# Presentation: 032987

## Easy to Read: Health and     Wellness Material for Consumers: 	Recognizing It, Finding It, Writing It,		 Rewriting It...

** **
- _[bwesc001@umaryland.edu](mailto:bwesc001@umaryland.edu)_
**NN/LM SE/A 1-800-338-7657**

- _[bwescott@hshsl.umaryland.edu](mailto:bwescott@hshsl.umaryland.edu)_
**NN/LM SE/A 1-800-338-7657**

**Notes:**
Movement away from “low literacy”
US gov’t using “plain language”
NCI uses “Clear and Simple”
FDA and NCADI use “easy to read”

##    Determinants of Health

**Income**
-   &
**Benefits**

**Gender**

**Occupation**
- Exposure, Control

**Education**

**Race /Ethnicity**
- Discrimination
- Bias

**Literacy**!!

-       **Age**

## Slide 3

## Health Literacy Skills

## Literacy and Age:

**Percentage of Population **
**Reading at Basic and Below Basic Level**

| Overall Population | Age, 16-18 | Age, 19-24 | Age, 25-39 | Age, 40-49 | Age, 50-64 | Age, 65+ |
| --- | --- | --- | --- | --- | --- | --- |
| 43% | 48% | 40% | 37% | 38% | 40% | 
61%
 |

- http://www.p4chc.org/health-literacy.aspx

## Prose Literacy

## National Adult Literacy Survey (NALS)

-  Most comprehensive study ever conducted.
-  Was repeated in 2004 with some health-related
- 	items. Results came out in 2006.
-  Surveyed over 26,000 adults.
-  Divided literacy tasks into 5 levels (not grade
- levels).
-  Level 1 is least proficient.
- Level 5 is most proficient.

## Prose Literacy - NALS

- <date/time>

**Prose Literacy - NALS**

## Prescription Label:If you were going to eat lunch at noon, what time should you take the medicine before lunch?

**Prescription Label:**

## Appointment Slip (Document):When is your next appointment?  Where?

## Newest Vital Sign

## Document Literacy - NALS

## Quantitative Literacy - NALS

## Reading Levels for Your Materials

- 6th-8th “grade” level = general public
-     which is NALS level 3
- 3rd-4th “grade” level = adults with limited literacy skills
- 	which is NLAS level 1+

## Stats and Facts - 

- 38% of job applicants were deficient in math reading, & writing. American Management Association, 1999* . *
*34.1% failure rate improves slightly from previous year, other forms of testing in decline*
*NEW YORK, May 8, 2001*
- Implications for Health and for Health Care:
- Disease Prevention
- Disease Management
- Decision Making

## CLAS Standards:Culturally & Linguistically Appropriate Services at www.omhrc.gov/clas/ 

- 14 National Recommended Standards: _inform_, _guide_, and _facilitate_ implementation of CLAS.
- Three themes:
- Culturally Competent Care (1-3);
- Language Access Services(4-7);
- Organizational Supports for Cultural Competence (8-14).

## Levels of Literacy per NALS and NAAL 

## What Happens?

- Limited general knowledge
- Do not ask for clarification
- Focus on details, hard to get them to prioritize
- Don’t understand Likert scales, math
- Deal in literal/concrete concepts, not abstract
- Essential vocabulary only
- Check answers without understanding

##  After being diagnosed with recurrent aphthous stomatitis involving the epithelium of the buccal mucosa, Winston did what he thought was necessary

**which is a funny thing to do for a canker sore**

## Clear Health Communication

**Agree** on purpose and audience
**Limit** content.
**Involve** the reader.
**Make** it easy to read.
**Make** it look easy to read.
**Select** visuals that clarify and motivate.

**Clear Health Communication**

## Factors Affecting Learning Ability

## Health Literacy Is Necessary for:

- Pill bottles
- Appointment slips
- Informed consents
- Discharge instructions
- Health education materials
- Insurance applications

- Medication
- Take as directed

- Dr. Hammond

- The ability to read, understand  and act on health care information.

## Write “easy to read”  also known as   clear health communication

**Tips for Writing**

## Keep the writing style simpleUse present tense & action verbs!

- Wrap the cut in a clean cloth.
- Keep it dry.
- _Use_			_Avoid_
- consider	    give consideration to
- pay		    make payment
- concerns     	    is concerned with

## Use active voice

- Roll to the left
- Put your feet on the floor
- Sit up
- Grab the railing
- Push to stand

##   Active		  vs	Passive

- You must sign	  It shall be signed
- We will notify you   You shall be notified

## Develop the sequence of information/instructions logically

- Wash yourself in warm water
- Rinse all over
- Dry well
- Pat toes dry
- Pull on clean, dry white cotton sox

## Use short words and sentences

- Return in one week
- Bring your log with you
- Sign in
- Copy the log
- Put the copy in the folder in tray “A”

## Use				Avoid

- So				Accordingly
- Allow			Afford an opportunity
- Later			At a later date
- Near			Close proximity
- If				In the event that
- Must			Incumbent upon
- Use			Utilize

## Avoid double negatives*

- Don’t forget to come back next week
- Without your log the visit will be useless
- So nobody will see your private log, you will not leave it in a public place
- 		 * Rewrite the above
- _Use_			_Avoid_
- He was present	He was not absent
- It will be effective	It will not be ineffective

## Avoid confusion, use consistent words and phrases

- Plan your meals a day ahead
- Eat three meals and two snacks a day
- Drink water often every day

## Watch out for

- nothing to show what’s important
- titles don’t give enough information
- directions buried in the text
- poor organization of material
- too much information
- irrelevant information
- material continued on another page
- From: _[http://www.on.literacy.ca/pubs/clear/clearite.pdf](http://www.on.literacy.ca/pubs/clear/clearite.pdf)_

## Use large, clean fonts and bold appropriately

- For text, use 12 points or larger font size
- Use Ariel or Tahoma, avoid script
- Use upper and lower case letters
- Bold headings and subheadings

## Use extra white space to separate sections

- Avoid clutter
- Use visual separation to help a topical separation

## Supplement instructions with pictures

- Use age, gender, ethnically appropriate illustrations
- Consider age of intended readers
- Consider diversity issues
- Use current styles
- Get user input for color choices

## Place accurate illustrations close to the related text

- This includes directions, charts and examples
- Text and pictures must agree, not conflict
- Pictures must be medically accurate and target the appropriate audience

## What Else Can You Do?

- Some people become confused about whether this entry was intended for ambulances or for patients

- The use of visuals clarify the message
- Contrast in color makes it easy to read
- Try to be consistent when hanging signs

- People Have Trouble Reading Signs so Add Visuals  _[http://www.askme3.org/PFCHC/professional](http://www.askme3.org/PFCHC/professional)_ __presentation.ppt#407,50,What Else Can You Do?_

##    Use Pictures That Relate

- http://www.dhs.ca.gov/dcdc/izgroup/pdf/imm747e.pdf

## Remember: Health Communication about Chronic Disease Management Needs to Reach a Broad Consumer Audience

**What You Need to Know About Low Blood Sugar**
- Treat low blood sugar quickly. If you have signs of low blood sugar, eat or drink something that has sugar in it. Some things you can eat are hard candy, sugar-sweetened soda, orange juice, or a glass of milk. Special tablets or gel made of glucose (a form of sugar) can be used to treat low blood sugar. You can buy these in a drug store. Always have some of these items handy at home or with you when you go out in case your blood sugar drops too low. After treating a low blood sugar reaction, eat a small snack like half a sandwich, a glass of milk, or some crackers if your next meal is more than 30 minutes away.
- Source: The National Institute of Diabetes and Digestive and Kidney Diseases

**Remember: Health Communication about Chronic Disease Management Needs to Reach a Broad Consumer Audience**

***70***

***150***

- Blood Sugar Is Too ***Low*** if It Is Under 70

- Blood Sugar Is Too ***High*** if It Is Over 240

**Good ****Range**

**Too****High**

**Too****Low**

**9th Grade Reading Level**

- _[http://www.askme3.org/PFCHC/professional](http://www.askme3.org/PFCHC/professional)_
- __presentation.ppt#382,16,Example of Health _
- _Communication That  May Not Reach a Broad Consumer Audience_

## Use simple grids to lessen the amount of text

- A chart of two columns with four rows may easily replace two paragraphs
- Food groups and portions fit well in a grid

## Question-and-answer format is especially helpful

- Anticipate the reader's questions and pose them as the reader would.
- What is cancer?
- Can I get breast cancer?
- What causes cancer?
- Can cancer be cured?

## Decide what you want them to do 

**Determine who you want to reach **
**Decide what you want them to ****do **
**Choose the right reading level **
**Write easy-to-read materials **
**Create clear graphics**
**>>>>>**** leads to Clear Health Communication**

**5-step approach to make sure that **
**your  target audience can understand**
**your  message**

##   Arrange sentences so that parallel    	ideas look parallel.

- The duties of the Chair are:
-           (parallel)
- to approve the minutes
- to write the monthly reports
- to answer all correspondence

- The duties of the Chair are:
-       (not parallel)
- to approve minutes
- writing of monthly reports
- the Chair answers letters

## Simple, Parallel, Short Phrases for “You” 

## Images of Battery Infusion Pump

## Plain Language Rewrite

- Immunizations can cause a child to
- experience irritability, a low fever, or a small
- lump at the injection site.
- After getting her shots, your child may:
- be cranky
- have a low fever
- have a small lump where the shot was given

## Rewrite Examples: Voluntary Nature of Participation

- “You voluntarily consent to participate in this research investigation.  You may refuse to participate in this investigation or withdraw your consent and discontinue participation in this study without penalty and without affecting your future care or your ability to receive alternative medical treatment at the University.”   (College)
- http://www.iom.edu/Object.File/Master/37/039/From%20Readability%20to%20Comprehension3.ppt#300,12,Examples: Voluntary Nature of Participation

- “You don’t have to be in this research study. You can agree to be in the study now and change your mind later. Your decision will not affect your regular care.”  (4th)

- (College)

## Sample Exercise in Rewriting

- Literacy and the Older Adult, from Topics in Geriatric Rehabilitation, Oct-Dec2005, Vol. 21 Issue 4, p275

## Rewrites: altered using the CHCS guidelines 

##      6 Simple Steps to Use

- Slow down
- Use living room language
- Show, draw pictures
- Limit information; repeat instructions
- Use a “teach back” or “show me” approach to confirm understanding
- Be respectful, caring, sensitive

## Health Information Can Be Confusing

- Everyone wants help with health information
- You are not alone if you find health information confusing at times
- Asking questions helps you understand how to stay well or to get better

*It Is Important to Be Prepared to Talk to Your Health**Care Provider- Doctor, Nurse or Pharmacist–**** ***
***Don’t Be Nervous to Ask Questions! 1,2,3 Questions!!!***

## Ask Me 3 – Good Questions for Your Good Health. At Your Next Health Care Visit:

- Ask Your Doctor, Nurse or Pharmacist

- _http://www.askme3.org/PFCHC/professional_presentation.ppt#358,1,Advancing Clear Health Communication to Positively  Impact Health Outcomes_

## Remember, Medical Studies Indicate Most 

- <date/time>

**Remember, Medical Studies Indicate Most **
**People Suffer a 68%****Hearing Loss When Naked.**** **

**    ****http://www.unitedhealthfoundation.org/tips/doc_ad.pdf**

## bwescott@hshsl.umaryland.edu

- Write easy-to-read, user-friendly    phrases
- Know your facts, your audience and your material
- Focus materials on desired behavior rather than on medical facts.
- Use clear health communication!!
- Review with staff and clients, annually
**Use feedback or it will ****stop!**

## Part 2

- for Health Educators,
-  in whatever guise
**Patient Skills Development**

## Part II Skills Development   Goals: 

- Clients will develop the skills necessary to ensure their health, and well-being
- Clients will develop skills related to preventing injuries

## A New Paradigm

- Determine patients’ learning capabilities
- Use audiovisual aids as adjuncts or primary learning materials
- Comprehension testing for key points
**Show me or Teach Back**
- GOAL: Patient Empowerment

## Skills development 			-2

**will** comprehend concepts related to health promotion and disease prevention

**will** demonstrate the ability to access valid health information and health-promoting products and services

## Skills development				-3

**will** demonstrate the ability to practice health-enhancing behaviors and reduce health risks

**will** analyze the influence of culture, media, technology, and other factors
-    on health

## Skills development				-4

**will** demonstrate the ability to use interpersonal communication skills to enhance health

**will** demonstrate the ability to use goal-setting and decision-making skills to enhance health

## Skills development				-5

**will** acquire and apply health promoting knowledge, skills and behaviors

**will** develop the knowledge and behaviors that relate to dietary habits and fitness activities that promote health

## 		Part III Internet Resources

**# 1    MedlinePlus.gov**
**See also: **_[http://www.nlm.nih.gov/medlineplus/tutorial.html](http://www.nlm.nih.gov/medlineplus/tutorial.html)_
- Interactive health education resources from the “Patient Education Institute.”
- Information is read simultaneously, so tutorials help the visually impaired, too.

## Slide 64

- CHID: Combined Health Information Database _[http://chid.nih.gov](http://chid.nih.gov/)_ CHID Discontinued 9-1- 2006
- CHID lists a wealth of health promotion and education materials and program descriptions that are not indexed elsewhere. See especially the subfile “Health Promotion and Education”
- National Women’s Health Information Center, Breastfeeding_[http://www.4woman.gov/search/siteresults.cfm?criteria=breastfeeding&searchtype=site](http://www.4woman.gov/search/siteresults.cfm?criteria=breastfeeding&searchtype=site)_

## http://nihseniorhealth.gov/

**Text Size: **
**Contrast: on off **
**Speech: on off **
**The web site's senior-friendly features include large print, short, easy-to-read segments of information and simple navigation. A "talking" function reads the text aloud and special buttons to enlarge the text or turn on high contrast make text more readable.**

## NLM’s NNLM’s Training Site

- _[http://www.nnlm.gov/training](http://www.nnlm.gov/training)__/_
- 	Easy-to-Read Consumer Health 	Information
- Federal, national and regional resources
- _[http://nnlm.gov/training/classes.html](http://nnlm.gov/training/classes.html)_

## AHRQ – Agency for Health-care Research and Quality

_**http://www.ahrq.gov**_
- Consumer versions of clinical practice guidelines, including:
-  		alzheimer’s disease,
- 		cancer pain,
- 		cardiac rehabilitation,
- 		cataract,
- 		ear fluid in young children,
- 		heart failure,
- 		low back problems,
- 		mammograms,
- 		recovering after stroke...

## U.S. Food and Drug Administration

- _http://www.fda.gov/opacom/lowlit/7lowlit.html_
- _http://www.fda.gov/opacom/lowlist.html_
- _[http://www.fda.gov/opacom/lowlit/spanlow.html](http://www.fda.gov/opacom/lowlit/spanlow.html)_
- HTML, PDF, English, Spanish

- FDA Healthy Heart

##   NCADI- National Clearinghouse for Alcohol and Drug Information

- Technical Assistance Bulletin:  You Can Prepare Easy-to-Read Materials
- _[http://ncadi.samhsa.gov/govpubs/MS499/](http://ncadi.samhsa.gov/govpubs/MS499/)_
- Easy-to-read materials are for everyone – because everyone benefits from materials that are clear and concise.
- Use the 5-step approach...

## Plain English/Plain Language

- _[http://www.plainlanguage.gov/howto/quickreference/glance.cfm](http://www.plainlanguage.gov/howto/quickreference/glance.cfm)_
- The business of government in the language of the people

## Non-English Language Resources

- _[http://www.mgh.harvard.edu/library/chrc/noneng.html](http://www.mgh.harvard.edu/library/chrc/noneng.html)_
- A three page webliography of multi-lingual health/wellness information sources
- Maintained by Treadwell Library, Massachusetts General Hospital