II. Patient Education and health literacy
Impact of patient education
Patient education and counselling contribute to behaviour change for the primary prevention of disease.21 More broadly, they may also help to create greater ‘health literacy’ – the knowledge and skills patients require to maintain their own health, including use of health services. The use of behavioural techniques, especially for self-monitoring, is recommended, as is the use of personal communication and written or other audiovisual materials.22
Patients view the general practitioner (GP) as a key first contact and credible source of preventive advice. Factors that increase the effectiveness of patient education delivered by GPs include:
- assessing the patient’s health literacy23
- the patient’s sense of trust in their GP24
- face-to-face delivery25
- patient involvement in decision making26–28
- highlighting the benefits and costs29,30
- strategies to help the patient remember what they have been told31
- tailoring the information to the patient’s interest in change32
- strategies that address the difficulty in adherence28,33
- the use of decision aids.34
Many preventive activities involve a change in health-related behaviour. In general practice, it may take at least six to eight sessions to discuss and see changes to diet, physical activity or weight loss. This will often require referral, which should be followed up by the general practice. As the patient plays a large role in making this happen, it is useful to facilitate more active inclusion of patients in their care. This process is an essential component of self-management support strategies35,36 and has the potential to increase the patient’s responsibility for their health. In addition, it:
- enhances the quality of communication37,38
- enhances the26
- can reduce the cost of aspects of care through better informed patients27
- increases the demand and use of appropriate referral to other health professionals and agencies38
- increases adherence to recommended preventive activities and therapeutic regimens.38,39
For those whose first language is not English, a professional interpreter should be considered.
Approaches to patient education
Patients need to develop their own understanding of the problem and what can be done about it. For simple behavioural changes, such as having a cervical cancer screening test, patients weigh up the perceived benefits and costs.40 These benefits and costs may include answers to the following questions:
- How big is the problem to the individual?
- What are the consequences of not doing the test?
- What are the benefits?
- What are the barriers?
Some health education may require more complex actions over a period of time, such as changing diet, stopping smoking or increasing physical activity.
There are a number of theoretical approaches to understanding and supporting behaviour change including the:
- Theory of planned behaviour41
- Health belief model42
- capability, opportunity and motivation (COM-B) system, which has been proposed by Michie et al as a way of representing the necessary conditions for behaviour change to occur43
- ‘stages of change model’,44 which proposes five stages of change, which are viewed as a cyclical, ongoing process during which the person has differing levels of motivation or readiness to change, and the ability to relapse or repeat a stage. Although there is a lack of evidence for greater effectiveness of stage-based approaches,45 this model provides a useful framework for clinicians to identify patients’ interest in behaviour change in the consultation and to provide tailored support in a way that is time efficient and likely to be well received.46
Support from the GP and/or practice nurse may involve motivational interviewing. This is an evidence-based counselling technique based on a therapeutic partnership that acknowledges and explores the patient’s ambivalence about a behaviour in a way that allows them to clarify what goals are important to them and to organise their reasons in a way that supports actions.
Motivational interviewing is a counselling philosophy that values patient autonomy and mutual respect, and the use of open-ended questions, affirmations, reflection and summarising.47
Further information about motivational interviewing and its application in general practice can be found in The Royal Australian College of General Practitioners’ (RACGP) Smoking, nutrition, alcohol and physical activity (SNAP): A population health guide to behavioural risk factors in general practice (www.racgp.org.au/your-practice/guidelines/snap) and Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (Green Book; www.racgp.org.au/your-practice/guidelines/greenbook).
It is well recognised that socioeconomic disadvantage has a profound impact on people’s health, and GPs are often in a good position to confront this.48
However, poverty is not evenly spread across Australia, and it is likely that GPs who see some patients with socioeconomic disadvantage will see many. Similarly, GPs are not evenly spread with respect to poverty. The Australian Bureau of Statistics (ABS) have shown that, in 2006, 11% of GPs worked in the most disadvantaged areas, while 24% worked in the least disadvantaged.49
Healthcare in communities that are socioeconomically deprived is often complex. As well as having more chronic health conditions, and more health behaviours leading to increased risk, there may be a lack of local support and infrastructure to improve the situation. General practices are often one of the few resources patients have to call on. There are often significant personal and social barriers to achieving change. As well as good communication skills, GPs may need to help patients navigate health, housing, welfare and legal systems. This often makes for more-frequent, longer, more-complex consultations. However, the long-term relationships GPs develop with patients are significant enablers for patients who are socioeconomically deprived to be able to make changes.
Health equity issues are more complex than just socioeconomic factors. There are specific issues for Aboriginal and Torres Strait Islander peoples, where an ongoing history of colonisation, dispossession and racism interact with a lack of economic opportunity. The National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edn50 provides extensive detail on specific preventive care issues facing Aboriginal and Torres Strait Islander peoples, and the health equity material canvassed here should be read in conjunction with those guidelines. They provide much more in-depth and important guidance on preventive healthcare strategies that are recommended for practitioners working with Aboriginal and Torres Strait Islander peoples and communities. In addition, GPs should optimise their use of Medicare Benefits Schedule (MBS) Item 715 that supports health checks in Aboriginal and Torres Strait Islander peoples and their use of Close the Gap provisions in ensuring affordable access to medicines. GPs should also proactively address cost barriers to referral to other services faced by Aboriginal and Torres Strait Islander peoples.
Supporting patient education and health literacy in disadvantaged groups
What are the key equity issues and who is at risk?
- The complex needs and health problems of disadvantaged groups, and the interactions between social, psychological, environmental and physical determinants of health mean that special effort is required for patient education to be effective.
- Socioeconomic disadvantage and low health literacy are linked. Health literacy is a key factor in how patient education leads to patient empowerment. It allows individuals to access, understand and use information to negotiate the health system and support self-management.51 Health literacy is important as low health literacy is associated with poorer health outcomes and lower utilisation of health services such as screening and preventive care.
- Other groups that require particular focus in patient education include Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) groups.52
What can GPs do?
A range of strategies can be used by GPs to help patients with low health literacy and to promote health-related behaviour changes.51,53 These include:
- specific communication techniques such as asking patients to ‘teach back’ what has been taught to them and the ‘ask me 3’ health education program based on three patient-led questions54 (https://npsf.site-ym.com/default.asp?page=askme3)
- motivational interviewing and counselling techniques
- plain-language and culturally appropriate written materials (explicitly asking about reading skills may be important)
- use of web-based or computer-based programs (explicitly asking about internet access, eg at home or through a library may be important)
- helping patients navigate the healthcare system to improve access to care, for example, by working in collaboration with other services such as community health centres and consumer organisations to access community health and group education programs.
Effective patient education for CALD populations means ensuring that health services and messages are accessible and relevant. GPs should:
- offer interpreter services during consultations. There is good evidence that interpreter services improve care experience and clinical outcomes55
- use patient education materials in plain English or those that are culturally and linguistically sensitive (eg have a range of patient material in relevant different languages in your practice)
- link individuals to specific community-based health programs.56,57
Cultural competence is important in providing appropriate patient education to all communities. This is particularly important in working with Aboriginal and Torres Strait Islander communities.58 It is important for GPs to better appreciate Aboriginal and Torres Strait Islander peoples’ perspectives on health, culture and history, and provide services within a culturally appropriate framework.59 This could be facilitated through:
- reading about the history and impact of colonisation on Aboriginal and Torres Strait Islander peoples and their health, nationally and locally60
- arranging Aboriginal and Torres Strait Islander cultural awareness training for themselves and practice staff (www.racgp.org.au/yourracgp/faculties/aboriginal/education/resources-for-gps-and-practice-staff/cultural-awareness)
- linking your practice and Aboriginal and Torres Strait Islander patients to local Aboriginal community controlled health services61
- developing relationships with your local Aboriginal and Torres Strait Islander community, and resources, people and services that can provide you with assistance and cultural mentorship.
- Bouleware LE, Barnes GJ, Wilson RF, et al. Systematic review: The value of the periodic health evaluation. Ann Intern Med 2007;146:289–300.
- Dolan M, Simons-Morton D, Ramirez G, Frankowski R, Green L, Mains D. A meta-analysis of trials evaluating patient education and counselling for three groups of preventive health behaviors. Patient Educ Couns 1997;32(3):157–73.
- Nutbeam D. Building health literacy in Australia. Med J Aust 2009;191(10):525–26.
- Trachtenberg F, Dugan E, Hall M. How patients’ trust relates to their involvement in medical care. J Fam Pract 2005;54(4):344–52.
- Ellis S, Speroff T, Dittus R, Brown A, Pichert J, Elasy T. Diabetes patient education: A meta-analysis and meta-regression. Pat Educ Couns 2004;52(1):97–105.
- Lewin S, Skea Z, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2002;4: CD003267.
- Mead N, Bower P. Patient-centred consultations and outcomes in primary care. Patient Educ Couns 2002;48(1):51–61.
- Rao J, Weinberger M, Kroenke K. Visit-specific expectations and patient-centred outcomes: Literature review. Arch Fam Med 2000;9(10):1149–55.
- Schauffler H, Rodriguez T, Milstein A. Health education and patient satisfaction. J Fam Pract 1996;42(1):62–68.
- Littell J, Girvin H. Stages of change: A critique. Behav Modif 2002;26(2):223–73.
- Ley P, editor. Patients’ understanding and recall in clinical communication failure. London: Academic Press, 1983.
- Steptoe A, Kerry S, Rink E, Hilton S. The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease. Am J Public Health 2001;91(2):265–69.
- Branch L, Rabiner D. Rediscovering the patient’s role in receiving health promotion services. Med Care 2000;38(1):70–77.
- O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2009;3:CD001431.
- Warsi A, Wang P, LaValley M, Avorn J, Solomon D. Self-management education programs in chronic disease: A systematic review and methodologic critique of the literature. Arch Intern Med 2004;164(15):1641–49.
- Ofman J, Badamgarav E, Henning J, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am J Med 2004;117(3):182–92.
- Joos S, Hickam D, Gordon G, Baker L. Effects of physician communication intervention on patient care outcomes. J Gen Intern Med 1996;11(3):147–55.
- Hibbard J. Engaging health care consumers to improve quality of care. Med Care 2003;41(1 Suppl):I61–70.
- Bodenheimer T, Wagner E, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288(14):1775–79.
- Rosenstock I. The health belief model and preventative health behaviour. Health Educ Monogr 1974;2:27–57.
- Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: A meta-analytic review. Br J Soc Psychol 2001;40(Pt 4):471–99.
- Janz NK, Becker MH. The health belief model: A decade later. Health Educ Q 1984;11(1):1–47.
- Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42.
- Cassidy C. Using the transtheoretical model to facilitate behaviour change in patients with chronic illness. J Am Acad Nurse Pract 1999;11(7):281.
- Cahill K, Lancaster T, Green N. Stage-based interventions for smoking cessation. Cochrane Database Syst Rev 2010;11:CD004492.
- Prochaska JO, Velicer WF, Redding C, et al. Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Prev Med 2005;41(2):406–16.
- Miller WR, Rollnick S. Motivational interviewing – Helping people change. 3rd edn. New York: Guildford Press, 2012.
- Watt G, Brown G, Budd J, et al. General practitioners at the deep end: The experience and views of general practitioners working in the most severely deprived areas of Scotland. Occasional paper. Edinburgh: Royal College of General Practitioners, 2012.
- Australian Bureau of Statistics. Australian social trends, Mar 2010. Canberra: ABS, 2010. Available at www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2010 [Accessed 29 April 2016].
- National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 2nd edn. South Melbourne, Vic: RACGP, 2012.
- Harris M, Taggart J, Williams A, et al. Effective interventions to improve health literacy in the management of lifestyle risk factors in primary health care. Paper presented at 6th Health Service & Policy Research Conference. Brisbane: Health Service & Policy Research Conference, 2009.
- Rodriguez V, Andrade AD, Garcia-Retamero R, et al. Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians. J Health Commun 2013;18:273–89.
- Harris M, Kidd M, Snowdon T. New models of primary and community care to meet the challenges of chronic disease management and prevention: A discussion paper for NHHRC: National Health and Hospitals Reform Commission. Canbera: Australian Government, 2008.
- Adams RJ, Stocks NP, Wilson DH, et al. Health literacy: A new concept for general practice? Aust Fam Physician 2009;38(3):144–47.
- Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007;42(2):727–54.
- Belintxon M, Lopez-Dicastillo O. The challenges of health promotion in a multicultural society: A narrative review. An Sist Sanit Navar 2014;37(3):401–09.
- Ethnic Communities’ Council of Victoria. An investment not an expense: Enhancing health literacy in culturally and linguistically diverse communities. Carlton, Vic: Ethnic Communities’ Council of Victoria, 2012.
- Abbott P, Reath J, Gordon E, et al. General practitioner supervisor assessment and teaching of registrars consulting with Aboriginal patients – Is cultural competence adequately considered? BMC Med Educ 2014;14:167.
- Vass A, Mitchell A, Dhurrkay Y. Health literacy and Australian indigenous peoples: An analysis of the role of language and worldview. Health Promot J Aust 2011;22(1):33–37.
- Eckermann A, Dowd T, Chong E, Nixon L, Gray R. Binan Goonj: Bridging cultures in Aboriginal health. 3rd edn. Chatswood, NSW: Elsevier Australia, 2010.
- Ware VA. Improving the accessibility of health services in urban and regional settings for Indigenous people. Canberra: Australian Institute for Health and Welfare, 2013.