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

(1)

University of Groningen

Improving communication in healthcare for patients with low health literacy

Kaper, Marise

DOI:

10.33612/diss.172455932

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.

Document Version

Publisher's PDF, also known as Version of record

Publication date: 2021

Link to publication in University of Groningen/UMCG research database

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

Copyright

Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

Take-down policy

If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.

(2)

559391-L-bw-Kaper 559391-L-bw-Kaper 559391-L-bw-Kaper 559391-L-bw-Kaper Processed on: 27-5-2021 Processed on: 27-5-2021 Processed on: 27-5-2021

(3)

Processed on: 27-5-2021 PDF page: 180PDF page: 180PDF page: 180PDF page: 180

180

Summary

In Europe, nearly half of the population has limited health literacy. As a result, people can experience difficulties in comprehending information, interacting with health professionals, finding their way in health care, and carrying out self-management activities to improve or maintain good health. Health literacy problems can worsen poor health outcomes and increase health differences. The impact of health literacy is exacerbated by increasingly complex health care systems, and expectations that people are able to (actively) participate in their own health care and treatment. Health care professionals and organizations can mitigate these problems by tailoring their communication and provision of care towards the needs and abilities of patients and to strengthen the health literacy skills and autonomy of patients. Therefore, the main aim of this thesis is to assess how health care professionals and organizations can improve communication with and provision of care to people with limited health literacy.

Chapter 1 introduces the concept health literacy and illustrates approaches for interventions to address it. To address health literacy-related problems in conversations with patients, and increase the effectiveness of health promotion and treatment, professionals need specific competencies. Unfor-tuna tely, existing training programs rarely address the wider scope of health literacy competencies which are needed to strengthen the autonomy and self-management of patients. Furthermore, along with better equipped professionals, better responsiveness of health care organizations is needed to make it easier for people to navigate, understand, and use information and their services. Studies have pointed to an urgent need for a systems approach to reduce health literacy problems, but such an approach requires more insight into the implementation processes and impact of organizational health literacy (OHL)-interventions. We describe the European project entitled “Intervention Research on Health Literacy among the Ageing Population” (IROHLA), which provided the context for this research. We also present the research objectives of this thesis, which are, as follows:

1. To develop and pilot test a comprehensive health literacy communication training for health professionals in Italy, Ireland, and the Netherlands. 2. To evaluate whether: (1) a comprehensive health literacy training increased

self-rated competencies of health professionals to address health literacy-related problems and support the development of people’s autonomy and self-management abilities after training and 6-12 weeks later; (2) professionals were satisfied with the training; (3) outcomes differed for the three participating European countries.

(4)

181

S

3. To assess whether this comprehensive Health Literacy Medical Consultation Skills (MCS)-training increased the health literacy competencies of undergraduate medical students in a Randomized Controlled Trial (RCT), with a waiting list condition.

4. To summarize the evidence on: (1) outcomes of Organizational Health Literacy (OHL)-interventions at patient, professional and organizational levels; and (2) factors and strategies that affect implementation and outcomes of these interventions.

5. To assess the implementation fidelity, moderators (barriers and facilitators), and the long-term impact of OHL-interventions in hospitals in Ireland and the Netherlands.

Chapter 2 reports on the development and pilot-testing of a comprehensive health literacy communication training for health professionals in Italy, Ireland, and the Netherlands, as investigated in a mixed-method study. Based on a literature review, we designed evidence-informed training-components to address functional, interactive, and critical health literacy. In focus group discussions, we explored health professionals’ perspectives and expectations regarding a training-program, and their views regarding the program after they had participated in the pilot-training. We also assessed their self-rated health literacy competency before and after the training. The training consisted of five components: health literacy education, gathering and providing information, shared decision-making, enabling self-management, and supporting behaviour change to apply the training into practice. Both the qualitative and the quantitative findings indicated that this comprehensive training can strengthen professionals’ health literacy knowledge, confidence, and skills to better communicate with people with limited health literacy. This training, evaluated and approved by professionals, has potential for wider application in European education and practice.

Chapter 3 reports on a multi-centre pre-post study to evaluate whether: (1) a comprehensive health literacy training increased self-rated health literacy competencies of health professionals, after training and six to twelve weeks later; (2) professionals were satisfied with the training; (3) outcomes differed for the participants in Italy, the Netherlands, and Northern Ireland. The training, lasting eight hours, involved the following components: health literacy knowledge, the practice of comprehensible communication skills, shared decision-making, enhancing self-management, and supporting behaviour change. We assessed self-reported health literacy competencies

(5)

182

Summary

and satisfaction with the training at baseline, directly after training, and six to twelve weeks later. Self-reported health literacy competencies of health professionals (n = 106) significantly increased following the training, and persisted at six to twelve weeks follow-up. The strongest increases involved strategies to enhance shared decision-making and to enable self-management. Professionals reported satisfaction with the training and considered it important for practice. Increases in competencies did not vary systematically between countries. These promising findings should be confirmed in an effectiveness study and further investigated during interaction with patients.

Chapter 4 reports the effects of a comprehensive training in health literacy competencies for undergraduate medical students, using an RCT, with waiting list condition. Participants were international and Dutch medical under-graduates at a medical faculty in the Netherlands. The training-intervention of eleven hours consisted of a health literacy lecture and five interactive small-group sessions, using role-play and videotaped conversations to practice gathering and providing information, shared decision-making, and enabling of self-management. We assessed self-reported health literacy competencies at baseline, and at follow-up after five and ten weeks (n = 79; intervention: 39; control: 40). In a subsample, we evaluated demonstrated skills in video-recorded consultations in order to validate the self-rated measurements. The training enhanced a wide range of health literacy competencies of undergraduate medical students and was well received by them. The greatest improvements reported were for providing comprehensible information, developing shared decision-making, and enabling self-management. Increases in observed skills validated the reported increases in self-rated competencies. We conclude that implementation of this training in education and clinical practice can help future doctors to acquire health literacy competencies.

Chapter 5 describes the findings of a scoping review of OHL-interventions. We investigated outcomes of OHL-interventions at patient, professional and organizational levels. We then unravelled factors and mechanisms that affect the implementation and outcomes of OHL-interventions. We searched and evaluated peer-reviewed articles from four scientific databases focusing on OHL-interventions. Twenty-three studies, reporting on health literacy problems in relation to OHL-assessment tools, showed that patients encounter problems particularly with communication, navigation, and fragmented health care. Thirteen studies discussed the use of the interventions, nine of these reporting that implementation of the intervention resulted in positive changes on the

(6)

183

S

OHL-domains regarding comprehensible communication, professionals’ competencies and practices, and strategic organizational changes. However, evidence on patient related outcomes is still scarce and needs reinforcement. Critical factors for organization-wide implementation of OHL-interventions were leadership support, a simultaneous top-down and bottom-up approach, a change champion and project committee, and staff commitment.

Chapter 6 focuses on the results of a long-term mixed method study to assess the implementation fidelity, moderators (barriers and facilitators), and long-term impact of OHL-interventions in one hospital in Ireland and three hospitals in the Netherlands. These interventions focused on improvement of navigation (i.e. finding your way in an organization) and comprehensible communication throughout organizations. Participants were hospital staff (n = 24) and older service users (n = 40). We assessed the degree of implementation, influence of barriers and facilitators, and impact at six, eight, and eighteen months, using questionnaires and in-depth semi-structured interviews. Both older adults and professionals identified a number of health literacy-related problems, such as difficulties in finding their way in health settings, and information that was too complex to understand. Professionals in particular implemented OHL-interventions aiming at better navigation and comprehensible communication. Implementation barriers were limited resources, and variation in organizational structures and procedures. Facilitators were participation by service users, leadership support, and stepwise implementation of interventions. The OHL-interventions were reported to lead to long-term organization-wide improvements, as shown by better embedding of health literacy policies, enhanced patient engagement, and provision of plain language training and comprehensible information. Findings were similar for the two countries, and indicate that long-term implementation of OHL-interventions can promote health equity and empowerment among health service users.

Chapter 7 presents the main findings of the various studies, addresses methodological issues, proposes implications for theory and practice, and outlines directions for future research. We conclude that comprehensive training sessions and organizational interventions can promote health literate communication by professionals and organizations. Comprehensive training sessions can significantly increase self-reported health literacy competencies of (future) health professionals, in particular regarding promotion of autonomy and self-management. Organization-wide implementation of comprehensive OHL-interventions seems to result in increased health literacy responsiveness

(7)

184

Summary

on the part of health care organizations and professionals, although evidence on patient-related outcomes is scarce. A wider application of comprehensive health literacy training and organizational interventions into European health care practice and education offers many opportunities to improve communication with and provision of care to people with limited health literacy.

(8)

185

(9)