May 17th, 2013
I was facilitating a workshop about health literacy recently and we were talking about schema – the mental maps we each have to organise what we know, believe and feel about health issues. When we receive new health information we evaluate it against our existing schema to see if it fits with what we already know – and if it fits we are likely to add the information to our schema. If new information contradicts our schema, or does not connect with what we already know, it can be hard to incorporate the new information into our schema.
A woman in the workshop (I’ll call her Sally) shared how she had been recently told she had high cholesterol by her GP. Sally said she found it hard to believe because she thought ‘skinny’ people didn’t have high cholesterol. She told her GP she was surprised but he didn’t give her much information other than to cut out high-cholesterol foods. Knowing she already had a healthy diet, she was quite confused about how she could have high cholesterol and spoke to a friend about it – who also had high cholesterol but had been put on medication by her GP and “didn’t worry about it anymore”. Sally wondered why her GP hadn’t discussed medication with her. She also went online to search out more information on cholesterol but thought the information was a bit varied and not specific enough for her needs. In the end she stopped thinking about it as it wasn’t helping her answer her questions and it was all a bit stressful.
She realised during the workshop that there wasn’t much in her schema about cholesterol – and what she did have contradicted the message from her GP so might not be accurate. She realised she’d never paid attention to messages about cholesterol because she didn’t anticipate it being an issue for her. She decided to renew her efforts and seek out some explanations from health professionals she knew so she could better understand her situation and what her options were.
I thought this is a great example of how we all have episodes of low health literacy when we encounter a new health issue. It can be challenging to work out where to get good, reliable health information – even when we’re motivated – process it, and then decide how to apply it. It’s also great that Sally feels re-energised to go and find out more. Her GP didn’t provide much help initially but she’s determined to ask more questions next time she sees him. Excellent!
Posted in Improving Health Literacy
May 1st, 2013
I read an interesting blog the other day on Kevin MD.com. The title of the blog was “If you build a patient portal, why won’t they come?”:
I have always been interested in patient portals because I think they can be a real asset for patients to access their health information. However, the portals I have seen seem to be afterthoughts or add-ons to the main event which is a clinical portal enabling the sharing of health information between different parts of the health system and health professionals. As such, these portals are very useful, providing timely access to data about patients no matter where they are in the health system – Accident and Emergency, at their GP, in a hospital clinic or even in a pharmacy.
The primary focus of most electronic record systems is to share data among health professionals. So the purpose of the system is established early on and the system’s architecture is based on that primary purpose. That is why it is so hard to “bolt on” a patient portal. There are two very different audiences and two very different purposes for the system. It is inevitable that the primary purpose will have precedence.
The blog post relates the story of the Mayo Clinic who are having a problem getting more than 50% of the 240,000 patients who have signed up for their patient portal to actually use the portal.
Mayo Clinic has pinpointed the fact that their portal doesn’t engage their patients. It is an interesting concept. We often think more of face to face interactions or resources needing to be engaging. As a result, Mayo Clinic has adapted social media and social networking models and developed an app so patients can access their health information.
Most people engage frequently with online shopping, social networking and social media sites and the attributes of these systems needs to form the architecture of great patient portals.
Developing a patient portal shouldn’t be an add-on but a separate and equally important development alongside a portal for health professionals. Each portal has a different purpose, a different audience and needs different architecture and features.
Posted in Improving Health Literacy
November 27th, 2012
I recently found the Health and Disability Commissioner’s easy read booklet (2012) on rights when you use a health or disability service. When compared to the earlier Consumers’ Rights leaflet (2009), this easy read booklet on consumers’ rights is just that – easy to read.
Each of the ten consumer rights are clearly explained using everyday language, and they also provide examples of what each right means. For example, Right #5 is “You have the right to be told things in a way you understand. This means:
- You should be spoken to in a way you understand;
- People should check that you have understood;
- People should use different ways to explain things to you;
- You should be able to talk freely, ask questions and be told the truth.
The author(s) of this resource have been clear about the booklet’s purpose and the diverse audience for the resource. The language is familiar and easy to understand, and the visuals support the messages.
November 15th, 2012
Due to our involvement in a Ministry of Health project on health literacy and skin infections this year, we read with interest the article in the New Zealand Herald in October about how our public pools are ‘festering cesspits of infection’.
We have all experienced some sort of discomfort about what might be “in” the water in public pools but we may not have experienced all the disgusting elements mentioned in the article. This reminds me of a scene from the movie Grown Ups when one of the fathers shamed the children by turning the swimming pool a deeper shade of blue (who knew they added these sorts of chemicals to swimming pools?).
However, one of the good things about chlorine swimming pools is that they help prevent skin infections. Regular bathing in chlorine treated water helps treat minor skin infections and prevent the infection getting worse. One of the downsides of the closure of school pools was an increase in skin infections.
Posted in News
November 13th, 2012
Your largest internal organs are your lungs, but your largest organ overall is your skin. A recent newspaper article in the New Zealand Herald revealed that in a survey of 2000 British people, 75% did not know that the skin was the correct answer. In addition, many people were unable to correctly locate their spleen or their liver.
These results remind me of an earlier blog I wrote about an Australian poster of human anatomy, which was developed for indigenous programmes, and had a number of errors in relation to parts of the body (i.e. labeling the ovaries as kidneys).
So where should people be acquiring basic information about the human body? In basic science classes at school? For many this may have been a long time ago, and without regular exposure, is easily forgotten.
With television medical shows such as ER, House, Private Practice and Casualty, people are being provided with a new exposure to the human anatomy.
While the article goes on to state that these television medical shows can be useful, they are also causing more people to self diagnose their illnesses rather than consult a GP. Please leave a comment below and tell us if you believe the popularity of television medical shows is a positive or negative influence on health literacy.
Posted in News
November 11th, 2012
It is easy to accept the words we read in newspapers and online publications as robust information, especially when it comes to health information published by credible sources. It would not often cross our minds to question the validity of the messages we are reading.
However, a group of Australian professionals working within various realms of the healthcare industry are asking us to question what we read in health related media. At their health media review website, Media Doctor, health articles provided in mainstream publications are scrutinised for robustness of message and methodology. They claim that they are “improving the accuracy of medical news reporting”.
Media Doctor‘s specific objectives include: ensuring that all important information concerning new treatments is provided; alerting GPs to media coverage of new treatments, and; providing feedback to journalists. Each article is rated out of 10 by one of the Media Doctor health professionals, either scoring a “Satisfactory” (1) or “Not Satisfactory” (0) for ten individual criteria (e.g. evidence, harms of treatment, cost of treatment). The reviewer then adds their comments to address their score decision.
In a time when there are countless information providers, often dealing in conflicting or scare-mongering information, it is great to see that websites such as Media Doctor are making sure the public have the opportunity to access robust and accurate health messages.
Posted in News
November 8th, 2012
I often get asked by people for a way to evaluate patient education materials. I always respond that there isn’t a specific framework. Instead people have to work out why they are evaluating the resources. If they want to know if patients read the resources then they need to ask the patients directly.
So I was interested to read this article from Scottish and Chinese researchers who have developed an evaluation framework. Unsurprisingly, the researchers are from linguistics, foreign languages and health psychology fields.
Their framework has three elements – readability, comprehensibility, and communicative effectiveness. Readability is no surprise – for some people it is the cornerstone of resource development. I get frustrated when I hear people tell me that the majority of New Zealanders read at a seven to ten year old level. These sorts of generalisations aren’t correct. Adults are not children and using these children’s reading ages to determine how to write patient materials gives a false sense of security. These reading ages are based on vocabulary – what vocabulary would a five year old be expected to read, and so on. In fact, children can develop quite sophisticated vocabulary depending on the sorts of children’s books they are exposed to – Eric Carle’s The Hungry Caterpillar is a good example. And J.K. Rowling’s Harry Potter books would have increased children’s vocabulary significantly.
Low literacy adults may have lower reading vocabulary than children but adults have greater life experience than children, and therefore are more likely to understand conceptual matters if they are properly explained to them.
Readability formulae measure two things – sentence length and number of multi-syllabic words. Readability formulae are based on the premise that long sentences (often containing multiple clauses) are harder to understand, and multiple syllable words lead to higher readability scores. So to reduce readability scores use short sentences and single syllable words.
How realistic is that in health situations with commonly used multiple syllable words such as cholesterol, diabetes and respiratory?
And shortening sentences and replacing multiple syllable words don’t guarantee that the text will make sense. Christina Zarcadoolas has been a fierce critic of “simple” writing. Better to have a “higher” readability score because of the use of required medical terminology and provide explanations of those terms.
The second element of the framework is comprehensibility. It is great that the researchers realise that readability in itself does not ensure reader comprehension. (A lot of people writing health education pamphlets need to understand this). The researchers define comprehensibility as a reader being able to integrate vocabulary and grammatical structures to create contextual meaning. Vocabulary refers to words and groups of words (phrases) such as General Practitioner. Grammatical structures relate to how sentences and paragraphs are put together. This second element makes sense. The researchers rightly identify that comprehensibility is a function of the interaction between the reader and the text. However the way the researchers assess this second element is through written questions. But assessing that interaction based on written questions places a higher cognitive load (writing) on the reader than an oral interaction would and may in fact cause incorrect responses.
The third and final element of the framework is what the authors call “communicative effectiveness”. They define this as a function of the reader’s cognition (expectations and understandings), affect (concerns, worries), as well as intentions and behaviour. The authors say all these things are formed by the reader as the result of reading the text. The authors identify that for this element it is important to ask questions of the target audience. Communicative effectiveness is drawn from the concept of “usability” or “optimal usability design”. The authors do agree that this element is more complex than the other two elements – readability and comprehensibility. The authors suggest that this element is measured based on the intentions of the target audience. If the audience’s intentions correspond with the objectives of the resources then there is communicative effectiveness.
However this is no simple task. The authors suggest assessing this element using recorded interviews which will identify if the target audience first grasp the objectives of the resource (first two elements) and then indicate whether the audience intend to follow the resource.
The authors of this article have pulled on a range of linguistic, psychological and behavioural concepts. However the framework is not simple to implement. A much better approach is that which is described in Rauemi Atawhai. This involves engaging with the target audience BEFORE developing any concepts or draft materials. And then the concepts and draft materials are assessed with the target audience until the materials meet the purpose required. If the process in Rauemi Atawhai is followed then you won’t need a framework to assess resources, the process will have taken care of it.
Posted in News
November 4th, 2012
Recently I was asked to access an online e-learning module and give feedback on it. Despite the explicit instructions given and a subsequent email giving different instructions, I just couldn’t get into the module. It kept sending me a message wanting me to update my profile which I thought was bizarre because in my mind I’d never got into the proper page in the first place. So I was ready to give up, thinking I had wasted quite enough of my time. Then I thought back to those 1000 plus literacy learners I worked with over the years. I had asked them to do much more difficult things including navigating new systems. I had watched them fail and then struggle and persist and persevere – sometimes well and sometimes not. And I have walked ahead and behind and beside pushing and pulling and admiring because that is what I signed up for when I became an adult educator.
So with my adult learner status firmly in my face I did what I always suggested my learners to do when they got really stuck – I asked for help. I think the administrator thinks I am a technophobe (an opinion shared by my daughter) but I don’t really care. Here’s hoping the new and different set of instructions I have been given work.
Posted in News
November 4th, 2012
In July 2012 the results of a University of Otago study were published showing women were more likely to defer health care for financial reasons.
Professor Peter Crampton, one of the study’s authors, identified that the results of the study were a concern not just because women weren’t accessing care for themselves, but the financial issues were possibly acting as a barrier for any children and older people cared for by this group of women. The study also confirmed that women had more long term conditions than men which meant women should in fact be accessing more health care rather than less.
The study identified critical factors why women didn’t access primary care – being younger, lower income, more deprived, smokers and having two or more illnesses.
In this study Māori women were not affected when it came to visiting the doctor, however, if the women were Māori or Pacific they were less likely to pick up prescriptions.
Crampton and co-author Dr Santosh Jatrama suggested that providing free or very low cost primary health care would help address the costs barriers for a population group who are more likely to be carers for other people in their whānau.
When it comes to health literacy statistics women have better literacy (reading) skills than men. However, men have better numeracy and document skills (form filling, reading tables) than women.
My concern is the fact that these women are more likely to have long term conditions. To self manage long term conditions properly requires a lot of knowledge and skill. That knowledge can be gleaned from good reliable sites on the internet or publications. But mostly this knowledge and skill will be developed through a number of interactions with health professionals where the women can ask questions and confirm understandings.
So I support Crampton and Jatrana’s call to provide solutions to enable this group to access primary health care.
Posted in News
October 26th, 2012
The other day I read an article from Dutch researchers looking at reasons for non-participation in disease preventions programmes in general practice. Their research identified that the differences in participation levels may partly be due to differences in recruitment strategies. The authors identified that more active personalised strategies resulted in higher participation levels compared to an invitation letter.
A couple of days after I read this article I recalled a letter in the mail inviting me to participate in research investigating the prevention of osteoporosis and fractures. According to the letter my name was randomly selected from the Electoral Roll.
If I am interested in participating in the study then I have to read a one page letter, fill in form and send it back to the University of Auckland. Now if I had low health literacy there is no way I would be able to understand the letter enough to respond appropriately and so I would probably just have ignored the letter.
With the Dutch article fresh in my mind I wondered what would have happened if someone had rung me or approached me in my GP’s office. If I had low health literacy this would be the only method which would encourage me to participate in this sort of trial. I realise the Dutch article did not refer to research trials but instead letters encouraging people to take part in screening or other programmes. However as long as we rely on written reminders participation rates may be variable.
Posted in News