Biases that affect the quality of research evidence for improving organisational health literacy Dr Jane Lloyd and A/Prof Marilyn Wise
Health literacy: what is it? Knowledge Skills Confidence Networks Necessary for: staying healthy accessing preventive screening deciding on treatment options self management effective communication
Health literacy: why is it important? The processes through which health literacy affects health: Access to and use of health care Patient-provider interactions The management of health and illness. Von Wagner C, Steptoe A, Wolf M, Wardle J. 2009. Health Literacy and Health Actions: A Review and a Framework from Health Psychology. Health Education and Behavior 36(5): 860-877
Health Literacy has many definitions Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. WHO, 1998 Sufficient basic skills in reading and writing to be able to function effectively in everyday situations Critical literacy More advanced cognitive skills which, together with social skills, can be applied to critically analyse information, and to use this information to exert greater control over life events and situations. Functional literacy More advanced cognitive and literacy skills which, together with social skills, can be used to actively participate in everyday activities, to extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances. Nutbeam, 2000 Interactive literacy A working knowledge of disease processes, ability to use technology, social networking and interaction, self-efficacy and motivation for political action regarding health issues. Berkman et al. 2011 [A]n awareness of and ability to navigate differences between the cultures of the health system and the public. Sorenson et al. 2012 identified 17 definitions of health literacy Coleman et al., 2014 Centre for Primary Health Care and Equity
Health literacy is a two-way street (ACSQHC, 2014)
Health literate organisations Health literate organisations make it easier for people to navigate, understand and use information and services Health and Medicine Division* s framework for the health literate health care organisation Effective Bidirectional Communication Embedded Policies and Practices Augmented Workforce Accessible Educational Technology Infrastructure *formerly the Institute of Medicine Organisational Commitment
Research on interventions to improve the health literacy of health care organisations and systems has been is limited Why?
What are cognitive biases? Automatic, fast thinking, that we do not directly control Not consciously aware of our biases and we are not aware of how they influence our decisions, feelings or behaviour Cognitive biases include ignoring relevant information, placing undue emphasis on unimportant aspects of the issues. Centre for Primary Health Care and Equity
Cognitive biases - examples Confirmation bias the selective gathering and discounting of information in order to support a previously held belief Affinity bias more supportive of people who are like us and with whom we have a shared understanding go to people we are comfortable dealing with mutual trust and understanding Framing bias - occurs when the social construction of the issue increases the probability of particular decisions being made. Fischhoff & Beyth Marom. 1983. Hypothesis Evaluation from a Bayesian Perspective. Psychological Review 90 (3): 239 Nickerson. 1998. Confirmation Bias: A Ubiquitous Phenomenon in Many Guises. Review of General Psychology 2(2): 175 Tversky and Kahneman. 1981. The Framing of Decisions and the Psychology of Choice. Science 211 (4481): 453-58 Centre for Primary Health Care and Equity
Why are cognitive biases important? They can mean that: different people, presented with the same evidence, can reach very different conclusions e.g. ignoring relevant information or placing undue emphasis on unimportant aspects of the issue. the social construction of the issue increases the probability of particular decisions being made e.g. framing health literacy as patient problem and risk factor to be mitigated, rather than framing health literacy as a system issue requiring an organisational response. Centre for Primary Health Care and Equity
Research question and methods How might research systems and researchers biases affect their ability to conduct research and act upon evidence? Case study of health literacy literature Critical examination of medical, health services, and population health research priorities
Findings biases in health literacy literature health literacy research has been heavily weighted toward patients health literacy so that the literature focuses on measuring patients health literacy and improving patients knowledge and skills and confidence so they can make better heath choices or better self manage their condition BUT, there is equal need to measure the health literacy of organisations and providers, to consider how to improve the health literacy of providers, and to reduce the complexity and demands of accessing health care services. Centre for Primary Health Care and Equity
Underlying research biases? identifying the best evidence has been interpreted as using epidemiological and biostatistical ways of thinking the use of short-cuts in the face of complexity fertile ground for assumptions can lead to a siloed approach to health systems research publication bias (positive results, undervalues qualitative research).
Conclusions Organisational and patient health literacy have vital roles in improving health care and health outcomes BUT the quality of research evidence for health literacy is limited - framed as a patient problem The concept of organisational health literacy hasn t been fully explored or responses implemented This may be partly due to biases about what constitutes rigorous, valid, reliable, relevant research.
Opportunities for health literacy research expose current biases (not overcome them) include social groups in the design, conduct, and reporting of research consider and value the patient experience as part of evidence generation interdisciplinary review health literacy research outputs and health policies to reflect upon framing and other cognitive biases.
Thank you Questions, comments? Jane Lloyd (j.lloyd@unsw.edu.au)