CPL Workshop-Fall 14: Plain Language: A Tool to Promote Health Literacy (Karen Baker)

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Center for Plain Language Workshop
Fall 2014

Plain Language: A Tool to Promote Health Literacy
Karen Baker
http://www.healthwise.org

Overview
In this interactive workshop, you will learn the many ways that plain language can help people understand health information and engage with the health care system. Understand who struggles with health literacy and why. (It can happen to any of us.) Learn how to use plain language techniques to promote understanding.

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  • First, some comic relief that I hope proves the value of plain language, and the Center for Plain Language, who is sponsoring this workshop…

    WonderMark Award from last year…
  • Today’s health literacy agenda… It’s the reason for any discussion about plain language.

    Almost 9 out of 10 adults have trouble using everyday health information. Nearly 36 percent of America’s adult population — 87
    million adults — is considered functionally illiterate.

    Then we’ll talk about plain language as a tool to improve HL a little later…
  • Patients can’t engage in their care unless they have information and understand their options, the risks and benefits, and think about their preferences and values. Health literacy means that both two-way communication and two-way understanding are happening.

    Engaged patients means better outcomes!

    Nearly 9 out of 10 adults have difficulty using health information to make informed decisions about their health.

    And the reality is: We likely all will have low health literacy at some point in our lives. It’s not just about how much education we have had.

    Education level, native language, age, socioeconomic status—they all increase the chances of low health literacy. But also: pain, fear, anxiety, confronting a decision, influence of meds. And, most people just are not familiar with the language of health care, no matter how educated they are. It is like a foreign language. And think about how you responded in an emergent situation…

  • In 2013, Organization for Economic Cooperation and Development released results of the International Assessment of Adult Competencies (PIAAC), comparing the skill levels of adult workers in 24 developed countries.
    The U.S. ranked 16th in literacy, 21st in numeracy, and 14th in problem solving using technology. Approximately one in six adults in the U.S. have low literacy skills and nearly one third have weak numeracy skills. 

    The next numbers relate to health literacy, specifically:

    The 2003 National Assessment of Adult Literacy (Dept. of Education) for the first time studied health literacy in the United States:

    --77 million people in the U.S.—more than 1/3-- have trouble understanding and using health information.

    --Only 53% of adults are proficient enough to read a pill bottle label.

    --238 billion = The economic drain is huge: Low health literacy is a major source of economic inefficiency in the U.S. healthcare system. One report by the University of Connecticut in 2007 estimated the costs at between $106 billion to $238 billion annually—between 7 percent and 17 percent of all personal healthcare expenditures.

    In 2030 The Education Testing Service predicts a Health Illiteracy Epidemic, given aging demographics, changing economy, declining literacy skills. High-school graduation rates peaked in 1969 and have been stagnant since 1995; reading and math skills of our school-aged kids, especially Hispanics and African Americans, has not improved much in the last few decades.
    So, given these trends and the aging of the population, low health literacy is expected to reach “epidemic” proportions by 2030—when entire baby boom generation is retired and when these now new-elderly are dealing with chronic diseases—and there are likely to be an insufficient number of primary doctors to help.

    And remember… Health literacy is a greater predictor of health status than income level, education, age… all of the traditional factors.

    What an opportunity for Plain Language!
  • Low literacy is associated with many adverse conditions and events—all of which add up to big dollars and poor outcomes. For example, people with limited health literacy are:

    Less likely to get a flu shot
    Unable to take meds correctly
    Less likely to get mammograms

    One study: While 98% of patients understood the term vomit, only about 1/3 understood the word orally, 18% understood malignant and just 13% the word terminal.  In this same study, the physicians thought they were actually switching to everyday language when communicating with patients.  Unfortunately those with low health literacy are less likely to ask questions of their physician.

    In terms of decision making, people with lower health numeracy—an aspect of health literacy--tend to overestimate their risk of disease and mortality, and they tend to overestimate treatment benefits, which can lead to a bias towards high-cost, more significant interventions.

  • Patient Protection and Affordable Care Act

    AHIP: Report earlier in year describes literacy programs of 30 insurers.

    PWA: requires the federal government to write all new publications, forms, and publicly distributed documents in a “clear, concise, well-organized” manner that follows the best practices of plain language writing. (Plain Regulations Act is pending.) Center for Plain Language was behind the Plain Writing Act and is advocating for the PRA—go to website to lend your support!

    Plain Language movement is growing around the world! “Details of a new petition being organised by the National Adult Literacy Agency (Nala) and calling for plain English to be used by Government have been unveiled in Dublin. The petition asks that all public information produced by Government and its agencies is written in plain English. ”

    Patient portals: Article in Wall Street Journal recently about radiologists pushing for clear communication. Recent letter in American College of Radiology Journal calls for better writing skills, to enhance patients’ understanding of imaging results. Lead author Michael Bruno at Penn State has been teaching workshops for radiology residents: emphasizes brevity, simple sentence construction, careful word choice to avoid ambiguity or misunderstanding.


  • When we think about health literacy… it includes so much more than being able to read a Patient Instruction.

    Look at all the places where literacy skills are needed in a health care environment: Medical history forms, signage at hospitals (What is “OPD”? “Service block”?), reading a label for a prescription, understanding an immunization schedule…

  • Study published in American Journal of Emergency Medicine in 2000:
    249 emergency room patients… 79 percent did not know that the word hemorrhage was the same as bleeding… 78 percent did not know that a fracture was a broken bone. Not illiterate population. 45 percent of the people in the study were college educated.
  • Literacy matters.

    People with low health literacy:
    Have less knowledge about their conditions.
    Have poorer disease control.
    Use preventive health services less.
    Ask fewer questions in visits.
    End up in the ER more.

    Research has shown that, in most contexts, health literacy is a more important predictor of health than race, socioeconomic status, or educational level.
    (Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107)
  • Dr. Dean Schillinger is a physician at University of California San Francisco who studies health literacy and how it impacts care.

    People who function perfectly well in other domains—work or home—may struggle in health context.
  • Using plain language is a strategy to address low health literacy that we all are committed to. The Center for Plain Language has been advocating for PL—and framing it as a RIGHT (Demand to understand!)—for more than 10 years.

    Plain language is about more than just how we write, though that is key. These 5 steps are included in various ways and words on a lot of PL checklists, including the Center for Plain Language. And remember, it’s all about clear communication.
  • People with low health literacy often have poor reading skills--whatever the reason. And there are many of them. 32 million adults in the US cannot read. That’s 14 percent of the population. Probably some of them are in your audience. (US Dept. of Education and the National Institute of Literacy)
  • Read: (Hint: the words are backwards.)

    Hold handle, and guide floss between teeth using a gentle back-and-forth motion. Move floss up and down against your tooth to help remove plaque and food particles above and below the gumline. Rinse floss as needed, and repeat for each tooth. To use the pick, place the tip of the pick between your teeth at the gumline…


  • KNOW YOUR AUDIENCE! Demographics, health status, where they are on their health journey, think about what’s the best way to engage them? (May not be words alone…) What tone will work best?

  • Factors other than education level and reading ability affect people’s ability to understand health information. Any of us could have low health literacy.
  • As you think about the audience…
    Yes, words matter—use examples like pasta AND tortillas, e.g.

    When you’re trying to communicate information, it needs to be relevant to the audience—the people receiving it. They need to be able to relate—and images can help or hinder that and whether you achieve clear communication.

    Know your audience. We live in a diverse world and we can’t always know who is reading our content or looking at our videos. Keep that in mind when you are planning imagery—and examples--in health information.

  • People can’t handle too much information at once. Make it easy for people to do tasks, to understand and remember—and act.
  • How well are these pages from an asthma workbook organized for the reader? What would you do differently?

    Headings not very helpful… Need verbs on page 2!
    What problems does this help the patient help solve? Hard to tell.
    Lots of text… Needs more leading…
    Little white space, quite intimidating…
    No hierarchy; hard to tell what’s most important… When to get help/Call 911 is at bottom right… Seems important!
  • Here’s a learning module on Asthma.

    Headings are clear, no ambiguity.
    White space helps make it inviting. Not so intimidating.
    Key concepts and takeaways about inhaler use are short and easy to scan: Check it. Track it. Toss it. (Maybe too “cute”?)

    It’s actionable; user knows what to DO. That is how we engage patients…
  • Lots to say about writing clearly, but these 5 tips will help you communicate more clearly. Imagine you are talking to a friend in your living room…


  • Songwriters know to use active voice in an effort to be clear and communicate with their listeners. Name these tunes—in the active voice, as the songwriter wrote them!

    The last one—to bring us back to health information: How would you rewrite it?
    Remember: Subject—verb--object, in that order. Start with the person doing the action—not the person or thing having something done to it. More direct, more clear.
  • One idea per sentence is how people talk. Read out loud to see if it’s choppy. (ALWAYS READ WHAT YOU WRITE OUT LOUD!) Use transitions as needed. (Starting sentences with “and,” “but,” and “so” can call attention to breaking things up into shorter sentences, so use those words thoughtfully.)

    Shortening your sentences is a quick and effective way to lower the reading level—which we’ll talk about in a minute.

    How can we shorten these sentences so the content is easier to read?

    --Maybe you’ve heard about different treatments for knee osteoarthritis. And maybe you’ve wondered which ones work and how you can help yourself.
     
    --Many people can manage knee pain for a long time without surgery. Other treatments are generally safe. And you can do many of them on your own.

  • Talk TO the user, not ABOUT her. Acknowledge her experience—and tell her what she can do. See the bullets here.
    Use the 2nd person; make it personal and relevant.
  • Think of some plainer alternatives to these words that have multiple syllables.

    Eliminate jargon—and when you need to use a technical term, teach it!

    You can build your own Plain Language Glossary, or use one that others have developed…
  • Even easy words can be hard to understand if they are jargon that your audience isn’t familiar with. This paragraph is simple for people who have participated in a theater production, but it’s gobbledygook to anyone else. It uses easy words, mostly one-syllable, and short sentences, but they’re used in a way that people may not understand. Not everyone—no matter their education level—will understand the theater context. The same is true for health care.

    Some examples of words that are medical jargon … familiar words that are used in unfamiliar ways: Draw blood, dressing a wound, tissue…
  • Both paragraphs have a reading level of 5.8. Reading-level formulas measure things like word length and sentence length. But they can’t tell you if a piece of text makes sense.

    They don’t factor in syntax, context, how sentences and words are connected, what visual cues there are—and they don’t take into account the unique circumstances of the user.

    Use formulas as a tool—AFTER you follow Plain Language guidelines!.
  • The quickest way to lower reading level is to shorten sentences. But what should you watch out for when you do this? (Choppy sentences, sentence fragments, lack of cohesion)

    You should always read the content out loud. Why? You will be able to hear the rhythm of the sentences, and you’ll notice choppiness and lack of cohesion.

    No. Reading level is only one measure of readability. Also, conversational style, active voice, concrete examples and wording, establish context first and then explanation, make strong and logical connections between sentences and paragraphs, limit information to “need to know,” make purpose and usefulness obvious, be guided by the reader’s interests, be friendly and positive …
  • This is a discharge instruction given to cardiac patients upon leaving a hospital.
  • Key piece of Plain Language best practices.
  • Testing feedback example: Healthwise Study = 1,633 participants, asked about understandability and usability in eight condition areas.

    Among the changes recommended in response to feedback:
    In ADHD: Tests for Other Disorders, add more information about the tests. Of the 69 users who rated this piece of content, 27 said that it listed only the names of the tests. It did not explain what they are or why they are done. This is very helpful user feedback that will assist us in providing users the most relevant information to meet their needs.

    Add more hope to content for people who have chronic conditions, particularly depression. Possible changes could include creating new content or reframing and emphasizing existing content about hope, optimism, and coping.

  • In the immortal words of Winnie the Pooh, here’s one of my favorite quotes about Plain Language!
  • CPL Workshop-Fall 14: Plain Language: A Tool to Promote Health Literacy (Karen Baker)

    1. 1. Karen Baker, MHS September 30, 2014 Plain Language: A Tool to Promote Health Literacy
    2. 2. First: Health Literacy • What is health literacy? • Why is it so important? • How can we address it?
    3. 3. Engagement Depends on Health Literacy …”capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” --Healthy People 2010, 2000; IOM, 2004
    4. 4. Health Literacy by the Numbers 16, 21, 14 77,000,000 53 238,000,000,000 2030 5
    5. 5. A Human and Economic Toll • Patient safety • Rx adherence • ER utilization • Hospitalization • Prevention • Disease management • Costs • Mortality 6
    6. 6. Trends That Affect Health Literacy • More focus on prevention, self-care. • Aging population = more interventions. • Outcomes are being measured, incented. • Affordable Care Act mandates use of plain language. • Insurance industry is responding. • Patients are assuming more responsibility. • President signed Plain Writing Act in 2010. • Patients have access to EHRs.
    7. 7. An Unfamiliar Landscape… 8
    8. 8. …And a Foreign Language • “Your prostate biopsy was positive for cancer.” (In office) • “You should either take ciprofoxacin 1-2 hours before eating or drinking dairy products or avoid eating and drinking these products for four hours after taking ciprofoxacin.” (Drug leaflet) • “We’re going to draw some blood…” (In lab) • “The left atrium is markedly abnormal.” (EHR note) • “Anterior abdominal wall defect in region of umbilicus consistent with fat-containing umbilical hernia.” (Ultrasound report)
    9. 9. Why Does It Matter?
    10. 10. Health Literacy Universal Precautions Structure the delivery of health care as if everyone may have limited health literacy. • You can’t tell by looking. • Higher literacy skills ≠ understanding. • Health literacy is a state, not a trait. • Everyone benefits from clear communication. --Dean Schillinger, MD
    11. 11. Plain Language: A Solution That Works Steps To Success 1. Know your audience. 2. Organize your message. 3. Write clearly. 4. Design for your audience. 5. Test with users.
    12. 12. 1. Know Your Audience
    13. 13. Can You Read It? Dloh eldnah, dna ediug ssolf neewteb hteet gnisu a eltneg kcab-dna-htrof noitom. Evom ssolf pu dna nwod tsniaga ruoy htoot ot pleh evomer euqalp dna doof selcitrap evoba dna woleb eht enilmug. Esnir ssolf sa dedeen, dna taeper rof hcae htoot. Ot esu eht kcip, ecalp eht pit fo eht kcip neewteb ruoy hteet ta eht enilmug…
    14. 14. How Did You Do? • How did reading this make you feel? • Would you know what to do?
    15. 15. Readers With Lower Skills: • Take words literally. • Read slowly and miss meaning. • Skip over unknown words. • Miss context clues. • Tire quickly. • Get frustrated and give up.
    16. 16. Readers of Health Content May: • Feel stressed or fearful. • Be shocked at a diagnosis. • Not feel well at this moment in care. • Worry about how they’ll pay their medical bills. • Have limited time with the doctor. • Be on medicine that impairs them.
    17. 17. Know Your Audience… It’s Not Just About the Words • Race/Ethnicity • Age • Gender • Socioeconomic status • Body type • Relationship depicted • Provider (if shown) ethnicity and gender
    18. 18. 2. Organize With the User in Mind • Put most important information first. • Have a purpose, and highlight it. • Chunk it! Use lists, bullets, tables, etc. • Write headings and subheadings that tell people what is coming and that they can scan.
    19. 19. 3. Write Clearly (Think Living-Room Language) • Use active voice. • Break up long sentences. • Focus on one idea. • Use pronouns. • Use familiar words. • Do not rely only on grade level to judge readability.
    20. 20. Get Active • It Was Heard Through the Grapevine By Me (Marvin Gaye) • You Will Always Be Loved By Me (Whitney Houston) • My Heart Was Left by Me in San Francisco (Tony Bennett) • You Are Loved by Her (The Beatles) • You may have been told by your doctor that you have osteoarthritis.
    21. 21. Shorter Is Better • Watch for long, complex sentences. Break them up into short sentences that focus on only one idea. Maybe you’ve heard about different treatments for knee osteoarthritis and wondered which ones work and what you can do to help yourself. Many people can manage knee pain for a long time without surgery. Nonsurgical treatments are generally safe, and you can do many of them on your own.
    22. 22. Get Personal
    23. 23. Find a Plain Alternative Contribute Lead to; Help cause; Add Demonstrate Prove; Show; Teach; Explain Difficulty Trouble; Problems Effective Works well; Useful; How well it works Evaluate Check to see if; Check; Rate; Decide; Think about Monitor Watch for; Keep track of; Check; Look for
    24. 24. Avoid Jargon Consider your audience. Now that you’re off book, remember how we blocked it. Enter up left, in front of the cyc. Cross down center, but arc the cross. When you get to the hot spot, cheat out, or your comic bit with the prop won’t read. And make sure to pick up your cues.
    25. 25. Beware the Formula Reading level is 5.8 Reading level is 5.8
    26. 26. If You’re Using a Formula… • What’s the quickest way to lower reading level? • What should you always do after you rewrite? • If the reading level is 6th-grade or lower, does it mean that your content is plain?
    27. 27. 4. Design to Help Users • Use headings and subheadings. • Use white space. • Pictures and/or videos help people learn. • Color and font can help people navigate. • Lists and bullets and boxes attract attention.
    28. 28. 5. Test With Target Audience • Test early, test often. • Test with people who are like your audience. • Test content, design, functionality. • Use test results to improve product. • Any testing is better than no testing!
    29. 29. The Results Are In… • “I did not know a lot of this information. Thank you for sharing it with me.” (Low-Salt Diets) • “This info was very helpful, since I had never had this condition explained to me.” (Diabetic Ketoacidosis) • “Give more background and information on the three tests listed.” (Tests for ADHD) • “Add some hope.” (Depression and Suicide)
    30. 30. To Sum It Up: 5 Things to Remember 1. Know your audience. (Anyone can have low health literacy.) 2. Organize your message. (Make it easy to follow.) 3. Write clearly. (You are in your living room…) 4. Design for your audience. (Use visual cues.) 5. Test with users. (Make sure you achieved the goal.)
    31. 31. It’s more fun to talk with someone who doesn’t use long, difficult words but rather short, easy words like “What about lunch?” -Winnie The Pooh
    32. 32. Thank you! If you have questions for the instructor or about the workshop, please contact: Karen Baker Healthwise kbaker@healthwise.org 208-345-1161 To learn more about the Center for Plain Language, go to: www.centerforplainlanguage.org Or contact: Rebecca Gholson gholsonr@gmail.com

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