PROMOTING HEALTH LITERACY THROUGH EASY-TO-READ MATERIALS Cheryl Rowan, MSLS Public Health Coordinator National Network of Libraries of Medicine, South Central Region
Dec 17, 2015
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
Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.
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 [email protected]/800-338-7657
Thank You!