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ShiningaLightonHealthLiteracy:What’stheBottomLineforSurgeons?
UAB
Gastrointestinalsurgery
April24,2018
TerryDavis,PhDProfessorof
Medicine,PediatricsandFeist-WeillerCancerCenter
LSUHSC-S
DisclosureInformationTerryC.Davis,PhD
ResearchFunding• NIH,LouisianaClinicalandTranslationalScienceCenter.• AmericanCancerSociety- “HealthLiteracyInterventionstoOvercomeDisparitiesinCRCScreening"• PCORI:“AchievingPatient-CenteredCareandOptimizedHealthInCareTransitionsbyEvaluatingtheValueofEvidence(PROJECTACHIEVE)”• PCORI:“PromotingSuccessfulWeightLossinPrimaryCareinLouisiana(PROPEL)”• NIDDK– “HealthLiteracyInterventiontoImproveDiabetesOutcomesAmongRuralPrimaryCarePatients”
HealthLiteracy:WhatdoSurgeonsNeedtoKnow?
• Healthliteracy- theabilitytoobtain,understandandusehealthinformationandservices- significantly impactspatientunderstandingandoutcomes.
• Nearly9of10adultshavedifficultyusinghealthinformationthatisroutinelyavailableinhealthcarefacilitiesandthemedia.
• Physiciansoftenfailtograspthewidechasmbetweenwhattheywanttocommunicateandwhatpatientsunderstand.
• Mostconsentdocumentsarenotdesignedtotrulyinformpatientsaboutprocedures,orresearch— patientsmaynotunderstandbasicconcepts.
• Itisincreasinglydifficultforpeopletoseparateevidence-basedhealthinformationonlinefrommisleadingadsandgimmicks.
America’s Health Rankings 2015; Department of Education National Assessment of Adult Literacy; Koh Health Affairs 2012
HealthLiteracyAffectsSurgeon/PatientCommunication
•Askfewerquestionsingeneral•Askfewerquestionsaboutsurgeryprocedureandtherapeuticregimen
AndTherefore:• Lackadequateunderstandingofthesurgicalprocedureanddischargeinstructions•Makemistakeswithmedication•Havemoresurgicalcomplications
PatientswithLimitedHealthLiteracy:
Menendez,vanHoorn,Mackert.ClinOrthopRelatRes.2017
CommonHealthLiteracyCommunicationProblems
• Orthopedicstudy.250patientsat1stpost-opvisit
• 45%knewbonefractured,19%knewexpectedhealingtime,45%knew
weightbearingstatus.
• Surgerystudy.100patients
• 95%ofsurgeonsbelievedpatientsunderstoodwhentoresumenormal
activitiesvs.only58%ofpatients.
• Surgeonsonlyoccasionally(29%ofthetime)askedpatients
iftheyhadquestions— whentheydid,most(79%)had
questions
Roter, D. 2011 Nursing Outlook; Korsch, B. Pediatrics 1968; Castro C 2007 Am J Health Behav; Kadakia, J Ortho Trauma, 2013; Calkins Arch Intern Med, 1997.
TheRippleEffectofLiteracyonSurgery• PoorMD/patientcommunication
• Inadequateconsentprocess
• Poorunderstanding&adherencetopre- &post-opinstructions
• ImproperlytakingmedsThesemayresultin:• avoidablesurgerycancellations&postponements
• wastedORtime
• ↑hospitalexpense
• ↓patientoutcomes
• ↓patientsatisfaction
Koster,Schmidt,Philbert.JPublicHealth.2017;Miller-Matero,Bryce,Hyde-Nolan.Psychosomatics.2016
NationalAssessmentofHealthLiteracyAssessedfunctionalclinical,preventive,&navigationaltask
n=19,000Adults,152tasks(28healthrelated)
Circledateondoctor’sappointmentslip.(AA24%,Hispanic41%)
Intermediate
Proficient
Below Basic
Basic Determinewhenit’sokaytodrinkbeforeamedicaltestbasedonshortinstructions.
Determinewhattimetotakeprescriptionmedicinebasedonthelabel.
Calculateemployshareofhealthinsurancebasedontable.
NationalAssessmentofAdultLiteracy(NAAL):NationalCenterforEducationalStatistics,U.S.Dept.ofEducation,2003
14%
22%
53%
12%
LowHealthLiteracyisPrevalentinAL:RatesByCounty
8
HealthLiteracyLevelsProficientIntermediateBasicBelowBasic
2014
“PerfectStorm”ofPatientSafety
• 39.5millionhospitaldischarges/year
• 20%ofpatientshaveapost-dischargeadverseevent
Hospitaldischargeisnotstandardized”
• Looseends– pending&post-dischargetests
• Communication– withPCP,ESL,healthliteracy
• PoorInformation– dischargesummaryquality&availability
• PoorPreparation– knowledgeofdiagnoses,meds,f/uappointments
• Fragmentation– whoisincharge?
Hansen.AnnInternMed2013.;WilliamsM.SMedJournal2014.
MedicationErrors2daysafterHospitalDischargePharmDcall(n=197)
IncorrectAdministration %
Wrongfrequency/interval 21%
Wrongdoseonprescription 18%
Patientdidnotthinks/heneedsmed 15%
Patientdidnotfillduetocost 17%
Patientdidnotpickupfrompharmacy 11%
Patientdidnotgetprescriptionondischarge 12%
Patientself-discontinuedduetosideeffects 11%
Patientdidnotfillbecauseofinsurance 8%
Overall,51%experiencederrorwithin2days!Jack BW, Ann Intern Med 2009
WeNeedtodoaBetterJobofPatientCommunicationandSupport
• Lessthan1in5patientsrecallwhatdoctorstellthem.• 20%-30%donotfillinitialprescriptions.• Upto50%donottakeprescriptionsasrecommended.• Clinicvisittimesandhospitalizationsareshorter.• Patientsaskedtoperformmorecomplexself-care.• Patientsoftenneedhelpandsupportinchanginghealthbehaviorandsustainingimprovement.
Video:It’sEasytoMakeaMistake
MedicationError- MostCommonMedicalMistake1.5Madverseevents (patienterror>700,000,persistenterror)
• 2outof3patientsleaveMDvisitwithRx
• 4billionretailRxfilledin2014• Up50%-60%in10years
• 82%adultstakeatleastonemed
• Elderlyfill20Rx/year,see8physicians
• 1in6pediatricRxnotdosedcorrectly(study:4in5atleast20%off-dosewhencupsused).
• >300,000OTCmeds(>600containacetaminophen)
• MostlabelsandinsertsareinEnglishonly
U.S.CensusBureau,2009;PDRforNon-PrescriptionDrugs,DietarySupplementsandHerbs (2007);IMSHealth2005;IOM2006;KaiserFamilyFoundation.Yin;jPeds2016
CanPatientsUnderstandRxlabels?“HowWouldYouTakeThisMedicine?”
• 46% didnotunderstandinstructions≥1labels• 38%withadequateliteracymissedatleast1label• <10%attendedtowarninglabels
395medicineclinicpatientsin3states48%<9th gradereading,averaged1.4meds
Davis,Wolf,Bass,Parker.AnnInternMed,2006.
“ShowMeHowManyPillsYouWouldTakein1Day”
0
20
40
60
80
100
Low Marginal Adequate
Cor
rect
(%)
Patient Literacy Level
Understanding
Demonstration
RatesofCorrectUnderstandingvs.Demonstration“TakeTwoTabletsbyMouthTwiceDaily”
71
35
84
63
8980
JohnSmithDr.Red
Taketwotabletsbymouthtwicedaily.
HumibidLA600MG1refill
PatientCenteredLabelCanImproveUnderstandingandAdherence
StateBoardofPharmacyinCApassedlegislationforthislabel.
StandardLabel PCLabel
Understanding(baseline) 59% 74%
Adherence(3 months) 30% 49%
RCTin11FQHCs.429ptswDMand/orHTN.39%lowliteracy
HiddenProblem:Numeracy
• Youdrinkthiswholebottleofsoda.Howmanygramsoftotalcarbohydratesdoesitcontain?
• 67.5grams
•32%answeredcorrectly
• 200primarycarepatients• 73%privateinsurance• 67%atleastsomecollege• 78%read> 9th grade• 37%math> 9th grade
RothmanR,AmJPrevMed,2006
•Approximatelyhalf ofU.S.adultsareunabletocalculateatip.
*KirschIS,etal.,AdultLiteracyinAmerica,1993;LipkusIM,etal.,MedDecisMaking,2001
• 20% ofcollege-educatedadultsdon’tknowwhatisahigherrisk– 1%,5%,or10%
Actualrestaurantreceipt
U.S.adultsscoredbelowadultsin23nationsinnumeracyandproblemsolving– OECD2013
Percentages&ProbabilityareChallengingforMany:
ImproveRiskCommunication
Providebothpositiveandnegativeframes.• “6in10menwhohavesurgerytotreatprostatecancerwillbeimpotent.Thismeans4in10willnot.”
Giveabsoluteestimates- notrelative.• DrugXcouldreduceyourriskofbreastcancerby50%(relative)• DrugXcouldreduceyour5-yearriskfrom4%to2%(absolute)
RedFlagsForLimitedLiteracy
• Vacantlook• Maysay“Iforgotmyglasses.”• Asksfewerquestions(ornoquestions)• Incompleteforms• Frequentlymissedappointments• Unabletogivecoherent,sequentialhistory• Nottakingmedicationscorrectly• Lackoffollow-throughwithreferrals
* Health Literacy and Patient Safety: Help Patients Understand – A Manual for Clinicians. 2nd edition. Chicago: AMA Foundation and AMA, 2007. www.ama-assn.org/ama1/pub/upload/mm/367/healthclinicians.pdf
HealthLiteracyandNumeracyMaybeLow;NowWhat?
• DHHS’sNationalHLActionPlanhealthinformationneedstobeaccurate,assessable,understandable,actionable.
• Wemustnotblameindividualsfornotunderstandinginformationthathasnotbeenmadecleartothem.
• Everyone,nomatterhoweducated,isatriskformisunderstandinghealthinformationiftheissueiscomplexoremotionallycharged.
HealthLiteracyInterventionstoOvercomeDisparitiesinCRCScreeninginRuralFQHCs
PatientEnrollment(N=620)
RaceAfrican-American66%White 34%
GenderFemale 55%Male 45%
Literacy<9th GradeReadingLevel40%>=9th GradeReadingLevel 60%
Pre-interventionCRCscreeningRate3%- 5%
AllparticipantsgivenCRCscreeningrecommendation,patientfriendlymaterials(writteninconversationallanguage,4th gradelevel,picturesfromclinic,focusedonbehavior,positivetone),FITkitwithsimplified,illustratedinstructionsandteachbackusedtoconfirmcomprehension.
Patientsrandomizedtopersonalfollow–upcallorautomatedcallin4and8weeksifnoFITreturned.
Methods
Year2and3materials&FITmailedwithsimplifiedinstructions.Follow-upcallsconductedasinfirstyear
Results– Year1
AutomatedCallArm(n=308)
69%completedFIT
• 40%neededatleastone
follow-upcall
PersonalCallArm(n=306)
67%completedFIT
• 41%neededatleastone
follow-upcall
620patientsenrolled- (6withdrewbeforecompletingtest)
58-60%patientsgivenFITinclinicreturnedwithoutprompting
ProvidingFIT+literacyappropriateeducationatclinic
visitwithfollow-upcall(ifneeded)increasedCRC
screeningratesoflowincome,ruralpatients.
Results– Year2
Automatedcallarm(n=)
40%completedFIT• 74%neededatleastonefollow-upcall
Personalcallarm(n=)
37%completedFIT• 74%neededatleastonefollow-upcall
23-25% patientsmailedreturnedFITwithoutphoneprompting
SustainingannualscreeningwithFITischallenging.Follow-upcallswereessentialinyear2.
Lowercostautomatedcalljustaseffectiveaspersonalcallbothyears
HealthLiteracyFocushasShiftedfromPatientstoProviders,Researchers,andHealthSystems
HealthLiteracyKeystoImprovingPatientEducation
• Slowdown• Avoidmedicaljargon,useplainlanguage• Usepictures,teachingtools(pamphlets,brownbagmeds)• Limitadvice(1-3concepts)•Writebrieftake-homeinformation
• Repeatandsummarizeinformation• ‘Teachback’/’showback’toconfirmunderstanding• Bepositiveandmotivating
•Lesion•Excision•Resection•Tracheostomy•Endoscopic•Portacath•Gastritis•CTvsMRI
ResidentsCommonlyUsedJargon
*Http://firstclinical.com/glossary/28
PicturesCanbeGoodTeachingToolsPatientsmaynotunderstandorusemeasurements
Healthy Carbs
Fruits and VeggiesProteins
StrategyforLimitingInformationLessonslearnedfrompatients
Tellme3•What’swrong?(briefly) (Diagnosis)•WhatdoIneedtodo? (Treatment)•WhyisitimportantthatIdothis? (Benefit/Context)
Ifmeds– “breakitdown”forme•What’sitfor?(indication)•When totake?Howmanypillsatatime,howlong?(duration)•Why?(benefit)•What toexpect?(sideeffects)
30
Teach-BackMethod
• “Tellmeyourunderstanding”• “Howwillyoudescribethistoyourfamily?”•Avoidasking:•Doyouunderstand?•Doyouhaveanyquestions?
Remember- what’scleartoyouiscleartoyou!
Thesinglebiggestproblemwithincommunicationistheillusionthatithastakenplace.GeorgeBernardShaw,Playwright
Communicationdoesnottakeplacebecausewetellsomebodysomething.
Communicationtakesplacewhenweobservepatientscloselyandgetsignalsthatweareontherighttrack;thatwehavestartedataplacetheyarefamiliarwithandtracktheirabilitytofollowus.Weforgetwhatit’slikenottoknowsomething.
AlanAlda,Actor.CenterforCommunicatingScience,StonyBrookUniversity
32
CommunicationInsightRelevantforSurgeons
AddressingLowHealthLiteracyatDischarge:ProjectRED
Aim:effectivelypreparepatientsforhospitaldischarge
RN‘DischargeAdvocate’workswithinpatientsto:• Educate themwithindividualizedinstructionbooklet(alsosenttoPCP)• Arrangefollow-upappointments• Confirmmedicationreconciliation• Avgtotaltime:87minperpatient(42minwpatients,45minreviewingEMR,communicatingwmedicalteam&preparingdischargebooklet)
ClinicalPharmDcallspatients2-4daysafterdischargetoreviewmedsandreinforcedischargeplan• Avgtotaltime:26minperpatient(10-19mincounseling)• 65%ofpatientshadatleast1medproblem
AHRQ March 2013
EACHDAYfollowthisscheduleforyourmedicinesWhattimeofdaydo Itakethismedicine?
WhyamItakingthismedicine?
MedicinenameAmount
HowmanydoItake?
HowdoItakethismedicine?
Morning
Noon
Evening
Bedtime
Onlyifyouneeditfor
REDTemplateforMeds
REDTemplateforFollow-upAppointments
WednesdayAugust8at11:30a.m.
Thursday,August 16At3:20p.m.
WednesdaySeptember 12At9:00a.m.
Dr.MarkAveryPrimarycaredoctor
Dr.AnitaJonesRheumatologist
Dr.LinWuCardiologist
100MainSt.2nd floorAnytownST
100PleasantRd, Suite105Anytown,ST
100ParkRd,Suite504Anytown,ST
Forafollowupappointment
For yourarthritis Tocheckyourheart
Officephonenumber(555)555- 5555
OfficePhone#:(555)555-5555
OfficePhone#:(555)555-4444
JohnDoeWhatismymainmedicalproblem?
ChestPainWhenaremyappointments?
ProjectREDEffectiveandCostEffectiveRandomizedControlTrial— 30daysafterD/C
REDvs.standarddischarge
• 30%lowerhospitaluse
• 30%morelikelytofollow-upPCP
• 34%lowercost
Jack BW, Ann Intern Med 2009
2007NationalQualityForum“SafePractice”forhospitaldischargebasedlargelyonRED
Participants– 749patients,meanage:50,meanstay:2.7days
– 59%lowliteracy;50%AA,27%White
ProblemsWithWrittenHealthInformation•Organizedusingmedicalmodel,notpatient-centered• Scientific/bureaucraticnotpersonal/conversational•Toolong,toomuchinformation,keymessageburied• Illustrationscomplex,confusing,or“don’tlooklikeme”• Lackofattentionto‘tone,’patientemotions• Lackofpatientandproviderinputindevelopment•Distributionandsustainabilitynotthoughtout• Howandwhenwillpatientsgettheinformation?Whogivesittothem?Whenisteachablemoment?Plantoupdate?
•Lackofawarenessofwhat’sonGoogle/blogs
LiteracyTestsUsedinHealthcareResearchYearsofschoolingisNOTagoodmeasureofliteracylevel
• Themostcommonlyused• REALM (RapidEstimateofLiteracyMedicine)• REALM-SF (shortform)• TOFHLA (TestofFunctionalHealthLiteracy)• NVS (NewestVitalSign)
• Theseareoften referredtoastestsofhealthliteracy
Qualitative:Howconfidentareyoufillingoutmedicalformsbyyourself?Extremely– QuiteABit– Somewhat– ALittleBit– NotAtAll(0) (1) (2) (3) (4)
Tests and ordering instructions are in resources at the end of the presentation.
HealthLiteracyCommunicationRecommendations
• Slowdown,sitdownandengagepatient(andfamilymember)• Useplainlanguage– avoidsurgicaljargon• Giveeasytounderstandinformationandinstructions• Usepicturestohelpconveymessageandteachbacktoconfirmunderstanding•Ensureclinicalandresearchmaterialsarewritteninplainlanguageandformattedforreadingandnavigationease•Websitesneedtobeeasytounderstandandnavigate•Encouragestafftoofferpatientshelpwithfillingoutforms
HealthLiteracySurgeryResearchIdeas
•Cansurgerydisparitiesbepartiallyexplainedbyinadequatehealthliteracy?•FewstudiesexamineroleofHLinperioperativesetting.• DoesHLinfluencefamilycaregiver/patientunderstandingofcomplexself-carepostsurgery?• QIprojectlookingatimpactofstaffofferinghelpwithformsorprovidersusingteachback.
TerryDavis,PhDDepartmentofMedicineandPediatrics
LSUHealthShreveport&[email protected](318)675-8694
ResearchAssistant:[email protected](318)675-4584
ResourcesInformedConsent
TemplatesandTerms
• TheAgencyforHealthcareResearchandQuality(AHRQ)InformedConsentandAuthorizationToolkitforMinimalRiskResearch.
• FirstClinicalResearchGlossaryforInformedConsent:http://firstclinical.com/icfglossary/http://firstclinical.com/glossary/
HelpfulLinksforWrittenHealthInformation
CDC(2013)ClearCommunicationIndexwww.cdc.gov/healthcommunication/ClearCommunicationIndex
AHRQ(2013)ThePatientEducationMaterialsAssessmentTool(PEMAT)www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/pemat/index.html
CMS (2011)Toolkitformakingwrittenmaterialsclearandeffectivewww.cms.gov/writtenmaterialstoolkit/
ScientificAmericanandTheAlanAldaCenterforCommunicatingScienceatStonyBrookUniversity (2017)FreeOnlineWritingWorkshopforScientistshttp://sb.cc.stonybrook.edu/news/general/2017-06-26-scientific-american-and-alda-center.php
44
AssessReadingStatisticsonMicrosoft
• Flesch- Kincaidestimatesdifficultyofreadingform
• Microsoft2007&2010• GotoFileTab;selectOptions• ClickonProofing• Check“ShowReadabilityStatistics”
• GotoReviewTab• SelectSpelling&Grammar• Readabilityresultswillshowafterspellinghasbeenchecked
Lexile–AnInternetProgramthatCalculatesReadingLevel
www.lexile.com• Scoresbasedonsentencelengthandwordfrequencyinpopularliterature
• Scoresrangefrom0(beginnerlevel)to2000(highervaluesindicatehigherreadingdifficulty.Aimfor<900
• Save text as Plain Text fileGo to www.lexile.comClick on Lexile AnalyzerUpload file and press analyze
Valuescanbeeasilytranslatedtoreadinggradelevels.
LexileValueof300à 2nd gradeLexileValueof400à 4th gradeLexileValueof1300à 12th grade
• Asystematicmethodtoassesspatienteducationmaterialsandevaluatetheirunderstandabilityandactionability
• Understandability:patientsofdiversebackgroundsandvaryinglevelsofhealthliteracycanprocessandexplainkeymessages.• Actionability:patientscanidentifywhattheycandobasedontheinformationpresented.
PEMAT-PforprintmaterialsPEMAT-A/Vforaudiovisualmaterialse.g.,videos,multimediamaterials,
PatientEducationMaterialsAssessmentTool(PEMAT)
HealthLiteracyResources• HealthLiteracyUniversalPrecautionsToolkit:http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
• HealthLiteracyasanEssentialComponenttoAchievingExcellentPatientOutcomes:http://www.iom.edu/~/media/Files/Perspectives-Files/2014/Discussion-Papers/BPH-EssentialComponent.pdf
• “WhatDidtheDoctorSay?:”ImprovingHealthLiteracytoProtectPatientSafety:http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf
• PromisingPracticesforPatient-CenteredCommunicationwithVulnerablePopulations:ExamplesfromEightHospitals:http://www.commonwealthfund.org/Publications/Fund-Reports/2006/Aug/Promising-Practices-for-Patient-Centered-Communication-with-Vulnerable-Populations--Examples-from-Ei.aspx
• DHHSHealthLiteracyActionPlan:http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf
• CDCPlainLanguageChecklist:http://www.cdc.gov/healthliteracy/pdf/checklist.pdf
HealthLiteracyInformation
KohHK,BrachC,HarrisLM,ParchmanML.Aproposed'healthliteratecaremodel'wouldconstituteasystemsapproachtoimprovingpatients'engagementincare.HealthAff(Millwood).2013Feb;32(2):357-67.
KohHK,BerwickDM,ClancyCM,BaurC,BrachC,HarrisLM,ZerhusenEG.Newfederalpolicyinitiativestoboosthealthliteracycanhelpthenationmovebeyondthecycleofcostly'crisiscare'.HealthAff(Millwood).2012Feb;31(2):434-43.
ShoemakerSJ,WolfMS,BrachC.DevelopmentofthePatientEducationMaterialsAssessmentTool(PEMAT):anewmeasureofunderstandabilityandactionabilityforprintandaudiovisualpatientinformation.PatientEducCouns.2014Sep;96(3):395-403.
AHRQhealthliteracywebsite
HealthLiteracyTests:
•REALMandREALM-Teen• [email protected]
•TOFHLA• http://peppercornbooks.com/catalog
•NVS• http://www.clearhealthcommunication.com/physicians-providers/newest-vital-sign.html
•SAHLSA• http://www.ahrq.gov/populations/sahlsatool.htm
•1Question• Chew,L.JGenInternMed.23(5)561-4
• TestingindividualpatientswillNOTconfirmtheir abilitytounderstandandactonhealthinformation.
• Noevidencethatindividualliteracytestingimproveshealthcareoroutcomeswhentestingisdonestrictlyforclinicaluse.
• Togetthemostaccuratemeasureofpatient’sspecifichealthliteracyclinicallyuse“teachback.”
• “Universalprecautions”(plainlanguage)arerecommendedtomakematerialsuser-friendly.
• Forclinicaluse–testclinics/systemsintheaggregate.
CautionsaboutAssessingHealthLiteracyClinically
List 1 List 2 List 3
fatflupilldoseeyestresssmearnervesgermsmealsdiseasecancercaffeineattackkidneyhormonesherpesseizurebowelasthmarectalincest
fatiguepelvicjaundiceinfectionexercisebehaviorprescriptionnotifygallbladdercaloriesdepressionmiscarriagepregnancyarthritisnutritionmenopauseappendixabnormalsyphilishemorrhoidsnauseadirected
allergicmenstrualtesticlecolitisemergencymedicationoccupationsexuallyalcoholismirritationconstipationgonorrheainflammatorydiabeteshepatitisantibioticsdiagnosispotassiumanemiaobesityosteoporosisimpetigo
REALM
0-18correct=< 3rd grade
19-44correct=4th-6th grade
45-60correct=7th-8th grade
61-66correct=highschool
Davis,FamMed,1993
REALM- SF
REALM- TeenS IRT Parameters
Item Proportion correct
Item-total correlation a-parameter SE (a) b-parameter SE (b)
diabetes .95 .48 3.29 0.56 -1.85 0.12 exercise .95 .49 6.27 1.91 -1.79 0.10 prevention .92 .53 3.42 0.59 -1.62 0.10 asthma .90 .55 2.97 0.41 -1.49 0.09 nausea .86 .57 2.84 0.36 -1.30 0.08 fatigue .73 .63 3.05 0.37 -0.71 0.06 adolescent .59 .56 2.18 0.24 -0.27 0.06 anemia .55 .54 2.07 0.22 -0.15 0.06 tetanus .45 .47 1.69 0.18 0.20 0.07 bronchial .40 .50 2.37 0.29 0.33 0.06
Raw Score Reading Level
0-2 3rd grade and below 3-4 4th to 5th grade 5-6 6th to 7th grade 7-8 8th to 9th grade
9-10 10th grade and above
S- TOFHLAPASSAGEAYourdoctorhassentyoutohavea____________X-ray.
a.stomach
b.diabetes
c.stitches
d.germs
Youmusthavean__________stomachwhenyoucomefor______.
a.asthma a.is.
b.empty b.am.
c.incest c.if.
d.anemia d.it.
TheX-raywill________from1to3_________todo.
a.take a.beds
b.view b.brains
c.talk c.hours
d.look d.diets
THEDAYBEFORETHEX-RAY.
Forsupperhaveonlya________snackoffruit,________andjelly,withcoffeeortea.
a.little a.toes
b.broth b.throat
c.attack c.toast
d.nausea d.thigh
Scoring:
0-16:
Inadequatefunc.HL
17-22
Marginalfunc.HL
23-36
Adequatefunc.HL
Parker,JGenInternMed,1995
NVS
6Questions
• Ifyoucanhave60gramsofcarbsforasnack- howmuchicecreamcanyouhave?
• Score:1pointforeachcorrectanswer0-1Inadequateliteracy
2-3Marginalliteracy
4-6Adequateliteracy
OrderingInformation
REALMandREALM-Teen• [email protected],TOFHLA-SpanishandSTOFHLA• http://peppercornbooks.com/catalogNVS• http://www.clearhealthcommunication.com/physicians-providers/newest-vital-sign.htmlWRAT• http://www3.parinc.com/products/product.aspx
EvaluationofReadingLevelforWrittenMaterials
• FleschKincaidReadingLevelandFleschReadingEase:• AutomaticallybundledwithMicrosoftWord• Testssentencecomplexity
• VocabularyProfiler:• Helpsdetermineuncommonwords• Veryusefulfornon-nativeEnglishspeakers• ex:http://www.sfu.ca/~msevier/WebVocabularyProfilerCS.htm
• LexileLevel• Analyzesbothsentencecomplexityandwordfrequency• http://www.lexile.com/analyzer/
• FryReadabilityFormula• Randomlyselectthreeseparate100wordpassages• Countthenumberofsentencesineach100wordsampletothenearesttenth• Countthenumberofsyllablesineach100wordsample• PlottheaveragesentencelengthandtheaveragenumberofsyllablesonaFryGraphtodeterminethegradelevel
SMOG
http://prevention.sph.sc.edu/tools/SMOG.pdf
CheckliststoEvaluateUser-Friendliness(Suitability)
• OsbornH.(2004)HealthLiteracyfromAtoZ:PracticalWaysto
CommunicateYourHealthMessage.
• ArnoldCL,DavisTC,OheneFrempongJ,etal(2006):Assessmentof
newbornscreeningparenteducationmaterials. Pediatrics.2006;117:320-5.
• DoakCC.(1996)TeachingPatientsWithLowLiteracySkills,2nd ed.,1996.
• RuddR.(1994)Learnerdevelopedmaterials:Anempoweringproduct.
HealthEducationquarterly.(Fall)1994.
SuitabilityAssessment(SAM)*Score
1.Content _____a)Purposeisevident _____b)Contentaboutbehaviors _____c)Scopeislimited _____d)Summaryorreviewincluded _____
2.LiteracyDemanda)Readinggradelevel _____b)Writingstyle,activevoice _____c)Vocabularyusescommonwords _____d)Contextisgivenfirst _____e)Learningaidsvia“roadsigns” _____
3.Graphicsa)Covergraphicsshowpurpose _____b)Typeofgraphics _____c)Relevanceofillustrations _____d)List,tables,etcexplained _____e)Captionsusedforgraphics _____
*Doak,1996
SuitabilityAssessment(SAM)*cont.
Score
4.LayoutandTypography _____a)Layoutfactors _____b)Typography _____c)Subheads _____
5.LearningStimulation,Motivationa)Interactionused _____b)Behaviorsaremodeledandspecific _____c)Motivation– selfefficacy _____
6.CulturalAppropriatenessa)Matchinlogic,language,experience _____b)Culturalimageandexamples _____
Scoreeach0– 2: TotalSAMscore: _______0ifnotsuitable,1ifok, TotalPossiblescore: _______2ifsuperior,N/A Percentscore: _______ifdoesnotapply *Doak,1996