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  • Equity in Choosing Wisely and beyond: the effect of health literacy on healthcare decision-making and methods to support conversations about overuse

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Original research
Equity in Choosing Wisely and beyond: the effect of health literacy on healthcare decision-making and methods to support conversations about overuse
  1. Danielle M Muscat1,
  2. Erin Cvejic2,
  3. Jenna Smith1,
  4. Rachel Thompson3,
  5. Edward Chang1,
  6. Marguerite Tracy2,
  7. Joshua Zadro4,
  8. Robyn Linder5,
  9. Kirsten McCaffery1
  1. 1 Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  2. 2 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  3. 3 School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  4. 4 Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  5. 5 NPS MedicineWise, Sydney, New South Wales, Australia
  1. Correspondence to Dr Danielle M Muscat; danielle.muscat{at}sydney.edu.au

Abstract

Objective To (a) examine whether the effect of the Choosing Wisely consumer questions on question-asking and shared decision-making (SDM) outcomes differs based on individuals’ health literacy and (b) explore the relationship between health literacy, question-asking and other decision-making outcomes in the context of low value care.

Methods Preplanned analysis of randomised trial data comparing: the Choosing Wisely questions, a SDM video, both interventions or control (no intervention). Randomisation was stratified by participant health literacy (‘adequate’ vs ‘limited’), as assessed by the Newest Vital Sign.

Main outcome measures Self-efficacy to ask questions and be involved in decision-making, and intention to engage in SDM.

Participants 1439 Australian adults, recruited online.

Results The effects of the Choosing Wisely questions and SDM video did not differ based on participants’ health literacy for most primary or secondary outcomes (all two-way and three-way interactions p>0.05). Compared with individuals with ‘adequate’ health literacy, those with ‘limited’ health literacy had lower knowledge of SDM rights (82.1% vs 89.0%; 95% CI: 3.9% to 9.8%, p<0.001) and less positive attitudes towards SDM (48.3% vs 58.1%; 95% CI: 4.7% to 15.0%, p=0.0002). They were also more likely to indicate they would follow low-value treatment plans without further questioning (7.46/10 vs 6.94/10; 95% CI: 0.33 to 0.72, p<0.001) and generated fewer questions to ask a healthcare provider which aligned with the Choosing Wisely questions (χ2 (1)=73.79, p<.001). On average, 67.7% of participants with ‘limited’ health literacy indicated that they would use video interventions again compared with 55.7% of individuals with ‘adequate’ health literacy.

Conclusion Adults with limited health literacy continue to have lower scores on decision-making outcomes in the context of low value care. Ongoing work is needed to develop and test different intervention formats that support people with lower health literacy to engage in question asking and SDM.

  • Decision making
  • Shared decision making
  • Communication

Data availability statement

Data are available on reasonable request. Deidentified participant data is available from the corresponding author (Danielle.muscat@sydney.edu.au) and will be made available upon reasonable request.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjqs-2024-017411

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    Data availability statement

    Data are available on reasonable request. Deidentified participant data is available from the corresponding author (Danielle.muscat@sydney.edu.au) and will be made available upon reasonable request.

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    Footnotes

    • X @smith_jenna_, @rachelthomp, @M_C_Tracy, @zadro_josh

    • Contributors DMM and KM conceived the original idea for this study, which was further refined by ECvejic, JS, EChang, RT, MT, JZ and RL. DMM and ECvejic wrote the first draft of the manuscript, and this was edited by all other authors. ECvejic provided valuable input regarding trial design and analytical considerations and performed all quantitative analyses. JS and RT led the qualitaitve content analysis. All authors contributed to and approved the final version of the manuscript. DMM is the guarantor.

    • Funding This study was funded by National Health and Medical Research Council (APP1113532).

    • Competing interests The University of Sydney owns IP on the ‘Video’ intervention described in this manuscript and DMM and KM are contributors to the intellectual property. DMM and KM are Directors of a Health Literacy Consultancy company: Health Literacy Solutions Pty LTD. RT discloses research grants on topics related to the content of this manuscript, personal royalties from the sale of a book on SDM, and ownership of copyright in several SDM interventions.

      KM is supported by an NHMRC Principal Research Fellowship (1121110) and DMM is supported by an Australian Research Council Discovery Early Career Research Award. Neither the NHMRC nor ARC had any role in the design of this study, the conduct or write-up of the study or in the decision to submit the findings for publication.

      NPS MedicineWise gave permission for investigators’ use of the 5 Questions resource without charge. RL is a former employee NPS MedicineWise which facilitated Choosing Wisely Australia. NPS MedicineWise did not have a role in the decision to submit the study findings for publication.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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