Addressing health literacy in patient decision aids

MethodsWe reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.ResultsAim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.ConclusionLower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients

Enhancing assertive community treatment with cognitive behavioral social skills training for schizophrenia: study protocol for a randomized controlled trial.

BackgroundSchizophrenia leads to profound disability in everyday functioning (e.g., difficulty finding and maintaining employment, housing, and personal relationships). Medications can effectively reduce positive symptoms (e.g., hallucinations and delusions), but they do not meaningfully improve daily life functioning. Psychosocial evidence-based practices (EBPs) improve functioning, but these EBPs are not available to most people with schizophrenia. The field must close the research and service delivery gap by adapting EBPs for schizophrenia to facilitate widespread implementation in community settings. Our hybrid effectiveness and implementation study represents an initiative to bridge this divide. In this study we will test whether an existing EBP (i.e., Cognitive Behavioral Social Skills Training (CBSST)) modified to work in practice settings (i.e., Assertive Community Treatment (ACT) teams) commonly available to persons with schizophrenia results in better consumer outcomes. We will also identify key factors relevant to developing future CBSST implementation strategies.Methods/designFor the effectiveness study component, persons with schizophrenia will be recruited from existing publicly funded ACT teams operating in community settings. Participants will be randomized to one of the 2 treatments (ACT alone or ACT + Adapted CBSST) and followed longitudinally for 18 months with assessments every 18 weeks after baseline (5 in total). The primary outcome domain is psychosocial functioning (e.g., everyday living skills and activities related to employment, education, and housing) as measured by self-report, testing, and observation. Additional outcome domains of interest include mediators of change in functioning, symptoms, and quality of services. Primary analyses will be conducted using linear mixed-effects models for continuous data. The implementation study component consists of a structured, mixed qualitative-quantitative methodology (i.e., Concept Mapping) to characterize and assess the implementation experience from multiple stakeholder perspectives in order to inform future implementation initiatives.DiscussionAdapting CBSST to fit into the ACT service delivery context found throughout the United States creates an opportunity to substantially increase the number of persons with schizophrenia who could have access to and benefit from EBPs. As part of the implementation learning process training materials and treatment workbooks have been revised to promote easier use of CBSST in the context of brief community-based ACT visits.Trial registrationClinicalTrials.gov NCT02254733 . Date of registration: 25 April 2014

The Scientist-Practitioner in a Counselling Psychology Setting

The human psyche is influenced by an extraordinary complexity of experiences. Many would therefore maintain that we can never completely understand another human being. As scientist-practitioners, is our purported allegiance to, and reliance upon, ‘official’ sources of knowledge (including theory and scientific evidence) sufficient for us to be confident that we can construct consistently helpful solutions from the myriad clinical data at our fingertips? Should we as psychologists accept that full understanding of causality is simply not an achievable objective? If we adopt the position that we can never fully explain causes, however, what role do we actually play? Can our interventions even be considered valid, let alone scientific? The question of how practitioners reflect upon their activity, and of the scientific assumptions behind their work, has occupied much debate in the field of psychology, and the many different strands of this debate are woven throughout the fabric of this book. In this chapter, we consider some of the many implications of this debate for counselling psychologists. Specifically, we begin by exploring the position of counselling psychology within the profession more broadly, and consider its place in the current controversy about the scientist-practitioner role. Next, we articulate some of our own practice in this regard, attempting not only to make note of the systematic approaches that we employ in counselling psychology but also to incorporate the wide range of expectation and experience that comes to the therapeutic endeavour. Finally, we try to define the type of scientist-practitioner that we envision in a counselling psychology setting

Structuring and coding in health care records: a qualitative analysis using diabetes as a case study

Background: Globally, diabetes mellitus presents a substantial burden to individuals and healthcare systems. Structuring and/or coding of medical records underpin attempts to improve information sharing and searching, potentially bringing clinical and secondary uses benefits. Aims and objectives: We investigated if, how and why records for adults with diabetes were structured and/or coded, and explored stakeholders’ perceptions of current practice. Methods: We carried out a qualitative, theoretically-informed case study of documenting healthcare information for diabetes patients in family practice and hospital settings, using semi-structured interviews, observations, systems demonstrations and documentary data. Results: We conducted 22 interviews and four on-site observations, and reviewed 25 documents. For secondary uses – research, audit, public health and service planning – the benefits of highly structured and coded diabetes data were clearly articulated. Reported clinical benefits in terms of managing and monitoring diabetes, and perhaps encouraging patient self-management, were modest. We observed marked differences in levels of record structuring and/or coding between settings, and found little evidence that these data were being exploited to improve information sharing between them. Conclusions: Using high levels of data structuring and coding in medical records for diabetes patients has potential to be exploited more fully, and lessons might be learned from successful developments elsewhere in the UK

Treatment Components and Mechanisms of Change in Guided Self-Help for Parents of Children with Externalizing Behavior Problems

Although self-help parent management training represents an effective form of treatment with low barriers for families, little is known about how change is induced. The present thesis analyzed treatment components and process mechanisms of telephone-assisted self-help parent management training with a behavioral basis and a nondirective basis for child externalizing behavior problems. In a randomized controlled trial, parents of children aged 4 to 11 years with externalizing behavior problems were allocated to telephone-assisted self-help parent management training with a behavioral basis or a nondirective basis, including self-help booklets and therapist consultations via telephone. The per-protocol sample included 108 families. Based on existing measures and predefined psychometric criteria, the Therapist Intervention Scale (TIS) was developed to analyze treatment components in the self-help booklets and the audiotaped telephone consultations. Furthermore, a potential mediating effect of therapist behavior on child outcomes was examined. From an exploratory perspective, parental adherence was analyzed as a potential sequential mediator following therapist behavior. Exploratory factor analyses suggested the formation of the TIS scales Guidance & Structures as well as Relationship & Emotions. Reliability indices were acceptable to excellent. Indices for construct validity were mostly in line with the hypotheses. As expected, therapists and booklets showed a stronger emphasis on guidance and structures in the behavioral intervention and a stronger emphasis on the emotions and relationships in the nondirective intervention. Furthermore, the findings suggest that the group effect on child attention-deficit/hyperactivity disorder severity and functional impairment was mediated by therapists’ emphasis on emotions and relationships in the nondirective intervention. The exploratory sequential mediation analyses indicated a potential sequential mediation effect of parental adherence following therapist behavior. We did not find a mediation effect for therapists’ emphasis on guiding and structuring or for the behavioral intervention. In conclusion, the analyses support the reliability as well as the validity of the self-developed TIS scales. In accordance with their theoretical basis, the two interventions showed distinct treatment profiles. The findings underline the importance of therapists’ emphasis on emotions and relationships for change in child outcomes as a potential unique process mechanism in the nondirective intervention and complement findings on process mechanisms of the behavioral intervention. Future research might analyze additional mediators of change and include potential moderators in one model, which might deepen our understanding of the process mechanisms underlying treatment approaches

Conceptual graph-based knowledge representation for supporting reasoning in African traditional medicine

Although African patients use both conventional or modern and traditional healthcare simultaneously, it has been proven that 80% of people rely on African traditional medicine (ATM). ATM includes medical activities stemming from practices, customs and traditions which were integral to the distinctive African cultures. It is based mainly on the oral transfer of knowledge, with the risk of losing critical knowledge. Moreover, practices differ according to the regions and the availability of medicinal plants. Therefore, it is necessary to compile tacit, disseminated and complex knowledge from various Tradi-Practitioners (TP) in order to determine interesting patterns for treating a given disease. Knowledge engineering methods for traditional medicine are useful to model suitably complex information needs, formalize knowledge of domain experts and highlight the effective practices for their integration to conventional medicine. The work described in this paper presents an approach which addresses two issues. First it aims at proposing a formal representation model of ATM knowledge and practices to facilitate their sharing and reusing. Then, it aims at providing a visual reasoning mechanism for selecting best available procedures and medicinal plants to treat diseases. The approach is based on the use of the Delphi method for capturing knowledge from various experts which necessitate reaching a consensus. Conceptual graph formalism is used to model ATM knowledge with visual reasoning capabilities and processes. The nested conceptual graphs are used to visually express the semantic meaning of Computational Tree Logic (CTL) constructs that are useful for formal specification of temporal properties of ATM domain knowledge. Our approach presents the advantage of mitigating knowledge loss with conceptual development assistance to improve the quality of ATM care (medical diagnosis and therapeutics), but also patient safety (drug monitoring)