How do current digital patient decision aids in maternity care align with the health literacy skills and needs of clients?: a think aloud study

Background: Patient decision aids (PDAs) have shown to be effective in facilitating shared decision-making (SDM) in maternity care. However, many PDAs are difficult to use for clients because of high cognitive demand. Objective: This study aimed to explore how current digital PDAs support clients’ health literacy skills (understanding, appraising, and applying information) and fit their needs for support in SDM in maternity care. Methods: Clients (n=21) in Dutch maternity care were invited to use five PDAs during think aloud interviews. The interviews were transcribed verbatim, coded with open and axial coding, and analysed using thematic analysis. A framework of health literacy skills for SDM was used to categorize the themes. Results: Clients reported a need for support to appraise and understand the purpose of PDAs. Most clients adequately used both benefit/harm information about available options and available Value Clarification Methods (VCM), indicating that these main PDA elements supported them to actively process this information in their decision-making process. However, these elements were only appreciated and adequately used when clients understood the pregnancy- and labour related terminology used. A lack of balanced probability information about outcomes of options for mother and child hindered further information use. VCM were only used when presented attributes were relevant for clients. Conclusions: Clients were in general able to process and use information presented in PDAs in maternity care tested in this study, thus PDAs were aligned with health literacy skills. Adequate understanding of terminology and perceived relevance of specific information elements were important preconditions.