Stage 1: E-consultation
Fifty-five health workers acting from community health services (73%), city councils (13%), and other health service providers (14%) participated in the e-consultation. Participants were located in Victoria (91%), or other Australian states and reported between 1 and 38 years of experience (median = 13). Collectively, participants submitted 364 questions they would use to enquire about health literacy with their patients. Of these questions, 198 were for the purpose of detecting health literacy strengths and challenges and 166 were for determining further details about these strengths and challenges. From these submissions, 100 unique questions were identified across the nine HLQ domains and the construct representing health beliefs and culture.
Stage 2: Workshop
There were eight workshop participants. Roles represented included health promotion (n = 2), counselling (n = 2), health assessment (n = 2), occupational therapy (n = 1), and nursing (n = 1). All workshop participants expressed agreement that six HLQ domains would provide the most clinically-relevant information. Domain 2. Having sufficient information to manage my health was considered to be too general to be relevant in the context of a time-limited clinical encounter, and given the patient is in a consultation with a health worker who will provide more information if needed. Domain 5. Appraisal of health information was seen as a higher order skill that is desirable but not essential for supporting healthcare outcomes. Domain 7. Navigating the healthcare system was considered to be less relevant because patients would already be connected with a healthcare provider at the time of administration. As an exception, participants’ appraisal of the health beliefs and values construct was mixed, however it was retained for initial pilot testing.
Workshop participants provided feedback on which individual questions from Stage 1 would be most useful for assessing each health literacy domain. Some participants reported concerns about patients responding positively to questions in order to avoid detection of potential health literacy issues. Multiple participants noted cases of patients providing inconsistent answers at interview for this reason. To minimise this possibility, it was suggested that open-ended questions be used to explore patients’ routine health behaviours in order to provide information on their health circumstances and reveal their understanding of their own health needs. Additionally, participants suggested specifically asking about patients’ experiences of barriers and supports when accessing, understanding, and using health information and services.
Based on these findings, a draft tool with supporting documentation was prepared for initial pilot testing. This tool was named the Conversational Health Literacy Assessment Tool (CHAT) and featured 13 questions across five areas of assessment. Using three questions, section 1 targeted supportive professional relationships (addressing HLQ domains 1. Healthcare provider support and 6. Ability to actively engage with healthcare providers). Using two questions, section 2 reflected supportive personal relationships (addressing HLQ domain 4. Social support for health). With two questions, section 3 represented access to and understanding of health information (addressing HLQ domains 8. Ability to find good health information and 9. Understand health information well enough to know what to do). Using two questions, section 4 evaluated limitations due to health beliefs and values. Lastly, using four questions, section 5 enquired about the health behaviours of patients on a regular daily, weekly, and yearly basis, followed by a question about general supports and barriers: “What is going well for you and what is harder to keep up on a regular basis?”
Stage 3: Initial pilot testing (13-item draft tool)
Nine health workers participated in the initial CHAT pilot testing and interviews. All nine were from community health services. Their roles included community health nursing (n = 3), occupational therapy (n = 2), physiotherapy (n = 2), clinical psychology (n = 1), and community dietetics (n = 1).
Several changes to the CHAT questions were made based on feedback from these interviews. Participants helped clarify the intention of each question by improving the expression. Both of the questions targeting health beliefs and values were removed because participants unanimously agreed that they were not immediately useful in the context of CHAT administration. For section 5, two participants noted that the yearly health behaviour question provided no value beyond the daily and weekly behaviour questions, and this was subsequently removed. One participant reported that some patients required prompting about health behaviours so supplementary prompts were added to guide conversation for these questions. Finally, the question regarding barriers and supports was divided into two discrete questions to streamline administration. Participants noted the value of closing the assessment positively with a question that highlighted patient’s perceived supports. The complete list of CHAT questions based on three stages of participant consultation is presented in Table
2.
Table 2
Conversational Health Literacy Assessment Tool (CHAT) Questions
Supportive professional relationships | 1. Who do you usually see to help you look after your health? |
2. How difficult is it for you to speak with [that provider] about your health? |
Supportive personal relationships | 3. Aside from healthcare providers, who else do you talk with about your health? |
4. How comfortable are you to ask [that person] for help if you need it? |
Health information access and comprehension | 5. Where else do you get health information that you trust? |
6. How difficult is it for you to understand information about your health? |
Current health behaviours | 7. What do you do to look after your health on a daily basis? (Prompt for diet, sleeping habits, medication, and treatment plan) |
8. What do you do to look after your health on a weekly basis? (Prompt for exercise, physical activities, social activities, and visits to healthcare professionals) |
Health promotion barriers and support | 9. Thinking about the things you do to look after your health, what is difficult for you to keep doing on a regular basis? |
10. Thinking about the things you do to look after your health, what is going well for you? |
Stage 4: Further pilot testing (10-item tool)
Thirteen health workers represented a range of services, including community health nursing (n = 3), physiotherapy (n = 3), occupational therapy (n = 3), case management (diversional therapy, social work; n = 2), clinical psychology (n = 1), and podiatry (n = 1). Participants reported working in their respective fields from 1 to 33 years (median = 17). In total, participants conducted 46 CHAT interview sessions with patients (median = 3, range = 1–5). Participants used the CHAT exclusively with new patients (38%), a mix of existing and new patients (38%), and existing patients only (24%).
Interviews explored how the CHAT questions could be used to obtain detailed information about patients’ health literacy strengths and challenges. Across CHAT questions, participants reported conversations that revealed issues such as patients who lack sources of social support and experience isolation despite assistance from social workers; where patients find health information and how much they trust those sources; ‘disconnects’ between patient health knowledge and behaviours; and factors that make it harder for patients to self-manage their health on an ongoing basis.
Question 6, which is about understanding health information, was reported as the most valuable CHAT question overall. Participants reported extended conversations with their patients about this question, particularly with those who were self-managing their condition: “It was really valuable to understand that clinicians need to spend enough time to help patients understand information that they are making decisions with… especially those who were trying to help themselves. Looking at how clinicians provide information to them and if there are other ways that clinicians could provide that information.”
A trend emerged whereby the perceived utility of the remaining CHAT questions differed according to health service context. Health workers who were engaged in development of care plans in rehabilitation settings or with patients who have chronic health conditions, had more interest in the questions that revealed a patient’s broader health context and circumstances. Personal relationships (questions 3 and 4), and barriers and supports (questions 9 and 10) were all reported as providing valuable information for health outcomes that require long-term planning, strategy, and goal setting.
The benefit of understanding how patients find health information was unclear in contexts where obtaining further information was unnecessary. For example, within patient sessions that concluded with a request for a patient to simply follow guidance for care. Similarly, the benefit of understanding the presence and utility of professional relationships (questions 1 and 2) was less evident for patients who were already engaged with appropriate healthcare providers and felt no need for further assistance.
Mixed responses were reported for the questions about current health behaviours (questions 7 and 8). These questions provide additional information about the patient’s health context and circumstances but were reported as being less immediately beneficial for health workers than the questions that target barriers and supports. While one participant reported that these questions were an improvement on current assessment questions, two participants noted that these questions did not provide much new information when working with patients with whom they had an existing relationship.
When discussing the practicality of the CHAT, participants reported that adopting the tool into their regular procedures was straightforward: “When I saw the questions, I felt quite comfortable that they would be easy to ask and administer without being confrontational, without making the patient feel like you are assessing their reading ability, numerical, and some of those other things”. Accommodating the length of administration time with other competing demands was the key noted limitation to adoption.
Overall, participating health workers expressed a clear need for such a tool. One provider noted that the CHAT was needed “...because for a lot of clinicians, they don’t know how to start the conversation. So I think it has got some useful questions for people who haven't developed that comfort to address all of those questions”. When asked if they would use patients’ responses to the CHAT in their practice, the majority of participants (69%) said they would refer to the information during a review of a patient’s care plan or at discharge, depending on the healthcare service provided. Almost all participants (85%) reported that they would recommend the CHAT to other health workers, particularly those with less experience.