ShiningaLightonHealthLiteracy:What’stheBottomLineforSurgeons?

UAB

Gastrointestinalsurgery

April24,2018

TerryDavis,PhDProfessorof

Medicine,PediatricsandFeist-WeillerCancerCenter

LSUHSC-S

DisclosureInformationTerryC.Davis,PhD

ResearchFunding• NIH,LouisianaClinicalandTranslationalScienceCenter.• AmericanCancerSociety- “HealthLiteracyInterventionstoOvercomeDisparitiesinCRCScreening"• PCORI:“AchievingPatient-CenteredCareandOptimizedHealthInCareTransitionsbyEvaluatingtheValueofEvidence(PROJECTACHIEVE)”• PCORI:“PromotingSuccessfulWeightLossinPrimaryCareinLouisiana(PROPEL)”• NIDDK– “HealthLiteracyInterventiontoImproveDiabetesOutcomesAmongRuralPrimaryCarePatients”

HealthLiteracy:WhatdoSurgeonsNeedtoKnow?

• Healthliteracy- theabilitytoobtain,understandandusehealthinformationandservices- significantly impactspatientunderstandingandoutcomes.

• Nearly9of10adultshavedifficultyusinghealthinformationthatisroutinelyavailableinhealthcarefacilitiesandthemedia.

• Physiciansoftenfailtograspthewidechasmbetweenwhattheywanttocommunicateandwhatpatientsunderstand.

• Mostconsentdocumentsarenotdesignedtotrulyinformpatientsaboutprocedures,orresearch— patientsmaynotunderstandbasicconcepts.

• Itisincreasinglydifficultforpeopletoseparateevidence-basedhealthinformationonlinefrommisleadingadsandgimmicks.

America’s Health Rankings 2015; Department of Education National Assessment of Adult Literacy; Koh Health Affairs 2012

HealthLiteracyAffectsSurgeon/PatientCommunication

•Askfewerquestionsingeneral•Askfewerquestionsaboutsurgeryprocedureandtherapeuticregimen

AndTherefore:• Lackadequateunderstandingofthesurgicalprocedureanddischargeinstructions•Makemistakeswithmedication•Havemoresurgicalcomplications

PatientswithLimitedHealthLiteracy:

Menendez,vanHoorn,Mackert.ClinOrthopRelatRes.2017

CommonHealthLiteracyCommunicationProblems

• Orthopedicstudy.250patientsat1stpost-opvisit

• 45%knewbonefractured,19%knewexpectedhealingtime,45%knew

weightbearingstatus.

• Surgerystudy.100patients

• 95%ofsurgeonsbelievedpatientsunderstoodwhentoresumenormal

activitiesvs.only58%ofpatients.

• Surgeonsonlyoccasionally(29%ofthetime)askedpatients

iftheyhadquestions— whentheydid,most(79%)had

questions

Roter, D. 2011 Nursing Outlook; Korsch, B. Pediatrics 1968; Castro C 2007 Am J Health Behav; Kadakia, J Ortho Trauma, 2013; Calkins Arch Intern Med, 1997.

TheRippleEffectofLiteracyonSurgery• PoorMD/patientcommunication

• Inadequateconsentprocess

• Poorunderstanding&adherencetopre- &post-opinstructions

• ImproperlytakingmedsThesemayresultin:• avoidablesurgerycancellations&postponements

• wastedORtime

• ↑hospitalexpense

• ↓patientoutcomes

• ↓patientsatisfaction

Koster,Schmidt,Philbert.JPublicHealth.2017;Miller-Matero,Bryce,Hyde-Nolan.Psychosomatics.2016

NationalAssessmentofHealthLiteracyAssessedfunctionalclinical,preventive,&navigationaltask

n=19,000Adults,152tasks(28healthrelated)

Circledateondoctor’sappointmentslip.(AA24%,Hispanic41%)

Intermediate

Proficient

Below Basic

Basic Determinewhenit’sokaytodrinkbeforeamedicaltestbasedonshortinstructions.

Determinewhattimetotakeprescriptionmedicinebasedonthelabel.

Calculateemployshareofhealthinsurancebasedontable.

NationalAssessmentofAdultLiteracy(NAAL):NationalCenterforEducationalStatistics,U.S.Dept.ofEducation,2003

14%

22%

53%

12%

LowHealthLiteracyisPrevalentinAL:RatesByCounty

8

HealthLiteracyLevelsProficientIntermediateBasicBelowBasic

2014

“PerfectStorm”ofPatientSafety

• 39.5millionhospitaldischarges/year

• 20%ofpatientshaveapost-dischargeadverseevent

Hospitaldischargeisnotstandardized”

• Looseends– pending&post-dischargetests

• Communication– withPCP,ESL,healthliteracy

• PoorInformation– dischargesummaryquality&availability

• PoorPreparation– knowledgeofdiagnoses,meds,f/uappointments

• Fragmentation– whoisincharge?

Hansen.AnnInternMed2013.;WilliamsM.SMedJournal2014.

MedicationErrors2daysafterHospitalDischargePharmDcall(n=197)

IncorrectAdministration %

Wrongfrequency/interval 21%

Wrongdoseonprescription 18%

Patientdidnotthinks/heneedsmed 15%

Patientdidnotfillduetocost 17%

Patientdidnotpickupfrompharmacy 11%

Patientdidnotgetprescriptionondischarge 12%

Patientself-discontinuedduetosideeffects 11%

Patientdidnotfillbecauseofinsurance 8%

Overall,51%experiencederrorwithin2days!Jack BW, Ann Intern Med 2009

WeNeedtodoaBetterJobofPatientCommunicationandSupport

• Lessthan1in5patientsrecallwhatdoctorstellthem.• 20%-30%donotfillinitialprescriptions.• Upto50%donottakeprescriptionsasrecommended.• Clinicvisittimesandhospitalizationsareshorter.• Patientsaskedtoperformmorecomplexself-care.• Patientsoftenneedhelpandsupportinchanginghealthbehaviorandsustainingimprovement.

Video:It’sEasytoMakeaMistake

MedicationError- MostCommonMedicalMistake1.5Madverseevents (patienterror>700,000,persistenterror)

• 2outof3patientsleaveMDvisitwithRx

• 4billionretailRxfilledin2014• Up50%-60%in10years

• 82%adultstakeatleastonemed

• Elderlyfill20Rx/year,see8physicians

• 1in6pediatricRxnotdosedcorrectly(study:4in5atleast20%off-dosewhencupsused).

• >300,000OTCmeds(>600containacetaminophen)

• MostlabelsandinsertsareinEnglishonly

U.S.CensusBureau,2009;PDRforNon-PrescriptionDrugs,DietarySupplementsandHerbs (2007);IMSHealth2005;IOM2006;KaiserFamilyFoundation.Yin;jPeds2016

CanPatientsUnderstandRxlabels?“HowWouldYouTakeThisMedicine?”

• 46% didnotunderstandinstructions≥1labels• 38%withadequateliteracymissedatleast1label• <10%attendedtowarninglabels

395medicineclinicpatientsin3states48%<9th gradereading,averaged1.4meds

Davis,Wolf,Bass,Parker.AnnInternMed,2006.

“ShowMeHowManyPillsYouWouldTakein1Day”

0

20

40

60

80

100

Low Marginal Adequate

Cor

rect

(%)

Patient Literacy Level

Understanding

Demonstration

RatesofCorrectUnderstandingvs.Demonstration“TakeTwoTabletsbyMouthTwiceDaily”

71

35

84

63

8980

JohnSmithDr.Red

Taketwotabletsbymouthtwicedaily.

HumibidLA600MG1refill

PatientCenteredLabelCanImproveUnderstandingandAdherence

StateBoardofPharmacyinCApassedlegislationforthislabel.

StandardLabel PCLabel

Understanding(baseline) 59% 74%

Adherence(3 months) 30% 49%

RCTin11FQHCs.429ptswDMand/orHTN.39%lowliteracy

HiddenProblem:Numeracy

• Youdrinkthiswholebottleofsoda.Howmanygramsoftotalcarbohydratesdoesitcontain?

• 67.5grams

•32%answeredcorrectly

• 200primarycarepatients• 73%privateinsurance• 67%atleastsomecollege• 78%read> 9th grade• 37%math> 9th grade

RothmanR,AmJPrevMed,2006

•Approximatelyhalf ofU.S.adultsareunabletocalculateatip.

*KirschIS,etal.,AdultLiteracyinAmerica,1993;LipkusIM,etal.,MedDecisMaking,2001

• 20% ofcollege-educatedadultsdon’tknowwhatisahigherrisk– 1%,5%,or10%

Actualrestaurantreceipt

U.S.adultsscoredbelowadultsin23nationsinnumeracyandproblemsolving– OECD2013

Percentages&ProbabilityareChallengingforMany:

ImproveRiskCommunication

Providebothpositiveandnegativeframes.• “6in10menwhohavesurgerytotreatprostatecancerwillbeimpotent.Thismeans4in10willnot.”

Giveabsoluteestimates- notrelative.• DrugXcouldreduceyourriskofbreastcancerby50%(relative)• DrugXcouldreduceyour5-yearriskfrom4%to2%(absolute)

RedFlagsForLimitedLiteracy

• Vacantlook• Maysay“Iforgotmyglasses.”• Asksfewerquestions(ornoquestions)• Incompleteforms• Frequentlymissedappointments• Unabletogivecoherent,sequentialhistory• Nottakingmedicationscorrectly• Lackoffollow-throughwithreferrals

* Health Literacy and Patient Safety: Help Patients Understand – A Manual for Clinicians. 2nd edition. Chicago: AMA Foundation and AMA, 2007. www.ama-assn.org/ama1/pub/upload/mm/367/healthclinicians.pdf

HealthLiteracyandNumeracyMaybeLow;NowWhat?

• DHHS’sNationalHLActionPlanhealthinformationneedstobeaccurate,assessable,understandable,actionable.

• Wemustnotblameindividualsfornotunderstandinginformationthathasnotbeenmadecleartothem.

• Everyone,nomatterhoweducated,isatriskformisunderstandinghealthinformationiftheissueiscomplexoremotionallycharged.

HealthLiteracyInterventionstoOvercomeDisparitiesinCRCScreeninginRuralFQHCs

PatientEnrollment(N=620)

RaceAfrican-American66%White 34%

GenderFemale 55%Male 45%

Literacy<9th GradeReadingLevel40%>=9th GradeReadingLevel 60%

Pre-interventionCRCscreeningRate3%- 5%

AllparticipantsgivenCRCscreeningrecommendation,patientfriendlymaterials(writteninconversationallanguage,4th gradelevel,picturesfromclinic,focusedonbehavior,positivetone),FITkitwithsimplified,illustratedinstructionsandteachbackusedtoconfirmcomprehension.

Patientsrandomizedtopersonalfollow–upcallorautomatedcallin4and8weeksifnoFITreturned.

Methods

Year2and3materials&FITmailedwithsimplifiedinstructions.Follow-upcallsconductedasinfirstyear

Results– Year1

AutomatedCallArm(n=308)

69%completedFIT

• 40%neededatleastone

follow-upcall

PersonalCallArm(n=306)

67%completedFIT

• 41%neededatleastone

follow-upcall

620patientsenrolled- (6withdrewbeforecompletingtest)

58-60%patientsgivenFITinclinicreturnedwithoutprompting

ProvidingFIT+literacyappropriateeducationatclinic

visitwithfollow-upcall(ifneeded)increasedCRC

screeningratesoflowincome,ruralpatients.

Results– Year2

Automatedcallarm(n=)

40%completedFIT• 74%neededatleastonefollow-upcall

Personalcallarm(n=)

37%completedFIT• 74%neededatleastonefollow-upcall

23-25% patientsmailedreturnedFITwithoutphoneprompting

SustainingannualscreeningwithFITischallenging.Follow-upcallswereessentialinyear2.

Lowercostautomatedcalljustaseffectiveaspersonalcallbothyears

HealthLiteracyFocushasShiftedfromPatientstoProviders,Researchers,andHealthSystems

HealthLiteracyKeystoImprovingPatientEducation

• Slowdown• Avoidmedicaljargon,useplainlanguage• Usepictures,teachingtools(pamphlets,brownbagmeds)• Limitadvice(1-3concepts)•Writebrieftake-homeinformation

• Repeatandsummarizeinformation• ‘Teachback’/’showback’toconfirmunderstanding• Bepositiveandmotivating

•Lesion•Excision•Resection•Tracheostomy•Endoscopic•Portacath•Gastritis•CTvsMRI

ResidentsCommonlyUsedJargon

*Http://firstclinical.com/glossary/28

PicturesCanbeGoodTeachingToolsPatientsmaynotunderstandorusemeasurements

Healthy Carbs

Fruits and VeggiesProteins

StrategyforLimitingInformationLessonslearnedfrompatients

Tellme3•What’swrong?(briefly) (Diagnosis)•WhatdoIneedtodo? (Treatment)•WhyisitimportantthatIdothis? (Benefit/Context)

Ifmeds– “breakitdown”forme•What’sitfor?(indication)•When totake?Howmanypillsatatime,howlong?(duration)•Why?(benefit)•What toexpect?(sideeffects)

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Teach-BackMethod

• “Tellmeyourunderstanding”• “Howwillyoudescribethistoyourfamily?”•Avoidasking:•Doyouunderstand?•Doyouhaveanyquestions?

Remember- what’scleartoyouiscleartoyou!

Thesinglebiggestproblemwithincommunicationistheillusionthatithastakenplace.GeorgeBernardShaw,Playwright

Communicationdoesnottakeplacebecausewetellsomebodysomething.

Communicationtakesplacewhenweobservepatientscloselyandgetsignalsthatweareontherighttrack;thatwehavestartedataplacetheyarefamiliarwithandtracktheirabilitytofollowus.Weforgetwhatit’slikenottoknowsomething.

AlanAlda,Actor.CenterforCommunicatingScience,StonyBrookUniversity

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CommunicationInsightRelevantforSurgeons

AddressingLowHealthLiteracyatDischarge:ProjectRED

Aim:effectivelypreparepatientsforhospitaldischarge

RN‘DischargeAdvocate’workswithinpatientsto:• Educate themwithindividualizedinstructionbooklet(alsosenttoPCP)• Arrangefollow-upappointments• Confirmmedicationreconciliation• Avgtotaltime:87minperpatient(42minwpatients,45minreviewingEMR,communicatingwmedicalteam&preparingdischargebooklet)

ClinicalPharmDcallspatients2-4daysafterdischargetoreviewmedsandreinforcedischargeplan• Avgtotaltime:26minperpatient(10-19mincounseling)• 65%ofpatientshadatleast1medproblem

AHRQ March 2013

EACHDAYfollowthisscheduleforyourmedicinesWhattimeofdaydo Itakethismedicine?

WhyamItakingthismedicine?

MedicinenameAmount

HowmanydoItake?

HowdoItakethismedicine?

Morning

Noon

Evening

Bedtime

Onlyifyouneeditfor

REDTemplateforMeds

REDTemplateforFollow-upAppointments

WednesdayAugust8at11:30a.m.

Thursday,August 16At3:20p.m.

WednesdaySeptember 12At9:00a.m.

Dr.MarkAveryPrimarycaredoctor

Dr.AnitaJonesRheumatologist

Dr.LinWuCardiologist

100MainSt.2nd floorAnytownST

100PleasantRd, Suite105Anytown,ST

100ParkRd,Suite504Anytown,ST

Forafollowupappointment

For yourarthritis Tocheckyourheart

Officephonenumber(555)555- 5555

OfficePhone#:(555)555-5555

OfficePhone#:(555)555-4444

JohnDoeWhatismymainmedicalproblem?

ChestPainWhenaremyappointments?

ProjectREDEffectiveandCostEffectiveRandomizedControlTrial— 30daysafterD/C

REDvs.standarddischarge

• 30%lowerhospitaluse

• 30%morelikelytofollow-upPCP

• 34%lowercost

Jack BW, Ann Intern Med 2009

2007NationalQualityForum“SafePractice”forhospitaldischargebasedlargelyonRED

Participants– 749patients,meanage:50,meanstay:2.7days

– 59%lowliteracy;50%AA,27%White

ProblemsWithWrittenHealthInformation•Organizedusingmedicalmodel,notpatient-centered• Scientific/bureaucraticnotpersonal/conversational•Toolong,toomuchinformation,keymessageburied• Illustrationscomplex,confusing,or“don’tlooklikeme”• Lackofattentionto‘tone,’patientemotions• Lackofpatientandproviderinputindevelopment•Distributionandsustainabilitynotthoughtout• Howandwhenwillpatientsgettheinformation?Whogivesittothem?Whenisteachablemoment?Plantoupdate?

•Lackofawarenessofwhat’sonGoogle/blogs

LiteracyTestsUsedinHealthcareResearchYearsofschoolingisNOTagoodmeasureofliteracylevel

• Themostcommonlyused• REALM (RapidEstimateofLiteracyMedicine)• REALM-SF (shortform)• TOFHLA (TestofFunctionalHealthLiteracy)• NVS (NewestVitalSign)

• Theseareoften referredtoastestsofhealthliteracy

Qualitative:Howconfidentareyoufillingoutmedicalformsbyyourself?Extremely– QuiteABit– Somewhat– ALittleBit– NotAtAll(0) (1) (2) (3) (4)

Tests and ordering instructions are in resources at the end of the presentation.

HealthLiteracyCommunicationRecommendations

• Slowdown,sitdownandengagepatient(andfamilymember)• Useplainlanguage– avoidsurgicaljargon• Giveeasytounderstandinformationandinstructions• Usepicturestohelpconveymessageandteachbacktoconfirmunderstanding•Ensureclinicalandresearchmaterialsarewritteninplainlanguageandformattedforreadingandnavigationease•Websitesneedtobeeasytounderstandandnavigate•Encouragestafftoofferpatientshelpwithfillingoutforms

HealthLiteracySurgeryResearchIdeas

•Cansurgerydisparitiesbepartiallyexplainedbyinadequatehealthliteracy?•FewstudiesexamineroleofHLinperioperativesetting.• DoesHLinfluencefamilycaregiver/patientunderstandingofcomplexself-carepostsurgery?• QIprojectlookingatimpactofstaffofferinghelpwithformsorprovidersusingteachback.

TerryDavis,PhDDepartmentofMedicineandPediatrics

LSUHealthShreveport&Feist-WeillerCancerCentertdavis1@lsuhsc.edu(318)675-8694

ResearchAssistant:KateLangdonKlangd@lsuhsc.edu(318)675-4584

ResourcesInformedConsent

TemplatesandTerms

• TheAgencyforHealthcareResearchandQuality(AHRQ)InformedConsentandAuthorizationToolkitforMinimalRiskResearch.

• FirstClinicalResearchGlossaryforInformedConsent:http://firstclinical.com/icfglossary/http://firstclinical.com/glossary/

HelpfulLinksforWrittenHealthInformation

CDC(2013)ClearCommunicationIndexwww.cdc.gov/healthcommunication/ClearCommunicationIndex

AHRQ(2013)ThePatientEducationMaterialsAssessmentTool(PEMAT)www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/pemat/index.html

CMS (2011)Toolkitformakingwrittenmaterialsclearandeffectivewww.cms.gov/writtenmaterialstoolkit/

ScientificAmericanandTheAlanAldaCenterforCommunicatingScienceatStonyBrookUniversity (2017)FreeOnlineWritingWorkshopforScientistshttp://sb.cc.stonybrook.edu/news/general/2017-06-26-scientific-american-and-alda-center.php

44

AssessReadingStatisticsonMicrosoft

• Flesch- Kincaidestimatesdifficultyofreadingform

• Microsoft2007&2010• GotoFileTab;selectOptions• ClickonProofing• Check“ShowReadabilityStatistics”

• GotoReviewTab• SelectSpelling&Grammar• Readabilityresultswillshowafterspellinghasbeenchecked

Lexile–AnInternetProgramthatCalculatesReadingLevel

www.lexile.com• Scoresbasedonsentencelengthandwordfrequencyinpopularliterature

• Scoresrangefrom0(beginnerlevel)to2000(highervaluesindicatehigherreadingdifficulty.Aimfor<900

• Save text as Plain Text fileGo to www.lexile.comClick on Lexile AnalyzerUpload file and press analyze

Valuescanbeeasilytranslatedtoreadinggradelevels.

LexileValueof300à 2nd gradeLexileValueof400à 4th gradeLexileValueof1300à 12th grade

• Asystematicmethodtoassesspatienteducationmaterialsandevaluatetheirunderstandabilityandactionability

• Understandability:patientsofdiversebackgroundsandvaryinglevelsofhealthliteracycanprocessandexplainkeymessages.• Actionability:patientscanidentifywhattheycandobasedontheinformationpresented.

PEMAT-PforprintmaterialsPEMAT-A/Vforaudiovisualmaterialse.g.,videos,multimediamaterials,

PatientEducationMaterialsAssessmentTool(PEMAT)

HealthLiteracyResources• HealthLiteracyUniversalPrecautionsToolkit:http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html

• HealthLiteracyasanEssentialComponenttoAchievingExcellentPatientOutcomes:http://www.iom.edu/~/media/Files/Perspectives-Files/2014/Discussion-Papers/BPH-EssentialComponent.pdf

• “WhatDidtheDoctorSay?:”ImprovingHealthLiteracytoProtectPatientSafety:http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf

• PromisingPracticesforPatient-CenteredCommunicationwithVulnerablePopulations:ExamplesfromEightHospitals:http://www.commonwealthfund.org/Publications/Fund-Reports/2006/Aug/Promising-Practices-for-Patient-Centered-Communication-with-Vulnerable-Populations--Examples-from-Ei.aspx

• DHHSHealthLiteracyActionPlan:http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf

• CDCPlainLanguageChecklist:http://www.cdc.gov/healthliteracy/pdf/checklist.pdf

HealthLiteracyInformation

KohHK,BrachC,HarrisLM,ParchmanML.Aproposed'healthliteratecaremodel'wouldconstituteasystemsapproachtoimprovingpatients'engagementincare.HealthAff(Millwood).2013Feb;32(2):357-67.

KohHK,BerwickDM,ClancyCM,BaurC,BrachC,HarrisLM,ZerhusenEG.Newfederalpolicyinitiativestoboosthealthliteracycanhelpthenationmovebeyondthecycleofcostly'crisiscare'.HealthAff(Millwood).2012Feb;31(2):434-43.

ShoemakerSJ,WolfMS,BrachC.DevelopmentofthePatientEducationMaterialsAssessmentTool(PEMAT):anewmeasureofunderstandabilityandactionabilityforprintandaudiovisualpatientinformation.PatientEducCouns.2014Sep;96(3):395-403.

AHRQhealthliteracywebsite

HealthLiteracyTests:

•REALMandREALM-Teen• tdavis1@lsuhsc.edu

•TOFHLA• http://peppercornbooks.com/catalog

•NVS• http://www.clearhealthcommunication.com/physicians-providers/newest-vital-sign.html

•SAHLSA• http://www.ahrq.gov/populations/sahlsatool.htm

•1Question• Chew,L.JGenInternMed.23(5)561-4

• TestingindividualpatientswillNOTconfirmtheir abilitytounderstandandactonhealthinformation.

• Noevidencethatindividualliteracytestingimproveshealthcareoroutcomeswhentestingisdonestrictlyforclinicaluse.

• Togetthemostaccuratemeasureofpatient’sspecifichealthliteracyclinicallyuse“teachback.”

• “Universalprecautions”(plainlanguage)arerecommendedtomakematerialsuser-friendly.

• Forclinicaluse–testclinics/systemsintheaggregate.

CautionsaboutAssessingHealthLiteracyClinically

List 1 List 2 List 3

fatflupilldoseeyestresssmearnervesgermsmealsdiseasecancercaffeineattackkidneyhormonesherpesseizurebowelasthmarectalincest

fatiguepelvicjaundiceinfectionexercisebehaviorprescriptionnotifygallbladdercaloriesdepressionmiscarriagepregnancyarthritisnutritionmenopauseappendixabnormalsyphilishemorrhoidsnauseadirected

allergicmenstrualtesticlecolitisemergencymedicationoccupationsexuallyalcoholismirritationconstipationgonorrheainflammatorydiabeteshepatitisantibioticsdiagnosispotassiumanemiaobesityosteoporosisimpetigo

REALM

0-18correct=< 3rd grade

19-44correct=4th-6th grade

45-60correct=7th-8th grade

61-66correct=highschool

Davis,FamMed,1993

REALM- SF

REALM- TeenS IRT Parameters

Item Proportion correct

Item-total correlation a-parameter SE (a) b-parameter SE (b)

diabetes .95 .48 3.29 0.56 -1.85 0.12 exercise .95 .49 6.27 1.91 -1.79 0.10 prevention .92 .53 3.42 0.59 -1.62 0.10 asthma .90 .55 2.97 0.41 -1.49 0.09 nausea .86 .57 2.84 0.36 -1.30 0.08 fatigue .73 .63 3.05 0.37 -0.71 0.06 adolescent .59 .56 2.18 0.24 -0.27 0.06 anemia .55 .54 2.07 0.22 -0.15 0.06 tetanus .45 .47 1.69 0.18 0.20 0.07 bronchial .40 .50 2.37 0.29 0.33 0.06

Raw Score Reading Level

0-2 3rd grade and below 3-4 4th to 5th grade 5-6 6th to 7th grade 7-8 8th to 9th grade

9-10 10th grade and above

S- TOFHLAPASSAGEAYourdoctorhassentyoutohavea____________X-ray.

a.stomach

b.diabetes

c.stitches

d.germs

Youmusthavean__________stomachwhenyoucomefor______.

a.asthma a.is.

b.empty b.am.

c.incest c.if.

d.anemia d.it.

TheX-raywill________from1to3_________todo.

a.take a.beds

b.view b.brains

c.talk c.hours

d.look d.diets

THEDAYBEFORETHEX-RAY.

Forsupperhaveonlya________snackoffruit,________andjelly,withcoffeeortea.

a.little a.toes

b.broth b.throat

c.attack c.toast

d.nausea d.thigh

Scoring:

0-16:

Inadequatefunc.HL

17-22

Marginalfunc.HL

23-36

Adequatefunc.HL

Parker,JGenInternMed,1995

NVS

6Questions

• Ifyoucanhave60gramsofcarbsforasnack- howmuchicecreamcanyouhave?

• Score:1pointforeachcorrectanswer0-1Inadequateliteracy

2-3Marginalliteracy

4-6Adequateliteracy

OrderingInformation

REALMandREALM-Teen• tdavis1@lsuhsc.eduTOFHLA,TOFHLA-SpanishandSTOFHLA• http://peppercornbooks.com/catalogNVS• http://www.clearhealthcommunication.com/physicians-providers/newest-vital-sign.htmlWRAT• http://www3.parinc.com/products/product.aspx

EvaluationofReadingLevelforWrittenMaterials

• FleschKincaidReadingLevelandFleschReadingEase:• AutomaticallybundledwithMicrosoftWord• Testssentencecomplexity

• VocabularyProfiler:• Helpsdetermineuncommonwords• Veryusefulfornon-nativeEnglishspeakers• ex:http://www.sfu.ca/~msevier/WebVocabularyProfilerCS.htm

• LexileLevel• Analyzesbothsentencecomplexityandwordfrequency• http://www.lexile.com/analyzer/

• FryReadabilityFormula• Randomlyselectthreeseparate100wordpassages• Countthenumberofsentencesineach100wordsampletothenearesttenth• Countthenumberofsyllablesineach100wordsample• PlottheaveragesentencelengthandtheaveragenumberofsyllablesonaFryGraphtodeterminethegradelevel

SMOG

http://prevention.sph.sc.edu/tools/SMOG.pdf

CheckliststoEvaluateUser-Friendliness(Suitability)

• OsbornH.(2004)HealthLiteracyfromAtoZ:PracticalWaysto

CommunicateYourHealthMessage.

• ArnoldCL,DavisTC,OheneFrempongJ,etal(2006):Assessmentof

newbornscreeningparenteducationmaterials. Pediatrics.2006;117:320-5.

• DoakCC.(1996)TeachingPatientsWithLowLiteracySkills,2nd ed.,1996.

• RuddR.(1994)Learnerdevelopedmaterials:Anempoweringproduct.

HealthEducationquarterly.(Fall)1994.

SuitabilityAssessment(SAM)*Score

1.Content _____a)Purposeisevident _____b)Contentaboutbehaviors _____c)Scopeislimited _____d)Summaryorreviewincluded _____

2.LiteracyDemanda)Readinggradelevel _____b)Writingstyle,activevoice _____c)Vocabularyusescommonwords _____d)Contextisgivenfirst _____e)Learningaidsvia“roadsigns” _____

3.Graphicsa)Covergraphicsshowpurpose _____b)Typeofgraphics _____c)Relevanceofillustrations _____d)List,tables,etcexplained _____e)Captionsusedforgraphics _____

*Doak,1996

SuitabilityAssessment(SAM)*cont.

Score

4.LayoutandTypography _____a)Layoutfactors _____b)Typography _____c)Subheads _____

5.LearningStimulation,Motivationa)Interactionused _____b)Behaviorsaremodeledandspecific _____c)Motivation– selfefficacy _____

6.CulturalAppropriatenessa)Matchinlogic,language,experience _____b)Culturalimageandexamples _____

Scoreeach0– 2: TotalSAMscore: _______0ifnotsuitable,1ifok, TotalPossiblescore: _______2ifsuperior,N/A Percentscore: _______ifdoesnotapply *Doak,1996