PROMOTING HEALTH LITERACYTHROUGHEASY-TO-READ MATERIALS

Cheryl Rowan, MSLS

Public Health Coordinator

National Network of Libraries of Medicine,

South Central Region

Agenda

Introduction The Problem of Health Literacy Internet Resources Writing/Examining Easy-to-Read

Materials Assessment Exercise Testing for Readability

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Your physician has recommended that you have a colonoscopy. Colonoscopy is a test for colon cancer. It involves inserting a flexible viewing scope into your rectum. You must drink a special liquid the night before the examination to clean out your colon.

Weiss, Barry: Health Literacy and Patient Safety: Help Patients Understand; AMA Foundation

The Literacy Problem

National Assessment of Adult Literacy (NAAL)

Conducted in 2003 More than 19,000 adults One-on-one administration GOAL: assess literacy in English http://nces.ed.gov/NAAL

Results of NAAL: Literacy Statistics

Functionally illiterate = 23% of adults Marginal literacy skills = 28% of adults Proficient = Only 13% of adults 66% of adults over age 60 have

inadequate or marginal literacy skills Average reading level in the U.S. is 8th

grade; 20% read at 5th grade level or below

Numbers by Literacy Level

3063

95

280

50

100

Below Basic Basic Intermediate Proficient.

Millions of adults

Three Types of Literacy

Prose Document Quantitative

Prose Literacy

Requires ability to search, comprehend, and use continuous text

Prose Literacy - NALS

Document Literacy

Non-continuous text Requires ability to search,

comprehend, and

use information

Document Literacy - NALS

Quantitative Literacy

Requires ability to identify and perform computations, using numbers within printed materials.

Readability Studies

Numerous studies document mismatch between patient reading skills and the readability level of health materials.

Readability Patient Skills

(mean grade level) Wilson (2003) 11th 6th

Davis (1994) 10th 7th

Jackson (1991) 12th 5th

Meade (1989) 10th 6th

Determinants of Health

Age Income Literacy Skills Employment Status Education Level Race or Ethnic Group

Factors Affecting Learning Ability Stress Illness Age Cultural Barriers Language Barriers

http://www.acpfoundation.org/materials-and-guides/video/videos-for-patients/health-literacy-video.html

What is Health Literacy?

“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions”*

*Ratzan, S., and R. Parker. (2000); Healthy People 2010 and Healthy People 2020

Functional Health Literacy

“The ability to read and comprehend prescription bottles, appointment slips, and the other essential health related materials required to successfully function as a patient”*

*AMA Council of Scientific Affairs

Health Literacy Levels

30 47

114

250

50

100

150

Below Basic Basic Intermediate Proficient.

Millions of adults

Task: Appointment Slip

Locate information in a simple document. When is your next appointment? Where?

CLINIC APPOINTMENT

CLINIC: Diabetic

DAY: Thursday DATE: April 2nd HOUR: 6:45

YOU MUST BRING YOUR PLASTIC CARD WITH YOU

Task: Prescription Label

Applying information in a document If you were going to eat lunch at noon,

what time should you take your medicine?

Bouvier, Patricia

FF9418262 Dr. Hibbert, Julius

DOXYCYCLINE 100 MG

Take medication on empty stomach one hour before or two to three hours after a meal unless otherwise directed by your doctor.

Medication Safety and Health Literacy

What’s “plenty” of water?

“Medicine will make you feel dizzy”

“Don’t take medicine if you’ve been in the sun too long.”

“Costs” of Low Health Literacy

Why is Health Literacy Important?

To fill out a patient information form To understand health-related instructions To follow discharge instructions To identify signs To keep appointments To understand insurance To sign consent forms

Chili with Beans

Nutrition FactsServing Size: 1 cup (253 g)Serving per container: 2

Amount per Serving:

Calories 260 Calories from Fat 72

% Daily Value

Total Fat 8g 13%

Saturated Fat 3g

Cholesterol 130 mg

Sodium 1010 mg

Carbohydrates 22g

Dietary Fiber 9g

Sugars 4g

17%

44%

42%

7%

36%Dietary Fiber 9g

7%

36%

Is this safe for someone on a low salt diet?

Note: We rarely say, “Pass the sodium, please.”

After being diagnosed with recurrent aphthous stomatitis involving the epithelium of the buccal mucosa, Winston did what he thought was necessary:

[which is a funny thing to do for a canker sore]

Medical studies indicate most people suffer a 68% hearing loss when naked.

And, furthermore…

Up to 80% of patients forget what a doctor told them as soon as they leave the office!

Nearly 50% of what they do remember is remembered incorrectly!

Improving Oral Communication

Communication is two-way Use “teach back” instructions Avoid medical jargon Use commonly understood words Limit information Videos

Internet Resources

MedlinePlus

http://medlineplus.gov Easy-to-Read materials Medical Dictionary

Understanding Medical Words tutorial Interactive tutorials How to write easy-to-read materials:

http://www.nlm.nih.gov/medlineplus/etr.html

NIHSeniorHealth

http://nihseniorhealth.gov/ Developed with the National Institute on

Aging Senior-friendly features:

Text Size Contrast Speech Short segments of information

Healthy Roads Media

http://www.healthyroadsmedia.org Materials in 20+ languages Various formats:

Written Audio Multimedia Web video iPod video

NN/LM SCR

Consumer Health Manual Websites Research information Bibliography http://nnlm.gov/outreach/consumer/

hlthlit.html

Plain English/Plain Language

http://www.plainlanguage.gov Promote the use of plain language for all

government communications Examples, word suggestions, thesaurus Separate section for health literacy

Key Players

Partnership for Clear Health Communication/AskMe3 Initiative

http://www.npsf.org/askme3/ Centers for Disease Control and Prevention – Simply

Put http://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion

http://www.health.gov/communication/literacy “Health Literacy Online: A Guide to Writing and

Designing Easy-to-Use Health Web Sites” (U.S. Dept. HHS)http://www.health.gov/healthliteracyonline/index.htm

More Key Players

Hablamos Juntos – “Universal Symbols in Health Care Workbook”

http://www.rwjf.org/pr/product.jsp?id=15864 Clear Health Communications (Pfizer)

http://www.pfizerhealthliteracy.com/ Health Literacy Consulting

http://www.healthliteracy.com North Carolina Program on Health Literacy

New “Health Literacy Universal Precautions Toolkit”

http://nchealthliteracy.org/ Agency for Healthcare Research and Quality (AHRQ)

http://www.ahrq.gov/browse/hlitix.htm

Now You Be the Patient

You just been you told have acute platypuscitis

What types of information would you like to receive from your healthcare provider?

Writing/Examining/Selecting Easy-to-Read Materials

Basic Tips for Message Content1. Limit the number of messages2. Tell readers what you want them to do3. Tell readers what they’ll gain from

reading your material4. Choose your words carefully5. Suitable for the audience

Cultural Competency

Tailor messages to intended audience

Avoid stereotypes Relevant photos/artwork Appropriate symbols Realistic recommended

behaviors Back-translate and field

test translated material “…more than a patients’

rights issue…critical to safety and quality of care”*

Cultural Competence?

Pepsi’s “Come alive with the Pepsi generation” slogan

Chevy selling the Nova in South America

Gerber baby food sales in Africa

Example: Food Pyramid

Standard Version Culturally Modified Version

Text is Important

12 point or larger font size Avoid ALL CAPITAL LETTERS; they are

hard to read Use common fonts such as Arial or

Tahoma; avoid scriptEat fruits and vegetables

Eat fruits and vegetables Use boldface type and underlining to cue

readers to important text

Present Tense & Action Verbs1. Wrap the cut in a clean cloth.2. Keep it dry.

Use:

Consider

Pay

Concerns

Avoid:

Give consideration to

Make payment

Is concerned with

Active Voice

Roll to the left Put your feet on the floor Sit up Grab the railing

Avoid:

It shall be signed

You shall be notified

Use:

You must sign

We will notify you

General Terms

Accordingly Afford an

opportunity At a later date Close proximity In the event that Incumbent upon Utilize

So Allow Later Near If Must Use

Avoid Use

Medical Terms

Physician Cardiac

Medical Terms

Tablets Nasal Congestion

Medical Terms

Hazardous Radiology

Logical Sequence of Instructions

1. Wash your hands with soap and water. 2. Place the fresh bandage on a clean

towel. 3. Take off the old bandage gently. 4. Wash the burned area gently. 5. Apply a thin layer of antibiotic cream.6. Cover with the clean bandage.

Use Short Words & Sentences Return in one week. Bring your insurance card with you. Please sign in. Brush along the gum line. Drink plenty of orange juice.

Rewriting

Straight Leg RaiseLying on your back, bend your opposite

knee straight and slowly lift your other leg up approximately 12 in, hold for 3s, and lower slowly.

Sample Exercise in RewritingStraight Leg Raise Lie on your back Bend left leg Lift right leg 12 inches Hold for 3 seconds Lower slowly

Literacy and the Older Adult, from Topics in Geriatric Rehabilitation, Oct-Dec2005, Vol. 21 Issue 4, p275

Tips for Overall Appearance

Make it look easy to read Use lots of white space

Aim for “50/50 split” Margins at least one inch wide

Use visuals for text (or with text) Place images close to related text Text and pictures must agree Pictographs may be used to represent ideas

or actions Avoid “ghosting” visuals Keep visual separation between topics

Easy to Read?

What is diabetes? Diabetes means your blood glucose (often called blood sugar) is too high. Your blood always has some glucose in it because your body needs glucose for energy to keep you going. But too much glucose in the blood isn’t good for your health.

How do you get high blood glucose? Glucose comes from the food you eat and is also made in your liver and muscles. Your blood carries the glucose to all the cells in your body. Insulin is a chemical (a hormone) made by the pancreas. The pancreas releases insulin into the blood. Insulin helps the glucose from food get into your cells.

What is diabetes?

Diabetes means your blood glucose (often called blood sugar) is too high. Your blood always has some glucose in it because your body needs glucose for energy to keep you going. But too much glucose in the blood isn’t good for your health.

Example: Visual Separation

How do you get high blood glucose?

Glucose comes from the food you eat and is also made in your liver and muscles. Your blood carries the glucose to all the cells in your body. Insulin is a chemical (a hormone) made by the pancreas. The pancreas releases insulin into the blood. Insulin helps the glucose from food get into your cells.

Visuals Should Reflect the Audience

Age of reader Consider diversity Use current styles Get user input for

color choices Review by target

audience

Identify with Your Audience

Message: Exercise during pregnancy

Message: Stop Smoking

What About Websites?

Audience Content Organization

Assessment Exercise

Testing for Readability

Overview

Method Word count Syllables Sentence length

Readability of Materials Fry SMOG

Patient Literacy (REALM, TOFHLA, Newest Vital Sign) Computer software

Fry Readability Test

1. Select 3 passages of 100 words each2. Count the number of sentences 3. Count the number of syllables4. Find the average number of sentences

and syllables 5. Plot the numbers on the graph to

determine grade level

Example: Fry Readability Test

A cold and the flu (also called influenza) are alike in many ways. But the flu can sometimes lead to more serious problems, such as pneumonia. A stuffy nose, sore throat, and sneezing are usually signs of a cold. Tiredness, fever, headache, and major aches and pains probably mean you have the flu. Coughing can be a sign of either a cold or the flu. But a bad cough usually points to the flu.

Know when to call your doctor. You usually do not have to call your doctor right away if you have signs of a cold or flu.

Count Sentences

A cold and the flu (also called influenza) are alike in many ways. But the flu can sometimes lead to more serious problems, such as pneumonia. A stuffy nose, sore throat, and sneezing are usually signs of a cold. Tiredness, fever, headache, and major aches and pains probably mean you have the flu. Coughing can be a sign of either a cold or the flu. But a bad cough usually points to the flu.

Know when to call your doctor. You usually do not have to call your doctor right away if you have signs of a cold or flu.

8 sentences

Count Syllables

A cold and the flu (al-so called in-flu-en-za) are a-like in m-any ways. But the flu can some-times lead to more se-ri-ous prob-lems, such as pneu-mo-nia. A stuffy nose, sore throat, and sneez-ing are usu-al-ly signs of a cold…

135 syllables

6th grade

SMOG

Simple Measure Of Gobbledygook1. Count off 10 sentences near the beginning,

middle and end of text.2. Circle every word containing 3 or more

syllables and total the number of words circled

3. Estimate the square root of the total number of words counted

4. Add three to the square root.http://www.harrymclaughlin.com/SMOG.htm

REALM

Rapid Estimate of Adult Literacy in Medicine

Asks patients to pronounce 66 words ranging from “fat” to “impetigo”

Test provides grade level scores for people who read below a ninth grade level

May be better suited for research Realm SF – Form

TOFHLA

Test of Functional Health Literacy in Adults Series of health-related reading tasks

that measure numeracy and reading comprehension

Patients asked to read passages in which every 5th to 7th word has been deleted and to insert the correct word from a choice of four words

Example TOFHLA

The Newest Vital Sign

Screening tool to identify patients with low health literacy

English and Spanish From Pfizer Clear Health

Communication Initiative Based on nutrition label from ice cream

container

http://community.sw.org/2010/03/decoding-the-nutrition-facts-label/

Computer Testing

Microsoft Word feature Tools Grammar check

Flesch–Kincaid Readability Tests Flesch Reading Ease Flesch–Kincaid Grade Level

Testing: Things to Remember Don’t write to the formula Formulas do not take into account other

factors such as personal relevance Some multisyllable terms are very

familiar Operation (4 syllables) Diarrhea (4 syllables)

Formatting is not a part of testing

Testing Exercise

Fry Readability Exercise

1. Select 3 different passages2. Count 100 words in each 3. Count the # of sentences in each4. Count the # of syllables in each5. Calculate the average # of sentences

and syllables6. Plot the numbers on the graph to

determine grade level

In Summary, or . . . Why Does it Matter?

“Literacy matters in healthcare because life-threatening or potentially harmful mistakes may happen when people cannot read or understand written information.” *

*Osborne, Helen. (2005). Health Literacy from A to Z. http://www.healthliteracy.com

And…

“As clinicians, what we say does not matter unless our patients are able to understand the information we give them well enough to use it to make good health-care decisions. Otherwise, we didn't reach them, and that is the same as if we didn't treat them.“**

**Benjamin, R. M. (2010). “Surgeon General’s Perspective for Improving Health by Improving Health Literacy.” Public Health Reports.

Cheryl Rowan, MSLSPublic Health CoordinatorNational Network of Libraries of Medicine, South Central Region

http://www.nnlm.gov/scr cheryl.rowan@exch.library.tmc.edu713-799-7880/800-338-7657

Thank You!