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Promoting Health Literacy throug

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					Promoting Health Literacy
        through
 Easy-to-Read Materials


           CHERYL ROWAN
PUBLIC HEALTH OUTREACH COORDINATOR
    NN/LM, SOUTH CENTRAL REGION
        HTTP://NNLM.GOV/SCR
            JULY 16, 2010
    UTSW MEDICAL CENTER LIBRARY
             DALLAS, TX
                         Agenda

 Overview
 Internet Resources
 Writing/Examining Easy-to-Read Materials
 Assessment Exercise
 Readability Test
 Readability Exercise
The Literacy Problem
                Literacy Statistics

 23% of adults are functionally illiterate
 28% have marginal literacy skills (i.e., unable to read
  above an 8th grade level)
 66% of adults over age 60 have inadequate or
  marginal literacy skills
 Only 13% of adults read at a level considered
  “proficient”
 Average reading level in the U.S. is 8th grade; 20%
  read at 5th grade level or below
National Assessment of Adult Literacy (NAAL)

 Conducted in 2003
 Representative sample of more than 19,000 adults
 over 16
    All 50 states and the District of Columbia
    Slightly less than 10% prisoners
 One-on-one administration
 Main objective to assess literacy in English
 http://nces.ed.gov/NAAL
                   Numbers by Literacy Level



        100
         80
Millions 60
                                         95
of adults 40
                              63
         20        30                                   28
          0
               Below Basic   Basic   Intermediate   Proficient.
          Three Types of Literacy




 Prose         • Document    • Quantitative
                     Prose Literacy




•Requires ability to search,
comprehend, and use
continuous text.
Prose Literacy - NALS
                Document Literacy

 Materials containing non-continuous text
 Requires ability to search, comprehend, and
  use information
 Job applications, maps, food labels
Document Literacy - NALS
                    Quantitative Literacy


Ability to identify and
perform computations,
using numbers within
printed materials.

Balancing a checkbook,
figuring a tip, etc.
               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://foundation.acponline.org/hl/hlvideo.htm
           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)
                            and Healthy People 2010
           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



       150


Millions100
of adults                               114
        50
                  30         47
                                                       25
         0
              Below Basic   Basic   Intermediate   Proficient.
             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

 Poor disease management – more likely to be
  hospitalized and for longer periods of time
 Financial consequences
 Failure to take medicine correctly
    Only about 50% of all patients take meds as directed!
    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 Facts
 Serving Size: 1 cup (253 g)
 Serving per container: 2
 Amount per Serving:
                                               Is this safe for
Calories 260           Calories from Fat 72
                               % Daily Value   someone on a
Total Fat 8g
   Saturated Fat 3g
                                       13%
                                       17%
                                               salt-free diet?
Cholesterol 130 mg                     44%
Sodium 1010 mg                         42%
Carbohydrates 22g                        7%    Note: We rarely say,
   Dietary Fiber 9g                    36%     “Pass the Sodium,
   Sugars 4g
                                               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.




  http://www.unitedhealthfoundation.org/tips/doc_ad.pdf
               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!
There were some
irregularities with your
mammogram…
           Oral Communication Tools

 Asking patients to “teach back” care instructions
 Videos
 Use commonly understood words
   “Keeps bones strong” vs. "Prevents osteoporosis”
   “Chest pain” vs. “Angina”

 Limit information given
   Less than ½ of the information provided to patients
    during a visit is retained
Internet Resources
                         MedlinePlus

                 http://medlineplus.gov
 Interactive tutorials
     From the Patient Education Institute
     Information is read simultaneously
 Easy-to-Read materials
 Medical Dictionary
   Understanding Medical Words tutorial

 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
                  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/od/oc/simpput.pdf
  http://www.cdc.gov/DHDSP/cdcynergy_training/Conte
  nt/phase4/phase4summaryresources.htm
 Clear Health Communications (Pfizer)
  http://www.pfizerhealthliteracy.com/
                  More Key Players

 Hablamos Juntos
  http://www.rwjf.org/pr/product.jsp?id=15864
 U.S. Department of Health & Human Services, Office of
  Disease Prevention and Health Promotion
  http://www.health.gov/communication/literacy
 Health Literacy Consulting
  http://www.healthliteracy.com
 North Carolina Program on Health Literacy
  New “Health Literacy Universal Precautions Toolkit”
 http://nchealthliteracy.org/
                      Exercise

You just been you told have acute platypuscitis

What types of information would you like to receive
 from your healthcare provider?
Writing/Examining Easy to
      Read Materials
             Tips for Message Content

1.   Limit the number of messages
2.   Tell readers what you want them to do
3.   Tell readers what they’ll gain from reading your
     material
4.   Choose your words carefully
5.   Be sensitive to cultural differences
             Cultural Competency


 Tailor messages to
  specific groups
 Avoid stereotypes
Example: Food Pyramid
                          Text

 12 point or larger font size
 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
          Present Tense & Action Verbs

1.   Wrap the cut in a clean cloth.
2.   Keep it dry.


            Avoid:                      Use:
     Give consideration to            Consider
     Make payment                     Pay
     Is concerned with                Concerns
                     Active Voice

 Roll to the left
 Put your feet on the floor
 Sit up
 Grab the railing


           Avoid:                     Use:
 It shall be signed            You must sign
 You shall be notified         We will notify you
                General Terms

        Avoid               Use
 Accordingly              So
 Afford an opportunity    Allow
 At a later date          Later
 Close proximity          Near
 In the event that        If
 Incumbent upon           Must
 Utilize                  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 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.
                     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
           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.
          Example B: 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.
  Visuals Should Reflect the Audience

 Age of reader
 Consider diversity
 Use current styles
 Get user input for color
 choices
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.   Test 3 passages of 100 words each
2.   Count the number of sentences
3.   Count the number of syllables
4.   Find the average number of sentences and
     syllables
5.   Plot the numbers on the graph to determine grade
     level
                        Example:

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 Gobbledygook
1.    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
                      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
                Computer Testing

 Flesch–Kincaid Readability Tests
   Flesch Reading Ease

   Flesch–Kincaid Grade Level

 MS Word feature
   Tools

   Grammar check
            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.   Count 100 words
2.   Count the number of sentences
3.   Count the number of syllables
4.   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…

 “Unless there are major strides forward in our ability
    to communicate essential health information, the
    “health gap” that currently exists in this country
    between those with high and low educational
    attainment is likely to grow.” *




   *Baker, D.W. (1999). “Deciphering the Connections Between Literacy and Health.”
    Journal of General Internal Medicine.
         Thank You!

          CHERYL ROWAN
CHERYL.ROWAN@EXCH.LIBRARY.TMC.EDU
           713-799-7880

				
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