LuAnne Stockton, B.A., B.S., Northeastern Ohio Universities College of Medicine Susan Labuda Schrop, M.S. Northeastern Ohio Universities College of Medicine Brian Pendleton, Ph.D. The University of Akron

Upon completion of this presentation, participants will be able to:  Discuss the impact of literacy and health literacy on patient care  Identify teaching strategies for incorporating literacy education into undergraduate medical education  Discuss potential educational strategies for involving medical students in the application of effective patient education techniques 2

Literacy An individual’s ability to read, write, and speak English, compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential. *National Literacy Act, National Institute for Literacy, Fact Sheet *Kutner et al.,

Health Literacy The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. *Kutner et al., 2006; Institute of Medicine, 2004; U.S. Dept. of Health and Human Services,

Health Literacy vs Overall Literacy  Limited health literacy is not restricted to adults with limited overall literacy skills.  Most health education materials are too difficult for people with low literacy skills and are also “above the heads” of average and above-average readers.  Many people suffer from low health literacy as a side effect of medications, illness, anxiety, fear, being in a medical environment, and many other factors. 5

Consequences of low health literacy  30% to 50% of patients can’t take medication as prescribed  Poorer communication between patients and health care providers  Poor health outcomes, including increased hospitalization rates, less frequent screening for diseases such as cancer *Bayer Institute for Health Care Communication; Kutner et al.,

Consequences of low health literacy  Disproportionately high rates of disease and mortality  Increased uses of emergency room for primary care  Those who have low literacy levels hide it very well *Bayer Institute for Health Care Communication; Kutner et al.,

Lecture – M2  Patient Education  2-hour session  Presented by patient educators  Overall Goal: clinical application of patient education techniques 8

Content of Patient Education Lecture  Rationale for patient education  Barriers to patient education  Adult learning principles  Definitions of literacy, health literacy, literacy statistics, reading levels  Problems associated with low health literacy 9

Content, continued  Interventions to deal with low health literacy and increase patient comprehension ◦ Content ◦ Reading Level ◦ Design/Layout  Health belief model  Stages of behavioral change 10

Assessment  Application – documenting patient education in the medical record subsequent to standardized patient interviews  Questions from lecture on written exam 11

PACE Synthesis Seminar – M3  Prepare a case presentation about a patient with a chronic problem  Select a piece of written patient education material about that chronic problem  Critique the patient education handout using the Checklist for Easy-to-Read Print Materials 12

Content The content of the material in this handout:  Is limited to three to five important points  Focuses on what patient can or should do; does not focus on what “not to do”  Summarizes key points at the end 13

Style of Writing The writing style of this handout:  Uses mainly syllable words  Uses mainly short sentences ( words per sentence)  Uses an active voice; uses present tenses  Addresses the reader as “you”  Is interactive as if talking to the reader 14

Design and Layout The layout of this handout:  Balances text with white space (about 50% text and 50% white space)  Uses headings and subheadings to help guide the reader  Uses at least 12-point font  Uses upper and lower case letters; avoids all caps  Emphasizes key points with bold, different color, box or larger print; avoids italics and underlining  Uses sharp contrast in color between ink color and paper color 15

Visuals Pictures in this handout:  Are simple  Use captions to help explain picture and reinforce message in the text  Provide only one message per picture 16

Overall Evaluation (Check one)  I would recommend this piece of material to a patient  I would not recommend this piece of material to a patient 17

To determine medical students’: ▶ Knowledge about health literacy as it applies to written patient education materials ▶ Retention of that knowledge ▶ Application of that knowledge 18

M3 Student assignment (review)  Select a written patient education handout regarding a chronic disease  Rate the handout using the Checklist for Easy-to-Read Print Materials  Complete a brief knowledge assessment regarding readability of printed patient education materials (one class) 19

“Expert” rating of written materials  Two of four experienced raters independently rated patient education handouts using the same Checklist for Easy-to-Read Print Materials  Those two raters met and reviewed the same handouts together and agreed on an “expert score” for each item 20

Materials assessment  Individual item rating  Category score  Overall recommendation Knowledge assessment  Individual items  Categories of items  Total test performance 21

Materials assessment  Individual rater ◦ individual item rating ◦ category score ◦ overall recommendation  Expert rating ◦ individual item rating ◦ category score ◦ overall recommendation 22

 Compare scores of each rater to the expert rating for each handout  Compare scores of the two raters for each handout for inter-rater reliability  Compare “expert scores” with student scores  Compare student vs expert score with student knowledge 23

Rater Agreement Score Inter-rater reliability Student Score Rater 1 Score Rater 2 Score Expert Score Similarity Score Application Score Student Knowledge Score 24

Student gender (n=110) ◦ 55% male ◦ 45% female 25

Content Rating (3 items) Student Mean Rating Expert Mean Rating T valueP value

Style of Writing Rating (5 items) Student Mean Rating Expert Mean Rating T valueP value

Design and Layout Rating (6 items) Student Mean Rating Expert Mean Rating T valueP value

Visuals Rating (3 items) Student Mean Rating Expert Mean Rating T valueP value

Total Items (17 items) Student Mean Rating Expert Mean Rating T valueP value

Overall Recommendation X 2 (4.095) p=.043 Fisher’s Exact p=.056 Contingency coefficient (.189) p= Expert Total Recommend Not recommend Student Recommend Not recommend Total

 M3 students and expert raters differ significantly when evaluating detailed aspects of readability of written patient education handouts  M3 students uniformly rate patient education materials as having more positive elements or better readability characteristics than the expert raters 32

 M3 students and expert raters may not differ when considering the readability of written patient education handouts overall  Expert raters reject more materials than the M3 students and this rejection rate is at the borderline for significance 33

 Rate second class of M3 students  Complete data analysis ◦ Inter-rater reliability ◦ Comparison of student knowledge assessment to the similarity score for second class (student v expert) 34

 How well did the students apply material from lecture in M2?  Potential educational strategies  Changes to the checklist 35

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