Molly Beinfeld, MPH, Solution Strategist
Editor’s Note: Join us as we explore important pregnancy topics that consumers and organizations are facing. Check back for additional posts, we’ll have a new one each week.
Did you know that 45% of all births in the U.S. are paid for by Medicaid? With over $50 billion in charges for labor and delivery and care of newborns annually, pregnancy is the number one hospital cost area for Medicaid. Recent studies have shown that up to 9% of Medicaid births are early elective deliveries, and 32% result in cesarean. There is growing consensus that these numbers are too high and that there is a strong need to engage women about these issues in a shared-decision-making process.
For many moms on Medicaid, though, the idea of being involved and informed about their care might be a new concept. So we wanted to validate that decision-aid tools used to support shared decision making are actionable and useful for such a diverse population. We wanted to know: can moms on Medicaid relate to the information and use it to guide their care?
To find out, we enlisted the help of health literacy experts at Louisiana State University and at University of California, Berkeley, to cognitively test a set of decision aids with 32 women recruited from clinics serving Louisiana Medicaid and Medi-Cal populations, respectively. These experts walked through the decision aid with the users in a semi-structured cognitive interview approach using an interview guide that they developed in collaboration with us. Based on early feedback, we made iterative changes to the tools as the testing proceeded.
Throughout the decision aids, we included videos of real women and health care providers to complement the text content. The users rated these videos highly, citing that they added authenticity and trustworthiness to the content. The videos were especially helpful for users who had difficulty reading. Overall, the use of the videos increased engagement with the content and the total time spent on the decision aid.
We got a lot of feedback on the production value of the videos. We found that short videos, between 1 and 2 minutes in length, were ideal. It was also important that the content of each video be unique to avoid repetition and that we use engaging video titles and thumbnail images to increase clicks on the video. We also learned that to leverage the educational value of the video medium, it’s important to “show, not tell” what’s involved in procedures, tests, etc., so that users can walk away with a realistic picture of what it’s like, for example, to be induced or have a fetal heart monitoring test.
Finally, an interesting finding was that users really responded to the stories and experiences of the women in the videos that most resembled their own. This was more important than the race or ethnicity of the women in the videos. For example, we included a video of a woman talking about managing the pain of early labor at home in her Jacuzzi tub. While this information—laboring in water—might have been useful, the mention of the Jacuzzi tub was off-putting to the users. They couldn’t relate to it.
In general, we found that less is more when it comes to content, and it is not enough just to ensure that it is written at a certain reading level. As a result, we focused on the key messages that we wished to convey and presented them in a concise, actionable format. The use of definitions embedded throughout the decision aid was also appreciated, so that users could click the word within the tool itself to find more information (and the pronunciation) of a medical term.
Finally, we found that tone is important. Our goal was to try to achieve a friendly tone that was not too serious, but also not dismissive of serious concerns. The only way to know that you are getting it right is by testing and iteration.
Overall, women rated these decision aids highly and wanted more information and to be involved in their care. Like all moms, moms on Medicaid want to do everything they can to ensure their health and the health of their babies.