Reference Manual for the Use of PROMS with People with Learning Disabilities and/or Low Literacy
- 1. Guide to Using Patient Reported Outcome Measures (PROMs) Inc lusively START Comments or Questions? Contact: deepa.jahagirdar@nhs.net 0141225 6870
- 2. 2 Table of Contents 1. Summary 2. Background 3. A problem with PROMs 4. Practical guidance to use PROMs 5. Case studies & resources Back Next Table of Contents Guide to Using PROMs Inclusively
- 3. 3 Summary This research-based guide provides an overview of PROMs and aims to help prevent the exclusion of people with low literacy skills and/or learning disabilities from PROM administration •Patient reported outcome measures (PROMs) are questionnaires patients complete on their health, and functionality. The information collected from PROMs can help to monitor patient progress or for healthcare quality improvement •Patients are meant to be involved in the development of PROMs to ensure they make sense but people low literacy skills and/or learning disabilities are generally excluded. This exclusion means that people low literacy skills and/or learning disabilities may not be able to complete PROMs •To address this issue, patient and professionals were consulted about their views on making PROMs accessible and easy to use as part of a 2 year project with the Universities of Glasgow and Dundee and Healthcare Improvement Scotland •The results suggested many practical adjustments to PROMs including larger font sizes and flexible administration •This guide presents these results along with case studies and Back Next resources for health professionals administering PROMs, to support Table of the inclusion of people with low literacy skills and/or learning Contents disabilities in PROMs initiatives Guide to Using PROMs Inclusively
- 4. 4 Background 1. What are PROMs? 2. How are PROMs used? 3. How are PROMs developed? Back Next Table of Contents Guide to Using PROMs Inclusively
- 5. 5 Background What are PROMs? Your health Patient Reported Outcome Measures (PROMs) are questionnaires about people’s health. They are used to gather information directly from patients about their symptoms, condition and overall quality of life. There are condition-specific PROMs, for instance the St George Respiratory Questionnaire for View example PROM respiratory conditions. There are also PROMs that can be used for any conditions, for instance the EQ-5D for health- Next Back related quality of life. Table of Contents Guide to Using PROMs Inclusively
- 6. 6 Background How are PROMs used? PROMs are used to measure the outcome of For example, PROMs are a health service intervention from people’s used for person-centred own perspectives. quality improvement. In England, PROMs data for The information collected directly from certain conditions is patients can be collated, analysed and fed compiled, analysed and fed back to inform others about how well a back to services for them to service intervention has worked. This can use in quality improvement. lead to changes in the way services are NHS Scotland is considering something similar. delivered if necessary. Gather data from More on English PROMs completed PROMs Health professionals can programme also use PROMs to monitor individual patient Improved outcomes (like symptoms Care Analysis and quality of life). This information can be used to Back Next make appropriate Table of adjustments to treatment Contents Feedback and care. results Guide to Using PROMs Inclusively
- 7. 7 Background How are PROMs developed? The process of development can take several months or even years. Your health Ideally PROMs are co-developed between researchers, patients and subject experts to make sure they cover what really matters to patients and what professionals consider good outcomes. They come up with a list of possible items for the PROM which are put through statistical testing that reduces the number of items that are finally included to a minimum. This testing ensures that the PROM makes sense to patients and ensures that the PROM will give us valid, useful information. Back Next Table of Contents Guide to Using PROMs Inclusively
- 8. 8 A problem with PROMs 1. Who might be excluded from using PROMs? 2. Why is this exclusion an important problem? 3. What is being done to overcome this problem? Back Next Table of Contents Guide to Using PROMs Inclusively
- 9. 9 Problem with PROMs Who might be excluded from using PROMs? Gather data from While researchers generally discuss PROMs completed PROMs with patients to decide on the content before finalizing it, they do not generally include people with learning disabilities or low literacy Improved Analysis Care skills. When PROMs are put into practice, people with learning disabilities or low literacy skills may struggle to complete them. Feedback results This means they may be left out of quality improvement and/or condition monitoring processes that use PROMs Back Next Table of Contents Guide to Using PROMs Inclusively
- 10. 10 Problem with PROMs Why is this exclusion an important problem? Lots of people may not be able to Excluding these groups also complete a PROM. counters NHS policies to As many as 1 in 5 adults have low literacy achieve full inclusion and the skills and there are approximately 1.5 UN Convention on the Rights million people with learning disabilities in the of Persons with Disabilities. UK. Professionals should not assume literacy. Patients sometimes feel ashamed or embarrassed to ask for help if they cannot read and have instead developed cover up and coping mechanisms that keep their struggle hidden. Giving PROMs to those who will struggle to read them might result in inaccurate Back Next completion or further alienation of these Table of patients from healthcare practices. Contents Guide to Using PROMs Inclusively
- 11. 11 Problem with PROMs What is being done to overcome this problem? Users can consult this guide to help make sure their PROMs practice is as inclusive as possible and help to collectively address exclusion and maximize PROMs’ potential. Over a year long research project between the University of Glasgow, University of Dundee and Healthcare Improvement Scotland, people with low literacy skills, This guide is the product of learning disabilities, other patients and health this university and NHS professionals were consulted to gather their research. It is geared views on how to make PROMs more towards those planning on accessible and easy to use. implementing and using PROMs in NHS Scotland. The focus was chronic obstructive pulmonary disease (COPD) but the results are applicable beyond this condition. The team also looked at other case studies where Back Next Table of organisations have made health information Contents accessible. Guide to Using PROMs Inclusively
- 12. 12 Practical Guidance to Use PROMs 1. Challenges & Suggestions a. Comprehension b. Reading c. Format 2. Other Considerations a. Assistance b. Modifications Back Next Table of Contents Guide to Using PROMs Inclusively
- 13. 13 Practical Guidance Challenges & Suggestions Comprehension Challenges A good example of a Certain question types and phrasing in PROMs are PROM with consistency in particularly difficult: questions in response -questions requiring long recall types is the Chronic -questions with too many options Respiratory -questions that try to address many things at once Questionnaire used for -scales with a large number of options, like the visual people with respiratory analogue scale on the EQ5D, which has a 1-100 scale conditions. Suggestions Select questionnaires without too many of the More information on above question types, with consistency in instrument selection questions and response options. It can be difficult to find the ‘perfect’ PROM, and if you cannot find a PROM that addresses these challenges and meets your needs, consider the Back Next Table of suggestions offered under ‘Reading’ after Contents introducing the PROM to the patient. Guide to Using PROMs Inclusively
- 14. 14 Practical Guidance Challenges & Suggestions Reading Challenges People may not be able to read the PROM, particularly if it is handed to them unexpectedly. It is not easy to Asking a few patients judge who will have difficulties because reading issues for their thoughts on a are often hidden. PROM before using it PROMs with more detail and harder words are also with all patients can intimidating. People may not be able to complete such also help make sure it is PROMs accurately. not particularly difficult. Suggestions After explaining what a PROM is, offer the patient a choice of whether to complete it with the health professional or take it away. This choice allows s/he to decide whether they want the professional’s help, a family member/care taker’s help at home, or to complete it alone. Read through PROMs to gauge their complexity and Back Next level of detail before you decide on one to use with all Table of Contents patients. Guide to Using PROMs Inclusively
- 15. 15 Practical Guidance Challenges & Suggestions Format Challenges Key points from Mencap’s The ‘look’ of a PROM can make it accessible information guidelines intimidating and hard to use if it makes applicable to PROMs include: the PROM seems difficult. Complicated formatting includes -text is straight across a page rather inconsistent alignment, unclear fonts, than in columns small font sizes, a lack of white space, -pictures, if any, should be on the and non prominent headings. left, words on the right Suggestions -Arial is a clear font -font size should be at least 16 pt Selecting a PROM that most closely adheres to these guidelines or working with someone -important words (like headings) with experience in accessible information to should be bold adjust the PROM can help to prevent difficulties associated with formatting. Back Next Resources and people to help with this are Table of listed in Case Studies & Resources Contents Guide to Using PROMs Inclusively
- 16. 16 Practical Guidance Other Considerations Assistance It is fine, and even helpful, if patients would like help to complete PROMs. Help in completing PROMs can sometimes improve its accuracy although there is always the risk that the PROM will represent the helper’s views rather than the patient’s. Although this is hard to prevent, it helps to observe any differences between what is written on a PROM and how a patient behaves, or whether the helper seems overbearing and continually corrects a patient. Patients can also complete PROMs by proxy but this is a last resort. Back Next Table of Contents Guide to Using PROMs Inclusively
- 17. 17 Practical Guidance Other Considerations Modifications Modifying a substantial part of the PROM itself As much as possible, try to like wording, content or adding pictures, or only modify the process by using some of the questions, can affect its which the PROM is meaning. administered (for instance, given to complete at This is because PROMs are developed with home or in a practice) so that rigour so that every item has been tested as it patients can complete it more stands. easily, rather than changing the PROM itself. Evidently people should be able to use PROMs so it is important to find a balance between minor modifications and the potential to change PROMs’ meaning. For example, font size changes are fine, since they will help lots of people and do not compromise the PROMs’ meaning to a large extent. But adding pictures can change the PROMs’ meaning, so it is important to carefully Back Next consider if this is beneficial to enough people to Table of make it worth it. Contents Guide to Using PROMs Inclusively
- 18. 18 Case Studies & Resources 1. Help to judge the accessibility of PROMs – Mencap Guidelines: http://www.mencap.org.uk/ – Communication for Health: http://www.nhsfife.scot.nhs.uk/easyread/ – Contact: Billy Pate, Community Learning Disabilities Nurse (NHS Forth Valley): wpate@nhs.net 2. Examples of accessible questionnaires – Adults with Learning Difficulties Questionnaire: www.solihull.gov.uk/akssolihull/images/att4030.doc 3. More information on PROMs General Comments or Questions? – Instrument Selection: http://phi.uhce.ox.ac.uk/instruments.php Contact: – Overview of PROMs’ potential by the King’s Fund: deepa.jahagirdar@nhs.net 0141225 6870 www.kingsfund.org.uk/document.rm?id=8607 – NHS England programme: http://www.ic.nhs.uk/proms Back Next Table of Contents Guide to Using PROMs Inclusively
Editor's Notes
- #18: Need to refer people to someone to decide on necessary modifications