Implementing person-centered communication in diabetes care: a new tool for diabetes care professionals.

PURPOSE: This study tested the clinical implementation of the CoMac Communication System, an empirically validated tool for individualized Diabetes Self-Management Education and Support (DSMES). This system provides immediate feedback and guidance to health care providers (HCPs) to facilitate speaking with persons with type 2 diabetes mellitus in language reflecting patients' own worldviews and health beliefs. PATIENTS AND METHODS: This 6-month implementation science study at an accredited diabetes care clinic in a Midwestern US hospital was conducted in two phases. Phase I consisted of CoMac implementation, qualitative interviews with HCPs, and evaluation of clinic flow among the diabetes education team. Seventy-two participants received CoMac's linguistically tailored patient-centric communication; a control group of 48 did not receive this intervention. In Phase II, glycosylated hemoglobin A1c (HbA1c) levels from the first visit to the follow-up visit for each group were compared. RESULTS: Interviews conducted during Phase I suggested that the system can be successfully implemented into DSMES practice. Knowing individual psychosocial profiles and participants' language use allowed for more effective patient counseling. In Phase II, multiple regression analysis with HbA1c change as the dependent variable showed that the key variable of interest, treated with the CoMac intervention, had a one-tailed t-value of -1.81, with a statistically significant probability value of 0.037. CONCLUSION: Findings suggest that use of the CoMac System by diabetes care professionals has the potential for improved patient health outcomes. Patients receiving the CoMac intervention showed significantly improved HbA1c levels, suggesting that this approach has great promise for effective DSMES management.

Variation in medication adherence across patient behavioral segments: a multi-country study in hypertension.

OBJECTIVES: This study determines the following for a hypertensive patient population: 1) the prevalence of patient worldview clusters; 2) differences in medication adherence across these clusters; and 3) the adherence predictive power of the clusters relative to measures of patients' concerns over their medication's cost, side effects, and efficacy. METHODS: Members from patient panels in the UK, Germany, Italy, and Spain were invited to participate in an online survey that included the Medication Adherence Report Scale-5 (MARS-5) adherence instrument and a patient segmentation instrument developed by CoMac Analytics, Inc, based on a linguistic analysis of patient talk. Subjects were screened to have a diagnosis of hypertension and treatment with at least one antihypertensive agent. RESULTS: A total of 353 patients completed the online survey in August/September 2011 and were categorized against three different behavioral domains: 1) control orientation (n=176 respondents [50%] for I, internal; n=177 respondents [50%] for E, external); 2) emotion (n=100 respondents [28%] for P, positive; n=253 respondents [72%] for N, negative); and 3) agency or ability to act on choices (n=227 respondents [64%] for H, high agency; n=126 [36%] for L, low agency). Domains were grouped into eight different clusters with EPH and IPH being the most prevalent (88 respondents [25%] in each cluster). The prevalence of other behavior clusters ranged from 6% (22 respondents, INH) to 12% (41 respondents, IPL). The proportion of patients defined as perfectly adherent (scored 25 on MARS-5) varied sharply across the segments: 51% adherent (45 of 88 respondents) for the IPH vs 8% adherent (2 of 25 respondents) classified as INL. Side effects, being employed, and stopping medicine because the patient got better were all significant determinants of adherence in a probit regression model. CONCLUSION: By categorizing patients into worldview clusters, we identified wide differences in adherence that can be used to prioritize interventions and to customize adherence messages. Also, the predictive power of segments was greater than that for variables measuring concerns over cost, side effects, and efficacy.

Development of the CoMac Adherence Descriptor™: a linguistically-based survey for segmenting patients on their worldviews.

Nonadherence to prescribed medication and healthy behaviors is a pressing health care issue. Much research has been conducted in this area under a variety of labels, such as compliance, disease management and, most recently, adherence. However, the complex factors related to predicting and, more importantly, understanding and explaining adherence, have nevertheless remained elusive. However, through an in-depth linguistic analysis of patient talk, the International Center for Intercultural Communication (ICIC) at Indiana University has produced a psycholinguistic coding system that uses patients' own language to cluster them into distinct groups based on their worldviews. ICIC's studies have shown, for example, that patients reveal their fundamental perceptions about themselves and their environment in their life narratives; clustering of individual patients based on these different perceptions is possible via the use of differential language in survey questions, and differential language can be used to tailor messages for individual patients in a manner that these individuals prefer over generically worded communication. In grant-funded research, an interdisciplinary team of researchers at the ICIC reviewed the literature and identified three basic psychosocial tenets related to adherence: control orientation, based on locus of control research; agency, based on self-efficacy; and affect or attitude and emotion. These three constructs were selected because, in the published literature, they have been consistently found to be connected to patient adherence. Based on this research, a survey, the CoMac Descriptor™ was developed. This report shows that The Descriptor™ questions and responses are valid and reliable in segmenting patients across psychosocial constructs, which will have positive implications for health care providers and patients.

Development of patient-centric linguistically tailored psychoeducational messages to support nutrition and medication self-management in type 2 diabetes: a feasibility study.

PURPOSE: This study evaluated the feasibility of developing linguistically tailored educational messages designed to match the linguistic styles of patients segmented into types with the Descriptor™, and to determine patient preferences for tailored or standard messages based on their segments. PATIENTS AND METHODS: Twenty patients with type 2 diabetes (T2DM) were recruited from a diabetes health clinic. Participants were segmented using the Descriptor™, a language-based questionnaire, to identify patient types based on their control orientation (internal/external), agency (high/low), and affect (positive/negative), which are well studied constructs related to T2DM self-management. Two of the seven self-care behaviors described by the American Association of Diabetes Educators (healthy eating and taking medication) were used to develop standard messages and then linguistically tailored using features of the six different construct segment types of the Descriptor™. A subset of seven participants each provided feedback on their preference for standard or linguistically tailored messages; 12 comparisons between standard and tailored messages were made. RESULTS: Overall, the tailored messages were preferred to the standard messages. When the messages were matched to specific construct segment types, the tailored messages were preferred over the standard messages, although this was not statistically significant. CONCLUSION: Linguistically tailoring messages based on construct segments is feasible. Furthermore, tailored messages were more often preferred over standard messages. This study provides some preliminary evidence for tailoring messages based on the linguistic features of control orientation, agency, and affect. The messages developed in this study should be tested in a larger more representative sample. The present study did not explore whether tailored messages were better understood. This research will serve as preliminary evidence to develop future studies with the ultimate goal to design intervention studies to investigate if linguistically tailoring communication within the context of patient education influences patient knowledge, motivation, and activation toward making healthy behavior changes in T2DM self-management.

Comprehensibility of patient consent forms for radiation therapy of cervical cancer.

OBJECTIVE: The construct of Health Literacy (HL) deals with patients' capacity to understand their health-related instructions, consent forms, and other documents. A significant challenge of providing healthcare to patients with low HL is the complex nature of the disease process, and of requisite treatments. In radiation oncology specifically, the delivery of ionizing radiation is difficult enough to describe; describing radiation toxicity in terms of the underlying physics and biology is daunting. A multimodal analysis of a small sample of patient consent forms was undertaken in order to address this issue more closely, and identify the extent to which such literature contributes to the challenges faced by patients with low HL. METHODS: Members of national cooperative group panels dealing with gynecologic cancer were asked to submit copies of consent forms provided to patients with stage II cervical cancer. Four such forms were submitted and reviewed by a single person with expertise in linguistics using standard tools. RESULTS: Three of the four consents scored within the lower portion of the "adequate" range. One consent was not suitable. Consent readability ranged from grades 12.18 to 16.13; this means that they required at least a high school education to interpret, and in two cases required post-graduate coursework. CONCLUSION: There is significant room for improvement in consent form design and structure. When considering cultural and socioeconomic appropriateness of patient consent forms, input of staff with expertise in linguistics should be sought.

Listening to patients' voices: linguistic indicators related to diabetes self-management.

A great deal of research in health care has examined a wide range of variables to better understand the degree to which patients follow the advice of medical professionals in managing their health, known as adherence. This paper explains the development of the linguistic systems to describe and evaluate two psychosocial constructs (i.e. control orientation and agency) that have been found to be related to adherence in previous research for subjects with diabetes (Trento et al. 2007; Wangberg 2007; O'Hea et al. 2009). The present data came from 43 semi-structured in-depth interviews of subjects with Type 2 diabetes. One-on-one interviews with open-ended questions elicited subjects' 'stories' about living with diabetes, and the transcribed interviews were analyzed to develop the linguistic systems of control orientation and agency. The resultant systems were applied to the 43 interviews by raters with high inter-rater reliability. The results showed demarcations of clearly identified codings of patient types. The paper presents the linguistic coding systems developed in the study, the results of their application to the patient interview data, and recommendations for improved communication with patients.

Patient-directed medicine labeling: text differences between the United States and Spain.

As part of a larger project to examine the complexities of patient adherence to medical directions, the current study compares written information given with prescribed medicines to patients in the United States (US) and Spain suffering from two chronic diseases. First, the legal context of the voluntary nature of the provision of such information in the US, and the mandatory nature of provision in Spain, was explored. Then, 30 drugs in common use in both countries, 19 for cardiovascular disease and 11 for endocrine disorders, were identified and the texts of the corresponding patient-directed written information were included in an electronic corpus and analysed. Ten rhetorical features common to both the US and Spanish texts were identified. Differences were found in the placement of two of the features in relation to the complete text: information on 'side effects' and concerning 'the need to seek medical advice' appeared more frequently throughout the US texts than in the Spanish texts. Detailed lexical analysis showed more technical vocabulary in use in the Spanish texts.

To err is human: patient misinterpretations of prescription drug label instructions.

OBJECTIVE: To examine the nature and cause of patients' misunderstanding common dosage instructions on prescription drug container labels. METHODS: In-person cognitive interviews including a literacy assessment were conducted among 395 patients at one of three primary care clinics in Shreveport, Louisiana, Jackson, Michigan and Chicago, Illinois. Patients were asked to read and demonstrate understanding of dosage instructions for five common prescription medications. Correct understanding was determined by a panel of blinded physician raters reviewing patient verbatim responses. Qualitative methods were employed to code incorrect responses and generate themes regarding causes for misunderstanding. RESULTS: Rates of misunderstanding for the five dosage instructions ranged from 8 to 33%. Patients with low literacy had higher rates of misunderstanding compared to those with marginal or adequate literacy (63% versus 51% versus 38%, p<0.001). The 374 (19%) incorrect responses were qualitatively reviewed. Six themes were derived to describe the common causes for misunderstanding: label language, complexity of instructions, implicit versus explicit dosage intervals, presence of distractors, label familiarity, and attentiveness to label instructions. CONCLUSION: Misunderstanding dosage instructions on prescription drug labels is common. While limited literacy is associated with misunderstanding, the instructions themselves are awkwardly phrased, vague, and unnecessarily difficult. PRACTICE IMPLICATIONS: Prescription drug labels should use explicit dosing intervals, clear and simple language, within a patient-friendly label format. Health literacy and cognitive factors research should be consulted.