Transcript Assessing Levels of Readibility in Health Education Materials

October 2010 KSHA Convention
Presented by Susan Jackson
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www.asha.org – long list of publications
http://www.asha.org/SLP/healthliteracy/
http://www.asha.org/slp/health_lit_resources
.htm
http://www.jointcommission.org/PatientSafet
y/DoNotUseList/ (listed on the ASHA web
site)
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“The degree to which individuals have the
capacity to obtain, process, and understand
basic health information and services needed
to make appropriate health decisions.”
Healthy People 2010
(http://www.healthypeople.gov/Document/p
df/uih/2010uih.pdf)
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“Patients are often faced with complex
information and treatment decisions. Some of
the specific tasks patients are required to carry
out may include:
◦ evaluating information for credibility and
quality,
◦ analyzing relative risks and benefits,
◦ calculating dosages,
◦ interpreting test results, or
◦ locating health information”
Source:
http://nnlm.gov/outreach/consumer/hlthlit.html
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In order to accomplish these tasks, individuals
may need to be:
◦ visually literate (able to understand graphs or
other visual information),
◦ computer literate (able to operate a computer),
◦ information literate (able to obtain and apply
relevant information), and
◦ numerically or computationally literate (able to
calculate or reason numerically).
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“According to the American Medical Association, poor
health literacy is "a stronger predictor of a person's
health than age, income, employment status,
education level, and race" (Report on the Council of
Scientific Affairs, Ad Hoc Committee on Health
Literacy for the Council on Scientific Affairs, American
Medical Association, JAMA, Feb 10, 1999).
In Health Literacy: A Prescription to End Confusion,
the Institute of Medicine reports that ninety million
people in the United States, nearly half the
population, have difficulty understanding and using
health information. As a result, patients often take
medicines on erratic schedules, miss follow-up
appointments, and do not understand instructions
like "take on an empty stomach".”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“Only 12 percent of adults have proficient health
literacy, according to the National Assessment of
Adult Literacy. In other words, nearly nine out of ten
adults may lack the skills needed to manage their
health and prevent disease. Fourteen percent of
adults (30 million people) have Below Basic health
literacy. These adults were more likely to report their
health as poor (42 percent) and are more likely to
lack health insurance (28 percent) than adults with
Proficient health literacy.6”
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6Kirsch
IS, Jungeblut A, Jenkins L, Kolstad A. 1993. Adult Literacy in America:
A First Look at the Results of the National Adult Literacy Survey (NALS).
Washington, DC: National Center for Education Statistics, U.S. Department of
Education.
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See handout “Health Literacy: Statistics at-a-Glance”
from the Partnership for Clear Health Communication at
the National Patient Safety Foundation.
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“Elderly (age 65+) - Two thirds of U.S.
adults age 60 and over have inadequate or
marginal literacy skills, and 81% of patients
age 60 and older at a public hospital could
not read or understand basic materials
such as prescription labels (Williams, MV.
JAMA, December 6, 1995).
Minority populations
Immigrant populations
Low income - Approximately half of
Medicare/Medicaid recipients read below
the fifth-grade level
People with chronic mental and/or physical
health conditions”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“Lack of educational opportunity - people
with a high school education or lower
Learning disabilities
Cognitive declines in older adults
Use it or lose it - Reading abilities are
typically three to five grade levels below the
last year of school completed. Therefore,
people with a high school diploma, typically
read at a seventh or eighth grade reading
level.”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“According to the Agency for Health Care
Research and Quality Report, Literacy and
Health Outcomes (January 2004), low health
literacy is linked to higher rates of
hospitalization and higher use of expensive
emergency services. This evidence-based
literature review highlights numerous studies
that provide a detailed analysis of the
correlation between low health literacy and poor
health. Below are just a few of the conclusions
from studies on health literacy and outcomes.”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“Cancer Treatment (Merriman, Betty, CA: A Cancer
Journal for Physicians, May/June 2002)
◦ Low literacy adversely impacts cancer incidence,
mortality, and quality of life. For example:
◦ Cancer screening information may be ineffective; as
a result, patients may be diagnosed at a later stage.
◦ Treatment options may not be fully understood;
therefore, some patients may not receive treatments
that best meet their needs.
◦ Informed consent documents may be too complex
for many patients and consequently, patients may
make suboptimal decisions about accepting or
rejecting interventions.”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“Diabetes (Schillinger, Dean, JAMA, July
24/31, 2002)
◦ Among primary care patients with Type 2
diabetes, inadequate health literacy is
independently associated with worse
glycemic control and higher rates of
retinopathy. Inadequate health literacy
may contribute to the disproportionate
burden of diabetes related problems
among disadvantaged populations.”
Source:
http://nnlm.gov/outreach/consumer/hlthlit.html
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“Asthma (Williams, MV, Chest, October 1998)
◦ Inadequate literacy was common and strongly
correlated with poorer knowledge of asthma and
improper metered-dose inhaler (MDI) use. More
than half of patients reading at a sixth-grade
level or less report they go to the Emergency
Department when they have an attack compared
with less than a third of literate patients. Less
than one third of patients with the poorest
reading skills knew they should see a physician
when their asthma was not symptomatic as
compared with 90% of literate patients.”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“Hypertension and Diabetes (Williams MV,
Archives of Internal Medicine, January 26,
1998)
◦ Almost half (48%) of the patients with
hypertension or diabetes in a study had
inadequate functional health literacy, and these
patients had significantly less knowledge of their
disease, important lifestyle modifications, and
essential self-management skills, despite having
attended formal education classes”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“In addition to the effects of low health
literacy on the individual patient, there are
economic consequences of low health
literacy to society. The National Academy on
an Aging Society estimated that additional
health care costs due to low health literacy
were about $73 billion in 1998 dollars
(Health Literacy Fact Sheet,
http://www.agingsociety.org/agingsociety/p
ublications/fact/fact_low.html).”
Source:
http://nnlm.gov/outreach/consumer/hlthlit.html
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“After adjusting for health status, education
level, socioeconomic status, and other
demographics factors, people with low
functional literacy have less ability to care for
chronic conditions and use more health care
services. The information below is from the
Center on an Aging Society at Georgetown
University
(http://hpi.georgetown.edu/agingsociety/pub
html/healthlit.html)
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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“Among adults who stayed overnight in a hospital in
1994, those with low health literacy averaged 6% more
hospital visits, and stayed in the hospital nearly two
days longer than adults with higher health literacy skills.
When self-reported health status is taken into account,
patients with low health literacy skills had fewer doctor
visits but used substantially more hospital resources.
The estimated additional health care expenditures due
to low health literacy skills are about $73 billion in 1998
health care dollars. This includes an estimated $30
billion for the population that is functionally illiterate
plus $43 billion for the population that is marginally
literate.”
Source: http://nnlm.gov/outreach/consumer/hlthlit.html
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Test of Functional Health Literacy (TOFHLA)
◦ 18-22 minutes to administer
◦ Assesses numeracy and reading comprehension
◦ $70 for the package that includes both long and short
versions in English and Spanish
◦ http://www.peppercornbooks.com/catalog/information.
php?info_id=5
Rapid Estimate of Health Literacy in Medicine (REALM) only available in English
◦ 66-item word recognition test of common medical terms
-handouts
REALM-R: 8 words (osteoporosis, allergic, jaundice,
anemia, fatigue, directed, colitis, constipation)
◦ A score of 6 or lower suggests reading difficulty (<6th
grade)
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See handouts for stimuli, questions and answers, and
interpretation
Serial testing of patient education materials/scenarios
on more than 1,000 patients
Average time to complete = 2.9 minutes
Number correct mean = 3.4
Available in English and Spanish
Correlates with the longer measures
http://www.pfizerhealthliteracy.com/physiciansproviders/newest-vital-sign.html
High risk group: did not complete high
school, minority, elderly
Does not know names of medicines
Frequent missed appointments
“I forgot my glasses”
Always comes with someone else:
• “surrogate reader”
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Your naicisyhp has dednemmocer that
you have a ypocsonoloc. Yposconoloc
is a test for noloc recnac. It sevlovni
gnitresini a elbixelf gniweiv epocs into
your mutcer. You must drink a laiceps
diuqil the thgin erofeb the
noitanimaxe to naelc out your noloc.
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Depends on
◦ The reader’s general aptitude (reading level
and subject knowledge)
◦ Clarity of communication (text organization)
◦ Feasibility of taking action (how well the
reader can remember or follow instructions)
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Processing information quickly
Understanding text that is densely packed with
new ideas or has complex syntax
Drawing inferences
Solving new problems
Manipulating different types of information at the
same time
Focusing on important new information without
being distracted by irrelevant details
Changing established beliefs and opinions
Remembering information
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Be direct and specific – clear and concise
◦ Give specific examples “eat healthier foods”
◦ Omit unnecessary words
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Limit the number of key points
Limit action steps
Use positive statements
Use active voice
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Active voice makes it clear who is supposed to do
what. It eliminates ambiguity about
responsibilities. Not: “It must be done.” But, “You
must do it.” Passive voice, which obscures who is
responsible for what, is one of the biggest
problems with government documents.
In an active sentence, the person or agency that’s
acting is the subject of the sentence. In a passive
sentence, the person or item that is acted upon is
the subject of the sentence. Passive sentences
often do not identify who is performing the
action.
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Passive sentences have two basic features,
although both may not appear in every passive
sentence.
• A past participle (generally with “ed” on the end); and
• A form of the verb “to be.”
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In a very few instances, passive voice may be
appropriate. For example, when one action
follows another as a matter of law, and there is no
actor (besides the law itself) for the second
action, a passive sentence may be the best
method of expression. You might also use passive
when it doesn’t matter who is doing an action.
• The lake was polluted
by the company.
• New regulations were
proposed.
• The following
information must be
included in the
application for it to be
considered complete.
• Regulations have been
proposed by the
Department of
Veterans Affairs.
 The company polluted
the lake.
 We proposed new
regulations.
 You must include the
following information
in your application.
 We have proposed
regulations. The
permit will be
approved by the
agency’s State office.
Support information with real examples and
stories
 Use pictures to illustrate
 Put key points up front
 Break lengthy text into shorter sections
 Repeat main points
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– 1. introduce what you want to say
– 2. Say it
– 3. Repeat what you said
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Reinforce main points with questions
Avoid complex diagrams
Avoid jargon
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Visual changes associated with aging can
complicate reading and health literacy
◦ Serif typeset- tails on ends of letters
create illusion to guide eyes across the
print
 Times New Roman
 Arial
 Cambria
◦ Minimum Font Sizes
 Use 12- to14-point font
 16- to18-point font if low vision
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Allow for white space
Avoid ALL CAPS
Double space body text if possible
Limit use of italics, underlining and bold font
Align text to left margin
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Don’t wrap text around a graphic
Keep normal spacing between letters
Avoid yellow and blue and green in close
proximity
Create contrast
Limit line length (use multiple columns)
Avoid awkward breaks at the end of lines
Avoid glossy paper or paper that is too thin
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General Content
– Limit content to one or two objectives.
– Limit to “need to know” content
– Use non-medical words
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Text
– 6th grade reading level or below
– One- or two-syllable words
– Short paragraphs
– Active voice
– Avoid complex tables and graphs
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Have open empty space on the page
◦ Avoid clutter with words or pictures
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Separate text with headings and subheadings
Bulleted lists are preferable to blocks of text
in paragraphs
Illustrations help if they depict common,
easy-to-recognize objects. Avoid complex
diagrams.
Your doctor has diagnosed you as having streptococcal
pharyngitis, or “strep throat.” Strep throat is caused by
Group A beta hemolytic streptococcus, a common
bacteria in the nose and throat that can cause sore
throat (pharyngitis) and skin infections. Symptoms of
strep throat include pain and redness n the throat,
difficulty swallowing, fever, and swollen glands in the
neck. Sometimes there is a rash going along with the
sore throat, in which case patients are said to have
“scarlet fever.” Strep throat occurs most commonly in
children.
The symptoms of strep throat go away by themselves,
even without treatment. Without treatment, however, a
small percentage of patients with strep throat will
develop rheumatic fever, a serious disease of the heart
and heart valves. When patients get rheumatic fever,
heart valves my be damaged, and in the future, the
patient may need open heart surgery to replace a heart
valve. Although rheumatic fever is uncommon, in recent
years there have been more cases reported.
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Treating Strep Throat
◦ Take your pills 2 times each day (once in
the morning and once in the evening)
◦ Take the medicine every day for 10 days –
even if you feel better before
◦ Stopping the pills before 10 days can
result in serious heart problems
College Reading Level
With the onset of nausea, diarrhea or other
gastrointestinal disturbances, consult your physician
immediately.
12th Grade Reading Level
If you experience nausea, diarrhea or other stomach or
bowel problems, call your physician immediately.
8th Grade Reading Level
If you start having nausea, loose bowel movements or
other stomach problems, call your doctor immediately.
4th Grade Reading Level
If you start having an upset stomach, loose bowel
movements, or other problems, call your doctor right
away.
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Ideally use 3rd -5th grade reading level
Limit paragraphs to 2-3 sentences each
Check readability using word processing
tools
◦ Flesch-Kincaid readability score (available
in Word)
Readability does not consider content or
vocabulary
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Medical jargon
◦ Cardiologist
◦ Catheterize bladder
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Chemotherapy
Echocardiogram
Malignancy
Noninvasive
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Alternate wording
◦ Heart doctor
◦ Put a tube in where urine
comes out
◦ Drugs to treat cancer
◦ Pictures of your heart
◦ Cancer
◦ Without surgery or
needles or cutting skin
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Interactive, thus more engaging
May be tailored to learners’ needs
Can vary age, skin color, and gender of
person in the instructional materials
Some found on web sites (check out before
recommending)
 Reading
skills in terms of U.S. school grade levels
can be determined by formula. Formulae, for the
most part, are applicable to narrative language
[running text] but not to lists, charts, and tables.
The majority of formulae establish readability
based on two factors:
 The number of difficult words (usually words with 3 or
more syllables) in a sample — difficult words mean more
syllables in the sample and a higher grade level.
 The average length of sentences — longer sentences
with more words than in the average sentence translate
to a higher grade level.
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Included in the Pfizer Clear Health
Communication Initiative
Easy to use
Takes 15-20 minutes
Uses small sample (100 words)
Suitable for short and longer documents
Recognized in educational professions
Not Copyrighted
(see handouts)
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Select three 100-word passages from the material you
wish to test. Count out exactly 100 words for each
passage, starting with the first word of a sentence (omit
headings).
If you are testing a very short pamphlet that may have
on a few hundred words, select a single 100-word
sample to test. Readability levels may vary considerably
from one part of your materials to another. Therefore,
select the three samples from different content topics, if
possible.
Additional Information:
 Count proper nouns and hyphenated words as one
word.
 A word is defined as a group of symbols with a space
on either side (i.e. “IRA,” “1994,” and “&” are each one
word.)
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Count the number of sentences in each 100
words, estimating the fractional length of
the last sentence to the nearest 1/10. For
example, if the 100th word occurs five
words into a 15-word sentence, the fraction
of the sentence is 5/15 or 1/3 or 0.3.
Count the total number of syllables in each
100-word passage. You can count by
making a small check mark over each
syllable. For initializations (e.g., IRA) and
numerals (e.g., 1994), count one syllable
for each symbol. So, “IRA” = three syllables
and “1994” = four syllables.
Calculate the average number of sentences and the
average number of syllables from the three passages.
This is done by dividing the totals obtained from the
three samples as shown in Table 1.
1st 100 words
5.9
124
2nd 100 words
4.8
141
3rd 100 words
6.1
158
Totals
16.8
423
Divide totals by 3
5.6 average
141 average
On the horizontal axis, find the line for the average number of syllables.
On the vertical axis, find the line for the average number of sentences.
The readability level of the material is found at the point where the two
lines intersect.
1.
2.
3.
4.
5.
Count off 10 consecutive sentences near the
beginning, in the middle, and near the end of the
text.
From this sample of 30 sentences, circle all of the
words containing three or more syllables
(polysyllabic), including repetitions of the same
word, and total the number of words circled.
Estimate the square root of the total number of
polysyllabic words counted. This is done by finding
the nearest perfect square, and taking its square
root.
Finally, add a constant of three to the square root.
This number gives the SMOG grade, or the reading
grade level that a person must have reached if he or
she is to fully understand the text being assessed.
Useful for brief materials
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A sentence is defined as a string of words
punctuated with a period (.), an exclamation
point (!) or a question mark (?).
Hyphenated words are considered as one
word.
Numbers which are written out should also
be considered, and if in numeric form in the
text, they should be pronounced to
determine if they are polysyllabic.
Proper nouns, if polysyllabic, should be
counted, too.
Abbreviations should be read as
unabbreviated to determine if they are
polysyllabic.
See handouts
Count all of the polysyllabic words in the
text.
2. Count the number of sentences.
3. Find the average number of polysyllabic
words per sentence as follows:
1.
◦ Total # of polysyllabic words
◦ Total # of sentences
4. Multiply that average by the number of
sentences short of 30.
5. Add that figure on to the total number of
polysyllabic words.
6. Find the square root and add the constant
of 3.
Aphasia is estimated to affect more than
one million individuals in the United
States, yet few people have ever heard
of it. So what is aphasia? It is an
impairment of language that affects
speaking, understanding, reading, and
writing. Imagine knowing what you
want to say and finding it impossible to
get your ideas across to others. A
person with aphasia might grope for
words, say the wrong words, or say
words that don't make sense.
What If You Couldn't Communicate?
When you have aphasia, it feels like living in a
country where you don't speak the language.
Suddenly you have trouble:
Having a conversation
Asking for help
Understanding directions
Reading and writing
You probably feel very alone and may be angry
or sad.
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“The "Teach Back" Method is simply asking your patients to
repeat in their own words what they need to do when they
leave your office. This method allows you to check your
patient's understanding of your medical instructions.
You do not want your patients to view the Teach Back task
as a test, but rather of how well you explained the concept.
You can place the responsibility on yourself by using this
suggested language:
"I want to be sure that I did a good job explaining your
blood pressure medications, because this can be confusing.
Can you tell me what changes we decided to make and how
you will now take the medication?"
If your patient is not able to repeat the information
accurately, try to re-phrase the information, rather than just
repeat it. Then, ask the patient to repeat the instructions
again until you feel comfortable that the patient really
understands the information.”
Source: www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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“Many people remember information better
when it is presented to them visually. You
can draw simple pictures or diagrams to
help explain your instructions.”
◦ Source:
www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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Example: How to create a pill card
www.ahrq.gov/qual/pillcard/pillcard.htm
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“Always clarify the meaning of words that
can interpreted in more than one way.
◦ "Stool," "gait" and "dressing" are words that can
have different meanings depending on how they
are used in a sentence. When possible, try to use
words that have only one meaning, or be sure to
clarify the meaning of a confusing word.”
◦ Source: www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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“Acronyms such as "CAT scan" and "HDL"
are common to you, but some of your
patients may not understand them.
◦ Say or write the complete phrase the first time you
use it, then explain the meaning. For example, you
can explain that "HDL" means "the good
cholesterol.”
 Source: www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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Use plain, non-medical language
◦ www.npsf.org/askme3/PCHC/download.php
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“When possible, you should try to avoid
using idioms unless you're sure the patient
understands the meaning.
◦ For example, instead of asking "I understand that
you've been feeling blue," a better choice of
words would be "I understand that you've been
feeling sad lately.“ “
◦ Source: www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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“Health measurements, such as cholesterol
or glucose levels, have little meaning to
patients unless you put them into a context
the patient can understand.
◦ Instead of just telling patients their numbers, give
them additional information such as high and low
parameters or a goal number. For example, "Your
cholesterol level is 305. A healthy cholesterol level
would be less than 200, so we need to talk about
how we can lower your number.” “
◦ Source:
www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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“Medical instructions can be
confusing, so slow down and take
pauses to give your patient time to
digest the information and ask for
clarification.”
Source:
www.pfizerhealthliteracy.com/physicia
ns-providers/tips-for-providers.html
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Don’t withhold info, but communicate the
most important few bits of info at each visit
(e.g., message at first visit may be that
treatment should be started)
Repeat info within a session
Review info across multiple sessions
Multiple healthcare providers should repeat
the info (nurse, physician, pharmacist,
dietician)
◦ Source: AMA publication “Health Literacy and patient safety:
Help patients understand”
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“Active listening means encouraging
patients to talk and can be used to gather
information.
◦ Allow your patients to tell their story or
information they feel is necessary for their visit.”
◦ Source: www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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“You may notice that your patient sometimes
may look confused, stare blankly, or may not
seem to be paying attention when you are
discussing medical instructions. These may be
signs that the patient does not understand what
you are explaining.
◦ Re-phrase your instructions by using simpler words
and concepts, and draw pictures if appropriate.
Remember to use the "Teach Back" method to ensure
that your patients understand and can communicate
what they are going to do when they leave your office.”
◦ Source: www.pfizerhealthliteracy.com/physiciansproviders/tips-for-providers.html
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“Patients are most comfortable in an office that
feels private and encourages communication.
◦ From the registration desk to the exam room, patients should
be encouraged to ask questions. Discussions with the patient,
whether it be with you or the nurse, should not be held in
front of other staff or patients but rather, covered during his
or her private consultation time.”
 Source: www.pfizerhealthliteracy.com/physicians-providers/tipsfor-providers.html
 The Ask-Me-Three questions
www.npsf.org/askme3/PCHC/what_is_ask.php
 What is my main problem?
 What do I need to do?
 Why is it important for me to do this?
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Health Literacy. American Medical
Association Foundation.
http://www.amaassn.org/ama/pub/about-ama/amafoundation/our-programs/publichealth/health-literacy-program.shtml
515 North State Street
Chicago, Illinois 60610
Pfizer Clear Health Communication
Initiative
http://www.pfizerhealthliteracy.com/
Health Literacy. National Network of
Libraries of Medicine
http://nnlm.gov/outreach/consumer/hlthlit.
html
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Health Literacy Consulting
http://www.healthliteracy.com/
Helen Osborne, M.Ed., OTR/L
31 Highland Street, Suite 201
Natick, MA 01760
Phone: 508-653-1199
Fax: 508-650-9492
Email: [email protected]
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
Health Literacy Studies
http://www.hsph.harvard.edu/healthliter
acy/index.html
Harvard School of Public Health
Department of Society, Human
Development and Health
677 Huntington Avenue, 7th Floor
Boston, MA 02115 USA
National Library of Medicine
◦ www.nlm.nih.gov/medlineplus/healthliteracy.
html

Medical Library Association
http://www.mlanet.org/resources/healthlit/
65 East Wacker Place, Suite 1900
Chicago, IL 60601-7246
Tel., 312.419.9094
Fax, 312.419.8950
[email protected]
A national organization of health science
librarians. The Health Information Toolkit
includes information for Health and Information
Professions, and information for Consumers.