Module 3: Using the nutrition assessment instrument (NAI) This is module 3, which will address how to use the nutrition literacy assessment instrument. Before beginning this module, you should print out a copy of the instrument. Heather Gibbs, M.S., R.D., L.D.N. Ph.D. Candidate, University of Illinois

Objectives Participants will be able to: Correctly use the NAI with clients. Match appropriate materials with levels of learning. The purpose of this module is to teach you how to use the NAI and how to target your teaching methods to the level of nutrition literacy as determined by the instrument.

Nutrition Literacy Assessment Instrument (NAI)-Page 1 Instructions: All clients should complete page one of the instrument. The following algorithm will assist you in determining whether clients should complete subsequent pages. This algorithm should be completed during the assessment phase of nutrition education, before any education is provided. Our preliminary research involving interviews with nutrition educators and researchers in health literacy suggested that the skills needed for making good nutrition choices are dependent upon the disease and diet required. Page 1 of the instrument (shown here), then, should be completed for all clients and includes an algorithm for determining which of the subsequent pages should be completed for the client.

Example: Sodium Restriction Nutrition Education: Food labels and high sodium foods ✓ ✓ Clients may need to complete all of the assessment instrument, or they may complete only certain portions. How much is completed is dependent upon the content of education you anticipate for the client. For example, if you intend to educate the client on a sodium-restricted diet, you will likely focus on reducing high sodium foods and checking food labels for sodium content. In this case, you would check no to the first two questions and yes to the second two questions. The client would then complete pages 1, 5, and 6. ✓ ✓ This client will complete pages 1, 5, and 6 of the NLI

Scoring Scoring is completed on the last page of NLI Score sections chosen by using the algorithm only All clients complete “Nutrition and Health” section Result Options High likelihood of inadequate nutrition literacy Marginal nutrition literacy Adequate nutrition literacy Once the instrument is completed, it needs to be scored. Each question answered correctly is given 1 point on the last page of the NAI. Remember, you will only score those sections indicated by the algorithm on the first page, and all clients should complete the “Nutrition and Health” section. For each section of the instrument, the client’s score can indicate either a “high likelihood of inadequate nutrition literacy,” “marginal nutrition literacy,” or “adequate nutrition literacy.” Please also note that you will need to record on the first page the amount of time the instrument takes to complete for each client.

What do I do with the results? Once the scoring is completed, you will then need to decide the appropriate educational methods. Targeting The client’s level of understanding with appropriate teaching methods

Inadequate Nutrition Literacy Limit the number of messages to 1 or 2 per session Provide specific examples for behavioral changes Do not make suggestions implied!! Written materials: Use few 6th grade reading level or lower Active voice Common words (i.e. “doctor” vs. “physician”) Provide pronunciation key and definition for difficult words, such as “cholesterol” Bullet points vs. paragraphs or sentences Simple pictures or illustrations that supplement text Adequate white space If a client is assessed as having inadequate nutrition literacy, here are some suggested teaching methods. Point 1: Most importantly, focus on only 1 or 2 messages per session. Too much information is overwhelming, difficult to remember and, consequently, ineffective. Shorter, frequent sessions are more effective. Point 2: Always determine specific behavioral goals with the client that he/she is able to state before the session ends Point 3: Use few written materials and be sure they are appropriate. Here are some tips to keep in mind with written materials for this audience.

Marginal Nutrition Literacy Choose up to 3 messages per session (depending on time constraints) Provide specific examples of behavior changes Written materials 9th grade reading level or lower Active voice Step by step instructions Simple pictures or illustrations For those with marginal nutrition literacy, Point 1: you may be able to focus on up to 3 different messages per session, but they should still be kept simple. Point 2: Again, specific behavioral changes should be identified with the client and the client should be able to name these changes at the end of the session. Point 3: A few written materials can be used, but should not exceed the 9th grade reading level and should use the active voice. Handouts with step-by-step instructions can be very useful and illustrations should be simple and relate directly to the educational message.

Adequate nutrition literacy More complex information can be shared, but avoid overload For those with adequate nutrition literacy, it may be tempting to provide a lot of information. Be careful, however, as too much information can be overwhelming for anyone.

Appropriate for all levels Open-ended questions Provide written information only if reviewed with client “Teach back” method Writing menus Choosing foods from restaurant menus Naming foods to treat low blood glucose There are many methods that are appropriate for any level of nutrition literacy. Point 1: Be sure to use open-ended questions of clients often to help clarify what is understood and what isn’t. Point 2: Avoid giving written information to clients for them to read on their own later. It is best to review information with clients so that they can ask you questions for clarification if needed. Besides, if you don’t review handouts with clients, you communicate the information is not important. Point 3: One of the best ways to ensure the client’s understanding is to use the “teach back” method. This approach requires the educator to teach the desired skill or concept and the client to “teach back” the same skill or concept to the educator. For example, the educator could teach the client how to write a lunch menu based on carbohydrate counting. The educator then asks the client to write a different lunch menu using the same approach.