swinburne - ophelia templates and additional resources fa2

Ophelia Templates and Additional Resources

Templates and resources to support application of the Ophelia Manual

Th is research was supported under Australian Research Council’s Linkage Projects funding scheme (project LP120200111). Th e Victorian Department of Health contributed funds and in-kind support to the project. Th e views expressed herein are those of the authors and are not necessarily those of the Australian Research Council or the Victorian Department of Health.

AuthorsEditors: Dr Alison Beauchamp, Dr Sarity Dodson, Mr Roy Batterham and Professor Richard OsborneContributors: Ms Silvana Cavalli, Ms Christina Cheng, Ms Melanie Hawkins, Ms Kirsten Phillips, and Ms Jayne Power.

Cover and inside design, and layout: RoscherCreative

Funders: Australian Research Council, Victorian Government, Deakin University, Monash University

Suggested citationBeauchamp A, Dodson S, Batterham RW and Osborne RH. Ophelia Templates and Additional Resources – Templates and resources to support application of the Ophelia Manual 2017.

© Swinburne University of Technology, 2019

Keywords1. Health literacy2. Health service access3. Consumer health information4. Health management and planning5. Health inequity6. Health promotion

Ophelia Templates andAdditional Resources

Templates and resources to support application of the Ophelia Manual

Templates and Additional Resources Copyright© 2019 Swinburne University of Technology

ContentsPhase 1 / Step 1 – Set up 1

Activity 1.1 Identify a project focus, scope and overall aim for the project 1

Activity 1.2 Establish a project team and identify roles and responsibilities 2

Activity 1.3 Identify existing sources of data and gaps in available data 3

Activity 1.4 Establish project timelines and budget 4

Phase 1 / Step 2 – Data collection and/ or extraction 5

Activity 2.1 Establish a data collection plan 5

Activity 2.2 Obtain ethical and other approvals required 6

Activity 2.3 Collect and or extract data 7

Activity 2.4 Prepare materials for the consultation activities 8

Phase 1 / Step 3 – Response ideas consultation workshops 9

Activity 3.1 Establish a consultation plan 9

Activity 3.2 Make arrangements for the consultation workshops 9

Activity 3.3 Undertake the consultation workshops 10

Activity 3.4 Prepare a summary of the results of the consultation workshops 12

Phase 2 / Step 4 – Intervention Design 13

Activity 4.1 Confi rm project focus, scope and overall aim, and specify objectives for the intervention 13

Activity 4.2 Conduct a rapid literature review and search for existing interventions 14

Activity 4.3 Identify which intervention ideas from the workshops match your intervention objectives 15

Activity 4.4 Select an intervention (or intervention package) 15

Activity 4.5 Work through the logic of your intervention, specifying how it will achieve its objective 16

Phase 2 / Step 5 – Intervention Planning 17

Activity 5.1 Identify members of your project team, and confi rm project timelines and budget 17

Activity 5.2 Identify a set of project milestones, and associated activities 18

Activity 5.3 Develop an evaluation plan 19

Phase 2 / Step 6 – Intervention development and refi nement 20

Activity 6.1 20


Activity 6.2 Undertake Quality Improvement cycles to test materials, training, manuals and processes 20

Activity 6.3 Refi ne materials and processes based on fi ndings of QI cycles 21

Phase 3 / Step 7 – Implementation and evaluation 22

Activity 7.1 Refi ne implementation and evaluation plan 22

Activity 7.2 Implement the intervention(s) 22

Activity 7.3 Undertake evaluation activities 23

Phase 3 / Step 8 – Development of an ongoing Quality Improvement strategy 24

Activity 8.1 Identify intervention components to be embedded into usual practice 24

Activity 8.2 Develop a continuous Quality Improvement plan 24

Additional resources

Activity 1.1 Additional examples of project focus, scope and aims 27

Activity 2.1 How many people should we collect data from? Examples of sample size considerations 27

Activity 2.2 Obtain ethical and other approvals required – example of invitation letter for clients 28

Activity 2.2 Example of wording for participant information sheet 28

Activity 2.3 Sample script for recruiting clients or community members to the project 29

Activity 2.4 How to score the HLQ and present the results 30

Activity 2.4 Using cluster analysis to identify fi ne-grained health literacy profi les 31

Activity 2.4 Steps in undertaking cluster analysis in SPSS 32

Activity 2.4 Creating ‘vignettes’ using HLQ data 33

Activity 2.4 Template for interview to support vignette writing 34

Activity 3.2 Make arrangements for consultation workshops – Example invitation for community members 36

Activity 3.2 Make arrangements for consultation workshops – Example email invitation for practitioners 37

Activity 3.4 Examples of linking intervention ideas and intervention objectives 37

Activity 4.4 Example of combining locally generated intervention ideas with ideas from the literature 40

Activity 4.4 Selecting an intervention – what are mechanisms? 41

Activity 4.5 Example of a program logic model 42

Activity 5.3 Example of Ophelia Implementation and Evaluation Plan 43


Phase 1 / Step 1Set up Activity 1.1 Identify a project focus, scope and overall aim for the project

What is the focus of your project (what is your project about / what issue do you want to address)?

What is the scope of your project (who will be included/ who is your target group)?

What is the aim of your project (what do you want to achieve and by when)?

Overall statement of project focus, scope and aims(e.g. our project focuses on participation in pap screening among Aboriginal and Torres Strait Islander women in our local government area. We aim to increase pap screening rates for Aboriginal and Torres Strait Islander women to the national average within 2 years).


Activity 1.2 Establish a project team and identify roles and responsibilities

Project team (examples in blue font)

Role Name Responsibilities

Project manager Primary project lead and liaison person for all stakeholders

Project offi cer Lead person for project implementation/data collection

Administration offi cer Administrative tasks/ support for project offi cer

Data offi cer Data management lead

Clinical leads Clinical/ practitioner support

Consumer representative Consumer perspectives (may be optional)

(Enter your information below)



Activity 1.3 Identify existing sources of data and gaps in available data

What sort of data do we need to tell us more about our target group?

Data type (Enter your information below examples in blue font)

Data type: Health status or outcomes data

What data could we collect? Data source How could we access this data?

e.g. Number of people in our service with diabetes and leg wounds; number of children under 5 with minor, self-limiting illness who present to Emergency; rates of smoking in our region

e.g. self-report; administrative data; local government data

e.g. conduct client survey; generate report from administrative datasets; access local government websites

Data type: Health/healthcare use


e.g. rates of Emergency Department presentations; numbers of people who fail to attend appointments

e.g. administrative data; self-report e.g. generate report from administrative datasets; conduct client survey

Data type: Health literacy strengths and limitations


e.g. capacity to access, understand and use information and services in relation to the project focus

e.g. interview clients; questionnaires e.g. administer the HLQ; conduct client interviews

Data type: Barriers and facilitators to engagement with health behaviours and services


e.g. consumer attitudes; clients’ previous experiences with service providers; referral processes; number of services available; transport costs; social support;

e.g. survey; service-audits; administrative data; interview clients

e.g. conduct client survey or interviews, generate report from administrative datasets, audit of referral processes.


Activity 1.4 Establish project timelines and budget

Anticipated timelines

Step Time in months (example only)

1 2 3 4 5 6 7 8 9 10 11 12

1 Set up

2 Data collection and/ or extraction

3 Response ideas workshop

4 Intervention selection/ design

5 Intervention planning

6 Quality Improvement cycles to refi ne intervention

7 Intervention implementation and evaluation

8 Develop continuous Quality Improvement strategy

Preliminary budget template (Enter your information below examples in blue font)

Items Considerations / How much do we have available / how much will it cost?

Staffi ng

Printing surveys for data collection

Catering for workshops

Venue hire for workshops

Items Considerations / How much do we have available / how much will it cost?


Phase 1 / Step 2 Data collection and/or extraction Activity 2.1 Establish a data collection plan

(Enter your information below examples in blue font)

Example Example Example

What data? Health literacy and demographic data Data related to clients’ experience engaging with health care services

Patterns of service use in target group

Source of data Sample will be 80-100 new clients with chronic disease attending a community health service

Sample will be 15 clients who have previously completed the HLQ and provided their consent to interview

Routine administrative data collected by local health service

How will the data be collected?

Paper-based HLQ with additional demographic questions

Telephone interviews using semi-structured interview guide

Extracted from administrative database

Timeframe 2 months 2 weeks 2 weeks

Staff involved Project offi cer, staff at health service Project offi cer Medical records staff

Steps – specifi c data collection activities

Train staff in HLQ administration. Invite all new clients at intake to complete the HLQ

Telephone clients directly and conduct semi-structured interview (15-20 minutes)

Discuss data needs with appropriate staff and seek permission to access data.


Activity 2.2 Obtain ethical and other approvals required

(Enter your information below examples in blue font)

Do we need ethics approval?

e.g. Our project aims to collect health literacy and use it in a Quality Improvement activity. We will discuss with the ethics offi cer for our healthcare service to see if clients need to provide written, informed consent

What strategies will we use to ensure people do not feel pressured to participate?

e.g. train staff in non-coercive methods of recruitment; ask staff who are not direct care providers to recruit clients; allow clients the option of discussing with family or other staff fi rst

How will we help people feel safe if they decide to withdraw from the study?

e.g. if providing written consent, give people a ‘withdrawal from study’ form to keep in case they change their mind; ensure people recruiting reinforce that withdrawal or refusal is permissible

How can we provide enough information to potential participants to allow them to give informed consent?

e.g. provide a clear ‘plain language statement’ if written consent is required; use teach-back to ensure that client understands; have simplifi ed wording and read aloud for all clients.

What measures do we need to put into place for clients who want to participate but do not want to sign a consent form

e.g. If written consent is required, check with ethics if a verbal consent (with witness signature) is an option


Activity 2.3 Collect and or extract data

Suggested considerations Examples

Training of data collectors

Who will deliver the training? Two project team members

Who will we train? 4 volunteers, 3 clinicians and 2 reception staff

When and where will we deliver training? Date, venue and time

What additional resources are needed for delivery of training? PowerPoint, handouts

Where can we obtain resources for training? Email [email protected] for Ophelia toolkit

Quality control strategies Develop a step by step guide that all data collectors must use

Have a central contact person that collectors can call if there are any issues or queries

One person to review all data collected aft er 2 weeks to ensure consistency

Monitoring data collection Set up a meeting with all data collectors aft er 2 weeks of commencing data collection to discuss any issues. Have regular fortnightly meetings thereaft er

Data collection methods

What strategies will we use All new clients to the service will be invited by their clinicians and reception staff to answer paper-based surveys. Volunteers will be available to assist clients with the survey.

How will we know if these are working? Meeting with data collectors every 2 weeks. Review demographic data every 2 weeks to ensure data is collected from a range of clients

Do we need to make changes to data collection methods? Discuss at fortnightly meetings

Do we need to notify our ethics committee of any changes? Yes

Recording the data

Where will data be recorded when, and by whom Use Excel spreadsheet entered weekly by xx

How will paper-based surveys be returned for data collection? Th is process to be discussed during initial training meeting to establish the most appropriate method


Activity 2.4 Prepare materials for the consultation activities

Example of how to present fi ndings for a workshop

Vignette 1: Fairly confi dent in own abilities but feels they have little support from other including health professionals

Mrs Smith is a 50 year old woman living on the outskirts of Melbourne. She was divorced 10 years ago and had to move to the outer suburbs to be able to aff ord to buy a home. She qualifi ed as a primary school teacher but since the birth of her fi rst child 25 years ago she has only done sessional work. All her children live and work away from the area.

She tries to keep healthy; she walks three times a week, and would like to do more but fi nds it diffi cult to fi t it in. She sees a male GP but sometimes feels that he is a bit impatient when she talks to him about her menopausal symptoms. She hears lots of things about how to manage hot fl ushes and mood swings, and sometimes goes on the internet to fi nd out more, but isn’t really sure what is relevant for her, and whether it is trustworthy information.

Health literacy profi le for Vignette 1

Possible score range 1-4 Possible score range 1-5

1 2 3 4 5 6 7 8 9Cluster number % of sample in

each clusterFeeling understood and supported by health-care providers

Having suffi cient information to manage health

Actively managing my health

Social support for health

Appraisal of health information

Ability to actively engage with healthcare providers

Navigating the healthcare system

Ability to fi nd good health information

Understand health information well enough to know what to do

1 24% 3.10 3.01 2.98 2.91 2.76 4.10 4.00 3.83 4.00

OverviewNumber of people in this cluster = 25Average age = 48.8% female = 80%% attended tertiary education = 40%Average number of health conditions = 0.9% people with musculoskeletal conditions = 53%Average BMI = overweight

Repeat this for each vignette. You may also like to present a summary of the demographic and health literacy fi ndings for the overall sample.


Phase 1 / Step 3 Response ideas consultation activitiesActivity 3.1 Establish a consultation plan

Consultation plan

Time frame e.g. February

Staff responsible e.g. Project manager, project offi cer and administrative assistant

Format e.g. Four workshops – two with local healthcare staff and two with local consumers. Professionals and consumers participate in separate workshops to enable each group to speak freely.

Participants Clinicians: e.g. invite a mix of experienced clinicians, team leaders and managers to the staff workshop. Th e workshops work best with a range of disciplines from across care pathways, and include the clinicians who really understand the service, community, their fi eld and, importantly the full range of clients they serve.

Consumers: Including some who participated in surveys, and from across the healthcare system (well through to long-term conditions). Include a range of ages and education. A range of people with no illness, recently diagnosed and long-term self-managers (successful and unsuccessful) of their health.

Recruitment approach e.g. Liaise with key contacts within the organisation to select appropriate staff . Invite consumers via their service providers, local media, and fl yers

How to capture ideas and insights e.g. Note taking and audio recording

Activity 3.2 Make arrangements required for the consultation workshops

Activity Responsibility and time line

Venue and catering

Printing

Background reading for participants (if required)

Audio-visual equipment

Preparation and set up on the day


Ophelia consultation workshops – what is involved?

Th e consultation workshops are brainstorming sessions where participants ‘respond to’ the HLQ vignettes. Th is is the step that is at the heart of the Ophelia process. Th e workshops need to have as good number of experienced frontline practitioners as possible. It is this group who see the many clients with the health literacy challenges we seek to support. Th e workshops allow the tacit knowledge of the best frontline clinicians and managers to emerge through a dynamic workshop environment. Given this, one of the most important attributes of the workshop facilitator is the ability to listen.

For each of the vignettes, ask the participants:

1. Do you see clients like this/ do you know people like this?

2. What sort of issues is this person facing?

3. What strategies could you use for an individual like this?

4. (for practitioners and managers) What could you do if you had many clients like this in your organisation?

Ideas are recorded by the note-taker and if desired, main themes/ ideas can also be noted on a whiteboard or fl ip char. Aim for at least 2 to 3 intervention ideas for each vignette.

In addition to discussing each of the vignettes, present the ‘interpretation of HLQ scales’ sheet (see the Ophelia Toolkit), and ask participants to brainstorm about what strategies they could use for people with lower scores on particular scales at both an individual and organisational level. It is not necessary to go through each of the scales, but target those scales which had lower mean scores in the overall sample from whom HLQ data was collected.

What do we mean by health literacy interventions?

In the workshops, participants are asked not to necessarily identify brand new strategies, but just to come up with response ideas. Th e ideas that are generated might be similar to normal practice, or may be something new. Th e interventions do not have to be about directly improving a client’s health literacy, but more about using health literacy as a means to achieving better health outcomes or improved access to services. Oft en, the interventions ideas are very broad strategies only, and the facilitator may need to gather more detail.

Key considerations for health literacy interventions are:• A focus on improving health and wellbeing outcomes.

Th is applies equally to eff orts to optimise individuals’ health literacy and the health literacy responsiveness of the health system.

• A focus on increasing equity in health outcomes and access to services for people with varying health literacy needs

• Prioritise local wisdom, culture and systems• Focus on improvements at, and across, all levels of the

health system

If time permits and the participants are still engaged, summarise and prioritise the intervention ideas, considering their feasibility and relevance for the local context. Factors to consider in prioritising intervention ideas are:• Resources and timelines• Th e likelihood of achieving the goals and objectives

set out in Step 1• Are the intervention ideas likely to be equitable and

sustainable?• What is the general level of enthusiasm?• Are there major risks?• Do you want the intervention to focus on one health

literacy profi le or on the broader target group?

Oft en, intervention ideas will overlap between diff erent HLQ vignettes. Sometimes it is possible to combine these ideas to form a wider-reaching intervention.

Activity 3.3 Undertake the consultation workshops


Example agenda for workshop

Time Activity Resources/ comments

10.00 -10.15 Introductions

10.15 -10.30Background to the project: aims and focus, description of client group from whom HLQ data collected.

PowerPoint

10.30 -10.45 Discuss fi rst vignette (see above questions) Brainstorming session. Could use a fl ip chart, whiteboard. Take notes10.45 -11.00 Discuss second vignette

11.00-11.15 Break

11.15 -11.30 Discuss third vignette Flip chart, whiteboard.

11.30 -11.45 Discuss responses to lower scores for each scale Interpretation of HLQ scores document.

11.45 -12.00 Discuss fourth vignetteFlip chart, whiteboard.

12.00 -12.15 If time permits, discuss fi ft h vignette

12.15 -12.45 Summing up and discussion of main themes/ common intervention ideas.


Activity 3.4 Prepare a brief summary of the results of the workshops

General refl ections and insights – example from a project aiming to improve clients’ management of acute exacerbation of heart failure

Vignette 1 Vignette 2 Vignette 3 Vignette 4

General insights about key issues

“Th is person would be someone who has a pile of information brochures from the hospital that just sit on their dining room table and never get read”

“Th is is a person that learns by listening to other people’s stories, like short videos or something. Th ey also like to be shown how to do things”

Th is is a person who struggles to operationalise their care plan. When you ask them what they will do fi rst, they can’t tell you”

Th is person has managed their health condition quite well until now, but now it is worsening. Th ey need to know what else they must do to keep condition stable”

Intervention ideas

Make sure that we match all our patient education to how each person learns, and what they want to know

Train staff in use of teach-back and other sensitive teaching methods

Source client education materials in a variety of learning formats

Find out about local peer support groups

Train all staff in use of teach-back methods

Clients need help putting things into action – use teach-back in every interaction

Talk to other providers and family members about ways of helping clients to use care plan

Don’t try to reinvent the wheel, build upon what the client already knows or what they already use that is eff ective


Phase 2 / Step 4Intervention designActivity 4.1 Confi rm the project focus, scope and overall aim for the project,

and specify the intervention objectives

Statement of project focus, scope and aims and intervention objectives

e.g. Our project focuses on supporting patients with heart failure to better manage their condition and avoid preventable exacerbations. We aim to reduce the proportion of patients who present to the Emergency Department with potentially preventable exacerbations by 10% in 6 months. To achieve this, our intervention will support clients to better understand what steps are required to manage an exacerbation, to provide them with appropriate resources and to increase their use of heart failure action plans.


Activity 4.2 Conduct a rapid literature review and search for existing interventions

Literature review for e.g. studies examining interventions to improve patient-provider communication

Intervention type/ author

Setting and sample Main components of intervention

Outcomes as reported by authors

Written communication tool

Farberg A. et al Journal Hospital Medicine 2013, 8, 10; 553–558

Hospitalised patients in a general medicine and a cardiology unit in the US

• Dear Doctor notepads provided to patients

• Intervention over 3 months

• All patients who used the notepads responded that communication with their physicians was enhanced.

Written communication tool

Talen, M et al. Families, systems and health 2011, 29, 3: 179-183

Adult patients seen in a family medicine health centre in the US

• Patient Information Form completed prior to meeting with physician designed to help patients describe symptoms clearly, and prioritize and organize health concerns

• Patients reported higher doctor-patient communication skills in understanding their health, communicating their health concerns, and feeling they were partners with their physician.

Audio-taped consultations

Heyn L, et al. Psychooncology. 2013, 22,1; 89-96

Adult cancer patients in US hospital

• Interactive, tailored patient assessment tool administered prior to consultation (aim to improve communication between patient and clinician)

• Intervention group more active participants in consultation

– More symptoms expressed

– Asked more questions – Clinician provided

more information

Webinar conferencing

Reinke L, et al. Am J Hosp Palliat Care 2011, 28, 3; 147–152.

Patients with severe chronic obstructive pulmonary disease

• Webinar specifi cally regarding conversations about end-of-life care entitled, ‘Diffi cult Conversations’

• Webinar was acceptable for the majority of patients.

• Improvements in audio and video bandwidth may facilitate more interaction among virtual participants


Activity 4.3 Identify which intervention ideas from the workshops match your newly established intervention objectives

Intervention objectives Intervention ideas

• Increase clients’ use of heart failure exacerbation plans from 30% to 50% in 6 months

• Clients with heart failure can describe the steps required to manage exacerbation of their condition.

• Supports and resources to enable clients to understand how to manage heart failure exacerbations

• Find out each client’s preferred learning style and use this as a basis for a discussion about their individual educational needs

• Provide material in formats that patients demonstrate they understand

• Use teach-back in every interaction

• Build upon what the client already knows and what they already use that is eff ective

Activity 4.4 Select an intervention (or intervention package)

Agreement between stakeholders about selected intervention – and brief description of reason for choice


Activity 4.5 Work through the logic of your intervention, specifying how it will achieve its objective

Program Logic Template

Longer-term Outcomes e.g. reduce unplanned admissions to hospital for heart failure

�Medium-term Outcomes e.g. clients use their heart failure action plans more eff ectively

�Short-term Outcomes e.g. clients have increased knowledge and confi dence to put their heart

failure plans into action

�Outputs e.g. clinicians use teach-back with clients to help them understand how

to use their heart failure action plan

�Activities e.g. train clinicians in use of teach-back and provide supporting resources

�Inputs e.g. Th e Ophelia learning styles assessment tool, develop understandable information for

clients, develop teach-back training program and resources for clinicians

Defi nitions

Resources/ inputs – What is needed for the activities to occur. Th ese can include human, organisational or community resources in any combination.

Activities – Th e specifi c actions that make up the program. Activities are synonomous with interventions

Outputs – What the specifi c activities will produceor create. Outputs can include descriptions of audiences or targets delivered by the program.

Outcomes – Changes as a result of the program. Th ese are oft en divided into short, medium and long-term outcomes

Figure 2 – Program logic template

Long term outcomes

Start with outcomes

Medium term

outcomes

Short termoutcomes

OutputsActivitiesResources/inputs


Phase 2 / Step 5 Intervention planningActivity 5.1 Identify members of your project team, identify roles and responsibilities,

and confi rm your project time frame and budget

Project team


Project manager Primary project lead and liaison with stakeholders

Project offi cer Lead person for intervention implementation/ evaluation

Administration offi cer Administrative tasks/ support for project offi cer

Training lead Trains staff in delivery of intervention

Clinical leads Clinical/ practitioner support

Working groups

Working group activities Staff

Develop implementation and evaluation plan

Develop training program and materials for staff

Develop resources for intervention delivery

Pilot testing

Evaluation of intervention and fi nal report

Budget

Items How much will it cost?

Staff training in delivery of the intervention

Staff time for delivering the intervention

Venue for staff training

Printing of resources used in training

Printing of resources used in delivery of the intervention

Timelines

Task Time

Finalise implementation and evaluation plan 2 weeks

Preparation of resources for training and intervention 4 weeks

Pilot testing of resources and processes 1 month

Delivery of training to all staff 2 weeks

Delivery of intervention 3 months

Evaluation of intervention 1 month


Activity 5.2 Identify a set of project milestones, and associated activities – for intervention development, implementation and evaluation

Milestone Example milestones Example activities

Milestone 1: Finalisation of the project implementation and evaluation plan

Produce a project implementation and evaluation plan that includes:a) an overview of the project focus, aims

and intervention objectives;b) the intervention logic model;c) a table specifying the evaluation plan,d) a summary of the project staffi ng, timelines

and budget, and;e) a table specifying the materials, staff training, tools and

equipment required for implementation and evaluation of the intervention, their availability and their cost.

Milestone 2: Finalisation of intervention materials and process guidelines

Purchase (or develop) the materials, training, manuals, etc. detailed in the implementation and evaluation plan

Test and refi ne the processes, materials, training, manuals, tools and equipment

Milestone 3: Ethics approval (if required) Submit ethics application/s and refi ne processes as required to obtain ethical approval

Milestone 4: Intervention commencement

Undertake intervention and evaluation activities as detailed in the implementation and evaluation plan

Milestone 5: Intervention completion

Milestone 6: Evaluation completion


Activity 5.3 Develop an evaluation plan

Process evaluation (e.g. for an intervention to support clients to better self-manage diabetes through training clinicians to use teach-back)

Intervention activities Measure of achievement

Deliver 1 hour training session to all staff on teach-back and assessing client learning styles

All staff have attended training session. Attendee satisfaction with session and confi dence to deliver intervention

Provide resources to support staff in ongoing delivery of intervention

Staff satisfaction with resources

Implement intervention using a staged approach Number of clients receiving intervention; staff use of resources; client satisfaction with the intervention

Outcome evaluation

Intervention objectives Measure of achievement

Clients can articulate the steps required for self-management of their condition

Interview clinicians and/ or clients; use of a validated and disease specifi c knowledge questionnaire before and aft er the intervention

Clinicians have a deeper understanding of their clients’ barriers to self-management and can discuss these issues with clients

Interview clinicians and/ or clients;

Clients are able to apply knowledge to better self-manage their condition

Interview clinicians and/ or clients; number of adverse events (measured before and aft er the intervention)


Phase 2 / Step 6Intervention development and refi nementActivity 6.1 Purchase or develop the materials, training, and processes

detailed in the implementation and evaluation plan

Materials/ trainings/ processes Staff responsible Planned Completion Date

Activity 6.2 Undertake Quality Improvement (QI) cycles to test materials,training, manuals and processes

Quality Improvement cycle e.g. for project aiming to improve referral processes between co-located dental service and primary health service

Plan Preparatory activities include the following:• Establish electronic referral process between dental services to primary health services. • Develop marketing material for dental team and for primary health care team• Orientate ‘pilot’ dentist(s) and primary health central intake staff to intervention

Planned completion date =

Do • One dentist engaged to action 1-2 referrals to primary health following agreed process. Referral actioned by central intake staff . Modify process and repeat if necessary.

• Provide marketing material to up to 5 clients of each service.• Modify intervention and repeat if necessary.


Study Undertake the following evaluation activities, review results and make decisions about required modifi cations to the interventions or evaluation strategies.• Participants referred between dental service and primary health services, and

participants viewing marketing material take part in evaluation activities (Semi structured phone interviews focused upon satisfaction with referral, marketing material, and utility of service provided in their daily lives.) Modify questions if required and repeat.

• All referrers, referees and intake staff take part in evaluation activities (Semi structured phone interviews focused upon satisfaction with process). Modify questions if required and repeat.

• Documentation of referrals made, rates of attendance of participants to primary health services


Act • Modify evaluation activities and repeat if necessary.• Modify interventions and repeat if necessary



Activity 6.3 Refi ne materials and processes based on fi ndings of QI cycles

Materials / trainings / processes

Changes required Staff responsible Planned Completion Date


Phase 3 / Step 7Implementation and evaluationActivity 7.1 Refi ne implementation and evaluation plan

What changes are needed?

Who is responsible for making these changes

By when Are additional resources required?

Activity 7.2 Implement the intervention(s)

Example of record keeping for an intervention to increase clients’ use of heart failure action plans

Monthly reports on:

Number of eligible clients

Number of clients seen

% that chose each of the learning styles

% who had their learning styles needs met

% clinicians who reported applying teach back

Reason for using teach-back

Average number of times teach-back used for each client

Any challenges noted by clinicians or clients

Any adverse events or other issues

Any changes made to the intervention as a result of the adverse event


Activity 7.3 Undertake evaluation activities

Example evaluation reportTh e interventions were implemented and evaluated between September and April 2015 as follows: • A total of 13 volunteers were trained in delivery of health messages • Volunteers then delivered health messages in a number of diff erent settings including

a tai-chi group, a community exercise group, during home visits, with family and friends

Evaluation activities were:• HLQ scales 2,5,6 tested at pre and post intervention with community members and volunteers

(scale 5 is comparison scale, i.e. one in which little change is expected). • Interviews with practitioners, community members and volunteers• Participation rates• Capturing of ripple eff ects via interviews

Results

HLQ data (volunteers and clients)

Have suffi cient information to manage my health (scale 2)

Appraisal of health information (scale 5) comparison scale

Ability to actively engage with healthcare providers (scale 6)

Mean (SD) Mean (SD) Mean (SD)

Pre Intervention (all, n=23) 2.99 (0.50) 2.96 (0.47) 4.04 (0.59)

HLQ scores in those participants completing both pre and post HLQ (n=19, scales 2, 3, n=18 scale 6)

Pre intervention 2.95 (0.49) 2.89 (0.49) 4.03 (0.50)

Post Intervention 3.22 (0.50) 3.07 (0.29) 4.34 (0.61)

Eff ect size for diff erence (95% CI) 0.56 (-0.09,1.20) 0.52 (-0.13, 1.16) 0.56 (-0.11, 1.22)

Summary of interview fi ndings (participants = 7 volunteers in one focus group + 3 phone/ face to face interviews. Clients = 4 in one focus group + another 2 phone interviews).

• Th e Good Questions Form: Th ere were reports of some GP’s providing positive feedback and even on one occasion requesting more forms. Lack of using the form appeared to be centred on fear on a negative response from the GP. However, multiple stories of positive health outcomes were reported as a result of using the form, asking more questions and being more prepared and assertive during GP visits.

• In terms of the dynamics of rural health promotion, using volunteers who were active community members to deliver simple, word-of-mouth messages to their community, health and social groups was hailed as successful. Volunteer responses indicated a sense of feeling useful, alongside pride and achievement from participating in a health promoting project. Discussing one’s health with close family and friends as well as within social, health and community groups appeared to be the norm in the participating areas. However, this lead to a ripple eff ect in terms of clinicians, volunteers and clients spreading the study’s message within existing circles.


• Lessons Learnt: – Training was well accepted with suggestions to provide additional support to participants as required

in future sessions, vs a single method of delivery. – Follow up with volunteers post training sessions. – Using success stories during training and delivery of the messages. – Delivery of training to roll out message more broadly (e.g. community groups, local staff ) – Embed the role within standard volunteer activities, but ensure taking up the role is not imposed. – Promote the project more widely (e.g. advertising, posters around town and in GP clinics etc.) – Make the form more user friendly (e.g. in the form of a note pad)

Participation rates

Volunteer participating in training and delivery of the messages n=14

Community members participating in evaluation (pre-post HLQ and/or interviews); n=7

Ripple eff ect (volunteers or clients discussing health messages with at least one other) out of a sample of 13 (excluded 3 clinicians who also spoke to at least one other) n= 11


Phase 3 / Step 8Development of an ongoing Quality Improvement strategyActivity 8.1 Identify intervention components to be embedded into usual practice

Does the organisation plan to continue to provide all or some of the interventions?

Do you envisage any problems or barriers to continuing to off er all or some of the interventions?

Do you see any benefi ts associated with continuing to off er all or some of the interventions?

Do you plan to make any changes to the materials or processes and why?

Activity 8.2 Develop a continuous Quality Improvement plan

Outline your strategy for continuing to develop the intervention:

What are the next steps?

Who will be responsible for developing this?

What will you do to overcome potential risks/problems?

What approach will you take to monitoring and reviewing progress and success?

What resources and supports do you / would you need to continue to off er the intervention and ensure it grows/develops/succeeds?

How, when and to whom will the QI activities be reported?

How will you ensure the intervention continues to be implemented?

Ophelia Manual –Additional Resources


Phase 1 Additional resourcesActivity 1.1 Establish a focus, scope and aim – additional examples of project focus, scope and aims

Project focus: High numbers of falls among elderly people in the community

Project scope: Older people in the community who are frail and socially isolated

Project aim: To decrease the rate of falls in older community members within 2 years

Project focus: Access to diabetes educational materials for people who are vision impaired

Project scope: Nationwide, people with diabetes who are vision impaired

Project aim: To develop educational materials that are appropriate for visually impairedpeople with diabetes

Project focus: Building emergency fi rst aid providers’ capacity to deliver health education in the community

Project scope: All emergency fi rst providers in 3 shanty towns in South Africa

Project aim: For 60% of emergency fi rst aid providers to routinely deliver health education in the community within 12 months

Project focus: Inappropriate use of General Practitioners’ (GP) services for minor illness in children under 5 years

Project scope: Parents and carers of children under 5 years in a GP catchment area

Project aim: To reduce the inappropriate use of GP services by 20% in 2 years

Activity 2.1 Establish a data collection plan.

How many people should we collect data from? Examples of sample size considerations

A multicultural service wanted to explore health service use in migrants. Th ey aimed to collect data from 150 people in total. Th eir sample included 50 people born in Australia, 50 people who were ‘new’ migrants, and 50 people who had emigrated to Australia more than 5 years previously.

A small service wanted to increase adolescent client’s use of action plans for exacerbation of asthma. Because they were a small service, they invited all eligible clients to participate in a survey. Data was collected from 73 of the 170 clients who were eligible to participate.

A university health service wanted to understand students’ health behaviours, particularly for international students. Th ey aimed to collect data from 300 students in total. Th is included students across 3 courses, half of whom were international students, and half domestic. Th is allowed for comparison of health behaviours between domestic and international students, and between students from the 3 diff erent courses.


Activity 2.2 Obtain ethical and other approvals required – example of invitation letter for clients

(minimum size 12 font)

You are invited to take part in a study about health information. We would like to fi nd out if the health information you are given by XXX is useful to you.

You do not have to help but if you would like to know more about this study, then please read the participant information form below.

Aft er you have read the participant information form, if you decide you would like to be in this study, please fi ll out the consent form and give it back to the person who discussed it with you.

Th e ethics committee of XXX has approved this research.

Activity 2.2 Obtain ethical and other approvals required – example of wording for participant information sheet

For ethics application for data collection using the HLQ

As a client of [service, program], you are invited to take part in a study about health information.

What the study is aboutTh e main reason for this study is to help your health service understand whether the information they give you is useful. Th is will help them to improve the services they provide.

What does being in the study involve?Being in the study involves fi lling in a survey. For most people it takes 10 to 20 minutes to complete the survey.

Th ere are three ways that you can fi ll in the survey: 1. Someone at the health service can help you. Th is could be someone you know, or – if you prefer – someone who is

not involved in your care.2. OR you can complete it yourself (a family member or friend can help), 3. OR a researcher from xx can telephone you and ask you the survey questions over the phone.

If you decide to be in the study we would also like your permission for [service provider] to give us some information about which programs and services they are providing to you.

Risks and potential benefi ts to participantsWe do not expect that there will be any risk to you from being in this study.

Th ere are no direct benefi ts to you if you take part in this study; however, your involvement will help[service provider] better understand what their clients need.

How your privacy and confi dentiality will be protectedYour privacy and confi dentiality will be fully protected. Your name or any identifying details will not be included in any reports or articles about the study. All data will be stored on password protected computers or in locked fi ling cabinets. Ethical approval for this study has been granted by XXX Human Research Ethics Committee.


How the study’s fi ndings will be publishedA summary of the results will be given to [service provider] and you will be able to get a copy. Conference papers and scientifi c journal articles will submitted for publication. You will not be identifi ed in any of these reports or publications.

Withdrawing from the studyYou have the right to withdraw from this study at any time, without giving a reason.

If you choose not to be in this study or if you choose to withdraw it will not aff ect your relationship with [service provider] in any way.

Researcher’s contact detailsIf you have any further questions about this study, please contact the study’s principal investigator (provide contact details)

ComplaintsIf you have any complaints about this study, the way it is being conducted, or any questions about your rights as a study participant, then you may contact: (provide contact details)

Activity 2.3 Collect and/ or extract data – Sample script for recruiting clients or community members to the project

Th is is a sample script that staff may wish to use when asking clients if they would like to participate in data collection.

I’d like to ask you about being in a project that [name of organisation/ service] is involved in. Th e project wants to fi nd out about how well our clients understand the information we give them, and the ways in which they use health services.

Would you like to contribute to this project? If so, you will need to complete a survey about health and health information. It takes about 20 minutes.

You can fi ll the survey in yourself or we can help you with it. It doesn’t need to be done all at once.

Your answers are confi dential. Only staff involved in the project will have access to your answers on the survey. If you don’t want to do the survey, that’s fi ne. It won’t aff ect or change anything about your care.

Please have a think about this, or talk to your family about helping with this project and let me know. [If signed consent to participate is required] If you do want to do the survey you will need to sign a form from the ethics committee at [xxx] to say you agree to be in the project.


Activity 2.4 Prepare materials for the consultation activities – How to score the HLQ and present the results

Th e HLQ is a multi-dimensional tool comprised of 9 separate scales. Th e HLQ is not designed to provide a single summative score; rather it provides a comprehensive picture of a person’s health literacy needs and strengths.

Th e HLQ has nine individual scales

HLQ scales Scores

1. Feeling understood and supported by healthcare providers High

2. Having suffi cient information to manage my health Mod

3. Actively managing my health Low

4. Social support for health Very high

5. Appraisal of health information Very low

6. Ability to actively engage with healthcare providers High

7. Navigating the healthcare system Low

8. Ability to fi nd good health information Very low

9. Understand health information well enough to know what to do Very high

Th is person scores more highly on their ability to understand health information and to engage with healthcare providers. Th ey have at least one trusted healthcare provider, and strong social support for health. Th ey have lower scores in their ability to fi nd and appraise health information to navigate the healthcare system. Th ey also score relatively low on actively managing their health.

Each scale contains between 4 to 6 questions. Scales are scored by summing the responses to each question and dividing by the number of questions in that scale. Th is provides a mean score for each scale. Th e fi rst 5 scales have a mean score range of 1-4, while the last 4 scales have a mean score range of 1-5.

HLQ data can be presented in several ways:

Presenting the mean scores for each scale for the overall sample:

Th e mean scores for each of the nine scales can be presented for an overall group of clients.

Or HLQ scores can be compared between two diff erent demographic groups to show where diff erences in health literacy profi les occur.

1

1.5

2

2.5

3

3.5

4

4.5

5

1

1.5

2

2.5

3

3.5

4

4.5

5

1.Healthcareprovidersupport health

4.Socialsupporthealth

5.Appraisalproviders health

1.Healthcareprovidersupport health

4.Socialsupporthealth

5.Appraisalproviders health


Activity 2.4 Using cluster analysis to identify fi ne-grained health literacy profi les

Within any group of clients/ community members, there will be variation in their health literacy profi les. Presenting just the overall mean scores for the group will hide this variation. Cluster analysis is a technique for grouping people with similar health literacy profi les together. Th e analogy we use is supermarket trolleys – the healthy eaters have more fresh, low fat items in their trolley and just a few high sugar items, while the less healthy eaters have more high sugar, high fat products, and fewer fresh items.

Cluster analysis can be undertaken in several common statistical packages including SPSS. Th e pivot table function in Excel is then used to format the data for presentation.

Example of health literacy profi les of a group of clients (using cluster analysis)


Cluster number % of sample in each cluster

1Feeling understood and supported by health-care providers

2 Having suffi cient information to manage health

3 Actively managing my health

4 Social support for health

5 Appraisal of health information

6 Ability to actively engage with healthcare providers

7 Navigating the healthcare system

8Ability to fi nd good health information

9 Understand health information well enough to know what to do

1 22% 3.68 3.45 3.40 3.50 3.16 4.55 4.40 4.26 4.46

2 24% 3.17 3.01 2.93 2.98 2.76 4.10 4.00 3.83 4.00

3 20% 3.35 2.91 3.08 3.12 2.84 3.74 3.47 2.96 2.83

4 20% 2.72 2.49 2.74 2.54 2.43 3.44 3.32 3.31 3.71

5 14% 2.83 2.39 2.70 2.68 2.23 2.38 2.19 1.94 2.24

A traffi c light system of colour coding is used, so that green cells represent higher scores and red cells represent lower scores for this sample. In this example, 22% of the sample have overall ‘higher’ health literacy scores (cluster number 1), 34% of the sample have ‘lower’ health literacy scores (cluster numbers 4 and 5), and 44% have a mix of scores (cluster numbers 2 and 3).

Importantly, the health literacy profi les of each cluster are distinctly diff erent from each other.


Activity 2.4 Steps in undertaking cluster analysis in SPSS

Data preparationEnsure any demographic or other variables that you want to include in your fi nal vignettes are either continuous (such as age) or binary (yes/no). Categorical data will need to be converted to binary.

Run cluster analysis in SPSS (more detail in SPSS handbook)1. Click ‘ hierarchical cluster analysis’ from ‘analyse’ menu (located within ‘classify’ option)2. Select the appropriate variables (in this case the nine scale scores)3. Label cases by ‘caseid’4. Cluster by ‘cases’5. Click ‘statistics’ button. Select ‘range of solutions’ option and enter 3 to 16 (you may decide

on more or less). Click ‘continue’6. Click ‘method’ button. Select ‘Ward’s method’ option from ‘cluster method’ drop down menu. 7. In the ‘method’ box, select ‘Standardize’. Select the z-scores option. 8. Click ‘save’ button. Save the same range of solutions entered in step 5.9. Click ‘OK’. 10. Click ‘save as’ option from ‘fi le’ menu. Save as ‘excel 2007 through to 2010’ fi le to appropriate location.

Finalise excel data fi le1. Give worksheet an appropriate name.2. Create StDev columns. One for the items in part 1 of the questionnaire and one for part 2.

Calculate stdev using stdev s (sample) option.3. Create ‘overall average score’ column. Calculate ‘overall average score’ for all HLQ items.4. Ensure binary (yes/no) variables are coded as 0 = no and 1 = yes (e.g. for gender, create a variable

called female, with females = 1 and males = 0)5. Find and replace ‘#NULL!’ with nothing.

Create pivot table1. Select ‘pivot table’ from the ‘data’ menu. Select ‘new sheet’ option.2. To ‘values’ fi eld add: – Caseid – Each scale score (change to average) – Overall score (change to average) – Std_dev for parts 1 and 2 (change to average) – Each scale score (change to Std_dev) – And any demographic variables that will help you describe the people in each cluster.

Examples of these are: • Age (change to average) • Sex (change to sum) • Number of conditions (change to average) – If demographic/ clinical variables are continuous data such as age, then change to average, if binary, then change to

sum.Examine cluster solutions1. Add a worksheet and label it ‘clusters’2. Set up column headings and ‘freeze’ top row3. Return to the pivot table, add ‘cluster 1’ to ‘row labels’ fi eld4. Copy and paste results from pivot table into ‘cluster’ worksheet. Check data corresponds


to heading labels.5. Examine available cluster solutions and select the most meaningful and usable solution.

Generally, this will be somewhere between 4 and 8 clusters. a) Consider standard deviation (SD). If > 0.6, this indicates there is still considerable variation within

a cluster. If the number of people in that cluster is very small, SD is likely to be naturally high, so is not a reliable indicator in this case.

b) Consider whether the pattern of health literacy scores in one cluster appear diff erent to others. Examine demographic and clinical data associated with that cluster to determine if there are obvious diff erences between clusters.

c) Th e agglomeration schedule can also be used to help determine the optimal cluster solution (see SPSS handbook for more detail).

Preparing materials for presentation1. Produce cluster summary document by copying relevant components of table outlining selected

cluster solution. 2. Develop vignettes to present alongside each selected cluster (see Activity 2.4, below).

– You will probably not have enough time to present a large number of clusters and vignettes during the workshop.

– Select a range of clusters that show the diversity in your sample.

Activity 2.4 Creating ‘vignettes’ using HLQ data

In cluster analysis, HLQ data can be combined with demographic data to provide a clear picture of what a typical person in each cluster might look like. Th is is done using pivot tables in Excel.

Example of health literacy profi les of a group of clients (using cluster analysis)


Cluster number % of sample in each cluster

1Feeling understood and supported by health-care providers

2 Having suffi cient information to manage health

3 Actively managing my health

4 Social support for health

5 Appraisal of health information

6 Ability to actively engage with healthcare providers

7 Navigating the healthcare system

8Ability to fi nd good health information

9 Understand health information well enough to know what to do

4 20% 2.72 2.49 2.74 2.54 2.43 3.44 3.32 3.31 3.71

Average age of people in cluster

% in cluster who are female

% in cluster who live alone

% in cluster with low education

% in cluster with private health insurance

% in cluster born overseas

% in cluster who speak other primary language

Average number of chronic conditions in people in cluster

% in cluster who report feeling depressed

76.3 years 73% 84% 69% 30% 81% 69% 3 77%


Demographic data for people in cluster number 4 shows that a typical person is female, older, and is likely to live alone. Th ey are also likely to have lower education (i.e. not completed secondary school), and to not have private health insurance, suggesting they may have lower socioeconomic status. Th ey are likely to be born overseas and to not speak the local language. Th e average number of chronic health conditions for people in this cluster is 4, and nearly 80% of this cluster report feeling depressed.

We can then combine the health literacy profi le of people in this cluster with their demographic data to build a vignette or ‘story’ about the challenges that person might experience in trying to look aft er their own health. An example of a scenario for a typical person from cluster 4, above, might be:

Lucinda is a 76 year old lady who lives alone. She was born in Poland, and left there 35 years ago. She speaks limited English. Her husband died some years ago, and Lucinda has an adult daughter who lives the other side of town. Lucinda doesn’t like to ask her daughter for help to get to medical appointments as she knows she is busy with her own family (HLQ scale 4). Lucinda has Type 2 diabetes, arthritis and back pain, and most of the time feels quite low in her mood. She sees lots of diff erent health professionals, but struggles to fi nd one she can really talk to and trust (scale 1). Recently her doctor told her that her blood pressure was too high and that she needed to start a low salt diet. She was too afraid to ask him questions about this (scale 6) as he always seems in too much of a hurry, and now she is not sure where she can go to for more help (scales 2 & 7) or information (scale 8). She thinks maybe she should ask her elderly neighbour for advice (scale 5). She is not sure that she can be bothered anyway to change her diet – it all seems too hard, and she has plenty of other things to worry about (scale 3).

Interviews can also be conducted with a sample of people who answered the HLQ to understand more about the answers they gave. Th is information can be used to provide further evidence for the vignettes (see below for interview template). Th ese vignettes can then be used in consultation activities with expert front-line practitioners, managers and/ or community members in order to generate practical and needs-based interventions to improve health outcomes.

Activity 2.4 Template for interview to support vignette writing

Purpose: the main purpose of these interviews is to explore the stories behind why participants have answered questions from the HLQ in the way that they have. Th is information will be used to provide context for vignette development.

Interview preparation: Th is stage is undertaken aft er HLQ data is collected and analysed. Th ere are two ways of identifying which clients to interview. You can either examine the HLQ results and randomly identify clients who appear to have overall patterns of lower, medium and higher scores, or you can undertake cluster analysis and then interview 2 or 3 clients from within 3-5 key clusters. You will need the client’s HLQ scores to determine in which domains they have lower scores and in which they have higher scores. Choose the most signifi cant HLQ domains only, there is no need to talk about them all.

Information for the participant: “Th e information you give will contribute to the work we are doing in understanding healthcare. It will take us about 15 – 30 minutes to answer the questions. Th e questions are about the answers you gave on the questionnaire. Th ere are no right or wrong answers, so please answer the questions based on your own experience. If you need to stop at any time, just let me know. I will be recording the interview for accuracy and writing up.”


Examples of interview questions as indicated by HLQ (lower /higher) scores

Scale 1. Feeling understood and supported by healthcare providers

Higher scores: Your answers for this scale suggest you have good relationships with your healthcare providers – is this how you see it? Why is this? OR

Lower scores: Your answer for this scale suggest that you’ve found it diffi cult to establish good relationships with healthcare providers. Has it always been this way? What would help you to improve these relationships?

Scale 2. Having suffi cient information to manage my health

Higher scores: What helps you to feel you have enough information to manage your health and make decisions? ORLower scores: What would help you to feel confi dent that you have enough information about your health?

Scale 3. Actively managing my health

Higher scores: How did you learn to manage your health? What do you do to manage your health? OR Lower scores: What do you need to help you manage your health diff erently?

Scale 4. Social support for health

Higher scores: What has helped you to build a strong system of support from family and friends? ORLower scores: What would help you to build relationships with family or friends?

Scale 5. Appraisal of health information

Higher scores: What helps you to understand health information? How do you work out what is best for you? ORLower scores: What would help you to understand health information and work out what is best for you?

Scale 6. Ability to actively engage with healthcare providers

Higher scores: How comfortable do you feel about talking about your health with healthcare providers? What has helped you with this? OR

Lower scores: How comfortable do you feel about talking with healthcare providers? What would help you to feel more comfortable to talk with them about your health?

Scale 7. Navigating the healthcare system

Higher scores: How do you fi nd out about the health and support services that you need? OR Lower scores: What would help you to fi nd out about health support services that you need?

Scale 8. Ability to fi nd good health information

Higher scores: What has helped you to fi nd information about your health? OR Lower scores: What would help you to fi nd information about your health?

Scale 9. Understanding health information well enough to know what to do

Higher scores: What has helped you to understand written health information? OR Lower scores: What would help you to understand written information about your health?


Activity 3.2 Make arrangements for consultation workshops – Example invitation for community members

(minimum size 12 font)

Community workshop on health literacy

We invite you to attend a group workshop at (venue) on (date) from (start time and end time)

What is the workshop about?

Th e group workshop is to fi nd out about how easy or diffi cult it is for you and people you know to:• talk with health care workers such as your family doctor• fi nd good health information• look aft er your own health and that of your family• get the health services that you needPeople from the community – like you – already know what they need to be able to do these things. Th is is what we will ask you about in the workshop

What will happen in the workshop?

We will fi rst show you some short ‘stories’ about the way in which people manage to look aft er their own health.

Th e people in these stories are made up, even though they may sound like someone you know.

We will then ask you, and other people in the group workshop some questions. Th ese questions will be about:• what you think that person might need, or• what their local health or community services might do you help them look aft er their health more easily. We will ask you these questions as a group. Please feel free to answer the question honestly and put forward any ideas you have.

Th e workshop will be run by (name of person running workshop)

What will happen to the answers I give?

Th e answers that the group provides will be recorded so that we can write them down and discuss them with local community organisations and health services.

You will not be identifi ed in anything that we write about this workshop. Your name will be removed from any notes that we take, and if you prefer, you can use a false name.

If you are interested in being part of this workshop, please contact xxxxx


Activity 3.2 Make arrangements for consultation workshops – Example email invitation for practitioners

You are invited to attend a workshop to discuss the results from the xxx project.

We have collected health literacy data from xxx clients of our service. We now seek to respond to this data, and need your help to do this.

As expert practitioners, team leaders and manager, you have the knowledge and experience of what works and doesn’t work for our clients. In the workshop we will be tapping into that collective wisdom to develop strategies to improve outcomes for our clients. We will present the results from the xxx project as vignettes – or stories – about our client’s health literacy, and then ask for your ideas about what you think might work for that client.

Th e workshop takes about 2 ½ hours.

Activity 3.4 Identify which intervention ideas from the workshops match your newly established intervention objectives.

Examples of linking intervention ideas from activity 3.4 and intervention objectives from activity 4.1

Example 1

General refl ections and insights – example from a project aiming to improve clients’ management of acute exacerbation of heart failure

“Vignette 1 would be someone who has a pile of information brochures from the hospital that just sit on their dining room table and never get read”

“Vignette 2 is a person that learns by listening to other people’s stories, like short videos or something. Th ey also like to be shown how to do things”

“Vignette 3 really struggles to operationalise their care plan. When you ask them what they will do fi rst, they can’t tell you”

“Vignette 4 has managed their health condition quite well until now, but now it is worsening. Th ey need to know what else they must do to keep condition stable”

Intervention ideas Associated vignettes

Make sure that we match all our client education to how each person learns, and what they want to know

Vignettes 1 and 2

Provide material that clients can understand Vignette 2

Clients need help putting things into action – use teach-back in every interaction

Vignettes 2 and 3

Don’t try to reinvent the wheel, build upon what the client already knows or what they already use that is eff ective

Vignette 4


Intervention objectives

Consumer health behaviours• Increase clients’ use of heart failure exacerbation plans from 30% to 50% in 6 months

Consumer skills, knowledge and attitudes• Clients with heart failure can describe the steps required to manage exacerbation of their condition.

Supports and resources for consumers• Supports and resources to enable clients to understand how to manage heart failure exacerbations

Linking intervention objectives with intervention ideas






• Provide material that clients can understand• Use teach-back in every interaction • Build upon what the client already knows

and what they already use that is eff ective

Example 2

General refl ections and insights- example from a project aiming to improve breast cancer survivors activity levels

“Vignette 1 would be someone who would likely exercise if she had someone to do it with”

“Vignette 2 is a person that gets inspired by listening to how other people have succeeded with something”

“Vignette 3 just doesn’t feel confi dent about exercising

Intervention ideas Associated vignettes

Use existing volunteers as health mentor ‘buddies’ for socially isolated or less motivated clients

Vignettes 1 & 3

Link clients to groups that already exist in the community Vignette 1

Share ‘success stories’ about how women have managed to increase their activity

Vignette 2


Intervention objectives

Consumer health behaviours• Increase average physical activity rates among our service’s breast cancer survivors

from 30 minutes to 120 minutes per week over the next fi ve years

Consumer skills, knowledge and attitudes• Breast cancer survivors have increased confi dence and motivation to exercise

Supports and resources for consumers• Supports and resources to enable clients to feel more confi dent and motivated to exercise

Linking intervention objectives with intervention ideas


• Increase average physical activity rates among our service’s breast cancer survivors from 30 minutes per week to 120 minutes per week over the next fi ve years

• Breast cancer survivors have increased confi dence and motivation to exercise

• Supports and resources to enable clients to feel more confi dent and motivated to exercise

• Use existing volunteers as health mentor ‘buddies’ for socially isolated or less motivated clients

• Link clients to groups that already exist in the community

• Share ‘success stories’ about how women have managed to increase their activity


Activity 4.4 Example of combining locally generated intervention ideas and relevant ideas from the literature

Project aims Project objectives Locally generated intervention ideas

Relevant intervention ideas from the literature

Example 1

To improve clients’ management of acute exacerbation of heart failure





• Provide material that clients can understand

• Use teach-back in every interaction

• Build upon what the client already knows and what they already use that is eff ective

Use of teach-back shown to improve medication compliance in people with heart failure (ref)

Example 2

To improve breast cancer survivors activity levels

• Increase average physical activity rates among our service’s breast cancer survivors from 30 minutes per week to 120 minutes per week over the next fi ve years

• Breast cancer survivors have increased confi dence and motivation to exercise

• Supports and resources to enable clients to feel more confi dent and motivated to exercise

• Use existing volunteers as health mentor ‘buddies’ for socially isolated or less motivated clients

• Link clients to groups that already exist in the community

• Share ‘success stories’ about how women have managed to increase their activity

Literature demonstrates….


Activity 4.4 Select an intervention – what are mechanisms?

What are ‘mechanisms’?

Mechanisms are the hypothesised or actual means by which an intervention produces a benefi t. Mechanisms always involve some change in client experiences (either a specifi c intervention or a change in the way services are delivered or exposure to new infl uences (people or information)) and nearly always this change is expected to produce some change in internal factors in the client (knowledge, beliefs, balancing of priorities, ability to link advice to action etc.) which, in turn, will lead to some change in actions. If the client experiences nothing new or diff erent then nothing will change.

While other mechanism operate at diff erent levels of an intervention (e.g. staff and organisational levels), these all support the activation of the core mechanism at the patient level:

Changes in what clients experience → changes in internal factors that enable changed health actions and outcomes

Th ree examples related to health literacy are:

1. Patients who contact the service for the fi rst time feel that they are being listened to and that their concerns are the primary interest of the staff rather than the completion of a set of bureaucratic activities is hypothesised to lead to patients have greater trust in the organisation and greater belief in its relevance and the likelihood that it will help them

2. Following a consultation with the doctor patients are given support to plan exactly how they will put the doctor’s advice into action is hypothesised to lead to increased ability to understand medical advice and translate it into a set of daily actions.

3. Patients have the opportunity to discuss practical issues related to caring for their health with other people who they consider to be ‘like them’ is hypothesised to lead to people have a greater belief that looking aft er their health well is possible and have a pool of practical ideas and access to problem solving support.

Diff erent interventions can be used to activate the same mechanism depending on client needs, the local context and the way in which the service is organised.

• For example, in example 2 above, the support for action planning could be provided in many diff erent ways: by the doctor, by a follow-up nurse consultation, by phone-follow-up, by community health volunteers etc. Th e most appropriate strategy may depend on workforce and scheduling issues, proximity to the community, availability of phones, community health infrastructure and so forth.

• Similarly a single intervention may activate many benefi cial mechanisms.

Focusing on the link between client experiences and internal processes (mechanisms) helps us to draw ideas and evidence from a broad body of literature

• For example, we may be led to examine questions such as ‘What experiences build trust between patients and doctors’? ‘What experiences help people translate advice into an action plan?’ ‘What experiences make people feel confi dent that they know which advice to trust?’ Th ese are mechanism oriented questions that will lead to a set of principles that still allow organizations in diff erent contexts, cultures, heath systems etc. to develop their own approaches to providing their client group with the requisite experiences.

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