1. JULY/AUGUST2013
33
PHARMACIST
This INFUSION article is cosponsored by Educational Review Systems (ERS), which is accredited by the
Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. ERS has
assigned 1.0 contact hour (0.1 CEU) of continuing education credit to this article. Eligibility to receive continuing
education credits for this article begins July 18, 2013 and expires July 18, 2016. The universal activity number for this
program is 0761­9999­13­224­H04­P and 0761­9999­13­224­H04­T. Activity Type: Knowledge­Based.
DIETITIAN
Educational Review Systems (Provider number ED002) is a Continuing Professional Education (CPE) Accredited Provider
withtheCommissiononDieteticRegistration(CDR).Registereddietitians(RDs)anddietetictechnicians,registered(DTRs)
willreceive1.0houror0.1continuingprofessionaleducationunit(CPEU)forcompletionofthisprogram/material.Eligibility
to receive continuing education credit for this article begins July 18, 2013 and expires July 18, 2015.
Dietitian Knowledge Level 2
Dietitian Learning Codes: 1140 ­ Written communication skills, publishing
6050 ­ Instructional materials development
NURSE
Educational Review Systems is an approved provider of continuing nursing education by Alabama State
Nurses Association (ASNA), an accredited approver of continuing nursing education by the American Nurses
Credentialing Center, Commission on Accreditation. Program # 05­115­13­004.
Educational Review Systems is also approved for nursing continuing education by the state of California, the state of Florida,
and the District of Columbia.
This program is approved for 1.0 hour of continuing nursing education. Eligibility to receive continuing education credits for
this article begins July 18, 2013 and expires July 18, 2015.
This continuing education article is intended for pharmacists, nurses, dietitians, and other alternate­site infusion professionals.
In order to receive credit for this program activity, participants must complete the online posttest and subsequent evaluation
questions available at this link: http://www.nhia.org/CE_Infusion. Participants are allowed two attempts to receive a minimum
passing score of 70%.
EDUCATIONAL LEARNING OBJECTIVES:
1. Compare and contrast basic literacy and health literacy
2. Describe the link between health literacy and clinical outcomes
3. Explain how health information and patient education tools can be adapted to increase patient comprehension
Continuing education credit is free to NHIA members, and available to non­members for a nominal processing fee. To
apply for nursing or pharmacy continuing education, go to www.nhia.org/CE_Infusion and follow the online instructions.
An Essential Tool for Patients—and Important Consideration
in Patient and Caregiver Education
By Ann Marie Parry, R.N., CRNI®
, VA­BC and Jeannie Counce
Continuing Education
CPE
Accredited
Provider
Health Literacy

2. 34
JULY/AUGUST2013
Just as the correlation between patient compliance
and outcomes is well documented, so, too, is the chal­
lenge in generating a sustained change in behavior. All
too often, compliance rates are low—especially among
patients with chronic conditions, whose exacerbations
necessitate further interventions and additional health
care costs. These costs can often be avoided.1­3
This is especially troubling when we consider the cur­
rent trend moving away from longer inpatient stays,
where compliance is largely the responsibility of the
trained health care providers that are available 24 hours
a day, to care that is provided mainly by the patient
and/or caregiver. In fact, poor clinical outcomes, fre­
quently resulting in the need for further hospitalization,
are often attributed to inadequate preparation of
patients as they transition from the hospital to home.4­6
In alternate­site and specialty infusion, we are accus­
tomed to working with patients as they are discharged
from the inpatient setting. As our health care system
evolves, resulting in the transition to an ambulatory set­
ting of increasingly complex medical care, patients and
caregivers will undoubtedly assume higher levels of
responsibility in the delivery of their own care. In addi­
tion, as reimbursement models continue to shift toward
pay­for­performance and risk sharing, providers in set­
tings such as ours will be held accountable for out­
comes that are not entirely under our control.
The Literacy Factor
There are well­established links between education and
health outcomes, according to the Institute of Medicine
(IOM). Health literacy may be one pathway that
explains the connection—one that the IOM says war­
rants further exploration.7
The National Literacy Act of
1991 defines literacy as an individual’s ability to read,
write, and speak in English, to compute and solve prob­
lems at levels of proficiency necessary to function on
the job and in society, to achieve one’s goals, and devel­
Continuing Education
www.nhia.org/CE_Infusion
Have you ever purchased a piece of electronic equipment,
or anything that required “assembly,” and struggled to
accurately follow the directions for use? That feeling of
frustration can be quickly amplified when you reach out
for help and encounter a language barrier. Imagine expe­
riencing a similar struggle with a complicated medical
procedure that you were prescribed to perform in your
home, and you can grasp the challenge many home infu­
sion patients face each day. Not only are they asked to
learn complicated medical procedures, but they’re often
asked to do so at a time when they are overwhelmed by
their medical condition, and the need for complex infu­
sion care in their home.
One step every home infusion provider can take to ease
this anxiety and facilitate a patient and caregiver’s self­
administration of therapy, is to provide educational tools
that match the patient’s/caregiver’s level of health litera­
cy. For instance, some patients will have no difficulty
grasping the operation of a multi­therapy ambulatory
infusion pump, whereas others will be overwhelmed with
the battery change procedure. Is the education tool you
provide for your ambulatory pump really a “one size fits
all” resource?
As health care providers, our goal is to provide the
care needed to obtain positive outcomes, which
result in improved health for our patients. In the
home­based care setting, clinical experts may be avail­
able to assist in the delivery of care, but patients and
their caregivers are essential participants in many of the
aspects of their care—from following a medication reg­
imen, monitoring their glucose or blood pressure, to
self­infusing medications, to access device care and per­
haps even dressing changes. In addition, patients must
also comprehend how a myriad of other factors—prop­
er nutrition and exercise, medication interactions, and
follow­up medical care, to name just a few—can impact
their health, and alter their behavior accordingly.
AUTHOR BIOS:
Ann Marie Parry, R.N., CRNI®
, VA­BC, is the R.N. Clinical Coordinator at VITALine Infusion Pharmacy Services, which is a part of
Geisinger Health System in Danville, Pennsylvania. She is responsible for the development of educational tools and resources
for the VITALine staff, home care nurses, and consumers where she applies key concepts of health literacy to ensure they can
be understood and followed by all patients. Parry has almost 20 years of home care and home infusion experience, and previ­
ously spent 10 years providing health care in Zambia. She has presented at a number of national nursing conferences and is
the chair of Association for Vascular Access’ (AVA) education committee.
Jeannie Counce is the Editor­in­Chief of INFUSION magazine. She has more than 15 years’ experience as a health care writer and
editor, covering topics related to outpatient pharmacy and nursing, reimbursement, regulations, and other business issues.
AUTHOR DISCLOSURE STATEMENTS:
The authors declare no conflicts of interest or financial interest in any product or service mentioned in this program, including
grants, employment, gifts, stock holdings, and honoraria.
Questions or comments regarding this article should be directed to Ann Marie at
570­271­5555 ext., 54784 or at amparry@geisinger.edu

3. 35
www.nhia.org/CE_Infusion
op one’s knowledge and potential. Health literacy, on
the other hand, is the degree to which individuals have
the capacity to obtain, process, and understand basic
health information and services needed to make appro­
priate health decisions.8
To meet this criteria, a person
must be able to read, understand, and act on informa­
tion on pill bottles, appointment slips, informed con­
sents, discharge instructions, health education materi­
als, insurance applications and similar pieces of infor­
mation.7,8
As the IOM points out in its expanded defini­
tion of health literacy, reading and writing skills—print
literacy—are important, but so are a variety of other
skills, including:7
• Numeracy—needed to calculate nutrition labels and
insurance co­pays, and for determining the proper
dosage and timing of medicines.
• Listening and speaking skills—essential for practi­
tioner–patient interactions, such as comprehending
care regimens.
• Cultural and conceptual knowledge—an under­
standing of health and illness and a conceptualiza­
tion of risks and benefits.
By nature, health information is complex. Although
the U.S. enjoys a relatively high overall literacy rate—99%
of citizens over 15 can read and write—nearly nine out of
10 adults have difficulty using the everyday health infor­
mation that is routinely available in health care facilities,
retail outlets, media, and communities.9,10
With more
than one­third of the U.S. population at “basic” or
“below basic” literacy levels, it’s no surprise that many
are unprepared to make educated decisions about and
participate in their own health care (see Exhibit 1).10
From understanding medical terminology and anato­
my and physiology, to knowing which type of practi­
Continuing Education
tioner to consult, to discerning between treatment
options and understanding insurance benefits, health
information can overwhelm people with advanced liter­
acy skills. This can occur even before they begin to
experience the stress and fear that come from a new
diagnosis or the mental and/or physical impairment that
can result from illness or the treatments meant to
address illness.
In terms of home infusion patients, health literacy
includes the ability to understand instructions on med­
ication labels and written patient education materials,
physician and home infusion provider directions, con­
sent forms, and disease state educational tools. It
requires a complex group of reading, listening, trou­
bleshooting, and decision­making skills that can be
applied in their situation when their physician or home
infusion clinician is not present. A patient with limited
health literacy skills has greater difficulty navigating
medication schedules, pump programming and trou­
bleshooting, caring for their vascular access device, and
following physician orders.11
Helping patients develop a functional health literacy
status is an essential tool for successful outcomes and
should be an important consideration in all patient and
caregiver education across the continuum of care. Poor
health literacy contributes to many barriers and chal­
lenges including shame and embarrassment related to
the inability to read or understand critical information.
To a patient with low health literacy, health care set­
tings are unfamiliar and intimidating, the time spent
with health care providers is confusing—and often
shorter—because communication on the part of the
provider involves unfamiliar words, there is an inhibi­
tion around asking questions, and written instructions
are complicated and puzzling.
MAY/JUNE2013/AUGUST2012
Exhibit 1
Health Literacy Among U.S. Adults
Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003
National Assessment of Adult Literacy. U.S. Department of Education. National Center for Education Statistics
(NCES) Publication No. 2006­483; September 2006.
Below Basic Basic Intermediate Proficient
14% 22% 53% 12%
30 million 47 million 114 million 25 million
Circle the date of a med­
ical appointment on a hos­
pital appointment slip.
Give two reasons a person
should be tested for a spe­
cific disease, based on
information in a clearly
written pamphlet.
Determine what time a per­
son can take a prescription
medication, based on infor­
mation on the drug label
that relates the timing of
medication to eating.
Calculate an employee’s
share of health insurance
costs for a year, using a
table.

4. 36
JULY/AUGUST2013
alternate­site and specialty infusion providers to
engage in effective communication with patients and
caregivers in order for them to be educated, active par­
ticipants in the delivery of care, and in a better position
to achieve positive clinical outcomes. The tools we pro­
vide and the positive experiences we foster can serve as
a foundation for better access to health care services
for these patients in the future.
Identifying Low Health Literacy
Health literacy is closely tied to overall literacy, which
may explain why those who are at higher risk have lim­
ited education, limited incomes, or grew up in a home
where English was not spoken (see Exhibit 3).
Understanding which patients are more likely to be at
risk for low health literacy is an essential element in
awareness. It is important, however, not to make
assumptions based on these factors alone. For exam­
ple, in a study of affluent retirement community resi­
dents, 30% scored poorly on a test of functional literacy
in health care situations.26
For clinicians and others working one­on­one with
patients, behavior is often the best indicator of limited
health literacy. Patients who appear passive, don’t ask
questions or engage in conversation about their health, or
don’t appear to understand prescribed treatments may be
experiencing health literacy as a barrier (see Exhibit 4). For
example, a patient with a wound infection, receiving IV
antibiotics every six hours, expressed concern on a week­
ly follow up call that his wound was not healing as quickly
as he expected. In speaking with him, it was discovered
that he had “extra doses” of his IV medication in the
home. He stated that due to his schedule it was difficult to
“get all the doses in every day.” Further, he believed that,
“missing a dose here and there didn’t matter.”
This patient was given additional education regard­
ing the relationship between compliance with the med­
Continuing Education
www.nhia.org/CE_Infusion
Why Health Literacy Matters
Research is beginning to show a link between limited
health literacy and poor health outcomes—even after
allowing for a variety of socio­demographic variables.12­15
Time and again, patients with chronic illnesses and lower
health literacy demonstrate a decreased knowledge of
how to manage their illnesses and self­report lower
health status.16­22
This is likely related to the impact low
health literacy has on a patient’s ability to fully engage in
the health care system (see Exhibit 2 for examples).
More specifically to our field, it means that patients with
low health literacy are less likely to adhere to activities
and schedules that assure compliance with their pre­
scribed treatment regimen.23
In addition to contributing to poor clinical outcomes,
health literacy can drive up health care costs through
more frequent uses of the health care system, more
medication errors, decreased compliance, longer inpa­
tient stays, more frequent use of emergency depart­
ments, and an overall higher level of illness. In one
example, the average annual health care costs for all
Medicaid enrollees in one state in 2004 was $2,891 per
person, but the annual cost for enrollees with limited
literacy skills averaged $10,688.24
Similarly, a 2005
study of Medicare enrollees found higher costs for
emergency room and inpatient care for people with
limited health literacy.25
There are additional concerns
that citizens with lower health literacy may misunder­
stand public health warnings and health information
updates; miss opportunities for health­related services,
such as free vaccines and preventive screenings; be
less prepared to cope with severe weather and other
emergencies; and miss warnings regarding environ­
mental health and safety.
Low health literacy creates barriers—barriers to
accessing health care services, barriers to diagnosis,
and barriers to successful treatment. It is imperative for
Exhibit 2
Health Literacy and Basic Health Care Tasks
Research has shown that of U.S. adults:
• 33% ­ Unable to read basic health care materials
• 42% ­ Could not comprehend directions for taking medication on an empty stomach
• 26% ­ Unable to understand information on an appointment slip
• 86% ­ Did not understand the Rights and Responsibilities section of a Medicaid application
• 60% ­ Did not understand an informed consent form
Sources: (a) Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two
public hospitals. JAMA. 1995; 274:1677­ 1682; (b) Baker DW, Parker RM, Williams MV, et al. The health care experience
of patients with low literacy. Arch Family Med. 1996; 5:329­334; (c) Fact Sheet: Health literacy and understanding med­
ical information. Lawrenceville, NJ: Center for Health Care Strategies; 2002; (d) Wolf MS, Davis TC, Tilson HH, Bass PF
III, Parker RM. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health
Syst Pharm. 2006; 63:1048­1055.

5. JULY/AUGUST2013
37
ication remaining in the home. Fortunately, the patient’s
lab values remained in the appropriate range and he suf­
fered no serious adverse effects. The patient received
additional education related to the dosing schedule.
There are a variety of testing tools for assessing basic and
health literacy, but most of them are used primarily in
research studies. Designed in 2005 for practical use in clini­
cal settings, the Newest Vital Sign (NVS) has proven in
numerous peer­reviewed studies to accurately assess
health literacy in populations ranging from parents of
young children to older adults, among racial/ethnic minori­
ties, and applied to a wide variety of health conditions. The
test, in which patients are asked a series of questions based
on the nutrition label from an ice cream container, can be
Continuing Education
www.nhia.org/CE_Infusion
ication schedule and wound healing, and the impor­
tance of not missing doses. In addition, his administra­
tion method was changed to an intermittent infusion
program on an electronic ambulatory infusion pump so
that it better fit with his schedule.
Another patient was prescribed an injectable medica­
tion that was to be administered once a week. The drug
was stable for a month; so all four doses were shipped to
the patient at one time. The patient received the med­
ication and written instructions (verbal instructions had
been given over the phone). He administered one dose
per day, four days in a row—rather than one dose per
week. The nurse called the day before the last dose was
to be given and found the patient did not have any med­
Exhibit 3
Patients at Risk for Low Health Literacy
• Elderly
• Limited education
• Ethnic minorities
• Did not speak English in their childhood home
• Unemployed
• Limited income
• Medicaid beneficiaries
Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003
National Assessment of Adult Literacy. U.S. Department of Education. National Center for Education Statistics (NCES)
Publication No. 2006­483; September 2006.
Exhibit 4
Clues and Red Flags in Health Literacy
Behaviors
• Patient registration forms that are incomplete or inaccurately completed
• Frequently missed appointments
• Noncompliance with medication regimens
• Lack of follow­through with laboratory tests, imaging tests, or referrals to consultants
• Patients say they are taking their medication, but laboratory tests or physiological parameters do not
change in the expected fashion
Responses to receiving written information
• “I forgot my glasses. I’ll read this when I get home. I don’t have time today.”
• “I forgot my glasses. Can you read this to me?”
• “Let me bring this home so I can discuss it with my children.”
Responses to questions about medication regimens
• Unable to name medications
• Unable to explain what medications are for
• Unable to explain timing of medication administration
Source: Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians, 2nd edition.
Chicago, IL: American Medical Association Foundation, 2007, page 17. Available at www.ama­assn.org/ama1/pub/
upload/mm/367/healthlitclinicians.pdf.

6. 38
JULY/AUGUST2013
learning good technique and becoming more indepen­
dent, but the sheer volume of information regarding
home infusion often means we leave behind printed
materials to reinforce teaching and as quick reference
tools. Many patient education materials are written on
a high school or college reading level, mostly because of
the medical­ and science­related terms they contain
that relate to diagnosis, medications, and so on. Yet,
the average reader in the U.S. cannot read and compre­
hend above an eighth grade level.34
Therefore,
providers are tasked with adapting materials so
patients and caregivers can comfortably review them
during the course of their infusion therapy.11
When developing written information for patients,
consider using more pictures and diagrams—and white
space—and less wording (see Exhibit 6 for a “Before
and After” example). When speaking with patients, use
terms that they may be familiar with, or relate the mes­
sage to something they know. For example, visualizing
a central venous access device as a straw could help
patients understand the device better when explaining
how it may become kinked or blocked. We can com­
pare using a thrombolytic to resolve a fibrin occlusion in
a catheter to opening a clogged sink with drain cleaner.
The concept of “health coaching” has grown in pop­
ularity over the past few years and is the subject of sev­
eral Medicare pilot studies. This model involves part­
nering with patients to enhance self­management
strategies for the purpose of preventing exacerbations
of chronic illness and supporting lifestyle change.35
Clinicians in home and specialty infusion are often a
trusted point of contact for patients and families, and
this rapport can be the basis for a coaching relationship
whereby the clinician effectively motivates behavior
change through a structured, supportive partnership.
The coach helps the participant to clarify goals and
provides insight into goal achievement through inquiry,
collaboration, and personal discovery.36
Coaching tech­
niques incorporate active teaching as well as active lis­
tening. Active listening means that the clinician will
work from the patient’s agenda. Common questions
that the clinician might ask the anti­infective infusion
patient mentioned earlier would include:
• What is most important to you about your condition
at this time?
• What concerns you the most about administering
your own intravenous medication?
• What outcome would you like to see regarding your
condition after you receive this medication?
By listening to these responses, the clinician can help
guide the educational process to meet the patient’s
own values and goals for therapy—thus, increasing the
likelihood of success.11
Continuing Education
www.nhia.org/CE_Infusion
administered in three minutes.27
The test and related infor­
mation is available at www.pfizerhealthliteracy.com/public­
policy­researchers/NewestVitalSign.aspx.
Whether or not you suspect a problem—or make it a
practice to test your patients’ skills—the end goal
should be communicating effectively in order to
enhance the patient’s understanding of the vital health
information being presented. Effective communication
between patients and clinicians has been shown to
improve overall health outcomes by reducing anxiety,
pain, and psychological distress, and increasing rates of
compliance and symptom resolution.28,29
Methods for Improving Health
Literacy
There are strategies clinicians can use to enhance
patient and caregiver understanding of health informa­
tion. The first of which is using “plain language” with all
patients. This means choosing smaller words and short­
er sentences, avoiding medical jargon, and minimizing
information about anatomy and physiology.
It’s important to note that speaking in simple terms does
not necessarily mean “dumbing down” the information.
Studies show that patients don’t understand, or forget, at
least 50% of what’s discussed in a typical physician’s office
visit, leaving much room for improvement.30
It was also
noted that of the 50% of information patients do remember,
up to half may be recalled incorrectly.31
Since only 12% of
Americans can be considered “proficient” in health literacy
skills, experts recommend adopting the practice of using
simple terms as a “universal precaution.”32
There are other ways we can improve our communi­
cation with patients and caregivers. Reducing our
reliance on print communications, focusing on actions
more than information, and becoming more aware of
cultural differences are all recommended practices (see
Exhibit 5 for ideas).33
Home and specialty infusion providers incorporate
many of these techniques into their patient education.
Demonstrations and teach­back are cornerstones of

7. JULY/AUGUST2013
39
Conclusion
Often as clinicians, we don’t give much thought to indi­
vidual learning styles and levels of readiness to receive
and process health information, which goes far beyond
basic literacy. When we teach our patients and care­
givers, we need to assess their understanding of what
they have been taught, and ensure that they compre­
hend information and instructions, recognize why it’s
important to be compliant, and take ownership of their
health care plan of treatment.
In addition, we need to be more aware of what health
literacy is and its impact on clinical outcomes. From
there, we can begin to adjust both our oral and written
communications with patients and caregivers to
achieve a constellation of benefits. By doing so, we will
not only improve the outcome of a single episode of
care, we can also engage patients and encourage them
to be more informed regarding their diagnosis, more
involved in their treatment options, and more invested
in their own health care.
References
1. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS.
Impact of medication adherence on hospitalization risk
and healthcare cost. Med Care. 2005;43:521­530.
Continuing Education
www.nhia.org/CE_Infusion
Exhibit 5
Tips for Improving Health Literacy
• Use plain language
▲ Choose simple words (1­2 syllables) with no medical jargon
▲ Speak in short paragraphs (2­3 sentences)
▲ Show or draw only simple pictures
▲ Minimize information about anatomy and physiology
▲ Slow down
▲ Create a shame­free environment
▲ Encourage questions
• Focus on key messages and repeat
▲ Give the most important information first
▲ Limit information by focusing on 1­3 key messages per visit
▲ Review key points several times
▲ Emphasize patient action
▲ Have other staff reinforce messages
▲ Prioritize what is most important
• Use culturally and linguistically appropriate messages
▲ Use a medically trained interpreter if necessary
▲ Elicit cultural beliefs and attitudes
▲ Be aware of body language
• Design messages that are patient­centered and require participation
▲ Use a “teach­back” or “show me” technique to check for understanding
▲ Welcome questions
▲ Employ several learning methods (printed materials, interactive tutorials, and return demonstration)
• Engage regularly with the patients/communities being targeted by the communication; consider their overall lit­
eracy level
• Evaluate the effectiveness of your communications
▲ Remember the acronym SPEAK:
■ Speech ­ How will my speech be received by the patient and/or caregiver?
■ Perception ­ How will the patient and/or caregiver perceive both the verbal and written content during
the communication with me?
■ Education ­ What is the education level of the patient and/or caregiver?
■ Access – How will the patient and/or caregiver access the health care system?
■ Knowledge – How will assessment of health literacy be carried out, and what tools will be used?
Source: U.S. Department of Health and Human Services Quick Guide to Health Literacy Available at
www.health.gov/communication/literacy/quickguide/healthinfo.htm

8. 40
JULY/AUGUST2013
2. National Council on Patient Information and Education.
Enhancing prescription medicine adherence: A national
action plan. August 2007. Available at: www.talka­
boutrx.org/documents/enhancing_prescription_medi­
cine_adherence.pdf (accessed 7/1/2013).
3. Cutler DM, Everett W. Thinking outside the pillbox:
Medication adherence as a priority for health care reform.
N Engl J Med. 2009 Apr 7.
4. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and
severity of adverse events affecting patients after dis­
charge from the hospital. Ann Intern Med.
2003;138(3):161–7.
5. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events
due to discontinuations in drug use and dose changes in
patients transferred between acute and long­term care
facilities. Arch Intern Med. 2004;164(5):545–50.
6. Coleman EA. Falling through the cracks: challenges and
opportunities for improving transitional care for persons
with continuous complex care needs. JAGS.
2003;51(4):549–55.
Continuing Education
www.nhia.org/CE_Infusion
Exhibit 6
Revamping Written Patient Communication for Better
Comprehension
BEFORE
Wash Your Hands!
This is one of the biggest ways you can prevent infections.
1. Turn on the tap and wet your hands
2. Apply an antibacterial soap
3. Wash your hands for at least 20 seconds, scrub fingers, thumbs, back of hands and wrists
4. Rinse well
5. Use a paper towel or clean towel to dry your hands thoroughly
6. Use the towel or paper towel to turn off the water.
AFTER
Wash Your Hands!
This is one of the biggest ways you can prevent infections.Clean Your Hands!
1.
WET
Clean Your Hands!
2.
SOAP
Clean Your
3.
WASH
20 seconds
ean Your Hands!
4.
RINSE
Clean Your Hands!
5.
DRY
Clean Your Hands
6. TURN OFF WATER
WITH PAPER TOWEL

9. JULY/AUGUST2013
41
7. Institute of Medicine (IOM). Health Literacy: A
Prescription to end confusion. 2004. National Academies
Press, Washington, DC.
8. Ratzan SC and RM Parker. 2000. Introduction. In National
Library of Medicine current bibliographies in medicine:
Health literacy, edited by Selden C, Zorn M, Ratzan SC, and
Parker RM. Bethesda, MD: National Institutes of Health,
U.S. Department of Health and Human Services.
9. Central Intelligence Agency (CIA). The World Factbook.
Available at https://www.cia.gov/library/publications/the­
world­factbook/fields/2103.html (accessed 7/1/2013)
10. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health
Literacy of America’s Adults: Results from the 2003
National Assessment of Adult Literacy. U.S. Department
of Education. National Center for Education Statistics
(NCES) Publication No. 2006­483; September 2006.
11. Epperson LA. Patient, caregiver and clinician education:
Key components to positive patient outcomes in home
infusion. 2011. INFUSION. 17(5):22­27.
12. Weiss BD, Hart G, McGee D, D’Estelle S. Health status of
illiterate adults: Relation between literacy and health sta­
tus among persons with low literacy skills. J Am Board Fam
Pract.1992;5:257­264.
13. Baker D, Parker R, Williams MV, Clark WS, Nurss J. The
relationship of patient reading ability to self­reported
health and use of health services. Am J Public Health.
1997;87:1027­1030.
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