Development of a complex intervention to improve health literacy skills

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<ul><li><p>Development of a complex intervention to improvehealth literacy skillsAstrid Austvoll-Dahlgren*, Stein Danielsen, Elin Opheim, Arild Bjrndal,, Liv Merete Reinar**,</p><p>Signe Flottorp*,, Andrew David Oxman &amp; Slvi Helseth</p><p>*Prevention, Health Promotion and Organisation Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway,Department of Cardio-thoracic Surgery, Oslo University Hospital, Oslo, Norway, Innlandet Hospital Trust, Brumunddal,</p><p>Norway, Regional Centre for Child and Adolescent Mental Health, Oslo, Norway, Faculty of Medicine, Institute of Health</p><p>and Society, University of Oslo, Oslo, Norway, **Primary Health Care Unit, Norwegian Knowledge Centre for the Health</p><p>Services, Oslo, Norway, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway,Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway, and Faculty of Health Sciences,</p><p>Oslo and Akershus University College of ApplieSciences, Oslo, Norway</p><p>Abstract</p><p>Background: Providing insight into the developmental processes involved in building interventions is animportant way to ensure methodological transparency and inform future research efforts. The objective ofthis study was to describe the development of a web portal designed to improve health literacy skillsamong the public.Methods: The web portal was tailored to address three key barriers to obtaining information, using theconceptual frameworks of shared decision-making and evidence-based practice and based on explicit crite-ria for selecting the content and form of the intervention.Results: The web portal targeted the general public and took the form of structured sets of tools. Contentincluded: an introduction to research methods, help on how to find evidence-based health information effi-ciently based on the steps of evidence-based practice, an introduction to critical appraisal, informationabout patient participation rights in decision-making, and a decision aid for consultations.Conclusions: The web portal was designed in a systematic and transparent way and address key barriersto obtaining and acting upon reliable health information. The web portal provides open access to the toolsand can be used independently by health care users, or during consultations with health professionals.</p><p>Keywords: consumer health information, decision support, evidence-based practice, health education,informatics, health; information seeking behaviour</p><p>Key Messages</p><p> Providing insight into how interventions are developed provides greater methodological transpar-ency</p><p> In this study, we describe the development of an intervention a web portal developed toimprove specific domains of health literacy</p><p> The intervention we developed may be a useful tool for members of the public, and a resource forhealth care information professionals and health educators</p><p> Researchers should aspire to provide insight into the developmental process of interventions inorder to inform the efforts of other researchers and developers</p><p> Further studies are needed to develop and evaluate interventions to improve health literacy</p><p>Introduction</p><p>Basing health care on the best available evidenceis an international priority.1 Evidence-based prac-tice requires that decisions about health care are</p><p>Correspondence: Astrid Austvoll-Dahlgren, Norwegian Knowledge Cen-tre for the Health Services: Prevention, Health Promotion and Organisa-tion Unit, PO Box 7004, St.Olavsplass, Oslo 0130, Norway. E-mail:astrid.austvoll-dahlgren@nokc.no</p><p> 2013 The authors. Health Information and Libraries Journal 2013 Health Libraries Group278 Health Information &amp; Libraries Journal, 30, pp. 278293</p><p>DOI: 10.1111/hir.12037</p></li><li><p>based on the best available, current, valid and rele-vant evidence. These decisions should be made bythose receiving care, informed by the tacit andexplicit knowledge of those providing care, withinthe context of available resources.1</p><p>The involvement of users of health care (hereaf-ter referred to as users) in health decisions abouttheir own health care is central to evidence-basedpractice and is widely acknowledged.13 In theshared decision-making, model users and healthprofessionals decide together in partnership inwhich information, responsibility and accountabil-ity are mutually shared.4 This shift from paternal-ism is argued to be the result of several factors,including political forces advocating health careusers autonomy, technological advancementsmaking health information widely available, andthe acknowledgement that user involvement isimportant for health outcomes and sustainablehealth care.46</p><p>However, effective participation is not onlydependent on the right to involvement, but also onaccess to reliable health information and the abilityto obtain such information.5,7 Evidence suggeststhat much of the health information available isincomplete, biased or not evidence-based.8,9 Thisis particularly of concern considering that manyusers have been found to have inadequate healthliteracy skills.10,11 Such health literacy skills aredescribed as the knowledge and skills that enableusers to obtain, understand and act upon healthinformation, and as the desired outcome of healtheducation by the World Health Organization.3,6 Ina systematic review of the relationship betweenhealth literacy and health carried out by Berkmanet al.,10 the evidence evaluated showed that lowhealth literacy levels are associated with poorerhealth, increased hospitalisations and health careservice use, incorrect drug use, low responsivenessto health education and a low uptake of diseaseprevention services. Furthermore, health literacyhas been found to be a stronger predictor of healthstatus than of the relationship between health liter-acy and health, the evidence evaluated showed thatlow health literacy levels are associated withpoorer health, increased hospitalisations andhealthcare service use, incorrect drug use, lowresponsiveness to health education and a lowuptake of disease prevention services (including</p><p>vaccinations). Furthermore, health literacy hasbeen found to be a stronger predictor of health sta-tus than age, income, employment status, educa-tion level and ethnicity.7 Consequently, there is aneed to prioritise interventions that facilitate healthliteracy competencies and enable the public toobtain and evaluate such information.5,7,12</p><p>Quality improvement initiatives in health ser-vices research can be challenging and complex innature and may include many points of interven-tion.13 Grol et al.13 argue that it would be unreal-istic to expect that one simple improvementmeasure is adequate to solve all targeted problems.Instead, they reason that these challenges are oftenbest addressed using complex interventions inwhich several factors are targeted and multipleintervention strategies are used.13</p><p>Significantly, the development of interventions isoften poorly reported in research. Providing insightinto how these steps were undertaken and whichmethods were used provides greater methodologicaltransparency. It can also help to inform the effortsof other researchers and developers.1416 In thispaper, we describe the development of a complexintervention a Norwegian web portal intended toimprove health literacy skills among the publicand the ability of users to obtain reliable healthinformation.</p><p>Methods</p><p>There is no universally optimal way of developingcomplex interventions, but explorative approachesare encouraged that are also systematic and trans-parent.13,17 Despite the methodological uncertaintiesassociated with such interventions, some guidingrules have been advanced.17,18 A complex interven-tion often includes several steps or stages (whichmay not necessarily occur in a linear sequence), inVan Boekhoven et al. model, which inspired ourwork, these steps include problem analysis, design-ing the intervention, piloting and feasibility testing,implementation and evaluations (see Figure 1).17,18</p><p>The development of our complex interventionincluded all of these steps. Decisions related to thecontent and main focus of our intervention, as wellas about which specific health literacy skills totarget, were informed by qualitative interviewsincluding members of the general public exploring</p><p> 2013 The authors. Health Information and Libraries Journal 2013 Health Libraries GroupHealth Information &amp; Libraries Journal, 30, pp. 278293</p><p>Improving health literacy, Austvoll-Dahlgren et al. 279</p></li><li><p>decision-making and beliefs associated with obtain-ing health information, and a questionnaire wherewe explored important predictors associated withintention to search. The results of these studieshave been previously published.1921 Supplement-ing these studies, we also conducted explorativesearches in Medline for studies describing barriersand facilitators to obtaining health informationrelated to health literacy, using the following terms:(public or patient or consumer) and (information orInternet or mass media) and (health behaviour orsearch or attitude or decision or participation). Wealso looked through reference lists of relevantstudies and searched for studies similar to these. Wealso scrutinised studies that had referenced thesestudies.</p><p>However, the focus of this paper is on thedevelopment phase. Essential to the developmentphase is analysing the problem and identifyingimportant barriers to and facilitators of change,so that these can be specifically targeted.13,17,18</p><p>Analysing the problem</p><p>Identifying the target population. Although theprevalence of inadequate health literacy skills hasbeen found to be higher in certain groups such asamong the elderly, people with chronic conditionsand lower socioeconomic groups; healthy literacyis found to be generally low across popula-tions.10,11 Consequently, health literacy is consid-ered a public health issue,3,6 and the target</p><p>Figure 1 Model describing phases of complex interventions by van Boekhoven et al.</p><p> 2013 The authors. Health Information and Libraries Journal 2013 Health Libraries GroupHealth Information &amp; Libraries Journal, 30, pp. 278293</p><p>Improving health literacy, Austvoll-Dahlgren et al.280</p></li><li><p>audience of our intervention was therefore thegeneral public.</p><p>Operationalisation of health literacy. Our overallgoal when initiating this project was to develop anintervention with the potential to improve usershealth literacy skills related to their ability toobtain health information within the conceptualframework of health literacy. What health literacyskills really entail has been defined in many differ-ent ways.5,12,22,23 In our study, we used the multi-dimensional model formulated by Zarcadoolaset al.,5 which contains four central domains: fun-damental literacy (reading, writing, speaking andworking with numbers), science literacy (under-standing and using science and technology), civicliteracy (skills and abilities that enables awareness,participation and involvement) and cultural literacy(skills and abilities to recognise, understand anduse of (others) beliefs, customs, worldviews andsocial identities). This model provided us with anexplicit framework for understanding and opera-tionalising health literacy in our intervention (seeFigure 2).</p><p>Identifying barriers to users ability to obtaininghealth information. Theoretical and empiricalresearch has suggested that interventions should bedeveloped to address the most important barriersto and facilitators of change.17,18,2426 Theunderlying assumption is that this will improve theeffectiveness of an intervention.17,18,2426 Identify-ing important barriers to change may entailreviewing the evidence base and conducting quali-tative and quantitative explorative studies involv-ing representatives of the target group.13,17,18 Theresults of such explorative research, in turn, helpto inform decisions about intervention content anddelivery in a feedback process often referred to astailoring the intervention.18 Following the pro-cess of interviews and literature review, we identi-fied three key barriers related to obtaininginformation related to specific health literacy skillsand potential targets for intervention. These arebriefly described belowBarrier 1: Inability to understand and critically</p><p>appraise health information: We found that theinability to understand and critically appraisehealth information is a key barrier to obtaining</p><p>A multi-dimensional model of health literacy </p><p>Fundamental literacy Reading, writing, speaking and working with numbers</p><p>Science literacy Skills and abilities for understanding and using (the process of) science and technology, including:</p><p>Knowledge of fundamental scientific conceptsAbility to comprehend technical complexityAn understanding of technologyAn understanding of scientific uncertainty and that change in accepted science is possible</p><p>Civic literacy Skills and abilities that enables citizens to become aware of public issues, participate in critical dialogue about them and become involved in the decision making process, including:</p><p>Media literacyKnowledge about civic and governmental systems and processesKnowledge of power, inequity and other hierarchical relationshipsKnowledge that the behaviour and choices of the individual affect others in larger community and society</p><p>Cultural literacy Skills and abilities to recognise, understand and use collective beliefs, customs, worldview and social identity of diverse individuals.</p><p>Figure 2 A multi-dimensional model of health literacy by Zarcadoolas et al.</p><p> 2013 The authors. Health Information and Libraries Journal 2013 Health Libraries GroupHealth Information &amp; Libraries Journal, 30, pp. 278293</p><p>Improving health literacy, Austvoll-Dahlgren et al. 281</p></li><li><p>information.19,20 In particular, research on decision-making about prevention and treatment strategies(including vaccination, mammography screeningand smoking) indicates that users understanding ofmedical and health-related research is poor and thatmany find it difficult to interpret concepts suchas randomisation, risk, uncertainty, causality andapplicability.2735 Similarly, many users rely oninformation that is based on personal anecdotes andexperience as opposed to information that is basedon research and may overrate the trustworthiness ofsuch information.30,36,37 Many do not check theaccuracy of the health information they find, andthose that do use criteria such as: the appearance,presentation of content, funding, currency andperceived reliability of the publisher.30,3638</p><p>Barrier 2: Inability to exchange information inconsultations: A second major barrier to obtaininginformation is the inability of users and providersto exchange information important for decision-making during consultations.19,21 Consultationsshould, ideally, be an arena in which appropriatehealth information is exchanged. But studies haveshown that users often want more information thanthey are actually given by health care providers,and that they may not obtain information that isimportant for decision-making.19,21,3942 Usersmay also not be made aware of their rights...</p></li></ul>

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