Communicating In Plain Language: Application for Community Nutrition

1. Communicating In Plain Language: Application for Community Nutrition Stephany Parker, PhDNutrition Education Asst. Specialist and Adjunct Assistant Professor, Oklahoma Cooperative Extension Service and the Department of Nutritional Sciences, Oklahoma State University

2. True or False? Most people with limited literacy are poor, immigrants or minorities. Most people with limited literacy have low IQs. People will tell you if they have problems reading. The number of years of schooling is a good general guide to determine literacy level. Some of you may want to start with this slide as an �ice-breaker�. (They are all false) But in my experience, most of your audience will know these answers. If you do use them, then segue to the next slide by saying, �Some of you may be surprised at some of these answers . In order to fully understand the problem, it is helpful to have a good working definition��Some of you may want to start with this slide as an �ice-breaker�. (They are all false) But in my experience, most of your audience will know these answers. If you do use them, then segue to the next slide by saying, �Some of you may be surprised at some of these answers . In order to fully understand the problem, it is helpful to have a good working definition��

3. Don�t fit a stereotype Many people with inadequate literacy Are born in USA (75%) Are white (50%) Hold full or part-time job (40%) Finished high school (25%)

4. Health Literacy Health literacy is an individual�s ability to read, understand and use health care information to make effective health care decisions and follow instructions for treatment. Healthy People 2010. Office of Disease Prevention and Health Promotion. Available at http://www.healthypeople.gov/ Does your patient, participant, or group understand what you are telling them? The title is �Health Literacy� written backwards�helps grab the attention of the audience but is NOT a good idea to put this on announcements of the talk because no one stops to figure it out and they don�t know what the topic is and so, do not attend. According to Healthy People 2010, an individual is considered to be "health literate" when he or she possesses the skills to understand information and services and use them to make appropriate decisions about health. Alarmingly, these skills and strategies are absent in more than half of the U.S. population. This fact is more disturbing when one considers that these are the very skills and strategies that often lead to longer life, improved quality of life, reduction of both chronic disease and health disparities, as well as cost savings[i].  It is vital that you define health literacy for your audience: The top bullet is the AMA definition. Health literacy is more complex than general literacy�experience with the health care system, complexity of information, the shorter lengths of stay (with less time for patient education), the increasing amount of self or home health care that is left to the patients and their families�all of these make health care harder to understand. For example: In 1965, there were 650 medications, in 2000, there were over 10,000 Or: In 1965, pts stayed in the hospital 4-6 weeks with an acute MI�now 2-4 days Diabetics spent avg. of 2 hrs/day for 3 weeks in pt. ed. Classes, now they get 0-3 hrs of outpt instruction on care. Literacy often defined as 8th grade ed or less, BUT you cannot go by the grade level completed�or the ability to read since comprehension is part of the equation. The majority of Medicaid enrollees are at a 5th grade level. The National Literacy Act of 1991 definition of Literacy: �An individual�s ability to read, write and speak in English and compute and solve problems at levels of proficiency necessary to function on the job and in society and to achieve one�s goals and to develop one�s knowledge and potential.� The important word here is functional. Segue to the next slide by saying, �Let me give you an example�� The last bullet is really the crux of the issue�can your patient understand what you are telling them?The title is �Health Literacy� written backwards�helps grab the attention of the audience but is NOT a good idea to put this on announcements of the talk because no one stops to figure it out and they don�t know what the topic is and so, do not attend. According to Healthy People 2010, an individual is considered to be "health literate" when he or she possesses the skills to understand information and services and use them to make appropriate decisions about health. Alarmingly, these skills and strategies are absent in more than half of the U.S. population. This fact is more disturbing when one considers that these are the very skills and strategies that often lead to longer life, improved quality of life, reduction of both chronic disease and health disparities, as well as cost savings[i].

5. What does it feel like? Your naicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc This is what it is like to be a NALS level 1 reader�the words are written backwards except the very simple, monosyllabic words. Have the audience read the slide together�do not let one person dominate the reading�leave it up only as long as it takes you to read the text the right way around�that should not be very long. You may give them the hints that it is written backwards and that the first word is �Cleaning�� When you go to the next slide, you will ask them �How do you clean the capstan?� The point is that EVEN if you can decipher the slide, you have used all your energy to translate it and you rarely retain the information in it� Other similar texts: Klots gshur 4 spo shiruf; po juvne weemps wism. (This is just dyslexic text�) Your maicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc. (This is a backwards description of colonoscopy prep orders�) GNINAELC�To erussa high ecnamrofrep, yllacidoirep naelc the tape sdaeh and natspac revenehw you eciton an noitalumucca of dust and nworb-der edixo selcitrap. Use a nottoc baws denetsiom with lyporposi lohocla. Be eruson lohocla sehcuot the rebbur strap, as it sdnet to dry and yllautneve kcarc the rebbur. This is what it is like to be a NALS level 1 reader�the words are written backwards except the very simple, monosyllabic words. Have the audience read the slide together�do not let one person dominate the reading�leave it up only as long as it takes you to read the text the right way around�that should not be very long. You may give them the hints that it is written backwards and that the first word is �Cleaning�� When you go to the next slide, you will ask them �How do you clean the capstan?� The point is that EVEN if you can decipher the slide, you have used all your energy to translate it and you rarely retain the information in it� Other similar texts: Klots gshur 4 spo shiruf; po juvne weemps wism. (This is just dyslexic text�) Your maicisyhp has dednemmocer that you have a ypocsonoloc. Ypocsonoloc is a test for noloc recnac. It sevlovni gnitresni a elbixelf epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc. (This is a backwards description of colonoscopy prep orders�) GNINAELC�To erussa high ecnamrofrep, yllacidoirep naelc the tape sdaeh and natspac revenehw you eciton an noitalumucca of dust and nworb-der edixo selcitrap. Use a nottoc baws denetsiom with lyporposi lohocla. Be eruson lohocla sehcuot the rebbur strap, as it sdnet to dry and yllautneve kcarc the rebbur.

6. So, what are the colonoscopy prep orders? Now make the point about their having missed the meaning of the text�even if many of them are able to read it, it will be surprising how often they have no idea how to clean the capstan! Now make the point about their having missed the meaning of the text�even if many of them are able to read it, it will be surprising how often they have no idea how to clean the capstan!

7. Why is Health Literacy Important to Community Nutrition? Limited ability to read and understand information translates to poor health outcomes. Single best predictor of health status. Less knowledge of their medical conditions, self-care and dietary instructions. Exhibit less healthy behaviors.

8. Risk Factors As much as half of American adults lack sufficient general literacy to effectively undertake and execute the medical treatments and preventive healthcare it needs. It is more common in certain demographic groups such as the elderly, the poor, members of minority groups, recent immigrants. The economic consequences of limited health literacy are considerable, estimated to cost between $50 billion and $73 billion per year. As much as half of American adults lack sufficient general literacy to effectively undertake and execute the medical treatments and preventive healthcare it needs. It is more common in certain demographic groups such as the elderly, the poor, members of minority groups, recent immigrants. The economic consequences of limited health literacy are considerable, estimated to cost between $50 billion and $73 billion per year.

9. These are slides from a Schillinger article: Association of Health Literacy with Diabetes Outcomes. JAMA. 2002; 288(4): 475-482. Each diabetic patient was given a TOFHLA reading test to ascertain their literacy level. (More about reading tests later�) For each 1 point decrement in the s-TOFHLA scoere, the HbA1c increased by 0.02 (p=.02). Literate patients had an average HbA1c of 7.2%; the illiterate patients had an average of 9.5. More illiterate patients had retinopathy by self-report as well. If you skipped the earlier slide about the types of health literacy, this is a good time to make three points: Diabetes�through it�s effect on eyesight�adds to the literacy issue Diabetes is a difficult disease to understand and has many facets to its control. This makes it more difficult for a patient to grasp the many parts of their care. Evidence is growing�some of it at UVA�that diabetics�and perhaps all of us�encode information in different places and in different ways depending on the level of our blood glucose. Ability to retrieve information learned when the glucose was high may only be possible when the glucose is again in that range. Similarly, info learned at a low blood sugar might need a similar sugar for retrieval. The moral of this: do your diabetic teaching at several blood glucose levels. These are slides from a Schillinger article: Association of Health Literacy with Diabetes Outcomes. JAMA. 2002; 288(4): 475-482. Each diabetic patient was given a TOFHLA reading test to ascertain their literacy level. (More about reading tests later�) For each 1 point decrement in the s-TOFHLA scoere, the HbA1c increased by 0.02 (p=.02). Literate patients had an average HbA1c of 7.2%; the illiterate patients had an average of 9.5. More illiterate patients had retinopathy by self-report as well. If you skipped the earlier slide about the types of health literacy, this is a good time to make three points: Diabetes�through it�s effect on eyesight�adds to the literacy issue Diabetes is a difficult disease to understand and has many facets to its control. This makes it more difficult for a patient to grasp the many parts of their care. Evidence is growing�some of it at UVA�that diabetics�and perhaps all of us�encode information in different places and in different ways depending on the level of our blood glucose. Ability to retrieve information learned when the glucose was high may only be possible when the glucose is again in that range. Similarly, info learned at a low blood sugar might need a similar sugar for retrieval. The moral of this: do your diabetic teaching at several blood glucose levels.

10. What is plain language? Requires use of plain language in all new documents written for the public, other government entities and fellow workers. Writing that is clear and to the point helps improve communication with the public since clear material takes less time to read and understand. Use plain language for all documents, presentations, and electronic communications

11. Four steps to developing quality educational materials Assess the needs of your target audience Evaluate the materials Pretest with your audience Use your material effectively

12. Evaluating Materials

13. Written Materials Review Reading & Comprehension Content Design & Quality Review Summary

14. Developing or Reviewing Client Education Materials Consider needs of target audience Define purpose / objectives Write clearly Use simple and familiar words Use words consistently Define terms Use active verbs Limit sentences ~ 25 words State info positively Use �you� Give reader info they can apply

15. Reading & Comprehension Level Readability testing Other comprehension factors

16. Assessing Reading Level Most pamphlets at 10-12th grade level Informed consents at 14.3�16th grade Federal guidelines call for all materials for patients to be written at a 5th grade level or less. Virtually no informed consent is that simple. Even if they are written at that level, good studies show that patients still do not comprehend them well. Federal guidelines call for all materials for patients to be written at a 5th grade level or less. Virtually no informed consent is that simple. Even if they are written at that level, good studies show that patients still do not comprehend them well.

17. Calculating reading level Flesch-Kincaid Grade Level formula SMOG Many others SMOG�the best and most consistently used test of readability for medical literature Count 10 consecutive sentences at the beginning, 10 in the middle and 10 at the end of the document for a total of 30. Count the polysyllabic words in those 30 sentences Take the square root of the total # of polysyllabic words (or nearest perfect square) , then add 3 to get the grade or reading level. Usually needs 100% comprehension rate Fry�s/FOG�Most widely used in general Very much alike�The FOG uses 100 successive words and uses sentence length and word difference and the Fry uses three passages rather than 100 successive words. Plot on graph from grade 1 through college Underestimates after grade 8 Flesh-Kincaid�is in the grammar check of Microsoft Utilizes word, syllable and sentence length counts to get a score from zero (practically unreadable) to 100 (easy for a literate person) Reads only physical characteristics of text--Xxxx xxx xxxxxx! Also uses a ratio of definite (concrete) words to total number of words Operates on premise that increased abstraction is harder to read. SMOG�the best and most consistently used test of readability for medical literature Count 10 consecutive sentences at the beginning, 10 in the middle and 10 at the end of the document for a total of 30. Count the polysyllabic words in those 30 sentences Take the square root of the total # of polysyllabic words (or nearest perfect square) , then add 3 to get the grade or reading level. Usually needs 100% comprehension rate Fry�s/FOG�Most widely used in general Very much alike�The FOG uses 100 successive words and uses sentence length and word difference and the Fry uses three passages rather than 100 successive words. Plot on graph from grade 1 through college Underestimates after grade 8 Flesh-Kincaid�is in the grammar check of Microsoft Utilizes word, syllable and sentence length counts to get a score from zero (practically unreadable) to 100 (easy for a literate person) Reads only physical characteristics of text--Xxxx xxx xxxxxx! Also uses a ratio of definite (concrete) words to total number of words Operates on premise that increased abstraction is harder to read.

18. Quick SMOG Identify 10 consecutive sentences at beginning, middle, end In these 30 sentences, count number of words with 3 or more syllables Look up approx. grad level on the chart

19. Quick SMOG Words 3 + syllables 0-2 3-6 7-12 13-20 21-30 31-42 43-56 57-72 73-90 >91 Approx Grade 4 5 6 7 8 9 10 11 12 College

20. Readability Tests Can�t Tell You�. How complex ideas are How well or poorly material is written Whether grammar is correct Whether the vocabulary & tone are appropriate Whether there is discriminatory language

21. Readability Tests Can�t Tell Whether� There is any bias Information is presented in a sequence that makes sense Readers can find the information The design makes the piece inviting & easy to read

22. Comprehension Factors Clear purpose Appropriate word usage Appropriate sentence structure Appropriate paragraph structure Appropriate overall organization Appropriate tone

23. Simple, Clear Words Fruits contain fiber Fruits have fiber Purchase whole-grain foods to help meet your daily fiber requirements Buy whole-grain foods to help get enough fiber every day.

24. Practice! A deficiency of calcium can increase your possibility of getting osteoporosis.

25. Technical Terms It is fruitless to become lachrymose over precipitately departed lactate fluid.

26. Active Role Passive Calcium pills should be taken at meals. Active Take calcium pills with meals.

27. Practice! Food can be kept safe by always washing hands before food handling.

28. Overall Organization Appropriate number of concepts Headings identify topics and concepts Key ideas are highlighted, repeated, or summarized

29. Tone Don�t give your baby juice or other sweet drinks in a bottle ever! Offer juice from a cup, not a bottle

30. HANDOUT Guidelines Is it simple? (The Rule of 3: 3 major points with 3 supporting points for each OR a maximum of 5 - 7 points) Is� it interactive? (Is there a place for the learner to write on the handout or circle foods they will eat?) Is it tailored to different cultural groups? (Messages may vary by cultural group) Are there quotes from "real people" ?(This personalizes the information and helps learners to see that others find the information useful).

31. Handouts Use font size appropriate for target audience Limit to one or two fonts Break up long blocks of text with headings, indentations, extra spacing, bullets or columns Right justification is easier to read Full justification sometimes has strange spacing Use spell checker, then proofread.

32. Handouts, cont�d Pictures and drawings � add to the meaning of text, draw attention to important points Lettering � large enough for target audience to read easily (12 pt, 14 or 18 for elderly) Layout on page � use headings, lots of white space Pilot test material with target audience

33. Content Accurate, credible information Appropriate information Useful information Appropriate recipes

36. Examples of good and bad pictures� Although the top one is only a partial figure, it is clear what the meaning of the pictures are� When you show the bottom picture, ask the audience in the back (seated too far away to read the caption which I have left here so that you can figure it out!) to tell you what they think the picture is trying to say�You may get some very creative and incorrect answers! Especially for the one on the right which looks like fur on the stick figure. It is meant to depict a rash� The point is that even though this is a cartoon; a simple stick figure, with lots of nice white space around it, it is still very difficult to figure out!Examples of good and bad pictures� Although the top one is only a partial figure, it is clear what the meaning of the pictures are� When you show the bottom picture, ask the audience in the back (seated too far away to read the caption which I have left here so that you can figure it out!) to tell you what they think the picture is trying to say�You may get some very creative and incorrect answers! Especially for the one on the right which looks like fur on the stick figure. It is meant to depict a rash� The point is that even though this is a cartoon; a simple stick figure, with lots of nice white space around it, it is still very difficult to figure out!

37. This pamphlet from our general medicine clinic also uses good spacing, large font, etc, but also uses clear, short and easily understood terms and pictures of African Americans who are the target of the document. The meaning is clear and reads on a 4th grade level except for the word �urinate� and perhaps �symptoms�.This pamphlet from our general medicine clinic also uses good spacing, large font, etc, but also uses clear, short and easily understood terms and pictures of African Americans who are the target of the document. The meaning is clear and reads on a 4th grade level except for the word �urinate� and perhaps �symptoms�.

38. Participatory Formative Evaluation Review all materials and use a consistent check list Engage members of the intended audience in a critical review process Re-work the materials based on reviews Pilot materials with members of the intended audience Re-work materials based on pilot test findings and solicited suggestions

40. Resources Dalton C. University of Virginia School of Medicine. Health Literacy. Recognition and Treatment of a Hidden Problem. Available at: http://www.healthsystem.virginia.edu/internet/som-hlc/Lecture.cfm Health Literacy Studies (HLS). Department of Society, Human Development and Health at the Harvard School of Public Health. Available at: http://www.hsph.harvard.edu/healthliteracy/index.html Health Literacy Web page at University of Washington . Available at: http://students.washington.edu/wcurioso/literacy.htm NIH. Plain Language Initiative. Available at: http://execsec.od.nih.gov/plainlang/guidelines/index.html Reed D. and Shuster E. Recipe Checklist: A Tool to Aid Development of Recipes for Audiences with Limited Resources. Available at: http://www.joe.org/joe/2002december/tt4.shtml