1. Health Literacy and Information Design Adam Thompson, NQC Coach July 18, 2013

2. 2 Agenda Welcome & Webinar Participation Expectations Overview of Health Literacy Health Literacy Assessment Tools for Patient Engagement Informational Design Application of Concepts Questions/Closing

3. 3 Learning Objectives Define Health Literacy and Health Literacy Environment Identify Methods and Tools to Assess Patient Health Literacy Levels Identify Tools for Patient Engagement to Improve Health Literacy Demonstrate Information Design Elements to Enhance Materials for Improving Health Literacy Explore Application of Concepts with Real World Examples

4. Health Literacy

5. 5 What is Health Literacy “ Health literacy is the ability to obtain, process, and understand health information to make informed decisions about health care.” 1 1 DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

6. 6 What is the Health Literacy Environment “The health literacy environment of a healthcare organization is the extent to which communication structures and processes facilitate access to the information patients need to manage and make decisions about their healthcare.” - Evelyn Bradley, DrPH, BCDH

7. 7 Universal Precautions 1 Providers don’t always know which patients have limited health literacy. Some patients with limited health literacy:  Have completed high school or college.  Are well spoken.  Look over written materials and say they understand.  Hold white collar or health care jobs.  Function well when not under stress 1 DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

8. Assessing Health Literacy Levels

9. 9 Health Literacy Assessment Prose Literacy  Prose examples include editorials, news stories, brochures, and instructional materials. Prose texts can be further broken down as expository, narrative, procedural, or persuasive. Document Literacy  Document examples include job applications, payroll forms, transportation schedules, maps, tables, and drug and food labels. Quantitative Literacy  Examples include balancing a checkbook, figuring out a tip, completing an order form, and determining the amount of interest on a loan from an advertisement. Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006).The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics

10. 10 Literacy Level Overview Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006).The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics

11. 11 Literacy Level Overview Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006).The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics

12. 12 Examples of Literacy Tasks Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006).The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics

13. 13 Examples of Literacy Tasks Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006).The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics

14. 14 REALM-SF Health Literacy Measurement Tools: Fact Sheet. January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html

15. 15 Instructions for Administering the REALM-SF Give the patient a laminated copy of the REALM-SF form and score answers on an un-laminated copy that is attached to a clipboard. Hold the clipboard at an angle so that the patient is not distracted by your scoring. Say: "I want to hear you read as many words as you can from this list. Begin with the first word and read aloud. When you come to a word you cannot read, do the best you can or say, 'blank' and go onto the next word." If the patient takes more than five seconds on a word, say "blank" and point to the next word, if necessary, to move the patient along. If the patient begins to miss every word, have him or her pronounce only known words. Health Literacy Measurement Tools: Fact Sheet. January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html

16. 16 REALM-SF Scoring Health Literacy Measurement Tools: Fact Sheet. January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html

17. Ice Cream Assessment

18. 18 I SCREAM, YOU SCREAM, WE ALL SCREAM FOR ICE CREAM Lucy Graham – St. Mary's Family Medicine, Grand Junction, CO

19. 19 Why read an ice cream label? 3 minutes to administer Easy to document Validated tool in English and Spanish Assesses  Prose literacy  Numeracy (Quantitative)  Document literacy From: National Quality Center Technical Assistance Call, October 18, 2012: Why read an ice cream label? Lucy Graham, RN, MPH, St. Mary’s Family Medicine, Grand Junction, Colorado.

20. 20 The Newest Vital Sign (Pfizer, Inc)

21. 21 Ice Cream Label Assessment Questions 1.If you eat the entire container, how many calories will you eat? Answer: 1,000 is the only correct answer 2.If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? Answer: Any of the following is correct: 1 cup (or any amount up to 1 cup), half the container. Note: If patient answers “two servings,” ask “How much ice cream would that be if you were to measure it into a bowl?” 3.Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? Answer: 33 is the only correct answer

22. 22 Ice Cream Label Assessment Questions 4.If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? Answer: 10% is the only correct answer READ TO SUBJECT: Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. 5.Is it safe for you to eat this ice cream? Answer: No 6.(Ask only if the patient responds “no” to question 5): Why not? Answer: Because it has peanut oil.

23. 23 Interpretation Number of correct answers: Tally up ‘Yes’ answers  Score of 0-1 suggests high likelihood (50% or more) of limited literacy.  Score of 2-3 indicates the possibility of limited literacy.  Score of 4-6 almost always indicates adequate literacy.

24. Tools for Patient Engagement

25. 25 Patient Engagement “Patient engagement is the blockbuster drug of the century.” - National Coordinator for Health IT, Dr. Farzad Mostashari http://www.nationalehealth.org/patient-engagement-framework

26. 26

27. 27 Patient Engagement Framework Tools http://www.nationalehealth.org/patient-engagement-framework

28. 28 Factors Necessary to Improve Health Outcomes and Tools to Help 1 1 DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

29. 29 Management of Education Materials Location Organization Supply Keep materials updated Training Design Easy to Read Materials Education DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

30. Information Design

31. 31 Design Matters “Good design can enhance poorly written text, to a degree, but poor design can ruin the best of text.” Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

32. 32 Design Matters To work well, design needs to accomplish three things: 1.Attract your readers’ attention 2.Hold their attention so they will read the material 3.Help them understand and use the messages in the material Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

33. 33 Good Design Interestingness Integrity Function Form http://www.informationisbeautiful.net/2009/interesting-easy-beautiful-true/

34. 34 Tips for Creating Effective Materials Health Education Materials Content Chunk the information Sentence Structure Word Choice Graphics Patient Forms Format Considerations  Use Checkboxes  Don’t Know Options  Bold Key Words  Use Common Medical Words DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.

35. 35 Design Guidelines 1.Design the size, shape, and general look of the material with its purpose and users in mind. 2.Make the material look appealing at first glance. 3.Create a clear and obvious path for the eye to follow through each page. 4.Create an overall design for the material that has a clear and consistent style and structure. Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

36. 36 Design Tip One: Size, Shape and General Look Functional  Making the size convenient for users  Adding to it’s usefulness  Removing possible barriers Economical  Postage Requirements  Web-based dissemination Size and Shape  Avoid tall and narrow formats  Use portrait versus landscape  Consider a size outside the norm Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

37. 37 Design Tip Two: Making Materials Appealing at First Glance Resist using a lot of text into limited space  Revise your product  Use a mock-up Be sure there is enough white space  “Breathing Room”  Keep white space consistent Analyze and de-clutter your materials Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

38. 38 Design Tip Three: Create and Clear Obvious Path Material Evaluation Questions  What do you look at first? Where do your eyes go next?  Do you move automatically in smooth progression from one area of the page to the next?  When you’re finished, look back at the page very closely: was there anything you missed when you first glanced through it? Design materials to be compatible with natural patterns of reading  Consider adhering to “Reading Gravity”  Don’t increase “navigational burden”  Use layout to your advantage Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

39. 39 Reading Gravity Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

40. 40 What not to do … Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

41. 41 What not to do … Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

42. 42 Example of Good Use of Reading Gravity Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

43. 43 Example of Good Use of Reading Gravity Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

44. 44 Example of Materials for Skilled Readers Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

45. 45 Unskilled Readers Face Navigational Challenges Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

46. 46 Options for Text in Margins Whenever feasible integrate it into an appropriate spot within the main body of text Use effective ways to emphasize main points If there is no obvious place to integrate the text, consider dropping it. Perhaps the point is too minor to include. Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

47. 47 Material Navigation Tips Establish a clear hierarchy of importance on each page, without too many elements fighting for attention all at once Use prominent headings, bullet points, text emphasis and other devices to help readers skim and find information of personal interest Maintain general consistency of layout and design elements from page to page Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

48. 48 Material Navigation Tips Try to avoid cross-references to other parts of the document If testing shows that your readers are confused about navigation, assess the content of your print piece Be alert to formats or features that make navigation more difficult for less skilled readers Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

49. 49 Traditional Fold for Materials Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

50. 50 Consider Accordion Fold Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

51. 51 Design Tip Four: Clear and Consistent Style and Structure For a clean and organized “look”:  Use a page grid and style sheets  Line up design elements in a clear and consistent way  Keep the same style throughout the material Clear and Consistent Structure  Makes your materials look more organized and “clean”  Makes your materials more predictable Clear and Consistent Style  Lends unity and avoids distracting reader from key elements Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

52. 52 Page Grid/Style Sheet A Page Grid is an invisible skeleton that forms the underlying structure of each page. Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

53. 53 Guidelines for Fonts For regular text use a “serif” font that is designed for ease of reading. For the headings in your printed materials use an easy-to- read “sans serif” font, preferably one that is a “font family” In general use no more than two or three different typefaces in a single piece of material Make the type size large enough for easy reading by your intended audience For all of your text, including titles and headings, use upper and lower case letters in combination Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

54. 54 Guidelines for Fonts To emphasize words or short phrases that are part of your regular text, use italics or boldface type For ease of reading:  use a dark colored text on a very light non-glossy background  do not print text sideways, on patterned or shaded backgrounds, or on top of photos or other images  and a cleaner look, adjust the line spacing in your material  use left justification throughout the material, for both the text and the headings  keep your lines of text to an appropriate length  watch where the lines break Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

55. 55 Serif and Sans Serif Fonts Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

56. 56 Which is easiest to read? Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

57. 57 Psychology of Color in Logo Design http://thelogocompany.net/blog/infographics/psychology-color-logo-design/

58. 58 Design Guidelines Recap 1.Design the size, shape, and general look of the material with its purpose and users in mind. 2.Make the material look appealing at first glance. 3.Create a clear and obvious path for the eye to follow through each page. 4.Create an overall design for the material that has a clear and consistent style and structure. Source: TOOLKIT for Making Written Material Clear and Effective; Center for Medicare & Medicaid Services – CMS Product 11476, September 2010

59. 59 Real World Application of Concepts

60. 60 Questions?

61. 61 Contact Information Adam Thompson National Quality Center Coach AdamTThompson@gmail. com 864.354.8468 Lucy Graham St. Mary's Family Medicine lucy.graham@stmarygj.o rg 970-298-1735 National Quality Center www.nationalqualitycenter.orgwww.nationalqualitycenter.org Flora Davis Health Planning Council of Northeast Florida flora_darby@hpcnef.org 386.323.2052