SHARE Approach Workshop Curriculum
Slide 1. Cover Slide
Slide 2. Module 3 Communication
Slide 3. Module 3—Purpose
Slide 4. Module 3—Learning objectives
Slide 5. Module 3—Learning objectives
Slide 6. SHARE Approach Workshop Curriculum Toolkit Covers
Slide 7. Communication Barriers and Solutions
Slide 8. Language, hearing, and eyesight barriers are common in the United States
Slide 9. Language, hearing, and eyesight barriers are common in the United States
Slide 10. Using effective decision aids
Slide 11. Have you tried these decision aids?
Slide 12. How about any of these?
Slide 13. Using decision and communication aids
Slide 14. AHRQ Decision Aids
Slide 15. Qualified medical interpreters can be
Slide 16. Off-site interpreters can include
Slide 17. Checklist for working with qualified medical interpreters
Slide 18. Checklist for working with qualified medical interpreters
Slide 19. Unqualified interpreters
Slide 20. Group discussion
Slide 21. Unqualified interpreters
Slide 22. Case study. Mrs. Morales and Jorge
Slide 23. Case study. Mrs. Morales and Jorge
Slide 24. Case study. Mrs. Morales and Jorge
Slide 25. Group discussion
Slide 26. Case study. Mrs. Morales and Jorge
Slide 27. When a minor child interprets
Slide 28. Health Literacy
Slide 29. Health literacy defined
Slide 30. 2003 National Assessment of Adult Literacy Survey (NAALS) revealed
Slide 31. Impact of limited literacy
Slide 32. Impact of limited literacy
Slide 33. Even skilled readers can find medical information challenging
Slide 34. Impacts of limited health literacy
Slide 35. People with limited healthy literacy are more likely to
Slide 36. People with limited health literacy are also more likely to
Slide 37. Skills needed to manage a chronic health condition can be daunting
Slide 38. Strategies when presenting decision aids
Slide 39. Takeaways from Health Literacy Section
Slide 40. Health Numeracy
Slide 41. Health Numeracy
Slide 42. Health numbers are difficult for many
Slide 43. When do patients need to use and understand health numbers?
Slide 44. Patients need to understand numbers when:
Slide 45. Patients need to understand numbers when:
Slide 46. Ways you can use numbers clearly and make them meaningful to your patients and their families
Slide 47. Present numbers in a way your patients can understand—Read aloud
Slide 48. Present numbers in a way your patients can understand—Read aloud
Slide 49. Strategies to maximize understanding of health numbers
Slide 50. Health numeracy reviewed
Slide 51. Teach-Back
Slide 52. The teach-back technique
Slide 53. What to say while using teach-back during shared decision making
Slide 54. What to say while using teach-back during shared decision making
Slide 55. Teach-Back Video and Discussion
Slide 56. Group discussion
Slide 57. Sometimes you need to explain it again
Slide 58. Teach-back review
Slide 59. Cultural Competence
Slide 60. Read and review tool 7—Taking Steps Toward Cultural Competence
Slide 61. Working with diverse patients
Slide 62. Learn how to interact with diverse patients
Slide 63. Learn how to interact with diverse patients
Slide 64. Provide culturally appropriate decision aids for diverse patients
Slide 65. Provide qualified medical interpreters and use teach-back with diverse patients
Slide 66. Work to build trust
Slide 67. Key takeaways
Slide 68. Key takeaways
Slide 69. Key takeaways
Slide 70. Citations
Slide 71. Citations
Slide 72. Citations
Slide 1: Cover Slide
The SHARE Approach. Essential Steps of Shared Decision Making
Slide 2: Module 3
Module 3: Communication
Slide 3: Module 3—Purpose
- The purpose of this module is to describe the role clear health communication plays in the shared decision-making process.
- Using effective communication can help you gain trust and build rapport during shared decision making.
Slide 4: Module 3—Learning objectives
At the conclusion of this activity, the participant will be able to:
- List communication barriers that get in the way, and describe how decision aids can enhance communication.
- List effective strategies when working with qualified medical interpreters, and describe the challenges in using unqualified interpreters.
Slide 5: Module 3—Learning objectives
- Explain the impact of limited health literacy on patient understanding.
- Describe effective universal health literacy strategies to use when presenting decision aids to your patients.
- Describe techniques to better communicate health numbers.
- Identify the steps of the teach-back technique.
- Explain that cultural factors influence our patients' health beliefs, behaviors, and responses to medical issues.
Slide 6: SHARE Approach Workshop Curriculum Toolkits
(Images of SHARE Approach workshop communication tools. Tools 3 through 7.)
Slide 7: Communication Barriers and Solutions
Communication Barriers and Solutions
(Image of Return to Contents
Slide 8: Language, hearing, and eyesight barriers are common in the United States
- About 9 out of 100 people have Limited English Proficiency (LEP).1
- About 2 out of 100 people have a visual disability.
- About 3 out of 100 people have a hearing disability.2
Slide 9: Language, hearing, and eyesight barriers are common in the United States
- Know the law: Civil Rights Act and Americans with Disabilities Act (ADA).
(Image in right hand corner shows four square icons representing disabilities such as hearing loss, blindness, physical disability, and mental disability.)
Note: Refer to page 2, Return to Contents
Slide 10: Using effective decision aids
(Images showing the variety of decision support resources for consumers available on the AHRQ Effective Health Care Program Web site. These include, English and Spanish translated publications, interactive patient decision aids, audio files that can be listened to with headphones, and mobile accessible materials.)
Slide 11: Have you tried these decision aids?
- Culturally appropriate, translated decision aids.
- Translated materials written in plain language.
- Pictures or hand-drawn pictures to explain a procedure.
- Videos with captions.
- Audio recordings.
Slide 12: How about any of these?
- Web sites with audio.
- TTY or text telephone.
- Screen reader software apps.
Slide 13: Using decision and communication aids
- Decision aids can help bridge communication gaps.
(Two images. The upper left image shows is a graphical depiction of two people with a break in their communication link. The lower right image shows a graphical depiction of two people connected by a communication link.)
Slide 14: AHRQ Decision Aids
- Consider sharing AHRQ consumer summaries and the interactive tools with patients.
(Image montage of a variety of AHRQ decision support resources.)
Note: Refer to page 7, Return to Contents
Slide 15: Qualified medical interpreters can be:
- Certified freelance interpreters for language and American Sign Language (ASL).
- Employees from language agencies.
- Trained bilingual clinicians and staff.
- Community-based medical interpreters.3
(Image of a male doctor speaking with a female patient with the assistance of a female sign language interpreter.)
Note: Refer to page 4, Return to Contents
Slide 16: Off-site interpreters can include:
- Over-the-phone interpreters
(Image of a sign language interpreter videoconferencing with a patient on a laptop.)
Note: Refer to page 5, Return to Contents
Slide 17: Checklist for working with qualified medical interpreters
- Prepare before the visit.
- Gather your decision aids.
- Make sure they match the needs of your patients.
- Consider using materials in Spanish for your Latino patients.
- Use videos with captions with patients who are deaf or who have hearing difficulties
Note: Refer to page 5, Return to Contents
Slide 18: Checklist for working with qualified medical interpreters
- Take these steps during the visit:
- Make sure everyone in the room can see each other.
- Make sure your patient knows the interpreter's name and what the interpreter will do.
- Let your patient know that the interpreter will not share any of the information discussed.
- Make sure your patient is making the health care decisions and not deferring to the interpreter to make choices for them—ask!
- Check for understanding via teach-back.
Slide 19: Unqualified interpreters
- Using unqualified medical interpreters is more likely to result in misunderstandings and medical errors.
- Having a family member, minor child, friend, or unqualified staff member interpret is not advisable.4
Slide 20: Group discussion
What are some possible challenges when using unqualified medical interpreters?
What can go wrong?
(Image of a whiteboard.)
Slide 21: Unqualified interpreters
- May be unfamiliar with technical or scientific language.
- Inadvertently commit interpretive errors.
- May editorialize your patient's responses.
- Impose personal view of your patient's health, and this may also pose a problem with your patient's privacy.
Slide 22: Case study: Mrs. Morales and Jorge
- This case was adapted from the culture diversity Web site at culturediversity.org, a nonprofit organization dedicated to increasing awareness to the issues of transcultural nursing, promoting cultural diversity in nursing, and proposing solutions when problems of bias or conflict arise.
Slide 23: Case study: Mrs. Morales and Jorge
- Alma Morales (age 37)
- Her son, Jorge Morales (age 19 acting as his mother's interpreter)
- Jorge is not trained as an interpreter.
- Mrs. Morales needs to sign a medical consent before surgery can be performed.
Slide 24: Case study: Mrs. Morales and Jorge
- When Jorge explained the procedure to his mother, he appeared to be translating accurately and indicating the proper body parts.
- Mrs. Morales signed the consent form willingly. The next day, however, she learned that her uterus had been removed.
- Because it can be considered inappropriate for a Hispanic male to discuss a woman's private parts, the embarrassed son had explained to his mother that a tumor would be removed from her abdomen and pointed to the general area.
- As Mrs. Morales could no longer bear children, she became very angry and threatened to sue the hospital.
Slide 25: Group discussion
What can we learn from this case study?
Slide 26: Case study: Mrs. Morales and Jorge
- Speaking the same language is not always sufficient.
- In general, it is best to use a same-sex interpreter when translating matters of a sexual or private nature.
- Using family members may not be advisable because they may editorialize.
- Cultural rules often dictate topics that can be discussed.
Note: More about culture when we introduce Tool 7: Taking Steps Toward Cultural Competence a little later in this module.
Slide 27: When a minor child interprets:
- The child is in a vulnerable position, and the practice is at risk for liability if something goes wrong.
- Your patients may be less likely to discuss more personal health topics.4
Note: Use the checklist on page 5 of Return to Contents
Slide 28: Health Literacy
Slide 29: Health literacy defined
- Health literacy is the degree that people can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.
- Health literacy goes beyond the individual. It is a two-way street between patients (caregivers and family members) and their health provider.
Slide 30: 2003 National Assessment of Adult Literacy Survey (NAALS) revealed
- Only 12% of U.S. adults (age 16 and older) have proficient reading skills.5
(Image of a woman reading an AHRQ decision support pamphlet.)
Slide 31: Impact of limited literacy
- Approximately 36 percent of the adult U.S. population lack adequate literacy skills—basic or below basic levels.5
- Limited literacy affects people of all ages, races, incomes, and education levels.
Slide 32: Impact of limited literacy
- The impact of limited health literacy disproportionately affects lower socioeconomic and minority groups.5
(Image of woman helping an older man with his medications.)
Slide 33: Even skilled readers can find medical information challenging
- Nearly 9 out of 10 adults lack full literacy, and they have difficulty using the everyday health information.6-8
(Image of female health care worker reviewing health information with an elderly woman.)
Slide 34: Impacts of limited health literacy
- Limited health literacy:
- Affects people's ability to search for and use health information, adopt healthy behaviors, and act on important health alerts.
- Is associated with worse health outcomes.
Slide 35: People with limited healthy literacy are more likely to:8-9
- Skip needed tests.
- Underuse preventive health care and screenings.
- Have more difficulty finding providers and services and fill out complex forms and health histories.
- Have more difficulty understanding health numbers, risks, and probability.
Note: Refer to page 2, Tool 4.
Slide 36: People with limited healthy literacy are more likely to:8-9
- Be hospitalized or visit the emergency room.
- Seek treatment at later stages in illness, not getting health screenings.
- Have difficulty complying with treatment plan.
- Have trouble filling out complex forms.
- Have difficulty managing a chronic illness.
(Image of male doctor speaking with a female patient in hospital bed.)
Slide 37: Skills needed to manage a chronic health condition can be daunting
- How can managing diabetes be difficult for someone with limited health literacy?
- What skills are needed?
(Image of whiteboard on the left. Image on the right is of a female nurse demonstrating the use of a glucose monitor with a female patient.)
Slide 38: Strategies when presenting decision aids
- Use universal health literacy techniques.
- Use the Patient Education Materials Assessment Tool (PEMAT) to ensure your materials are understandable and actionable.*
- Speak slowly and show empathy.
- Avoid medical jargon; use plain language.
- Present in a way your patients understand.
- Use teach-back. (Tool 6)
Note: * Refer to page 3, Tool 4 for link to PEMAT.
Slide 39: Takeaways from Health Literacy Section
- More than 1/3 of adults in the United States are impacted by limited health literacy.5
- Even good readers have trouble navigating the health care system when they are sick, scared, or in pain.
- Use universal precautions (speak slowly, avoid jargon, check for understanding, and offer easy-to-understand decision aids).
Slide 40: Health Numeracy
Slide 41: Health Numeracy
- The ability to use numeric information in the context of health.
- A two-way street with individuals bringing their skills with health numbers and the provider offering easier-to-understand explanations.
Slide 42: Health numbers are difficult for many
- Limited numeracy can impact shared decision making.
- Studies show that even college grads have difficulty with health numbers.
- Best to use universal precautions with all your patients when conveying health numbers.
- Like limited health literacy, low health numeracy can result in poor health outcomes. Patients are less likely to make choices and take actions to stay well.
Slide 43: When do patients need to use and understand health numbers?
When do patients need to use and understand health numbers?
(Three images of health care professionals explaining health numbers to patients. The upper left image shows a pharmacist using a booklet to explain health information to an elderly woman. The middle right image shows a female doctor using an electronic tablet to explain health numbers to a male patient. The lower left image shows a female health care worker explaining information about prescriptions to a female.)
(Image of a white board on the far right.)
Slide 44: Patients need to understand numbers when:
- Choosing treatments—weighing risks and benefits.
- Doses are dependent on measurement (i.e., weight, blood sugar).
- Trying to follow medication instructions and take as prescribed.
- Using measurement devices, and recording and tracking results (blood glucose, peak flow meters, etc.)
- Using multiple devices (pills, injection, inhaler, liquid, nasal, eye drops, lotions, etc.)
Slide 45: Patients need to understand numbers when:
- Following discharge instructions (take 25 milligrams of a medicine, when each pill is only 5 milligrams).
- Comparing prescription drug coverage plans.
- Calculating premiums, co-pays, and deductibles.
- Trying to discern percentages and proportions.
- Reading appointment slips.
Slide 46: Ways you can use numbers clearly and make them meaningful to your patients and their families
- Tool 5, Communicating Numbers offers you practical tips, techniques, and strategies.
- Let's take turns reading the six tips.
Note: Refer to pages 2-3, Tool 5.
Slide 47: Present numbers in a way your patients can understand—Read aloud
- Elaborate by providing estimated numbers.
- Use frequencies instead of decimals or percentages.
- Keep denominators and timeframes about the same when you compare numbers.
Note: Refer to page 2, Tool 5.
Slide 48: Present numbers in a way your patients can understand—Read aloud
- Give absolute risk instead of relative risk.
- Frame outcomes in both positive and negative terms.
- Find out your patient's preferred measurement system10-14
Note: Refer to page 2, Tool 5.
Slide 49: Strategies to maximize understanding of health numbers
- Use only when needed. For example, when precision is needed (risks, benefits, healthy blood sugars, dosing).
- Use everyday words (about ½ instead of 49%).
- Use visual aids (icon arrays, pie graphs, line graphs, bar graphs for risks in context).
Note: Refer to page 3, Tool 5.
Slide 50: Health numeracy reviewed
- Remember, conveying health numbers can be challenging.
- Refer to Tool 5 as needed.
- Practice this skill as you work to convey numbers in a way your patients can understand.
Slide 51: Teach-Back
Slide 52: The teach-back technique
- Patients use their own words to explain what they need to know about their health or what to do to get better.
- It helps you make sure YOU are conveying information in a way your patient can understand.
- The teach-back technique can take as little as 1 to 2 minutes.
(Image of female doctor explaining health information to an elderly female.)
Slide 53: What to say while using teach-back during shared decision making
- Explain things clearly using plain language, and avoid medical jargon and vague terms.
- Make sure your patients know your goal is to check how well you explain the health information, not to test THEIR knowledge.
Note: Refer to page 3, Tool 6.
(Image of female doctor explaining health information to an elderly male.)
Slide 54: What to say while using teach-back during shared decision making
- Encourage patients to use their own words rather than copying you or others on your team.
- Ask "open-ended" questions that start with "what" or "how," and avoid questions that result in "yes" and "no" answers.
- When appropriate, ask your patient to demonstrate a skill (peak flow meter, blood glucose testing).
Slide 55: Teach-Back Video and Discussion
Teach-Back Video and Discussion
Daily Weight Monitoring
Shown with permission from:
Program on Health Literacy
Cecil G. Shops Center for Health Services Research
University of North Carolina at Chapel Hill
Slide 56: Group discussion
What conversation starters did the provider use if any? Which ones might you use?
How could you use a decision aid during teach-back?
Note: Refer to pages 3-4, Tool 6.
Slide 57: Sometimes you need to explain it again
- Step 1. Say, "I must have not done a good job explaining. Let me try again."
- Step 2. Explain the health information a second time using a different approach. Create a simple drawing, or demonstrate the behavior.
- Step 3. Use the teach-back technique again to check for comprehension.
Note: Refer to page 3, Tool 6.
Slide 58: Teach-back review
- It takes a few minutes to implement.
- Try teach-back when you explain important concepts, such as:
- Treatment options.
- Clinical trial participation.
- Benefits and risk.
- Adherence to a treatment plan.
Slide 59: Cultural Competence
Slide 60: Read and review tool 7—Taking Steps Toward Cultural Competence
- Many of you have taken courses in cultural competence.
- Tool 7 addresses considering cultural differences as you build effective relationships with your patients during shared decision making.
Slide 61: Working with diverse patients
- Ask your patients about their health beliefs.
- The meaning or value of prevention, intervention, and treatment may vary greatly among cultures. You may want to ask your patients about their beliefs regarding their health condition.
- Consider asking: "What do you think caused the problem?" "What do you fear most about the sickness?" or" Why do you think it started when it did?" These can allow you to make the most of your interactions during shared decision making.
Note: Refer to page 2, bullet 2, Tool 7.
Slide 62: Learn how to interact with diverse patients
- Reach out to cultural brokers to learn more about your patients' health beliefs
- Health care workers, social service workers, and community and cultural group leaders can offer insight.
Has anyone worked with health care and social service workers, cultural leaders, or faith-based leaders? What was the result?
Note: Refer to page 2, bullet 5, Return to Contents
Slide 63: Learn how to interact with diverse patients
- Invite your patients to explain what is important to them, and how getting and staying well works in their community.
Has anyone tried that? If so, would you share what you gained/learned?
Note: Refer to page 2, bullet 6, Tool 7.
Slide 64: Provide culturally appropriate decision aids for diverse patients
- Ask your patients about their preferred style of learning.
- Providing information using the patient's preferred format—print, video, or audio—can help patient comprehension.
- Try showing a model, making a drawing, or demonstrating an action.
- You may find your patient likes to get their information in a variety of ways.
Note: Refer to page 3, bullet 1, Tool 7.
Slide 65: Provide qualified medical interpreters and use teach-back with diverse patients
- Use qualified medical interpreters for patients with limited English proficiency for clear communication.
- Consider using teach-back to expose any cultural misunderstandings.
- Remember, nodding and saying "yes" doesn’t always mean your patients fully understand.
- Gently ask patients or family members to convey back in their own words.
Note: Refer to page 3, Tool 7.
Slide 66: Work to build trust
- Recognize that in many cultures, family members are deeply involved in health decisions.
- Try to involve extended family members when planning care.
- Encourage your patients to ask questions.
- Explain that asking questions is a good way to learn about their health problems and treatment options.
- You might probe with, "What questions do you have for me today?"
- Create a welcoming environment.
- Put a "Welcome" sign in a variety of languages on the office door.
- Place a few magazines or other print materials in the patient’s native language.
Note: Refer to page 3, Tool 7.
Slide 67: Key takeaways
- Offer your patients appropriate decision aids when applying shared decision making. For example, use decision aids that are:
- Culturally sensitive.
- Easy to read.
- In multiple formats, such as print, video, and audio for people with communication challenges.
Slide 68: Key takeaways
- Work with qualified medical interpreters when possible to ensure accurate translations and understanding when practicing shared decision making.
- Use universal health literacy precautions during shared decision making with all your patients because you can't tell by looking who has limited health literacy.
Slide 69: Key takeaways
- Follow the strategies for making numbers easier to understand when conveying benefits and risk and treatment options; even college graduates struggle with health numbers.
- Use teach-back to make sure you have conveyed your health message in a way that your patients can understand as you engage in shared decision making.
- Ask your patients about their health beliefs and cultural norms to build relationships based on trust and concern during shared decision making.
Clear health communication is key to effective shared decision making.
Slide 70: Citations
1. National Assessment of Adult Literacy. National Center for Education Statistics; 2003.
2. Disability Status Report United States. Employment and Disability Institute at the Cornell University ILR School; 2011.
3. A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations. Office of Minority Health; 2005.
4. Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality: Tool 9—page 43; 2010.
5. National Assessment of Adult Literacy Survey. National Center for Education Statistics; 2003.
6. Nielsen-Bohlman L, Panzer AM., Kindig DA (Eds). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press; 2004.
Slide 71: Citations
7. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department of Education, National Center for Education Statistics; Washington, D.C.; 2006.
8. Rudd RE, Anderson JE, Oppenheimer S, Nath C. Health literacy: An update of public health and medical literature. In J. P. Comings, B. Garner, & C. Smith (Eds), Review of adult learning and literacy. Mahwah, NJ: Lawrence Erlbaum Associates; 2007.
9. Berkman ND, Sheridan SL, Donahue KE, et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Agency for Healthcare Research and Quality. Rockville, MD; 2011.
10. Paling J. Strategies to help patients understand risks. BMJ 2003 Sept. 27; 316: 745-8.
11. National Heart, Lung, and Blood Institute. What Are the Risks of Having a Stent; 2013. http://www.nhlbi.nih.gov/health/health-topics/topics/stents/risks.html.
Slide 72: Citations
12. Fagerlin A, Zikmund-Fisher B, Ubel P. Helping Patients Decide: Ten Steps to Better Risk Communication. JNCI J Natl Cancer Inst 2011; doi: 10.1093/jnci/djr318.
13. Waters EA, et al. Formats for Improving Risk Communication in Medical Tradeoff Decisions. Journal of Health Communication 2006; 11, 2: 167–182.
14. Fischhoff B, Brewer N, Downs J (Eds). Communicating Risks and Benefits: An Evidence-Based User's Guide. U.S. Food and Drug Administration; 2011.