Qualitative insights into the experience of teaching shared decision making within adult education health literacy programmes for lower‐literacy learners

Abstract Background Enhancing health literacy can play a major role in improving healthcare and health across the globe. To build higher‐order (communicative/critical) health literacy skills among socially disadvantaged Australians, we developed a novel shared decision making (SDM) training programme for adults with lower literacy. The programme was delivered by trained educators within an adult basic education health literacy course. Objective To explore the experience of teaching SDM within a health literacy programme and investigate whether communicative/critical health literacy content meets learner needs and teaching and institutional objectives. Design and participants Qualitative interview study with 11 educators who delivered the SDM programme. Transcripts were analysed using the Framework approach; a matrix‐based method of thematic analysis. Results Teachers noted congruence in SDM content and the institutional commitment to learner empowerment in adult education. The SDM programme was seen to offer learners an alternative to their usual passive approach to healthcare decision making by raising awareness of the right to ask questions and consider alternative test/treatment options. Teachers valued a structured approach to training building on foundational skills, with language reinforcement and take‐home resources, but many noted the need for additional time to develop learner understanding and cover all aspects of SDM. Challenges for adult learners included SDM terminology, computational numerical risk tasks and understanding probability concepts. Discussion and conclusions SDM programmes can be designed in a way that both supports teachers to deliver novel health literacy content and empowers learners. Collaboration between adult education and healthcare sectors can build health literacy capacity of those most in need.


| INTRODUCTION
Given that lower health literacy is associated with poorer health outcomes 1 and higher healthcare utilization and costs, 2 improving health literacy is a policy initiative in most developed countries. Enhancing health literacy can play a major role in improving healthcare and health across the globe. 3 Health literacy describes specific literacy skills needed to obtain, understand and use information to make decisions and take actions that will have an impact on health status. 4 According to Nutbeam (2000), health literacy skills comprise three levels; functional, communicative and critical health literacy. 5 Functional health literacy refers to the basic skills for obtaining health information; communicative and critical health literacy require more advanced skills to extract information, derive meaning from and critically evaluate health-related material. 5 Shared decision making (SDM) may be viewed within Nutbeam's conceptual framework as corresponding to communicative and critical health literacy. Specifically, SDM occurs when patients and health professionals both contribute to decision making by exchanging information and deliberating about available treatment options. SDM is endorsed as the ideal model for treatment decision making in national and international quality standards, 6,7 supported by evidence that it can improve health outcomes. SDM skills represent a transferable health literacy asset which can support greater autonomy in health decision making situations.
Like general literacy, functional, communicative and critical health literacy can be developed through formal education. 4 Adult basic education settings are increasingly recognized as an avenue to deliver health content and build health literacy capacity. [8][9][10] In Australia, existing adult learning infrastructure can be harnessed to capture diverse learner groups including older adults, people living with disabilities, indigenous populations and culturally and linguistically diverse learners. 8 Health-education partnerships have shown ability to facilitate meaningful support in health-related learning for those most in need. 11 However, SDM has not been incorporated into health literacy programmes for adult learners, and communicative/critical-level health literacy content has not been evaluated. Including teachers in the evaluation of adult education programs can provide useful insights regarding the learning needs of lower-literacy learners and the appropriateness of programme content. Qualified teachers have expertise and experience in teaching and reflective practice 12 which enables them to consciously reflect on their own teaching as well as students' learning experiences and outcomes. As a key stakeholder, exploring teachers' perspectives can help to construct meaningful knowledge and understandings and improve the reach and translation of adult education health literacy initiatives. 13 We developed a novel SDM training programme for adults with lower literacy to develop communicative and critical health literacy skills. 14 The programme was delivered in Australian adult basic education settings in 2014 by trained adult educators as a core component of a broader health literacy programme and was evaluated as a cluster-randomized controlled trial. 15 An exploratory qualitative substudy was conducted with adult educators who participated in the trial to explore views and experiences of teaching health literacy skills (including SDM) and determine whether the programme is contextually appropriate and sufficiently tailored to learner needs, and teaching and institutional objectives.

| Intervention: the health literacy programme
The health literacy programme embedded key Learning, Literacy and Numeracy (LLN) skills development into health-related content. 15 SDM comprised a 6-hour core component of the course. Box 1.

| Programme delivery and setting
The health literacy programme was delivered by adult educators at Technical and Further Education (TAFE) sites across New South Wales (NSW). TAFE NSW is a government-funded adult education provider offering low-cost basic LLN courses. Entry requirements are often flexible, and learners may not have completed secondary schooling. In 2014, over half a million learners were enrolled in TAFE across NSW, including a high proportion of women, unemployed adults, those with a language background other than English, those with low socioeconomic status, mature-aged learners and learners from regional and remote areas. 16 All TAFE teachers require a minimal qualification of Certificate IV in Teaching and Assessment. Participating teachers attended a full-day training course, including a 1-hour SDM session led by the first author and received a teaching manual with guided lesson plans, learner resources and answers.

| Learner population
In total, 167 learners enrolled in basic/beginner LLN courses across regional (33%) and metropolitan (67%) areas of NSW participated in the health literacy programme. The average age of participants was 45 years. The majority were women (69%), spoke a language other than English at home (77%) and had a long-standing illness or disability (70%). Seventy-nine percent of participants had inadequate health literacy as measured by the Newest Vital Sign. 17

Box 1 SDM programme aims
To develop learners' self-efficacy and understanding of:

| Qualitative interview sampling and recruitment
Adult education teachers who delivered the health literacy programme (n=18) were invited to participate 18  Interviews were audio-recorded, transcribed verbatim and analysed using the Framework approach to qualitative data analysis 19 (Table 1). This analysis focuses on teachers' reflections on SDM programme components. Data relating to the other components of the health literacy programme are reported elsewhere. 20 While the focus of this article is on teachers' experience of delivering SDM content within a health literacy programme, quotes from adult learners are incorporated throughout to support teachers' reflections on subjective learner experiences. An in-depth analysis of learner interviews will be reported elsewhere.

| RESULTS
Three teachers who delivered the health literacy programme could not be contacted following course completion because they lost their jobs in the state-wide restructure of TAFE NSW. Interviews were conducted with 15 of 18 teachers. Four interviews with teachers in a job sharing arrangement where the teaching partner delivered SDM content were excluded from this analysis as SDM was not discussed. All 11 teachers included in the final SDM analysis were female. Average teaching experience in adult education was 17 years (Range=1-34).
We present four themes identified from the data: (i) cultural and institutional fit, (ii) learning experience: a teacher's perspective, (iii) teaching experience, (iv) applying skills beyond the classroom. Quotes included in the text are followed by an identification number, with the letters 'T' and 'L' used to differentiate teachers' and learners' quotes.
Learners with the same letter at the end of their ID were enrolled in the same class.

| Theme 1: cultural and institutional fit
Shared decision making was perceived by teachers to be an appropriate topic for a basic/beginner adult education context, given learner characteristics and an institutional commitment to learner empowerment.
Teachers described their cohort collectively as a "passive" and "dis-

| New knowledge and main messages
From an educator's perspective, the SDM programme was successful in creating awareness among adult learners of (i) patients' right to participate in decision making, (ii) question-asking as a means to participation and (ii) the availability of test/treatment options.
Teachers felt that raising awareness among learners that they could rightfully share in decision making was a powerful contribution of the programme. The SDM programme was perceived to "challenge" learners' established belief that health professionals are solely responsible for decision making and provide an alternative to their usual passive approach, empowering them to ask questions and engage with providers. This sentiment was echoed in students' accounts, whereby they reported a new appreciation of the right/responsibility to participate in decision making and increased assertiveness and self-efficacy for health consultations.

| Challenges for adult learners
Teachers perceived there to be challenges for learners throughout the programme, including learning new SDM terminology, understanding the concept of likelihood/risk and interpreting numerical risk presented in different formats.

SDM terminology
The language of SDM embedded within the AskShareKnow questions was challenging for adult learners who were unfamiliar with terms such as "options," "benefits," "harms" and "likelihood." Developing understanding took time, particularly for learners from linguistically diverse backgrounds.

I was able to get them to understand. But it took a little bit of work. Basically because of that language. (HL T4)
Teachers felt that activities (e.g. alternative terminology activities) and elements of programme design (e.g. repetitive language) were useful, but also used supplementary activities such as additional vocabulary exercises to reinforce the meanings of particular key terms. Some teachers reported that they replaced words within the AskShareKnow questions with lay terms to support understanding. One learner reported that they had found the teacher's explanation valuable in terms of supporting understanding.

| Teaching facilitators
Progressive knowledge/skill development The SDM programme was considered "very clear and well structured," logically presenting SDM concepts that were new to learners. The AskShareKnow questions provided a logical framework for teaching the multidimensional concept of SDM. Activities and resources focusing on progressive knowledge and skill development were seen by teachers as key facilitators to teaching and learning. This was often discussed with reference to numeracy activities which began with more simple tasks (eg understanding risk labels) and progressed gradually to more complex tasks (eg comparing risks presented as natural frequencies).
It stepped the students through it well, um, so they understood it and seemed to really catch on to that one.

Take-home resources
Teachers felt that learners were enthusiastic about receiving the AskShareKnow pocket card (Figure 1). They valued having a tangible tool to keep after the lesson given that training occurred outside of the healthcare setting. For teachers, the card was used to facilitate discussion and activities including role plays.
And the little card, I have to say, was invaluable. I mean we used it in many contexts, whether they were, you know, in role-play talking to the chemist, or talking to an acupuncturist, whatever. (HL T10)

Supporting social integration
Five teachers reported that the activities within the SDM programme stimulated class discussion and increased integration as learners reflected on content and shared past healthcare experiences.
When we talked a bit more about it, the shyer people that came out later on shared stories… so we could then discuss it and use the things they had talked about earlier.

| Teaching challenges
Breadth and depth in content coverage

| Conceptual vs verbatim retention
When asked about the application of SDM knowledge and skills in healthcare settings, most teachers were positive about the potential impact of the programme. Teachers felt that learners were engaged with the concept and empowered to ask questions about treatment options.
However, some teachers felt that learners may not use the verbatim wording of the AskShareKnow questions due to the complexity of language. This was consistent with learner interviews in that some students reported asking questions which captured the meaning of the original AskShareKnow questions, simply using alternative terms. For example, many replaced the term harms with "side-effects" and options with "choices." One thing I'll say they might not go in and ask the three questions and that, but I think they would be more em-

| Barriers to behaviour change
Although teachers were generally positive about the programme's potential to facilitate participation, there was acknowledgement that particular learners within basic LLN courses may have difficulty applying the knowledge and skills taught in healthcare encounters due to internal (e.g. intellectual disability) and external (e.g. healthcare provider) factors. sectors is needed to support the uptake of SDM programmes in this setting, 23 such that teachers are provided with content and resources while maintaining the flexibility to tailor programmes based on their literacy expertise. There is value in continuing to explore teachers' perspectives in the evaluation of future programmes to gain insights into both learning and teaching. Additional research should explore novel approaches to developing conceptual risk understanding within programmes of this kind.
Pertaining to practice, our findings reinforce that SDM may be a novel concept for health consumers with lower literacy and from culturally and linguistically diverse backgrounds who may not be aware of their right to participate in healthcare decisions. 24 This is compounded by language barriers and difficulties understanding numerical risk estimates and probability concepts. Providing all consumers with 'permission' to participate and then using accessible language and risk formats (e.g. icon arrays 25 ) is necessary to ensure that all consumers can meaningfully engage in healthcare decision making. Communitybased programmes, such as our health literacy programme, must be complimented by a healthcare environment which is supportive of, and responsive to, lower-literacy needs.

| CONCLUSION
Adult basic education is rooted in a historical context that emphasizes learner empowerment. SDM training for critical and communicative health literacy develops a transferable skill-set which can support autonomy in a range of settings and situations; an outcome which wholly aligns with the culture and values of adult education.
Teachers are positive about teaching SDM skills within health literacy programmes delivered in this setting, and our study suggests that programmes can be designed in a way that both supports teachers to deliver novel SDM content and empowers learners. There is benefit in fostering collaboration between adult education and healthcare sectors to reach disadvantaged populations who are rarely the focus of SDM interventions, but who stand to benefit the most from them.