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Promoting Health Literacy through Easy-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

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Promoting health literacy through easy to read materials l.jpg

Promoting Health LiteracythroughEasy-to-Read Materials

Cheryl Rowan, MSLS

Public Health Coordinator

National Network of Libraries of Medicine,

South Central Region


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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 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


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The Literacy Problem


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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


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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


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Numbers by Literacy Level

Millionsof adults


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Three Types of Literacy

  • Prose

  • Document

  • Quantitative


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Prose Literacy

  • Requires ability to search, comprehend, and use continuous text


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Prose Literacy - NALS


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Document Literacy

  • Non-continuous text

  • Requires ability to search, comprehend, and

    use information


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Document Literacy - NALS


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Quantitative Literacy

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


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Readability Studies

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

    ReadabilityPatient Skills

    (mean grade level)

    • Wilson (2003) 11th6th

    • Davis (1994) 10th7th

    • Jackson (1991) 12th5th

    • Meade (1989) 10th6th


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Determinants of Health

  • Age

  • Income

  • Literacy Skills

  • Employment Status

  • Education Level

  • Race or Ethnic Group


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Factors Affecting Learning Ability

  • Stress

  • Illness

  • Age

  • Cultural Barriers

  • Language Barriers


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


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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


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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


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Health Literacy Levels

Millionsof adults


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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


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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.


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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


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“Costs” of Low Health Literacy


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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


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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.”


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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]


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


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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!


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Improving Oral Communication

  • Communication is two-way

  • Use “teach back” instructions

  • Avoid medical jargon

  • Use commonly understood words

  • Limit information

  • Videos


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Internet Resources


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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


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NIHSeniorHealth

http://nihseniorhealth.gov/

  • Developed with the National Institute on Aging

  • Senior-friendly features:

    • Text Size

    • Contrast

    • Speech

    • Short segments of information


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Healthy Roads Media

http://www.healthyroadsmedia.org

  • Materials in 20+ languages

  • Various formats:

    • Written

    • Audio

    • Multimedia

    • Web video

    • iPod video


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NN/LM SCR

  • Consumer Health Manual

  • Websites

  • Research information

  • Bibliography

  • http://nnlm.gov/outreach/consumer/hlthlit.html


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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


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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


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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


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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?


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Writing/Examining/Selecting Easy-to-Read Materials


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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


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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”*


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Cultural Competence?

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

  • Chevy selling the Nova in South America

  • Gerber baby food sales in Africa


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Example: Food Pyramid

Standard Version

Culturally Modified Version


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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


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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


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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


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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


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Medical Terms

Physician

Cardiac


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Medical Terms

Tablets

Nasal Congestion


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Medical Terms

Hazardous

Radiology


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Logical Sequence of Instructions

  • Wash your hands with soap and water.

  • Place the fresh bandage on a clean towel.

  • Take off the old bandage gently.

  • Wash the burned area gently.

  • Apply a thin layer of antibiotic cream.

  • Cover with the clean bandage.


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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.


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Rewriting

Straight Leg Raise

Lying on your back, bend your opposite knee straight and slowly lift your other leg up approximately 12 in, hold for 3s, and lower slowly.


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Sample Exercise in Rewriting

Straight 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


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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


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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.


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Example: Visual Separation

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.


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Visuals Should Reflect the Audience

  • Age of reader

  • Consider diversity

  • Use current styles

  • Get user input for color choices

  • Review by target audience


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Identify with Your Audience

Message: Exercise during pregnancy


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Message: Stop Smoking


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What About Websites?

  • Audience

  • Content

  • Organization


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Assessment Exercise


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Testing for Readability


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Overview

  • Method

    • Word count

    • Syllables

    • Sentence length

  • Readability of Materials

    • Fry

    • SMOG

  • Patient Literacy

    (REALM, TOFHLA, Newest Vital Sign)

  • Computer software


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Fry Readability Test

  • Select 3 passages of 100 words each

  • Count the number of sentences

  • Count the number of syllables

  • Find the average number of sentences and syllables

  • Plot the numbers on the graph to determine grade level


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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.


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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


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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-ousprob-lems, such as pneu-mo-nia. A stuffy nose, sore throat, and sneez-ing are usu-al-ly signs of a cold…

135 syllables


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6th grade


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SMOG

Simple Measure Of Gobbledygook

  • Count off 10 sentences near the beginning, middle and end of text.

  • Circle every word containing 3 or more syllables and total the number of words circled

  • Estimate the square root of the total number of words counted

  • Add three to the square root.

    http://www.harrymclaughlin.com/SMOG.htm


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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


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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 l.jpg

Example TOFHLA


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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/


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Computer Testing

  • Microsoft Word feature

    • Tools

    • Grammar check

  • Flesch–Kincaid Readability Tests

    • Flesch Reading Ease

    • Flesch–Kincaid Grade Level


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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


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Testing Exercise


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Fry Readability Exercise

  • Select 3 different passages

  • Count 100 words in each

  • Count the # of sentences in each

  • Count the # of syllables in each

  • Calculate the average # of sentences and syllables

  • Plot the numbers on the graph to determine grade level


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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


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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.


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Thank You!

Cheryl Rowan, MSLS

Public Health Coordinator

National Network of Libraries of Medicine, South Central Region

http://www.nnlm.gov/scr

[email protected]

713-799-7880/800-338-7657


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