Stfm 2006 Presentation


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Stfm 2006 Presentation

  1. 1. Let’s Create Materials Patient’s Can Read And Understand Betty J. Westmoreland, MBEd, CPA President Pritchett & Hull Associates, Inc.
  2. 2. Objectives <ul><li>Understand the role low-literacy plays in healthcare and the need to assess each patient </li></ul><ul><li>Understand the principles of creating patient education materials for the low-literate </li></ul><ul><li>Judge the appropriateness of the patient education materials you use </li></ul>Upon completion of this presentation, you should be able to:
  3. 3. Answers Needed <ul><li>How do we assess our patients’ ability to read and understand our teaching? </li></ul><ul><li>How do we go about developing patient teaching materials that are suitable for our patients? </li></ul><ul><li>How do we know whether the teaching materials we are using are what we need? </li></ul>
  4. 4. How do we assess our patients’ ability to read and understand our teaching?
  5. 5. Literacy <ul><li>An individual’s ability to read, write and speak English, compute and solve problems sufficient to function in society, develop one’s knowledge and potential, and to achieve one’s goals. </li></ul>
  6. 6. Scope of the Problem <ul><li>21% of adult Americans (40 – 44 million) are functionally illiterate and read at or below a 5 th grade level </li></ul><ul><li>An additional 25% (50 million) are marginally illiterate </li></ul>
  7. 7. National Adult Literacy Survey (1992) <ul><li>90 million adults (47%) read at the lowest levels </li></ul><ul><li>75% of Welfare recipients read at the lowest levels </li></ul>
  8. 8. Low-literacy is Prevalent Among All Ages and Ethnic Groups <ul><li>More than 66% of adults > 60 years of age have inadequate or marginal skills </li></ul><ul><li>Greatest number of low-literate Americans are native born whites </li></ul><ul><li>Other groups with literacy problems: </li></ul><ul><ul><li>52% of Hispanics </li></ul></ul><ul><ul><li>41% of African Americans </li></ul></ul><ul><ul><li>35% of Asians </li></ul></ul><ul><li>Kirsch, et al., Adult Literacy in America, 1993 </li></ul>
  9. 9. Health Literacy <ul><li>The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions </li></ul>
  10. 10. Significance <ul><li>Groups with highest prevalence of chronic disease and greatest need demonstrate the least ability to read and comprehend information </li></ul><ul><li>It is worse among the most vulnerable </li></ul>
  11. 11. Literacy and Health <ul><li>People with Lowest Literacy Levels </li></ul><ul><li>Report poorer health </li></ul><ul><li>Incur higher expenses for health care </li></ul><ul><li>More outpatient and ED visits </li></ul><ul><li>Greater likelihood of hospitalizations </li></ul>Weiss, et al., Illiteracy among Medicaid recipients (1991) Baker, et al., Functional health literacy, self reported health status (1997)
  12. 12. Health Literacy Research <ul><li>42% are able to understand directions for taking medicine on an empty stomach </li></ul><ul><li>26% do not understand information regarding when a next appointment is scheduled </li></ul><ul><li>60% cannot understand an informed consent form </li></ul><ul><li>33% do not understand instructions for an upper GI tract x-ray written at a 4th grade level </li></ul>Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients at Two Public Hospitals. JAMA. 1995; 274:1677-1682.
  13. 13. Source: IMS America, 1997
  14. 14. Patients at Risk <ul><li>Older age </li></ul><ul><li>Low income </li></ul><ul><li>Unemployed </li></ul><ul><li>Ethnic minorities (Hispanic, African American) </li></ul><ul><li>Fewer years of school completed </li></ul><ul><li>Recent immigrants to the U.S. </li></ul><ul><li>Born in U.S. with English as 2 nd language </li></ul>
  15. 15. Illiteracy means being unable to read or write Low-literacy does not mean illiterate
  16. 16. Comprehension <ul><li>Grasping the meaning of the instruction </li></ul>
  17. 17. Logic Language Experience Comprehension
  18. 18. Patient Variables that Affect Comprehension <ul><li>Illness-related stress </li></ul><ul><li>Perceived threat </li></ul><ul><li>Motivation </li></ul><ul><li>Physical and mental energy </li></ul><ul><li>Visual acuity </li></ul><ul><li>Length of formal education </li></ul>
  19. 19. Low Literacy Learner’s Behaviors <ul><li>Perspective limited to direct personal experience </li></ul><ul><li>Insensitive to the need to give information </li></ul><ul><li>Does not think in terms of categories of information </li></ul><ul><li>Gives information in bits and pieces without an identifiable pattern </li></ul>
  20. 20. Good Readers <ul><li>Use prior knowledge </li></ul><ul><li>Associate randomly </li></ul><ul><li>Are fluent </li></ul><ul><li>Hesitant </li></ul><ul><li>Get help </li></ul><ul><li>Skip over words </li></ul><ul><li>Interested </li></ul><ul><li>Not focused </li></ul><ul><li>Continuous </li></ul><ul><li>Skip around </li></ul>Poor Readers
  21. 21. Elderly Learners
  22. 22. Barriers to Learning <ul><li>Functional limitations </li></ul><ul><li>Fatigue </li></ul><ul><li>Motivation </li></ul><ul><li>Experience with learning </li></ul><ul><li>Depression </li></ul><ul><li>Medications </li></ul><ul><li>Pain </li></ul><ul><li>Disabilities </li></ul>
  23. 23. To Facilitate Comprehension <ul><li>Adapt teaching to sensory changes </li></ul><ul><ul><li>Presbyopia </li></ul></ul><ul><ul><li>Presbyacusis </li></ul></ul><ul><li>Pace the delivery </li></ul><ul><li>Enhance readability of teaching materials </li></ul><ul><li>Use concrete, familiar examples </li></ul>
  24. 24. Cultural Considerations
  25. 25. Reaching Patients of Different Cultural Backgrounds <ul><li>Do a culturally sensitive assessment </li></ul><ul><li>Teach within cultural context </li></ul><ul><li>Translate oral and written instructions using member of cultural community </li></ul><ul><li>Build on culturally compatible experiences </li></ul><ul><li>Must make sense within cultural context </li></ul>
  26. 26. Recognizing Signs of Low-literacy
  27. 27. Signs of Low-literacy <ul><li>Ask you to fill out forms for them, or make mistakes when they fill them out </li></ul><ul><li>Bring a friend to help </li></ul><ul><li>Take forms home to complete </li></ul><ul><li>Miss appointments, imaging tests, lab tests, etc. </li></ul><ul><li>Noncompliant with medication regimens </li></ul><ul><li>Use excuses for not reading – “Left glasses,” “Didn’t have time” </li></ul>
  28. 28. <ul><li>Ask you to explain what they have just read </li></ul><ul><li>Eyes fail to move right while “reading” </li></ul><ul><li>Fail to respond to mailed notices, bills </li></ul><ul><li>Ask you to call rather than mail information </li></ul><ul><li>Turn down opportunities that require reading and/or writing </li></ul>Foulk, D., Carroll, P., Wood, S. Addressing Health Literacy (2001)
  29. 29. Assessing Health Literacy <ul><li>REALM (Rapid Estimate of Adult Literacy in Medicine) </li></ul><ul><ul><li>LSU Medical Center </li></ul></ul><ul><li>TOFHLA (Test of Functional Health Literacy in Adults) </li></ul><ul><ul><li>Center for Study of Adult Literacy </li></ul></ul><ul><ul><li>Georgia State University </li></ul></ul>
  30. 30. Patient and Family Education Assessment <ul><li>What problems have your illness caused for you? </li></ul><ul><li>What concerns you most about this illness? </li></ul><ul><li>What bothers you most about this illness? </li></ul><ul><li>What do you fear most about your illness? </li></ul><ul><li>What do you think caused the problem? </li></ul><ul><li>Why do you think it happened when it did? </li></ul><ul><li>What do you think this illness does to you? </li></ul><ul><li>How does it work? </li></ul><ul><li>How severe is your illness? </li></ul><ul><li>How long do you think it will last? </li></ul><ul><li>What kind of treatment do you think you should get? </li></ul><ul><li>What are the most important results you hope to get from this treatment? </li></ul><ul><li>What do you need to know to take care of yourself at home? </li></ul><ul><li>The last time you wanted to learn something, how did you go about it? </li></ul><ul><li>What do you want to learn more about? </li></ul><ul><li>Provided by © (2005) Fran London, MS, RN, Phoenix Children’s Hospital </li></ul>
  31. 31. How do we go about developing patient teaching materials that are suitable for our patients?
  32. 32. What to look for in teaching materials <ul><li>Legibility </li></ul><ul><li>Organization and flow of content </li></ul><ul><li>Effective use of visuals </li></ul><ul><li>Relevance and personalization to the reader </li></ul><ul><li>Interactivity </li></ul>
  33. 33. Basics <ul><li>Poor readers read one word at a time </li></ul><ul><li>Short sentences are better </li></ul><ul><li>First sentence in a paragraph should contain the most important information- “how to do it” </li></ul><ul><li>Avoid big (multi-syllabic) and technical words </li></ul>
  34. 34. <ul><li>Only tell what the patient needs to know </li></ul><ul><li>Use bold rather than ALL CAPS to emphasize importance </li></ul><ul><li>Do not use italics —hard to read </li></ul><ul><li>Use a lot of white space so it’s not cluttered </li></ul>
  35. 35. <ul><li>Use at least 13 point type </li></ul><ul><li>Use black ink on white or cream colored paper for good contrast </li></ul><ul><li>Use visuals that teach—good visuals can lower the readability of material by two grade levels </li></ul>
  36. 36. <ul><li>Write text as you would talk to the reader </li></ul><ul><li>Interactive materials are more personal to the reader because they involve him </li></ul><ul><li>Summarize and repeat, clearly and simply, the most important points you want the reader to remember </li></ul>
  37. 37. Plain Language Initiative from the NIH An important tool for improving health literacy
  38. 38. Plain Language <ul><li>Writing that effectively communicates with the specific audience being addressed. </li></ul><ul><li>Insures that your patient can understand the information you provide </li></ul>
  39. 39. <ul><li>It is critical to: </li></ul><ul><ul><li>Know your patient </li></ul></ul><ul><ul><li>Have patients test materials being used </li></ul></ul><ul><ul><ul><li>Before they are developed </li></ul></ul></ul><ul><ul><ul><li>During the development </li></ul></ul></ul><ul><ul><ul><li>After they are developed </li></ul></ul></ul><ul><li>Speaking plainly is just as important as writing plainly </li></ul>
  40. 40. Plain Language is Not <ul><li>Unprofessional writing </li></ul><ul><li>Talking down to the reader </li></ul>
  41. 41. Plain Language is <ul><li>Grammatically correct </li></ul><ul><li>Tells the reader only what he/she needs to know </li></ul><ul><li>Uses common everyday words </li></ul><ul><li>Uses the active voice </li></ul><ul><li>Uses pronouns (you, your, your child, etc.) </li></ul><ul><li>Uses design features that are easy to understand (bullets, lists, etc.) </li></ul>
  42. 42. The Visual Message
  43. 43. The Visual Message… <ul><li>Can improve visual learning by directing the eye to the message </li></ul><ul><li>Uses lots of white space </li></ul><ul><li>Uses visuals that communicate the content </li></ul>
  44. 44. The visuals should reinforce the text
  45. 47. Use visuals that readers can identify with (within their cultural framework)
  46. 48. Use the Subjective Point of View 200 METERED INHALATIONS
  47. 49. Edit Out Extraneous Details
  48. 50. Identify Steps Clearly 1 2 3
  49. 51. Show the Proper Point of Reference
  50. 52. Avoid Stereotypes and Exaggerations in Caricatures
  51. 53. Use of exaggerations can help to reinforce negative concepts at times ?
  52. 54. How do we know whether the teaching materials we are using are what we need?
  53. 55. Readability Tests <ul><li>SMOG </li></ul><ul><li>Fry </li></ul><ul><li>Flesch </li></ul><ul><li>Fog </li></ul>
  54. 56. Cautions About Using Readability Tests <ul><li>Reading level is only one element in assessing the appropriateness of printed materials </li></ul><ul><li>Just because it is written at a low reading level does not mean that it is clear and well-written </li></ul><ul><li>Readability tests do not address the visual elements which are key in assessing reading ease and appeal </li></ul>
  55. 57. <ul><li>Readability formulas are only estimates-not precise fact </li></ul><ul><li>Readability formulas tell you nothing about your patient </li></ul><ul><ul><ul><li>Level of knowledge </li></ul></ul></ul><ul><ul><ul><li>Experience </li></ul></ul></ul><ul><ul><ul><li>Cultural background </li></ul></ul></ul><ul><ul><ul><li>Motivation and interest </li></ul></ul></ul>
  56. 58. Suitability Assessment of Materials (SAM) <ul><li>Attributes that define easy-to-read materials </li></ul><ul><ul><li>Content </li></ul></ul><ul><ul><li>Literacy </li></ul></ul><ul><ul><li>Graphics </li></ul></ul><ul><ul><li>Layout </li></ul></ul><ul><ul><li>Learning motivation </li></ul></ul><ul><ul><li>Cultural appropriateness </li></ul></ul>
  57. 59. Recommendations <ul><li>Know how to assess patients for their reading abilities </li></ul><ul><li>Don’t rely on “grade reported as completed” for reading ability </li></ul><ul><li>Use materials written at a 6th to 7th grade level </li></ul>
  58. 60. The ultimate test! <ul><li>What do your patients think about it? </li></ul><ul><li>Test the material on them! </li></ul><ul><ul><li>Do they like it? </li></ul></ul><ul><ul><li>Do they understand it? </li></ul></ul><ul><ul><li>Can they learn from it? </li></ul></ul>
  59. 61. The End
  60. 62. References <ul><li>National Institute for Literacy, FACT SHEET: Literacy & Health </li></ul><ul><li>Doak, Cecilia C., Leonard G. Doak and Jand H. Root, Teaching Patients with Low Literacy Skills, 2 nd Edition, Philadelphis, JB Lippincott Co., 1996 </li></ul><ul><li>Redman, Barbara Klug, The Process of Patient Education, 7 th Edition, Chapter 7, St. Louis, Mosby-Year Book, Inc., 1993 </li></ul><ul><li>Plain Language Action and Information Network. </li></ul><ul><li>US Dept. of Health and Human Services, 2001, National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC, Office of Minority Health </li></ul><ul><li>Institute of Medicine. 2004. Health Literacy” A Prescription to End Confusion . Washington, DC, The National Academies Press </li></ul><ul><li>National Center for Education Statistics, 2005, National Assessment of Adult Literacy (NAAL): A first Look at the Literacy of America’s Adults in the 21 st Century , US Dept. of Education </li></ul>