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What is the potential impact of SDM on health inequalities ?

What is the potential impact of SDM on health inequalities ? . Kerry Joyce k erry.joyce@ncl.ac.uk. Me. Background in public health (wider determinants of health) Interest in interventions to reduce inequity and increase social justice

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What is the potential impact of SDM on health inequalities ?

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  1. What is the potential impact of SDM on health inequalities? Kerry Joyce kerry.joyce@ncl.ac.uk

  2. Me • Background in public health (wider determinants of health) • Interest in interventions to reduce inequity and increase social justice • Bring thinking from work around inequalities to doctor patient encounter & SDM

  3. SDM & Health Inequalities • Shared decision making commonly regarded as a wholly positive and uncontested notion. • However studies of the effectiveness of decision support tend to measure outcomes at the individual level • Population level impacts, in particular effects by different social groups are not well understood • Do inequalities exist in terms of access to, and effectiveness of, SDM between different social groups?

  4. Hypothesis I • SDM increases health literacy so is likely to offer the biggest gains to those who are most disadvantaged e.g. by - increasing knowledge of treatment options - personalising risks and benefits • Hence, SDM could potentially lead to reductions in health inequalities. • BUT health literacy is more than numeracy and literacy skills, lack of confidence/voice & feeling disempowered shape the extent to which an individual participates in decision making.

  5. Hypothesis II SDM interventions might be taken up disproportionately by more advantaged groups • So that those least in need have greatest access to SDM (Tudor-Hart, 1971) • Poorly designed decision support might be more effective in groups with greater health literacy • Unintended consequences of SDM disproportionately spread across certain population groups. e.g. increased sense of responsibility about health status and health care decisions

  6. What the literature says… • Suggestion that younger, better educated patients are more likely to want to engage in SDM (Say & Thomson, 2006) • Intervention generated inequalities - introduction of inequality at different stages of the care pathway (White, Adams & Heywood, 2009)

  7. What the literature says… • Correlation between SEP and length of consultation with patients of a lower SEP having shorter consultations (Stirling et al., 2001). • Developments in decision aids have overlooked adults with lower health literacy (McCaffery et al. 2010). • Criticism that materials for less educated groups restrict availability of choice, limit information & sometimes oversimplify messages (McCaffery et al. 2010).

  8. Dangerous assumptions • Narrative review of equity in doctor patient interactions (12 studies) patients of lower SEP disadvantaged because of misplaced assumptions about • their desire for involvement, • need for information • ability to participate in decision making (Willems, 2005).

  9. Opportunities for the introduction of inequality within the doctor -patient consultation

  10. Decision support for underserved groups • Computerized Entertainment Education “Edutainment decision aid”, soap opera format to contextualise content (Jibaja-Weiss & Volk, 2007) Aimed at adults with low health & digital literacy – increased knowledge & self-efficacy • Just in time techniques for values clarification Where patients flag issues of concern for review after completion of a decision aid (Jibaja-Weiss et al., 2006) • Patient narratives/testimonials Effective in increasing understanding & engagement BUT potential to bias decision making

  11. Decision support for underserved groups • Before and after study (Volandes et al., 2012) • Video decision aid (advanced dementia) for Spanish speaking patients • Primary outcome = preferences for care (comfort care versus life-prolonging care) • Before intervention 40% wanted comfort care and educational level was an independent predictor of preferences • After video 75% wanted comfort care (4% unsure) and there were no longer any differences in preferences by education level • Video decision aids for other conditions showed similar results with 25-50% patients switching their preference after viewing the video. • Decisions were found to be stable over time.

  12. Where to next? • Understand need for universal or targeted interventions or both? • Defining characteristics of successful interventions for lower literacy groups • Optimum methods for: • risk communication & • values clarification for lower literacy groups (McCafferyet al., 2010) • Approaches to empower and give voice to groups with lower health literacy (are decision aids enough?)

  13. In Progress Systematic Review Durand, M., Wellsted, D., Bunn, F., Elwyn, G. Does shared decision making reduce health inequalities: a systematic review. PROSPERO 2012:CRD42012002200 Available at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012002200 Review question(s) * What is the effect of Shared Decision Making interventions on disadvantaged groups? * What are the characteristics and accessibility of Shared Decision Making interventions intended for disadvantaged groups? * Can Shared Decision Making decrease health inequalities?

  14. References Jibaja-Weiss, M.L., Volk, R.J., Friedman, L.C., et al. Preliminary testing of a just-in-time, user-defined values clarification exercise to aid lower literate women in making informed breast cancer treatment decisions. Health Expect 2006, 9(3):218-31. McCaffery, K.J., Smith, S.K., Wolf, M. The challenge of Shared Decision Making Among Patients with Lower Literacy: A framework for Research & Development. Medical Decision Making 2010, 30: 35-44. Say, R.E., Thomson, R. The importance of patient preferences in treatment decisions—challenges for doctors. BMJ 2003, 327: 542. Stacey, D., Kryworuchko, J., Bennett, C., et al. Decision Coaching to Prepare Patients for Making Health Decisions. Med Decis Making 2012 32: E22 Tudor-Hart, J. The inverse care law. Lancet. 1971; 1(7696): 405-412. TugwellP, Petticrew M, Robinson V, Kristjansson E, Maxwell L, Cochrane Equity Field Editorial Team. Cochrane and Campbell Collaborations, and health equity. Lancet 2006, 367(9517): 1128-30. Volandes, A.E., Ariza, M., Abbo, E.D. et al., Overcoming Educational Barriers for Advance Care Planning in Latinos with Video Images. Journal of Palliative Medicine 2008, 11(5): 700-706. Volk, R.J., Jibaja-Weiss, M.L., Hawley, S.T., Kneuper, S., Spann, S.J., Miles, B.J., Hyman, D.J. Entertainment education for prostate cancer screening: a randomized trial among primary care patients with low health literacy. Patient EducCouns 2008, 73(3): 482-9 White, M., Adams, J., Heywood, P. How and why do interventions that increase health overall widen inequalities within populations? In: Babones S (Ed). Health, inequality and society. Bristol: Policy Press. (2009). Willems, S., De Maesschalck, S., Deveugele, M., Derese, A., De Maeseneer, J. Socio-economic status of the patient and doctor–patient communication: does it make a difference? Patient EducCouns2005, 56(2): 139-46.

  15. Synergies & challenges • From what you’ve heard this morning about health literacy and SDM what are the key: (i) Synergies (ii) Challenges?

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