Promoting Health Literacy through Eash-to-Read Materials

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Promoting Health Literacy
through
Easy-to-Read Materials

TERRI OTTOSEN
CONSUMER HEALTH COORDINATOR
NN/LM, SOUTHEASTERN ATLANTIC REGION
HTTP://NNLM.GOV/SEA
Agenda

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

YouTube Video: Health and the City
Determinants of Health

 Age
 Income
 Literacy Skills
 Employment Status
 Education Level
 Race or Ethnic Group
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
Fill in the Blanks

•One out of ? American adults reads at the 5th grade level or
below, on average.

•On average, Americans read at the 8th to 9th grade level, yet
most health care materials are written above the ? grade level.
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
NAL Numbers by Literacy Level
Trends in Literacy Over Time

A comparison of National Adult Literacy Survey (1992)
and the National Assessment of Adult Literacy (2003)

 The percentage of adults with below basic levels of literacy
remained constant
 The percentage of adults with proficient levels of literacy has
declined
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
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, 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”*

 Functional health literacy also includes the ability to
understand and follow directions, and to ask questions
when necessary for full understanding.

*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

 Videos
Healthy Roads Media

http://www.healthyroadsmedia.org

 Materials in 20 languages
 Various formats:
 Written

 Audio

 Multimedia

 Web video
NN/LM

 Consumer Health Manual
 Websites
 Research information
 Bibliography
 http://nnlm.gov/outreach/consumer/hlthlit.html
 Toolkit:
http://nnlm.gov/sea/outreach/healthlitkit/
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

http://www.lib.umich.edu/plain-language-dictionary
Plain Language Widget and App
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/healthmarketing/pdf/Simply_Put_
082010.pdf

 Clear Health Communications (Pfizer)
http://www.pfizerhealthliteracy.com/
More Key Players

 Health Literacy Consulting: http://www.healthliteracy.com

 Health Literacy Universal Precautions Toolkit (AHRQ and
UNC-Chapel Hill): http://www.ahrq.gov/qual/literacy/

 U.S. Department of Health & Human Services, Office of
Disease Prevention and Health Promotion
http://www.health.gov/communication/literacy

 Universal Symbols in Health Care Workbook:
http://www.rwjf.org/pr/product.jsp?id=15864
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
Tips (cont.)

 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

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
Before and After Examples

 Letter to Parents of New Baby
 How do you turn an impersonal form letter into
something that is pleasing and easy to read?
Before

After

*Examples from: Iowa Department of Public Health:
http://www.idph.state.ia.us/health_literacy/examples.asp
Before and After Examples

 Documents on Understanding Heart Failure
 How Trinity Regional Medical Center turned a 24-
page document into a one-page chart, making it
easier for heart failure patients to read and
understand.

Before

After
Before and After Examples

 "Iowa Get Screened" Colorectal Cancer Program
 Too much information is overwhelming, even with
white space and pleasing color scheme. Revision
added appropriate graphics, reduced to important
info only and improved reader navigation.

Before

After
Assessment Exercise
Testing for Readability
Problems with Measuring Literacy

 Sensitive topic
 May offend some
 If it is seen as a “test” it can be threatening
 Patients hide low literacy
 Inappropriate labeling
 Time
Overview

 Method
 Word count
 Syllables
 Sentence length

 Readability of Materials
 Fry
 SMOG

 Patient Literacy (REALM, TOFHLA, Newest Vital Sign)
 Computer software
Quick Readability Testing in Word

•Click the Microsoft Office Button, then click Word Options
•Click Proofing
•Be sure Check grammar with spelling is checked
•Under When correcting grammar in Word, select the Show
readability statistics check box
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

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 multi-syllable 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!

TERRI OTTOSEN
TOTTOSEN@HSHSL.UMARYLAND.EDU
NANCY PATTERSON
NPATTERS@HSHSL.UMARYLAND.EDU
410-706-2855 OR
800-338-7657