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Stfm 2006 Presentation

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

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