Let’s Create MaterialsPatient’s Can Read

And Understand

Betty J. Westmoreland, MBEd, CPABetty J. Westmoreland, MBEd, CPA

PresidentPresident

Pritchett & Hull Associates, Inc.Pritchett & Hull Associates, Inc.

ObjectivesObjectives

Understand the role low-literacy Understand the role low-literacy plays in healthcare and the need to plays in healthcare and the need to assess each patientassess each patient

Understand the principles of creating Understand the principles of creating patient education materials for the patient education materials for the low-literatelow-literate

Judge the appropriateness of the Judge the appropriateness of the patient education materials you usepatient education materials you use

Upon completion of this presentation, you should be able to:

Answers NeededAnswers Needed

• How do we assess our patients’ ability to How do we assess our patients’ ability to read and understand our teaching?read and understand our teaching?

• How do we go about developing patient How do we go about developing patient teaching materials that are suitable for our teaching materials that are suitable for our patients?patients?

• How do we know whether the teaching How do we know whether the teaching materials we are using are what we need?materials we are using are what we need?

How do we assess our How do we assess our patients’ ability to patients’ ability to

read and understand read and understand our teaching?our teaching?

LiteracyLiteracy

An individual’s ability to read, An individual’s ability to read, write and speak English, compute write and speak English, compute and solve problems sufficient to and solve problems sufficient to function in society, develop one’s function in society, develop one’s knowledge and potential, and to knowledge and potential, and to achieve one’s goals.achieve one’s goals.

Scope of the ProblemScope of the Problem

• 21% of adult Americans (40 – 44 21% of adult Americans (40 – 44 million) are functionally illiterate million) are functionally illiterate and read at or below a 5and read at or below a 5thth grade grade levellevel

• An additional 25% (50 million) An additional 25% (50 million) are marginally illiterateare marginally illiterate

National Adult Literacy National Adult Literacy Survey (1992)Survey (1992)

90 million adults (47%) read at the 90 million adults (47%) read at the lowest levelslowest levels

75% of Welfare recipients read at the 75% of Welfare recipients read at the lowest levelslowest levels

Low-literacy is Prevalent Low-literacy is Prevalent Among All Ages and Ethnic Among All Ages and Ethnic

GroupsGroups• More than 66% of adults > 60 years More than 66% of adults > 60 years

of age have inadequate or marginal of age have inadequate or marginal skillsskills

Greatest number of low-literate Greatest number of low-literate Americans are native born whitesAmericans are native born whites

Other groups with literacy problems:Other groups with literacy problems:o 52% of Hispanics52% of Hispanicso 41% of African Americans41% of African Americanso 35% of Asians35% of Asians•Kirsch, et al., Adult Literacy in America, 1993

Health LiteracyHealth Literacy

The degree to which individuals The degree to which individuals have the capacity to obtain, have the capacity to obtain, process, and understand basic process, and understand basic health information and services health information and services needed to make appropriate needed to make appropriate health decisionshealth decisions

SignificanceSignificance

Groups with highest prevalence of Groups with highest prevalence of chronic disease and greatest need chronic disease and greatest need demonstrate the least ability to demonstrate the least ability to read and comprehend informationread and comprehend information

It is worse among the most It is worse among the most vulnerablevulnerable

Literacy and HealthLiteracy and Health

People with Lowest Literacy LevelsPeople with Lowest Literacy Levels Report poorer healthReport poorer health Incur higher expenses for health careIncur higher expenses for health care More outpatient and ED visitsMore outpatient and ED visits Greater likelihood of hospitalizationsGreater likelihood of hospitalizations

Weiss, et al., Illiteracy among Medicaid recipients (1991)Baker, et al., Functional health literacy, self reported health status (1997)

Health Literacy ResearchHealth Literacy Research

42% are able to understand directions for 42% are able to understand directions for taking medicine on an empty stomachtaking medicine on an empty stomach

26% do not understand information regarding 26% do not understand information regarding when a next appointment is scheduledwhen a next appointment is scheduled

60% cannot understand an informed consent 60% cannot understand an informed consent formform

33% do not understand instructions for an 33% do not understand instructions for an upper GI tract x-ray written at a 4th grade upper GI tract x-ray written at a 4th grade levellevel

Williams MV, Parker RM, Baker DW, et al. Inadequate Functional HealthLiteracy Among Patients at Two Public Hospitals. JAMA. 1995; 274:1677-1682.

Percent of People with Problems using Rx

0% 50% 100%

Antiarthritics

Estrogen/progesterone

Antispasmodics

Serotonin reuptakeinhibitors

Beta-blockers

Cholesterol-reducingagents

ACE-inhibitors

Calcium-channelblockers

Benzodiazepinetranquilizers

Dru

g ty

pe

Percentage

Failure to take properly

Failure to fill/refill

Source: IMS America, 1997

Patients at RiskPatients at Risk Older ageOlder age Low incomeLow income UnemployedUnemployed Ethnic minorities (Hispanic, Ethnic minorities (Hispanic,

African American)African American) Fewer years of school Fewer years of school

completedcompleted Recent immigrants to the U.S.Recent immigrants to the U.S. Born in U.S. with English as 2Born in U.S. with English as 2ndnd

languagelanguage

Illiteracy means being Illiteracy means being unable to read or writeunable to read or write

Low-literacy does not Low-literacy does not mean illiteratemean illiterate

ComprehensionComprehension

Grasping the meaning of the Grasping the meaning of the instructioninstruction

Logic

LanguageExperience

Comprehension

Patient Variables that Affect Patient Variables that Affect ComprehensionComprehension

• Illness-related stressIllness-related stress• Perceived threatPerceived threat• MotivationMotivation• Physical and mental energyPhysical and mental energy• Visual acuityVisual acuity• Length of formal educationLength of formal education

Low Literacy Learner’s Low Literacy Learner’s BehaviorsBehaviors

• Perspective limited to direct personal Perspective limited to direct personal experienceexperience

• Insensitive to the need to give Insensitive to the need to give informationinformation

• Does not think in terms of categories Does not think in terms of categories of informationof information

• Gives information in bits and pieces Gives information in bits and pieces without an identifiable patternwithout an identifiable pattern

GoodGoodReadersReaders

•Use prior knowledge •Associate randomly

•Are fluent •Hesitant

•Get help •Skip over words•Interested •Not focused

•Continuous •Skip around

PoorReaders

Elderly LearnersElderly Learners

Barriers to LearningBarriers to Learning

• Functional limitationsFunctional limitations• FatigueFatigue• MotivationMotivation• Experience with learningExperience with learning• DepressionDepression• MedicationsMedications• PainPain• DisabilitiesDisabilities

To Facilitate ComprehensionTo Facilitate Comprehension

• Adapt teaching to sensory changesAdapt teaching to sensory changes• PresbyopiaPresbyopia• PresbyacusisPresbyacusis

• Pace the deliveryPace the delivery• Enhance readability of teaching Enhance readability of teaching

materialsmaterials• Use concrete, familiar examplesUse concrete, familiar examples

Cultural ConsiderationsCultural Considerations

Reaching Patients of Different Reaching Patients of Different Cultural BackgroundsCultural Backgrounds

• Do a culturally sensitive assessmentDo a culturally sensitive assessment• Teach within cultural contextTeach within cultural context• Translate oral and written instructions Translate oral and written instructions

using member of cultural communityusing member of cultural community• Build on culturally compatible Build on culturally compatible

experiencesexperiences• Must make sense within cultural Must make sense within cultural

contextcontext

Recognizing Signs of Recognizing Signs of Low-literacyLow-literacy

Signs of Low-literacySigns of Low-literacy

Ask you to fill out forms for them, or Ask you to fill out forms for them, or make mistakes when they fill them outmake mistakes when they fill them out

Bring a friend to helpBring a friend to help Take forms home to completeTake forms home to complete Miss appointments, imaging tests, lab Miss appointments, imaging tests, lab

tests, etc.tests, etc. Noncompliant with medication Noncompliant with medication

regimensregimens Use excuses for not reading – “Left Use excuses for not reading – “Left

glasses,” “Didn’t have time”glasses,” “Didn’t have time”

Ask you to explain what they have just readAsk you to explain what they have just read Eyes fail to move right while “reading”Eyes fail to move right while “reading” Fail to respond to mailed notices, billsFail to respond to mailed notices, bills Ask you to call rather than mail informationAsk you to call rather than mail information Turn down opportunities that require reading Turn down opportunities that require reading

and/or writingand/or writing

Foulk, D., Carroll, P., Wood, S. Addressing Health Literacy (2001)

AssessingAssessing Health Literacy Health Literacy

• REALMREALM (Rapid Estimate of Adult (Rapid Estimate of Adult Literacy in Medicine)Literacy in Medicine)• LSU Medical CenterLSU Medical Center

• TOFHLATOFHLA (Test of Functional Health (Test of Functional Health Literacy in Adults)Literacy in Adults)• Center for Study of Adult LiteracyCenter for Study of Adult Literacy• Georgia State UniversityGeorgia State University

Patient and Family Education Assessment

What problems have your illness caused for you? What concerns you most about this illness? What bothers you most about this illness? What do you fear most about your illness? What do you think caused the problem? Why do you think it happened when it did? What do you think this illness does to you? How does it work? How severe is your illness? How long do you think it will last? What kind of treatment do you think you should get? What are the most important results you hope to get from this

treatment? What do you need to know to take care of yourself at home? The last time you wanted to learn something, how did you go about it? What do you want to learn more about?

Provided by © (2005) Fran London, MS, RN, Phoenix Children’s Hospital

How do we go about How do we go about developing patient developing patient

teaching materials that teaching materials that are suitable for our are suitable for our

patients?patients?

What to look for in What to look for in teaching materialsteaching materials

LegibilityLegibility Organization and flow of contentOrganization and flow of content Effective use of visualsEffective use of visuals Relevance and personalization to Relevance and personalization to

the readerthe reader InteractivityInteractivity

BasicsBasics

Poor readers read one word at a timePoor readers read one word at a time Short sentences are betterShort sentences are better First sentence in a paragraph should First sentence in a paragraph should

contain the most important contain the most important information- “how to do it”information- “how to do it”

Avoid big (multi-syllabic) and Avoid big (multi-syllabic) and technical wordstechnical words

Only tell what the patient needs to Only tell what the patient needs to knowknow

Use Use bold bold rather than ALL CAPS to rather than ALL CAPS to emphasize importanceemphasize importance

Do not use Do not use italicsitalics—hard to read—hard to read Use a lot of white space so it’s not Use a lot of white space so it’s not

clutteredcluttered

Use at least 13 point type Use at least 13 point type Use black ink on white or cream Use black ink on white or cream

colored paper for good contrastcolored paper for good contrast Use visuals that teach—good Use visuals that teach—good

visuals can lower the readability of visuals can lower the readability of material by two grade levelsmaterial by two grade levels

Write text as you would talk to the Write text as you would talk to the readerreader

Interactive materials are more personal Interactive materials are more personal to the reader because they involve himto the reader because they involve him

Summarize and repeat, clearly and Summarize and repeat, clearly and simply, the most important points you simply, the most important points you want the reader to rememberwant the reader to remember

Plain Language InitiativePlain Language Initiativefrom the NIHfrom the NIH

An important tool for An important tool for improving health literacyimproving health literacy

Plain LanguagePlain Language

Writing that effectively Writing that effectively communicates with the specific communicates with the specific audience being addressed.audience being addressed.

Insures that your patient can Insures that your patient can understand the information you understand the information you provideprovide

It is critical to:It is critical to:o Know your patientKnow your patiento Have patients test materials being usedHave patients test materials being used

• Before they are developedBefore they are developed• During the developmentDuring the development• After they are developedAfter they are developed

Speaking plainly is just as important Speaking plainly is just as important as writing plainlyas writing plainly

Plain Language is NotPlain Language is Not

Unprofessional writingUnprofessional writing Talking down to the readerTalking down to the reader

Plain Language isPlain Language is

Grammatically correctGrammatically correct Tells the reader only what he/she Tells the reader only what he/she needs needs

to knowto know Uses common everyday wordsUses common everyday words Uses the active voiceUses the active voice Uses pronouns (you, your, your child, Uses pronouns (you, your, your child,

etc.)etc.) Uses design features that are easy to Uses design features that are easy to

understand (bullets, lists, etc.)understand (bullets, lists, etc.)

The Visual MessageThe Visual Message

The Visual Message…The Visual Message…

Can improve visual learning by Can improve visual learning by directing the eye to the messagedirecting the eye to the message

Uses lots of white spaceUses lots of white space Uses visuals that communicate the Uses visuals that communicate the

content content

The visuals should reinforce the text

Use visuals that readers can identify with

(within their cultural framework)

Use the Subjective Point of Use the Subjective Point of ViewView

200 METEREDINHALATIONS

Edit Out Extraneous DetailsEdit Out Extraneous Details

Identify Steps ClearlyIdentify Steps Clearly

1 2 3

Show the Proper Point of Show the Proper Point of ReferenceReference

Avoid Stereotypes and Exaggerations in Caricatures

Use of Use of exaggerations can exaggerations can help to reinforce help to reinforce negative concepts negative concepts at timesat times

?

How do we know whether How do we know whether the teaching materials we the teaching materials we

are using are what we are using are what we need?need?

Readability TestsReadability Tests

• SMOGSMOG• Fry Fry • Flesch Flesch • FogFog

Cautions About Using Cautions About Using Readability TestsReadability Tests

• Reading level is only one element in Reading level is only one element in assessing the appropriateness of printed assessing the appropriateness of printed materialsmaterials

• Just because it is written at a low reading Just because it is written at a low reading level does not mean that it is clear and well-level does not mean that it is clear and well-writtenwritten

• Readability tests do not address the visual Readability tests do not address the visual elements which are key in assessing reading elements which are key in assessing reading ease and appealease and appeal

• Readability formulas are only Readability formulas are only estimates-not precise factestimates-not precise fact

• Readability formulas tell you Readability formulas tell you nothing about your patientnothing about your patient

• Level of knowledgeLevel of knowledge• ExperienceExperience• Cultural backgroundCultural background• Motivation and interestMotivation and interest

Suitability Assessment of Suitability Assessment of Materials (SAM)Materials (SAM)

Attributes that define easy-to-read Attributes that define easy-to-read materialsmaterials ContentContent LiteracyLiteracy GraphicsGraphics LayoutLayout Learning motivationLearning motivation Cultural appropriatenessCultural appropriateness

RecommendationsRecommendations

Know how to assess patients for Know how to assess patients for their reading abilitiestheir reading abilities

Don’t rely on “grade reported as Don’t rely on “grade reported as completed” for reading abilitycompleted” for reading ability

Use materials written at a 6th to 7th Use materials written at a 6th to 7th grade levelgrade level

The ultimate test!The ultimate test!

What do What do youryour patients think about it? patients think about it?

Test the material on them! Test the material on them! • Do they like it?Do they like it?• Do they understand it?Do they understand it?• Can they learn from it?Can they learn from it?

The EndThe End

ReferencesReferences

1.1. National Institute for Literacy, FACT SHEET: Literacy & HealthNational Institute for Literacy, FACT SHEET: Literacy & Health2.2. Doak, Cecilia C., Leonard G. Doak and Jand H. Root, Doak, Cecilia C., Leonard G. Doak and Jand H. Root, Teaching Teaching

Patients with Low Literacy Skills,Patients with Low Literacy Skills, 2 2ndnd Edition, Philadelphis, JB Edition, Philadelphis, JB Lippincott Co., 1996Lippincott Co., 1996

3.3. Redman, Barbara Klug, Redman, Barbara Klug, The Process of Patient Education,The Process of Patient Education, 7 7thth Edition, Chapter 7, St. Louis, Mosby-Year Book, Inc., 1993Edition, Chapter 7, St. Louis, Mosby-Year Book, Inc., 1993

4.4. Plain Language Action and Information Network. Plain Language Action and Information Network. www.plainlanguage.govwww.plainlanguage.gov

5.5. US Dept. of Health and Human Services, 2001, US Dept. of Health and Human Services, 2001, National National Standards for Culturally and Linguistically Appropriate Services Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC, Office of Minority Healthin Health Care. Washington, DC, Office of Minority Health

6.6. Institute of Medicine. 2004. Institute of Medicine. 2004. Health Literacy” A Prescription to Health Literacy” A Prescription to End ConfusionEnd Confusion. Washington, DC, The National Academies Press. Washington, DC, The National Academies Press

7.7. National Center for Education Statistics, 2005, National Center for Education Statistics, 2005, National National Assessment of Adult Literacy (NAAL): A first Look at the Literacy Assessment of Adult Literacy (NAAL): A first Look at the Literacy of America’s Adults in the 21of America’s Adults in the 21stst Century Century, US Dept. of Education, US Dept. of Education