Promoting Health Literacy through Easy-to-Read Materials

1. Promoting Health LiteracythroughEasy-to-Read Materials Cheryl Rowan, MSLS Public Health Coordinator National Network of Libraries of Medicine, South Central Region

2. Agenda • Introduction • The Problem of Health Literacy • Internet Resources • Writing/Examining Easy-to-Read Materials • Assessment Exercise • Testing for Readability

3. 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

4. The Literacy Problem

5. 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

6. 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

7. Numbers by Literacy Level Millionsof adults

8. Three Types of Literacy • Prose • Document • Quantitative

9. Prose Literacy • Requires ability to search, comprehend, and use continuous text

10. Prose Literacy - NALS

11. Document Literacy • Non-continuous text • Requires ability to search, comprehend, and use information

12. Document Literacy - NALS

13. Quantitative Literacy • Requires ability to identify and perform computations, using numbers within printed materials.

14. Readability Studies • Numerous studies document mismatch between patient reading skills and the readability level of health materials. ReadabilityPatient Skills (mean grade level) • Wilson (2003) 11th 6th • Davis (1994) 10th 7th • Jackson (1991) 12th 5th • Meade (1989) 10th 6th

16. Determinants of Health • Age • Income • Literacy Skills • Employment Status • Education Level • Race or Ethnic Group

17. Factors Affecting Learning Ability • Stress • Illness • Age • Cultural Barriers • Language Barriers

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

19. 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

20. FunctionalHealth 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

21. Health Literacy Levels Millionsof adults

22. 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

23. 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.

24. What’s “plenty” of water? “Medicine will make you feel dizzy” “Don’t take medicine if you’ve been in the sun too long.” Medication Safety and Health Literacy

25. “Costs” of Low Health Literacy

26. 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

27. Is this safe for someone on a low salt diet? Chili with Beans Nutrition Facts Serving Size: 1 cup (253 g) Serving per container: 2 Amount per Serving: Calories 260 Caloriesfrom Fat 72 % Daily Value Total Fat 8g 13% 17% Saturated Fat 3g Cholesterol 130 mg 44% Sodium 1010 mg 42% Carbohydrates 22g 7% 7% Dietary Fiber 9g Dietary Fiber 9g 36% 36% Sugars 4g Note: We rarely say, “Pass the sodium, please.”

28. 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]

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

30. 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!

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

32. Internet Resources

33. 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

34. NIHSeniorHealth http://nihseniorhealth.gov/ • Developed with the National Institute on Aging • Senior-friendly features: • Text Size • Contrast • Speech • Short segments of information

35. Healthy Roads Media http://www.healthyroadsmedia.org • Materials in 20+ languages • Various formats: • Written • Audio • Multimedia • Web video • iPod video

36. NN/LM SCR • Consumer Health Manual • Websites • Research information • Bibliography • http://nnlm.gov/outreach/consumer/hlthlit.html

37. 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

38. 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

39. 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

40. 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?

41. Writing/Examining/Selecting Easy-to-Read Materials

42. Basic Tips for Message Content • Limit the number of messages • Tell readers what you want them to do • Tell readers what they’ll gain from reading your material • Choose your words carefully • Suitable for the audience

44. 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”*

45. Cultural Competence? • Pepsi’s “Come alive with the Pepsi generation” slogan • Chevy selling the Nova in South America • Gerber baby food sales in Africa

46. Example: Food Pyramid Standard Version Culturally Modified Version

47. 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 script Eat fruits and vegetables Eat fruits and vegetables • Use boldface type and underlining to cue readers to important text

48. Present Tense & Action Verbs • Wrap the cut in a clean cloth. • Keep it dry. Avoid: Give consideration to Make payment Is concerned with Use: Consider Pay Concerns

49. 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

50. General Terms Avoid Use • Accordingly • Afford an opportunity • At a later date • Close proximity • In the event that • Incumbent upon • Utilize • So • Allow • Later • Near • If • Must • Use