schinckus, L. Implementation fidelity questionnaire diabetes health education interventions.; 2014, UCLouvain, Belgium.

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Table S6. Frequency scores of moderator ‘organisational context’ (Implementation stage 2).2

Ireland (N = 4) Netherlands (N = 8) Agree Disagree Neither

A/D1 Agree Disagree Neither A/D

Moderators associated with the organizational context

- Formal ratification by management 1 3 - - 8

-- Replacement when staff leave - 3 1 - 7 1

- Staff capacity 2 - 2 2 5 1

- Financial resources - 1 3 - 4 4

- Time available 2 1 1 2 4 2

- Material resources and facilities 1 1 2 1 3 4

- Coordinator 3 1 - 5 3

-- Unsettled organisation 2 2 - 7 1

-- Information accessible about use of the

innovation 1 3 - 8 -

-- Performance feedback 2 2 - 4 1 3

- Observability 1 2 1 3 2 3

1 _{Neither A/D= neither agree/disagree.}2 _{This questionnaire was informed by: Schinckus, L. et. al.} Assessment of implementation fidelity in diabetes self-management education programs: A systematic review. Patient Educ. Couns., 2014, 96 (1), 13–21; and Schinckus, L. Implementation fidelity questionnaire