The effect of a healthcare communication intervention — ask me 3; on health literacy and participation in patients attending physiotherapy

Background

The European Health Literacy Survey 2012 reported possible limited health literacy in half of all the Europeans [1]. Participation – with patients contributing to the selection of their treatment plan – is enhanced by health literacy and a clinic atmosphere that welcomes discussion [2]. Bilateral healthcare communication interventions incorporating teach back, a technique where patients reiterate explanations in their own words, have been shown to facilitate participation [3]. Patients’ right to participate in their own healthcare is enshrined in the European Patient Charter [4,5]. As patients are expected to self-monitor and follow treatment regimes between health care visits, healthcare professionals need a method of ensuring that patients understand what is expected of them.

Ask Me 3 is a bilateral healthcare communication intervention [6]. It welcomes all dialogue and focuses on three core questions which patients are encouraged to ask during consultation: What is my main problem? What do I need to do? and Why is it important for me to do this? Healthcare professionals are asked to use lay language and visual models to promote understanding and teach back to confirm how much information has been absorbed. Frequent pauses allow time for the patient to process information and raise queries while allowing the healthcare professional assess how much information to impart in that particular session.

Purpose

To establish a baseline level of health literacy and participation in patients attending primary care physiotherapy and compare the impact of implementing Ask Me 3 on patients´ level of health literacy and participation.

Methods

Five physiotherapists and twenty-nine physiotherapy patients were recruited to participate in a cluster control pilot intervention study in two primary care clinics over a five-week period. All the patients had attended ≥1 physiotherapy appointment(s) prior to the study.

Participants allocated to the intervention clinic were trained to use the Ask Me 3 communication intervention during physiotherapy treatment sessions. The intervention clinic displayed Ask Me 3 posters during the trial period, which encourage patients to engage with the process during consultation. Information leaflets were distributed to patient participants and made readily available in this clinic.

Participants allocated to the control clinic made no change to usual physiotherapy treatment sessions and no changes were made to the clinic environment. The physiotherapists were blind to the Ask Me 3 intervention but were informed the study was related to health literacy.

All patient participants were invited to one-to-one interviews before and after the intervention period wherein the researcher administered a bespoke mixed method questionnaire which included the study outcome measures.

The primary outcome measure was the Newest Vital Sign [7] health literacy assessment which involves six questions, each with a score of 1 point per correct answer, a score of 4 or more almost always indicates adequate health literacy. The secondary outcome measures were the scores generated by the bespoke questionnaire developed from a review of the literature on patient clinician communication and participation. It consisted of multiple choice questions and 10-point numerical rating scales to quantify the following patient reported variables: Patients’ (a) demographics and lifestyle behaviours, (b) perceived understanding in clinical situations, (c) comfort levels when asking questions in clinical situations, (d) health and healthcare information seeking behaviour, (e) patient’s role preference – active or passive – in shared decision making (f) compliance with prescribed medication, therapeutic exercise and lifestyle recommendations. Comments on each variable were noted by the researcher and treated as qualitative data.

Physiotherapists were invited to complete a post-study feedback questionnaire. Quantitative data were analysed for changes within and between groups using SPSS version 20. Qualitative data was interpreted using thematic analysis.

Results

Twenty patient participants, ten in each group, completed the study, the remaining nine were unavailable for a post study interview. Five patients that completed the study in each group had adequate health literacy in the first interview and both groups reported similar numerical ratings modes both groups. Doctors – understanding 7; comfort questioning 8; compliance with medication 9. Physiotherapists – understanding 9; comfort questioning 9, compliance with therapeutic exercise 7 intervention, 8 control (Table 1). Results for shared decision indicated that most patients were happy to engage with it (Table 2).

Table 1. Patients' mean scores, mean changes and mean group difference in measured variables.

	Intervention group n = 10		Control group n = 10		Comparison between groups
Variable	Mean ± SD	Mean change	Mean ± SD	Mean change	Mean diff	t test equality of means
Newest vital sign	3.3 ± 2.4	+1.2	3.5 ± 2.0	+1.4	−0.2	−0.29
Physiotherapy visits	1.7 ± 0.8	−0.2	3.2 ± 2.1	+0.5	−0.5	−0.42
U/s Doctors	7.2 ± 1.7	0.0	6.8 ± 1.1	+0.9	−0.9	−1.27
U/s Physiotherapists	8.5 ± 1.2	−0.1	8.3 ± 1.5	+0.2	−0.3	−0.39
C/Q familiar doctor	8.2 ± 0.9	−0.1	8.6 ± 1.3	+0.5	−0.6	−0.81
C/Q specialist doctor	7.7 ± 2.2	+0.4	6.9 ± 2.6	+1.9	−1.5	−1.23
C/Q physiotherapist	8.3 ± 1.2	+0.2	8.7 ± 1.0	+0.4	−0.2	−0.40
INFO internet	5.5 ± 3.7	+0.3	5.5 ± 3.9	−0.6	+0.9	+1.20
INFO HCP	8.7 ± 1.5	+0.2	8.5 ± 1.0	+0.3	−0.1	−0.20
COM medication	9.0 ± 1.4	+0.5	8.8 ± 2.6	−0.4	+0.9	+1.60
COM therapeutic Ex.	7.6 ± 1.7	+1.5	8.1 ± 1.6	+0.7	+0.8	+1.86
COM lifestyle advice	8.3 ± 1.4	−0.8	8.1 ± 1.7	+0.5	−1.3	−1.77

U/s: Understanding; C/Q: Comfort questioning; INFO: Seeks information from COM: Compliance with; Ex: exercise.

Table 2. Patient reported preferences in shared decision making (SDM).

	No. of patients
When there are treatment options, which role do you like to play?	Pre	Post
HCP takes the initiative and decides what is best for me	0	0
My ideas are considered but final decision rests with HCP	4	5
HCP and I make the final decision together	12	13
I make all of the final decision	4	2

Mean number of physiotherapy sessions were 1.7 in the intervention group and 3.2 in the control group. No statistical difference was found between the two groups’ outcome measures in any quantitative analysis. Health literacy improved significantly (p ≤ .01) and most elements of participation increased slightly in both the groups.

The qualitative data contained positive statements from patients in the intervention group regarding trust and empowerment to participate with five patients reporting changes in behaviour, improved trust or confidence after the study saying they ‘no longer fearing questions would be construed as criticism’ ‘now asks when unsure’ and it’s use allayed ‘fears that information is being with-held’.

Reported barriers to participation were complicity of language, feeling rushed, and fear of being bothersome. Patients reported being more likely question a specialist than a doctor they knew well, citing they waited so long to see the specialist they tended to be more prepared, have support with them and a list of questions. Reported enablers to participation were mutual respect, feeling heard, chronic illness, history of a serious health event and having time.

Physiotherapists delivering Ask Me 3 (n = 3) reported finding the questions and use of lay language easy, the teach back and pausing somewhat challenging, but would continue to use it in their practice and recommend further use of Ask Me 3 in clinics.

Conclusions

This study had two confounding limitations which may have contributed to the minimal differences between the two groups’ quantitative outcomes:

• Significant differences in the frequency of physiotherapy visits of the study.

• Physiotherapists in both groups had increased health literacy awareness which facilitates language simplification.

The study used a health literacy outcome measure over time in physiotherapy patients affirming that attending physiotherapy [8] can improve health literacy. As health literacy improves, patients become more receptive to healthcare professionals advice (Table 2).

Patients exposed to the Ask Me 3 intervention even for a very short time felt entitled and empowered to question and seek clarity on issues that concern them during healthcare consultations – facilitating parity in the therapeutic relationship. The questions patients asked during consultation highlighted their concerns and thus elicited targeted answers, while the teach back confirmed how much the patient understood. This clarity may improve treatment outcomes with fewer physiotherapy visits.

Implications

Ask me 3 is simple to use, inexpensive to implement and facilitates simple communication. A poster in a waiting area has the potential to prime a patient to clarify his concerns and accept his responsibilities during consultation. In clinical interactions where interim compliance is important, the Ask me 3 helps clinician ensure patients understand what is expected of them and also raises the concept of patient responsibility. Physiotherapists and all clinicians are tasked with being respectful and empowering whilst trying to explain simply without condescension [9–11], allowing patients to accept or reject advice, yet, remain clinically effective. Reports from patients exposed to it were positive [12,13] giving them the courage to continue questioning until they found answers. Patient generated questions give healthcare professionals clues to the level of understanding, acceptance and insight of the condition, which guides the practitioner to deliver the appropriate dose of information at the right time. In effect, it lightens the practitioner’s burden and empowers the patient, thus sharing responsibility for management and care.

Ethics approval

Ethics approval was obtained from Research Ethics Committee, Sligo University Hospital, Sligo, Ireland.

Acknowledgments

Thank you to the primary care physiotherapy staff of Sligo and Leitrim.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was unfunded.