Health Literacy Universal Precautions Toolkit, 2nd Edition

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Overview

Practices often ask patients to fill out forms or provide them with written materials to read. With 36% of the U.S. adult population having limited health literacy skills, it is likely that many of your patients don't understand all of the written materials they receive. Assessing, selecting, and creating easy-to-understand forms and educational materials can help you improve patient comprehension.Learn from patients.

Action

Train a staff member to evaluate the quality of materials you give to patients.

• Have at least one person in your practice learn to assess the materials you distribute. Focus first on important and frequently used materials, such as your lab results letter, after-visit-summary, appointment reminder, or fact sheets about managing chronic conditions. Be sure to review materials developed by your practice as well as materials obtained from outside sources.

Assess whether patient materials are easy to read and understand.

• There are numerous methods for assessing patient materials. Some approaches focus on how readable materials are. Others examine a broad array of features that can make materials easy to understand. You should use both types of methods in assessing your materials.
• Readability Formulas:
  • Readability formulas focus on the length of the words and sentences in a document and provide an estimate of how difficult text is to read. Several Web sites are available for conducting readability assessments using commonly used formulas, including the Fry formula, SMOG, and Flesch Reading Ease. Search the Internet for "readability formulas" to find free online resources.
  • In most cases, these sites indicate the grade level at which a patient would have to read to understand the material. The average adult reads at the 8^th or 9^th grade level, and 20% read at the 5^th grade level or below. Therefore, to ensure wide understanding, it is best for materials to be written at the 5^th or 6^th grade level.
• Understandability Assessments:
  • Several methods are available to examine features of patient materials, other than readability, that affect understanding (e.g., word choice, organization of information, formatting).
  • AHRQ's Patient Education Materials Assessment Tool (PEMAT) can help you assess written and audiovisual patient education materials. It provides separate measures of how easy materials are to understand and to act on.
  • CDC's Clear Communication Index assesses the clarity and ease of use of written materials, particularly those with behavioral recommendations or those that communicate information about risk.
  • The Suitability Assessment of Materials (SAM) assesses the suitability of health information materials, including how well materials stimulate learning and how culturally appropriate they are.
• Ask patients to evaluate your forms and other written materials that you hand out or are available on your patient portal. Include both materials that you developed and those you obtained from external sources. Go to Tool 17: Get Patient Feedback for suggestions.
• Watch out for numbers. Ensure that your materials follow recommendations for improving communication of health-related numbers:
  • Provide only the information patients must have to make informed decisions.
  • Provide patients with numbers, not just verbal descriptors (e.g., "low risk").
  • Use simple graphics to express numbers.
  • Provide absolute risk (e.g., a decrease from 4% to 2%) rather than relative risk (e.g. a reduction of 50%), especially when risk reductions are small.
  • Express risk/benefit in whole numbers, not fractions, decimals or percentages (e.g., "1 in 10,000" rather than ".01 %").
  • Provide both the positive and the negative (e.g., "5 in 100 people are expected to get the outcome, meaning that 95 out of 100 will not get the outcome").
  • Use consistent denominators to facilitate comparisons and prevent confusion (e.g., 2 in 1,000 versus 30 in 1,000).
  • Present risk in terms of a time span that is meaningful for patients, such as a 10-year period rather than lifetime.

Choose or make materials that are easy to understand.

• Identify poor-quality materials. Identify materials that performed poorly on your assessment. Working with your Health Literacy Team, consider whether these materials can be modified or whether they will need to be replaced.
• Select better materials. When you identify deficient materials that cannot be revised, search for new ones.
• Consider alternatives to written materials. As one-fifth of adults read below the 5^th grade level, it is best not to rely too heavily on the written word. Audio and video resources as well as talking in plain language may be better for many patients. Videos are particularly useful for demonstrating self-care activities such as injecting insulin, using an inhaler, or exercising. Make sure that patients have the equipment, bandwidth, and know-how needed to view audiovisual materials before distributing them.
• Use the Internet. There are many free health educational resources available on the Web, such as the MedlinePlus "easy to read" collection, which contains interactive tutorials. Assess all new materials using the tools mentioned above. When directing patients to a Web site, be sure it has simple navigation and is easy to read and understand. Refer to the Department of Health and Human Services' Health Literacy Online for guidance on easy-to-use Web sites.
• Provide materials in languages your patients speak. Making easy-to-understand materials available to your non-English speaking patients can be helpful. Keep in mind that some patients with limited English proficiency may also have limited literacy in their native language; make sure you consider alternatives to written materials. Go to Tool 9: Address Language Differences.
• Create new materials to fill gaps, and revise homegrown materials that need improvement. Sometimes you just can't find easy-to-understand instructions or information you want to share with your patients. Or you realize that the materials your office has created are not as easy to understand as you'd like.
• Use guides. The Department of Health and Human Services has several guides to help you design or revise materials and Web sites so these are easy to understand. Check out Toolkit to Make Written Materials Clear and Effective, Health Literacy Online: A Guide for Simplifying the User Experience, Simply Put: A guide for creating easy-to-understand materials (PDF, 1.9 MB), and Everyday Words for Public Health Communication (PDF, 282 KB). The Harvard School of Public Health also has a set of short Guidelines for Creating, Assessing, and Rewriting Materials.
• Streamline forms. Make sure forms ask only for information that you absolutely have to have, and ask for it only once.
• Involve patients. Invite patients to contribute to the development of new materials. They're the experts on what information is important to them and what makes sense.
• Consult on legal issues. When using a form for a legally binding purpose, consult a lawyer for legal advice. Having patients sign something they don't understand isn't legally binding, however. So, be sure to advocate for plain language.
• Obtain approvals. Some practices (e.g., those affiliated with large health systems) may need administrative approval to revise or replace written materials. Changes to materials accessed through the EHR or patient portal also may require administrative approval and technical support. Consult with your administration for guidance on how to obtain approval for revised materials and to garner their support for your efforts.

Track Your Progress

Every 4 months, tally the number of materials that have been assessed and the percentage of those that were rated poor that have replaced or revised. Are you making the progress you planned to make?

Before you start using Tool 11, tally the percentage of questions that were not answered on forms filled out by patients in a given week. In 2, 6, and 12 months, do it again and see if the percentage of unanswered questions has gone down.

If you field questions from the Health Literacy Patient Survey, calculate what percentage of patients responded "Always" to question #29.

If you use the Patient Portal Feedback Form, check whether patients answered "Yes" to question #8.

Resources

The following example patient forms are written with guidelines for clear communication in mind and were tested with patients with limited health literacy skills. Your practice can edit and use these forms to meet your specific needs.

• Adult Initial Health History Form.
• Young Child Health History Form.
• Adult Return Visit Update Form.
• Consent to Treat Form.
• Release of Medical Information.
• Lab Results Letter.
• Appointment Reminder.

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