SHARE Approach Workshop Curriculum

Module 3—Communication: Training Guide

Contents

Module Goal/Aim
Learning Objectives
Timing
Learning Methodology Checklist
Materials Checklist
Instructor Preparation
Module 3 Communications (3 minutes)
     Slide 1. Cover Slide
     Slide 2. Module 3 Communication
     Slide 3. Module 3—Purpose 
     Slide 4. Module 3—Learning objectives
     Slide 5. Module 3—Learning objectives
     Slide 6. SHARE Approach Workshop Curriculum Toolkit Covers
     Slide 7. Communication Barriers and Solutions
Communication Barriers and Solutions (20 minutes) 
     Slide 8. Language, hearing, and eyesight barriers are common in the United States
     Slide 9. Language, hearing, and eyesight barriers are common in the United States
     Slide 10. Using effective decision aids
     Slide 11. Have you tried these decision aids?
     Slide 12. How about any of these?
     Slide 13. Using decision and communication aids
     Slide 14. AHRQ Decision Aids
     Slide 15. Qualified medical interpreters can be
     Slide 16. Off-site interpreters can include
     Slide 17. Checklist for working with qualified medical interpreters
     Slide 18. Checklist for working with qualified medical interpreters
     Slide 19. Unqualified interpreters
     Slide 20. Group discussion
     Slide 21. Unqualified interpreters
     Slide 22. Case study. Mrs. Morales and Jorge
     Slide 23. Case study. Mrs. Morales and Jorge
     Slide 24. Case study. Mrs. Morales and Jorge
     Slide 25. Group discussion
     Slide 26. Case study. Mrs. Morales and Jorge
     Slide 27. When a minor child interprets
Health Literacy (15 minutes) 
     Slide 28. Health literacy
     Slide 29. Health literacy defined
     Slide 30. 2003 National Assessment of Adult Literacy Survey (NAALS) revealed
     Slide 31. Impact of limited literacy
     Slide 32. Impact of limited literacy
     Slide 33. Even skilled readers can find medical information challenging
     Slide 34. Impacts of limited health literacy
     Slide 35. People with limited healthy literacy are more likely to
     Slide 36. People with limited health literacy are also more likely to
     Slide 37. Skills needed to manage a chronic health condition can be daunting
     Slide 38. Strategies when presenting decision aids
     Slide 39. Takeaways from Health Literacy Section
Health Numeracy (15 Minutes)
     Slide 40. Health numeracy
     Slide 41. Health numeracy
     Slide 42. Health numbers are difficult for many
     Slide 43. When do patients need to use and understand health numbers?
     Slide 44. Patients need to understand numbers when:
     Slide 45. Patients need to understand numbers when:
     Slide 46. Ways  you can use numbers clearly and make them meaningful to your patients and their families
     Slide 47. Present numbers in a way your patients can understand—Read aloud
     Slide 48. Present numbers in a way your patients can understand—Read aloud
     Slide 49. Strategies to maximize understanding of health numbers
     Slide 50. Health numeracy reviewed
Teach-Back (20 minutes)
     Slide 51. Teach-back
     Slide 52. The teach-back technique
     Slide 53. What to say while using teach-back during shared decision making
     Slide 54. What to say while using teach-back during shared decision making
     Slide 55. Teach-Back video and discussion
     Slide 56. Group discussion
     Slide 57. Sometimes you need to explain it again
     Slide 58. Teach-back review
Cultural Competence (15 minutes)
     Slide 59. Cultural competence
     Slide 60. Read and review tool 7—Taking Steps Toward Cultural Competence
     Slide 61. Working with diverse patients
     Slide 62. Learn how to interact with diverse patients
     Slide 63. Learn how to interact with diverse patients
     Slide 64. Provide culturally appropriate decision aids for diverse patients
     Slide 65. Provide qualified medical interpreters and use teach-back with diverse patients
     Slide 66. Work to build trust
     Slide 67. Key takeaways
     Slide 68. Key takeaways
     Slide 69. Key takeaways
     Slide 70. Citations
     Slide 71. Citations
     Slide 72. Citations


 Module Goal/Aim

The goals of this module are to provide several solutions to overcome communication barriers that can get in the way of good health care. To that end, participants will learn methods to working with qualified medical interpreters and the roles of health literacy, health numeracy, and teach-back in the shared decision-making process. In addition, participants will receive a brief introduction to cultural awareness.

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 Module Learning Objectives

At the conclusion of this activity, the participant will be able to:

  • List some communication barriers, and describe how decision aids can enhance communication.
  • List effective strategies when working with qualified medical interpreters, and describe the challenges in using unqualified interpreters.
  • Explain the impact of limited health literacy on patient understanding.
  • Describe effective universal health literacy strategies to use when presenting decision aids to your patients.
  • Describe techniques to better communicate health numbers.
  • Identify the steps of the teach-back technique.
  • Explain the influence of cultural factors on patients' health beliefs, behaviors, and responses to medical issues.

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 Timing

This module will take 90 minutes to present (Note to Instructor: Specific breakdown of times allotted for discussion/activity will appear within the module).

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 Learning Methodology Checklist

  • Large group work.
  • Video on the teach-back technique with group discussion.
  • PowerPoint slide presentation.

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 Materials Checklist

  • LCD projector and laptop.
  • Internet access in the room where training is taking place; this is required to play the video on the teach-back technique.
  • Flip chart (with tape or sticky band) or a whiteboard.
  • Markers.
  • Module 3 Participant Guide—one per participant (see details below under Instructor Preparation).

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 Instructor Preparation

2 weeks before training

On the day of training

  • Have the SHARE Approach screen saver showing on your computer to share with participants as they come into the classroom.
  • Have the Module 3: Communication PowerPoint file open and minimized on the computer.
  • Have the Video on the teach-back technique—"Daily Weight Monitoring" link (https://www.youtube.com/watch?v=_Vo9Q_EfBX8) open and minimized on the computer.

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 Module 3 Introduction (3 Minutes)

  Slide 1: Cover Slide

Slide 1: Cover Slide. The SHARE Approach. Essential Steps of Shared Decision Making Workshop Course.

Training Guide Script

Do: Open PowerPoint called, Module 3: Communication.

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  Slide 2: Module 3

Slide 2: Module 3: Communication.

Training Guide Script

Say: Module 3 is titled, "Communication."

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  Slide 3: Module 3—Purpose

Slide 3: Module 3--Purpose. The purpose of this module is to describe the role clear health communication plays in the shared decision-making process. Using effective communication can help you gain trust and build rapport during shared decision making.

Say: This module addresses the role clear health communication plays in the shared decision-making process.

Using effective communication techniques—along with offering your patients accurate evidence-based educational materials—can help you gain trust and build rapport during shared decision making.

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  Slide 4: Module 3—Learning objectives

Slide 4: Module 3--Learning objectives. At the conclusion of this activity, the participant will be able to:List communication barriers that get in the way, and describe how decision aids can enhance communication.List effective strategies when working with qualified medical interpreters, and describe the challenges in using unqualified interpreters.

Training Guide Script

Say: In the next 90 minutes, we'll discuss common communication barriers and solutions.

We will also do a group exercise about working with qualified medical interpreters.

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  Slide 5: Module 3—Learning objectives

Slide 5: Module 3--Learning objectives. Explain the impact of limited health literacy on patient understanding. Describe effective universal health literacy strategies to use when presenting decision aids to your patients.Describe techniques to better communicate health numbers.Identify the steps of the teach-back technique.Explain that cultural factors influence our patients' health beliefs, behaviors, and responses to medical issues.

Training Guide Script

Say: You will get an overview of health literacy.

Next, you'll learn about health numeracy and communicating numbers in a meaningful and understandable way for your patients.

You will see a short video on the teach-back technique. Using teach-back is helpful during shared decision making to help you check for patient understanding.

Finally, we will briefly talk about how cultural factors influence our patients' health beliefs, behaviors, and responses to medical issues.

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  Slide 6: SHARE Approach Workshop Curriculum Toolkit

Slide 6: SHARE Approach Workshop Curriculum Toolkits. Images of SHARE Approach workshop communication tools. Tools 3 through 7.

Training Guide Script

Say: AHRQ has five tools available to help you enhance communication skills: Tools 3, 4, 5, 6, and 7. We will highlight key components of each tool during Module 3. Pull the tools out now and again after the course for quick reference.

Do: Hold up the Tools.

Say: We realize this is a lot of ground to cover in an hour and a half. Our goal today is to offer you basic background information and provide "how to" techniques to apply when you get back to your job.

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 Introduce Communications Barriers and Some Solutions (20 minutes)

  Slide 7: Communication Barriers and Solutions

Slide 7: Communication Barriers and Solutions. Image of SHARE Approach Tool 3, Overcoming Communication Barriers With Your Patients.

Training Guide Script

Do: Pass out Tool 3.

Say: Let's begin by talking about what can happen when there are communication barriers between patients and providers.

We will be referring to Tool 3, Overcoming Communication Barriers With Your Patients.

This reference guide offers background information on solutions to help you work with patients who have sight, hearing, and English language challenges.

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  Slide 8: Language, hearing, and eyesight barriers are common in the United States

Slide 8: Language, hearing, and eyesight barriers are common in the United States. About 9 out of 100 people have Limited English Proficiency (LEP). About 2 out of 100 people have a visual disability. About 3 out of 100 people have a hearing disability.

Training Guide Script

Say: We know that language, hearing, and eyesight barriers are common in the United States.

Approximately 9 out of 100 people have limited English proficiency, called LEP for short.

About 2 out of 100 people have a visual disability, and 3 out of 100 people have a hearing disability.

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  Slide 9: Language, hearing, and eyesight barriers are common in the United States

Slide 9: Language, hearing, and eyesight barriers are common in the United States. Know the law: Civil Rights Act and Americans with Disabilities Act (ADA). Image in right hand corner shows four square icons representing disabilities such as hearing loss, blindness, physical disability, and mental disability. Note: Refer to page 2, Tool 3.

Training Guide Script

Say: Page 2 of Tool 3 lists the Civil Rights Act and Americans with Disabilities Act, or ADA for short. You may want to take time after today's class to familiarize yourself with these laws, which outline what you are required to provide to support patients with disabilities.

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  Slide 10: Using effective decision aids

Slide 10: Using effective decision aids. Images showing the variety of decision support resources for consumers available on the AHRQ Effective Health Care Program Web site. These include, English and Spanish translated publications, interactive patient decision aids, audio files that can be listened to with headphones, and mobile accessible materials.

Training Guide Script

Say: Using effective decision aids can enhance communication with patients who have limited English proficiency or problems hearing or seeing.

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  Slide 11: Have you tried these decision aids?

Slide 11: Have you tried these decision aids? Culturally appropriate, translated decision aids. Translated materials written in plain language. Pictures or hand-drawn pictures to explain a procedure. Models. Videos with captions. Audio recordings.

Training Guide Script

Do: Read the list below. Ask participants to raise their hand when you mention a decision aid they have used with patients.
Ask: When offering decision aids, how many of you have:

  • Offered patients culturally appropriate, translated decision aids?
  • Given patients translated materials written in plain language?
  • Showed pictures or made drawings to explain a procedure to people with LEP?
  • Used models?
  • Showed videos with captions?
  • Used audio recordings for people with visual barriers?

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  Slide 12: How about any of these?

Slide 12: How about any of these? Web sites with audio. TTY or text telephone. Screen reader software apps. Others.

Training Guide Script

Say: How about any of these?

  • Directed patients to a Web site with audio?
  • Used a TTY or text telephone for patients who are deaf or have trouble hearing?
  • Used a screen reader software or app?
  • Used others, such as programs that "re-present" information such as braille output?

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  Slide 13: Using decision and communication aids

Slide 13: Using decision and communication aids. Decision aids can help bridge communication gaps. Two images. The upper left image shows is a graphical depiction of two people with a break in their communication link. The lower right image shows a graphical depiction of two people connected by a communication link.

Training Guide Script

Do: Assess responses based on the show of hands. In the following, say "some" or "many" people, based on show of hands.

Say: It looks like [some, many] people are finding that decision aids can help bridge communication gaps. That's great.

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  Slide 14: AHRQ Decision Aids

Slide 14: AHRQ Decision Aids. Consider sharing AHRQ consumer summaries and the interactive tools with patients.Image montage of a variety of AHRQ decision support resources. Note: Refer to page 7, Tool 3.

Training Guide Script

Say: As we discussed in Module 2, AHRQ provides many interactive decision aids and consumer summaries. Many are available in both English and Spanish. You can refer to page 7 in Tool 3 to learn more about them.

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  Slide 15: Qualified medical interpreters can be:

Slide 15: Qualified medical interpreters can be: Certified freelance interpreters for language and American Sign Language (ASL).Employees from language agencies. Trained bilingual clinicians and staff. Community-based medical interpreters. (Image of a male doctor speaking with a female patient with the assistance of a female sign language interpreter.) Note: Refer to page 4, Tool 3.

Training Guide Script

Say: Now let's talk about working with qualified medical interpreters. When your patients get information in a way they can understand, they can more readily engage in effective shared decision making. 

Qualified medical interpreters can be:

  • Certified freelance interpreters.
  • Employees from language agencies.
  • Trained bilingual clinicians and staff.
  • Community-based medical interpreters from local colleges, faith-based organizations, social services programs, and migrant health clinics.

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  Slide 16: Off-site interpreters can include:

Slide 16: Off-site interpreters can include: Over-the-phone interpreters. Videoconferencing. Image of a sign language interpreter videoconferencing with a patient on a laptop. Note: Refer to page 5, Tool 3.

Training Guide Script

Say: Off-site interpreters can include:

  • Over-the-phone interpreters.
  • Videoconferencing, which allows you to observe the patient's body language.

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  Slide 17: Checklist for working with qualified medical interpreters

Slide 17: Checklist for working with qualified medical interpreters. Prepare before the visit. Gather your decision aids. Make sure they match the needs of your patients. Consider using materials in Spanish for your Latino patients. Use videos with captions with patients who are deaf or who have hearing difficulties Note: Refer to page 5, Tool 3.

Training Guide Script

Say: Let's turn to page 5 in Tool 3. This checklist can help you prepare for working with a medical interpreter before and during your patient's office visit.
Before the visit:

  • It is a good idea to gather your decision aids.
  • Make sure they match the needs of your patient. Consider using materials in Spanish for your Latino patients.
  • Perhaps make videos with captions available for patients who are deaf or who have hearing difficulties.

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  Slide 18: Checklist for working with qualified medical interpreters

Slide 18: Checklist for working with qualified medical interpreters. Take these steps during the visit: Make sure everyone in the room can see each other. Make sure your patient knows the interpreter's name and what the interpreter will do. Let your patient know that the interpreter will not share any of the information discussed. Make sure your patient is making the health care decisions and not deferring to the interpreter to make choices for them--ask! Check for understanding via teach-back.

Training Guide Script

Say: During the visit:

  • Make sure everyone in the room can see each other.
  • Make sure your patient knows the interpreter's name and what the interpreter will do.
  • Let your patient know that the interpreter will not share any of the information discussed.
  • Make sure your patient is making the health care decisions and not deferring to the interpreter to make choices for them—ask!
  • And finally, checkbox five encourages you to check for understanding.

We will be going over the teach-back technique a bit later in this module.

Pull out this checklist now and again so you can be prepared for the interpreter's visit.

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  Slide 19: Unqualified interpreters

Slide 19: Unqualified interpreters. Using unqualified medical interpreters is more likely to result in misunderstandings and medical errors. Having a family member, minor child, friend, or unqualified staff member interpret is not advisable.

Training Guide Script

Say: We understand it is not always financially possible to secure a qualified medical interpreter. Yet, there are some caveats when working with unqualified interpreters.

Using unqualified medical interpreters can result in misunderstandings and medical errors.

Having a family member, minor child, friend, or unqualified staff member interpret is not advisable.

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Group Exercise

  Slide 20: Group discussion

Slide 20: Group discussion. What are some possible challenges when using unqualified medical interpreters? What can go wrong? Image of a whiteboard.

Training Guide Script

Ask: What are some possible challenges when using unqualified medical interpreters? What can go wrong?

Do: Write responses on a flip chart or white board.

Possible responses can include:

  • They may be unfamiliar with technical or scientific language.
  • They may inadvertently commit interpretive errors.
  • They may editorialize your patient's responses (for example, they may not list herbs or folk medicines the patient is taking).
  • When a family member interprets, the person may impose personal views of your patient's health, and this may also pose a problem with your patient's privacy.

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  Slide 21: Unqualified interpreters

Slide 21: Unqualified interpreters... May be unfamiliar with technical or scientific language. Inadvertently commit interpretive errors. May editorialize your patient's responses. Impose personal view of your patient's health, and this may also pose a problem with your patient's privacy.

Training Guide Script

Do: Show slide 21 after group discussion.

Summarize any of the listed options that were not mentioned during the group discussion.

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  Slide 22: Case study: Mrs. Morales and Jorge

Slide 22: Case study: Mrs. Morales and Jorge. This case was adapted from the culture diversity Web site at culturediversity.org, a nonprofit organization dedicated to increasing awareness to the issues of transcultural nursing, promoting cultural diversity in nursing, and proposing solutions when problems of bias or conflict arise.

Training Guide Script

Say: I am going to share a case study with you in which a relative serves as the interpreter. This case was adapted from the culture diversity Web site at culturediversity.org, a nonprofit organization dedicated to increasing awareness to the issues of transcultural nursing to promote cultural diversity in nursing and propose solutions when problems of bias or conflict arise.

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  Slide 23: Case study: Mrs. Morales and Jorge

Slide 23: Case study: Mrs. Morales and Jorge. Alma Morales (age 37). Her son, Jorge Morales (age 19 acting as his mother's interpreter). Jorge is not trained as an interpreter. Mrs. Morales needs to sign a medical consent before surgery can be performed.

Training Guide Script

Read: A Hispanic woman, Alma Morales, age 37, had to sign an informed consent form for a hysterectomy. The patient spoke no English, and the hospital staff relied on her 19-year-old bilingual son, Jorge, to serve as the interpreter.

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  Slide 24: Case study: Mrs. Morales and Jorge

Slide 24: Case study: Mrs. Morales and Jorge. When Jorge explained the procedure to his mother, he appeared to be translating accurately and indicating the proper body parts. Mrs. Morales signed the consent form willingly. The next day, however, she learned that her uterus had been removed. Because it can be considered inappropriate for a Hispanic male to discuss a woman's private parts, the embarrassed son had explained to his mother that a tumor would be removed from her abdomen and pointed to the general area. As Mrs. Morales could no longer bear children, she became very angry and threatened to sue the hospital.

Training Guide Script

Read: When Jorge explained the procedure to his mother, he appeared to be translating accurately and indicating the proper body parts.

Mrs. Morales signed the consent form willingly. The next day, however, she learned that her uterus had been removed. 

Because it can be considered inappropriate for a Hispanic male to discuss a woman's private parts, the embarrassed son had explained to his mother that a tumor would be removed from her abdomen and pointed to the general area.

As Mrs. Morales could no longer bear children, she became very angry and threatened to sue the hospital.

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Group Exercise

  Slide 25: Group discussion

Slide 25: Group discussion. What can we learn from this case study?

Training Guide Script

Ask: What can we learn from this case study?

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  Slide 26: Case study: Mrs. Morales and Jorge

Slide 26: Case study: Mrs. Morales and Jorge. Speaking the same language is not always sufficient.In general, it is best to use a same-sex interpreter when translating matters of a sexual or private nature. Using family members may not be advisable because they may editorialize. Cultural rules often dictate topics that can be discussed. Note: More about culture when we introduce Tool 7: Taking Steps Toward Cultural Competence a little later in this module.

Training Guide Script

Do: Show slide 26 after group discussion.

Write on white board and record responses.

Answers can include:

  • Speaking the same language is not always sufficient.
  • In general, it is best to use a same-sex interpreter when translating matters of a sexual or private nature.
  • Using family members may not be advisable because they may editorialize.
  • Cultural rules often dictate topics that can be discussed.

Say: We will be discussing more about culture when we introduce Tool 7, Taking Steps Toward Cultural Competence a little later in this module.

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  Slide 27: When a minor child interprets:

Slide 27: When a minor child interprets: The child is in a vulnerable position, and the practice is at risk for liability if something goes wrong. Your patients may be less likely to discuss more personal health topics. Note: Use the checklist on page 5 of Tool 3, Overcoming Communication Barriers, to help you work effectively with onsite qualified medical interpreters.

Training Guide Script

Say: Jorge is 19 years old, so he is not a minor. Now, let's look at what can happen when using minor children as interpreters.

When a minor child interprets:

  • The child is in a vulnerable position, and your practice is at risk for liability if something goes wrong.
  • Your patients may be less likely to discuss more personal health topics.

When possible, using qualified medical interpreters is optimal. As mentioned earlier, use the checklist on page 5 of Tool 3, Overcoming Communication Barriers, to help you work effectively with onsite qualified medical interpreters.

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 Introduce Health Literacy (15 minutes)

  Slide 28: Health literacy

Slide 28: Health Literacy. Image of SHARE Approach Tool 4, Health Literacy and Shared Decision Making.

Training Guide Script

Do: Hand out Tool 4, or remind people it is in their notebooks.

Say: Our second communication topic area is health literacy. We'll be referring to Tool 4, Health Literacy and Shared Decision Making.

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  Slide 29: Health literacy defined

Slide 29: Health literacy defined. Health literacy is the degree that people can obtain, process, and understand the basic health information and services they need to make appropriate health decisions. Health literacy goes beyond the individual. It is a two-way street between patients (caregivers and family members) and their health provider.

Training Guide Script

Say: Health literacy is the degree to which people can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.

Yet, health literacy goes well beyond the individual. It is two-way street between patients (caregivers and family members) and their health providers.

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  Slide 30: 2003 National Assessment of Adult Literacy Survey (NAALS) revealed

Slide 30: 2003 National Assessment of Adult Literacy Survey (NAALS) revealed. Only 12% of U.S. adults (age 16 and older) have proficient reading skills. (Image of a woman reading an AHRQ decision support pamphlet.)

Training Guide Script

Say: Here's a bit of background information. The 2003 National Assessment of Adult Literacy Survey (NAALS for short) reveals that only 12 percent of U.S. adults (age 16 and older) have proficient reading skills.

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  Slide 31: Impact of limited literacy

Slide 31: Impact of limited literacy. Approximately 36 percent of the adult U.S. population lack adequate literacy skills--basic or below basic levels. Limited literacy affects people of all ages, races, incomes, and education levels.

Training Guide Script

Say: Approximately 36 percent of the adult U.S. population lack adequate literacy skills—basic or below basic levels.

Limited health literacy affects people of all ages, races, incomes, and education levels.

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  Slide 32: Impact of limited literacy

Slide 32: Impact of limited literacy. The impact of limited health literacy disproportionately affects lower socioeconomic and minority groups. Image of woman helping an older man with his medications.

Training Guide Script

Say: Yet the impact of limited health literacy disproportionately affects lower socioeconomic and minority groups.

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  Slide 33: Even skilled readers can find medical information challenging

Slide 33: Even skilled readers can find medical information challenging. Nearly 9 out of 10 adults lack full literacy, and they have difficulty using the everyday health information. Image of female health care worker reviewing health information with an elderly woman.

Training Guide Script

Say: However, even very skilled readers can have challenges complying with medical regimens.

Nearly 9 out of 10 adults lack full literacy and have difficulty using the everyday health information that is routinely available in health care facilities, retail outlets, media, and communities.

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  Slide 34: Impacts of limited health literacy

Slide 34: Impacts of limited health literacy. Limited health literacy: Affects people's ability to search for and use health information, adopt healthy behaviors, and act on important health alerts. Is associated with worse health outcomes.

Training Guide Script

Say: Limited health literacy affects people's ability to search for and use health information, adopt healthy behaviors, and act on important public health alerts.

It is also associated with worse health outcomes and higher costs.

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  Slide 35: People with limited healthy literacy are more likely to:

Slide 35: People with limited healthy literacy are more likely to: Skip needed tests.Underuse preventive health care and screenings. Have more difficulty finding providers and services and fill out complex forms and health histories. Have more difficulty understanding health numbers, risks, and probability.

Training Guide Script

Say: People with limited health literacy are also more likely to skip needed tests and underuse preventive health care and screenings.

This makes it hard to find providers and services and to fill out forms and health histories.

As we will discuss soon, health numbers are especially difficult to understand for those who have limited health literacy.

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  Slide 36: People with limited healthy literacy are more likely to:

Slide 36: People with limited healthy literacy are more likely to: Be hospitalized or visit the emergency room. Seek treatment at later stages in illness, not getting health screenings. Have difficulty complying with treatment plan. Have trouble filling out complex forms. Have difficulty managing a chronic illness. (Image of male doctor speaking with a female patient in hospital bed.)

Training Guide Script

Say: Now let's turn to page 2, Tool 4, which addresses health literacy.

While even seasoned readers are impacted by the demands and challenges of the health care system, people with limited health literacy are more likely to:

  • Be hospitalized or visit the emergency room.
  • Seek treatment at later stages in illness or not get health screenings.
  • Have difficulty complying with treatment plan.
  • Have trouble filling out complex forms.
  • Have difficulty managing a chronic illness.

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Group Exercise

  Slide 37: Skills needed to manage a chronic health condition can be daunting

Slide 37: Skills needed to manage a chronic health condition can be daunting. How can managing diabetes be difficult for someone with limited health literacy? What skills are needed? (Image of whiteboard on the left. Image on the right is of a female nurse demonstrating the use of a glucose monitor with a female patient.)

Training Guide Script

Ask: Let's talk about managing a chronic illness. How can managing diabetes be difficult for someone with limited health literacy? What skills are needed?

Do: Write on a flip chart or white board the skills necessary to manage this chronic health problem.

Possible answers may include (instructor can add some of these to the list generated by participants):

  • Read a glucose monitor.
  • Track blood sugar levels.
  • Follow a medicine regimen.
  • Inject insulin, and know when to do it.
  • Follow healthy meal plan.
  • Know what to do for episodes of low AND high blood sugar.
  • Cope with comorbid conditions, such as high blood pressure.
  • Make lifestyle changes.
  • Conduct foot checks the correct way.

Say: These tasks we just listed in coping with a chronic health condition can be daunting for skilled readers; they can be especially difficult for someone with limited health literacy.

You can't tell by looking who has limited health literacy. That is why we suggest using universal strategies with ALL your patients during the shared decision-making process.

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  Slide 38: Strategies when presenting decision aids

Slide 38: Strategies when presenting decision aids. Use universal health literacy techniques. Use the Patient Education Materials Assessment Tool (PEMAT) to ensure your materials are understandable and actionable. Speak slowly and show empathy.Avoid medical jargon; use plain language. Present in a way your patients understand.Use teach-back. (Tool 6)Note: Refer to page 3, Tool 4 for link to PEMAT.

Training Guide Script

Say: These include:

  • Making sure decision aids are understandable and actionable. There is a tool, called the Patient Education Materials Assessment Tool (PEMAT for short), that can help you assess the tools you are already using. You can find the link on page 3 of the Health Literacy Tool, or Tool 4.
  • Speak slowly and in a caring voice.
  • Use plain language, and avoid medical jargon.
  • Make sure you present the information in a way your patients understand.
  • Use the teach-back technique to ensure understanding. We will discuss this technique a bit later on in this module.

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  Slide 39: Takeaways from Health Literacy Section

Slide 39: Takeaways from Health Literacy Section. More than 1/3 of adults in the United States are impacted by limited health literacy. Even good readers have trouble navigating the health care system when they are sick, scared, or in pain. Use universal precautions (speak slowly, avoid jargon, check for understanding, and offer easy-to-understand decision aids).

Training Guide Script

Say: Before we move on to health numbers, let's review key takeaways from health literacy.

More than one third of adults in the United States are impacted by limited health literacy.

Even good readers have trouble navigating the health care system when they are sick, scared, or in pain.

Use universal precautions (speak slowing, avoid jargon, check for understanding, and offer easy-to-understand decision aids when participating in shared decision making).

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 Introduce Health Numeracy (15 min)

  Slide 40: Health numeracy

Slide 40: Health Numeracy. (Image of SHARE Approach Tool 5, Communicating Numbers to Your Patients: A Reference Guide for Heath Care Providers.)

Training Guide Script

Do: Pass out Tool 5, Communicating Numbers to Your Patients: A Reference Guide for Heath Care Providers.

Say: Our next section is on health numeracy.

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  Slide 41: Health numeracy

Slide 41: Health numeracy. The ability to use numeric information in the context of health. A two-way street with individuals bringing their skills with health numbers and the provider offering easier-to-understand explanations.

Training Guide Script

Say: Health numeracy is defined as the ability to use numeric information in the context of health.

Like health literacy, conveying health numbers is a two-way street with individuals bringing their skills with health numbers and the provider offering easier-to-understand explanations.

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  Slide 42: Health numbers are difficult for many

Slide 42: Health numbers are difficult for many. Limited numeracy can impact shared decision making. Studies show that even college grads have difficulty with health numbers. Best to use universal precautions with all your patients when conveying health numbers. Like limited health literacy, low health numeracy can result in poor health outcomes. Patients are less likely to make choices and take actions to stay well.

Training Guide Script

Say:  Limited numeracy can impair the ability to communicate and understand health information and participate in shared decision making.

Understanding numbers can be difficult. People with college degrees have trouble using and making sense of numbers, so use universal precautions with all your patients, not just those you think have limited health literacy.

Like limited health literacy, low health numeracy (or understanding health numbers) is associated with poor health outcomes because patients may be less likely to make the choices and take the actions they need to stay well.

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Group Activity

  Slide 43: When do patients need to use and understand health numbers?

Slide 43: When do patients need to use and understand health numbers? When do patients need to use and understand health numbers?(Three images of health care professionals explaining health numbers to patients. The upper left image shows a pharmacist using a booklet to explain health information to an elderly woman. The middle right image shows a female doctor using an electronic tablet to explain health numbers to a male patient. The lower left image shows a female health care worker explaining information about prescriptions to a female.) (Image of a white board on the far right.)

Training Guide Script

Say: Numbers are prevalent in health care.

Ask: What are some examples in which patients may need to understand health numbers?

Do: Write on a flip chart or white board. Share slides 43 and 44 with group AFTER the group discussion.

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  Slide 44: Patients need to understand numbers when:

Slide 44: Patients need to understand numbers when: Choosing treatments--weighing risks and benefits.Doses are dependent on measurement (i.e., weight, blood sugar). Trying to follow medication instructions and take as prescribed.Using measurement devices, and recording and tracking results (blood glucose, peak flow meters, etc.) Using multiple devices (pills, injection, inhaler, liquid, nasal, eye drops, lotions, etc.)

Training Guide Script

Say: Good responses! Let's go over two review slides, which highlight times when patients need to understand numbers. These include when:

  • Choosing treatments—weighing risks and benefits.
  • Doses are dependent on measurement (i.e., weight, blood sugar).
  • Trying to follow medication instructions and taking as prescribed.
  • Using measurement devices, and recording and tracking results (blood glucose, peak flow meters, etc.)
  • Using multiple devices (pills, injection, inhaler, liquid, nasal, eye drops, lotions, etc.)

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  Slide 45: Patients need to understand numbers when:

Slide 45: Patients need to understand numbers when: Following discharge instructions (take 25 milligrams of a medicine, when each pill is only 5 milligrams). Comparing prescription drug coverage plans. Calculating premiums, co-pays, and deductibles. Trying to discern percentages and proportions. Reading appointment slips.

Training Guide Script

Say:  This can also include when:

  • Following discharge instructions (take 25 milligrams of a medicine, when each pill is only 5 milligrams).
  • Comparing prescription drug coverage plans.
  • Calculating premiums, co-pays, and deductibles.
  • Trying to discern percentages and proportions.
  • Reading appointment slips.

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  Slide 46: Ways you can use numbers clearly and make them meaningful to your patients and their families

Slide 46: Ways you can use numbers clearly and make them meaningful to your patients and their families. Tool 5, Communicating Numbers offers you practical tips, techniques, and strategies.Let's take turns reading the six tips. Note: Refer to pages 2-3, Tool 5.

Training Guide Script

Say: Let's explore ways you can use numbers clearly and make them meaningful for your patients and their families during shared decision making.

Pages 2 and 3 of Tool 5, Communicating Numbers, offer you practical tips, techniques, and strategies. Let's go over them now. Let's take turns reading the six tips on page 2.

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  Slide 47: Present numbers in a way your patients can understand—Read aloud

Slide 47: Present numbers in a way your patients can understand--Read aloud. Elaborate by providing estimated numbers. Use frequencies instead of decimals or percentages. Keep denominators and timeframes about the same when you compare numbers. Note: Refer to page 2, Tool 5.

Training Guide Script

Ask: Could I get some volunteers to take a turn reading? [Participants will take turns reading.]

Class members read:

  1. Elaborate by providing estimated numbers. Instead of "low risk," say 1 out of 100 people who have this stent. 
  2. Use frequencies instead of decimals or percentages. Say "13 out of 100" instead of ".13 or 13 percent."
  3. Keep denominators and timeframes about the same when you compare numbers. For example, say "about 6 out of 10 women like you, who do not take this medicine, will break a bone in the next 10 years. About 3 out of 10 women like you who take this medicine will break a bone in the next 10 years. Taking the medicine can lower your chance of breaking a bone by about half."

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  Slide 48: Present numbers in a way your patients can understand—Read aloud

Slide 48: Present numbers in a way your patients can understand--Read aloud. Give absolute risk instead of relative risk. Frame outcomes in both positive and negative terms. Find out your patient's preferred measurement system. Note: Refer to page 2, Tool 5.

Training Guide Script

  1. Give absolute risk instead of relative risk. Absolute risk estimates the number of health events among individuals in a group, and it gives a better sense of personal or individual risk. For example, say, "3 out of 1,000 nonsmokers may have a stroke in their lifetime, and 6 out of 1,000 smokers may have a stroke in their lifetime," instead of "smokers have 2 times the risk of having a stroke in their lifetime."
  2. Frame outcomes in both positive and negative terms. For example, say, "With this treatment, 2 out of 10 people get side effects, and 8 out of 10 people do not."
  3. Find out which measurement system your patient uses: standard or metric. For example, say, "Would you like me to explain using ounces or grams?"

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  Slide 49: Strategies to maximize understanding of health numbers

Slide 49: Strategies to maximize understanding of health numbers. Use only when needed. For example, when precision is needed (risks, benefits, healthy blood sugars, dosing). Use everyday words ('about half' instead of 49 percent). Use visual aids (icon arrays, pie graphs, line graphs, bar graphs for risks in context). Note: Refer to page 3, Tool 5.

Training Guide Script

Say: Using these six tips can help you convey health numbers with your patients. Some additional strategies listed on page 3 of Tool 5 include:

Limiting the use of numbers. Use numbers only when precision is needed, such as for risk and benefits statistics, healthy blood sugar numbers, and dosing instructions.

Also using everyday words, such as "about half" instead of "49 percent." This can maximize patient understanding.

Using visual aids, such as icon arrays, pie graphs, line graphs, and bar graphs with text, can help patients see the risks in context.

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  Slide 50: Health numeracy reviewed

Slide 50: Health numeracy reviewed. Remember, conveying health numbers can be challenging. Refer to Tool 5 as needed. Practice this skill as you work to convey numbers in a way your patients can understand.

Training Guide Script

Say: In review, numbers in health can be difficult to convey. Even college-educated patients have difficulty with health numbers. It is a good idea to review Tool 5, Communicating Numbers when you want hints about communicating numbers to your patients.

This is one skill that may take practice as you work to convey numbers in an easier-to-understand way for your patients.  

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 Introduce the Teach-Back Technique (20 minutes)

 Slide 51: Teach-back

Slide 51: Teach-Back.(Image of SHARE Approach Tool 6, Using the Teach-Back Technique.)

Training Guide Script

Say: Let's move on to the teach-back technique. We'll be using Tool 6, Using the Teach-Back Technique.

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  Slide 52: The teach-back technique

Slide 52: The teach-back technique. Patients use their own words to explain what they need to know about their health or what to do to get better. It helps you make sure YOU are conveying information in a way your patient can understand. The teach-back technique can take as little as 1 to 2 minutes. (Image of female doctor explaining health information to an elderly female.)

Training Guide Script

Do: Hand out Tool 6, Using the Teach-Back Technique: A Reference Guide for Health Care Providers.

Say: First, I'll explain the main components of effective teach-back. Later in this section, we'll watch a short video and discuss whether you found the provider followed the teach-back method well or not.

Teach-back is a technique in which your patients use their own words to explain what they need to know about their health or what to do to get better.

Teach-back can help you make sure you are conveying information in a way that your patients can understand. As your patients teach-back what they have learned during the visit, you are assured that you have effectively communicated with them.

The good news is teach-back can be done in as little as 1 to 2 minutes.

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  Slide 53: What to say while using teach-back during shared decision making

Slide 53: What to say while using teach-back during shared decision making. Explain things clearly using plain language, and avoid medical jargon and vague terms. Make sure your patients know your goal is to check how well you explain the health information, not to test THEIR knowledge. Note: Refer to page 3, Tool 6. (Image of female doctor explaining health information to an elderly male.)

Training Guide Script

Say: Let's look at how to do effective teach-back with shared decision making.

What to say while using teach-back during shared decision making:

  • Explain things clearly using plain language, and avoid using medical jargon and vague directions.
  • Make sure your patients know your goal is to check how well you explain the heath information, not to test their knowledge.

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  Slide 54: What to say while using teach-back during shared decision making

lide 54: What to say while using teach-back during shared decision making. Encourage patients to use their own words rather than copying you or others on your team. Ask open-ended questions that start with what or how, and avoid questions that result in yes and no answers. When appropriate, ask your patient to demonstrate a skill (peak flow meter, blood glucose testing).

Training Guide Script

Say: Encourage patients to use their own words, rather than copying you or others on your clinical team.

Ask open-ended questions that start with "what" or "how," and avoid questions that result in "yes" and "no" answers. For example, say, "What questions do you have today?" instead of "Do you have any questions today?"

And when it is appropriate, ask your patients to demonstrate their skills, such as using a peak flow meter. Let's view the teach-back technique in action.

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  Slide 55: Teach-Back video and discussion

Slide 55: Teach-Back Video and Discussion Daily Weight Monitoring. https://www.youtube.com/watch?v=_Vo9Q_EfBX8 Shown with permission from: Program on Health Literacy. Cecil G. Shops Center for Health Services Research. University of North Carolina at Chapel Hill.

Training Guide Script

Do: Show group the short video on teach-back.

Say: Keeping the components we just went over in mind, let's watch this short video on teach-back.

https://www.youtube.com/watch?v=_Vo9Q_EfBX8

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Group Activity

  Slide 56: Group discussion

 Slide 56: Group discussion. What worked? What didn't? What conversation starters did the provider use if any? Which ones might you use? How could you use a decision aid during teach-back? Note: Refer to pages 3-4, Tool 6.

Training Guide Script

Ask: What worked? What didn't?

A possible response for what worked:

The provider asked the patient how the man would explain to his wife what was discussed during his medical appointment.

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  Slide 57: Sometimes you need to explain it again

Slide 57: Sometimes you need to explain it again. Step 1. Say, I must have not done a good job explaining. Let me try again. Step 2. Explain the health information a second time using a different approach. Create a simple drawing, or demonstrate the behavior. Step 3. Use the teach-back technique again to check for comprehension. Note: Refer to page 3, Tool 6.

Training Guide Script

Say: There will be times when teach-back reveals your patient does not fully understand the information you offered. Follow these three steps:

Step 1: Say, "I must have not done a good job explaining. Let me try again."

Step 2: Explain the health information a second time, using a different approach. Create a simple drawing or demonstrate the behavior.

Step 3: Use the teach-back technique again to check for comprehension.

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  Slide 58: Teach-back review

Slide 58: Teach-back review. It takes a few minutes to implement. Try teach-back when you explain important concepts, such as: Treatment options. Clinical trial participation. Benefits and risk. Adherence to a treatment plan.

Training Guide Script

Say: Takeaways from teach-back show that, in most cases, it doesn't take more than a few minutes to implement. Use teach-back whenever you explain an important concept, such as treatment options, participating in a clinical trial, weighing benefits and risk, or adherence to a treatment plan.

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 Introduce Cultural Competence (15 minutes)

  Slide 59: Cultural competence

Slide 59: Cultural Competence. (Image of SHARE Approach Tool 7, Taking Steps Toward Cultural Competence: A Fact Sheet.)

Training Guide Script

Say: Thus far, we've talked about communication barriers, health literacy, health numbers, and the teach-back technique in this communication module.

The final area we are going to address is cultural competence.

Do: Hand out Tool 7, Taking Steps Toward Cultural Competence: A Fact Sheet, or remind participants that it is in their notebooks.

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  Slide 60: Read and review tool 7—Taking Steps Toward Cultural Competence

Slide 60: Read and review tool 7..Taking Steps Toward Cultural Competence. Many of you have taken courses in cultural competence. Tool 7 addresses considering cultural differences as you build effective relationships with your patients during shared decision making.

Training Guide Script

Say: Many of you have likely attended on-the-job workshops on cultural competence, and as you know, this training can be an entire day or a series of trainings.

While we are not able to address this important topic in-depth today, we encourage you to read Tool 7, Taking Steps Toward Cultural Competence and become familiar with it. It provides guidance for how to consider cultural differences as you build effective relationships with your patients during shared decision making.

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  Slide 61: Working with diverse patients

Slide 61: Working with diverse patients. Ask your patients about their health beliefs. The meaning or value of prevention, intervention, and treatment may vary greatly among cultures. You may want to ask your patients about their beliefs regarding their health condition. Consider asking: What do you think caused the problem? What do you fear most about the sickness? or Why do you think it started when it did? These can allow you to make the most of your interactions during shared decision making. Note: Refer to page 2, bullet 2, Tool 7. src=

Training Guide Script

Say: Let's look at some key takeaways from the "Learn how to interact with diverse patients" section found on page 2 of the tool.

Let's go over bullets 2, 5, and 6.

Bullet 2 addresses asking patients about their health beliefs. Because the meaning or value of prevention, intervention, and treatment may vary greatly among cultures, you may want to ask your patients about their beliefs about their health condition.

Questions—such as, "What do you think caused the problem?" "What do you fear most about the sickness?" or "Why do you think it started when it did?"—can allow you to make the most of your interactions during shared decision making. You may want to refer to this list and consider asking your patients these questions.

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  Slide 62: Learn how to interact with diverse patients

Slide 62: Learn how to interact with diverse patients. Reach out to cultural brokers to learn more about your patients' health beliefs. Health care workers, social service workers, and community and cultural group leaders can offer insight.Has anyone worked with health care and social service workers, cultural leaders, or faith-based leaders? What was the result? Note: Refer to page 2, bullet 5, Tool 7.

Training Guide Script

Say: Bullet 5 addresses the importance of reaching out to cultural brokers to learn more about your patients' health belief systems. These health care workers, social service workers, and community and cultural group leaders can offer insight.

Ask: Has anyone worked with health care and social service workers, cultural leaders, or faith-based leaders? What was the result?

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  Slide 63: Learn how to interact with diverse patients

Slide 63: Learn how to interact with diverse patients. Invite your patients to explain what is important to them, and how getting and staying well works in their community. Has anyone tried that? If so, would you share what you gained/learned? Note: Refer to page 2, bullet 6, Tool 7.

Training Guide Script

Say: Bullet 6 reminds you to let your patients know if you are not familiar with their culture.

Invite patients to explain what is important to them and how getting and staying well works in their community.

Ask: Has anyone tried that? If so, would you share what you gained/learned?

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  Slide 64: Provide culturally appropriate decision aids for diverse patients

Slide 64: Provide culturally appropriate decision aids for diverse patients. Ask your patients about their preferred style of learning. Providing information using the patient's preferred format--print, video, or audio--can help patient comprehension.Try showing a model, making a drawing, or demonstrating an action. You may find your patient likes to get their information in a variety of ways. Note: Refer to page 3, bullet 1, Tool 7.

Training Guide Script

Say: Let's turn to the top of page 3 of Tool 7. Bullet 1 encourages providers to ask patients about their preferred style of learning. Providing your patient's with decision aids using their preferred format—print, video, or audio—can help patient comprehension.

Try showing a model, making a drawing, or demonstrating an action.

You may find your patient likes to get information in a variety of ways.

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  Slide 65: Provide qualified medical interpreters and use teach-back with diverse patients

Slide 65: Provide qualified medical interpreters and use teach-back with diverse patients. Use qualified medical interpreters for patients with limited English proficiency for clear communication. Consider using teach-back to expose any cultural misunderstandings. Remember, nodding and saying yes doesn’t always mean your patients fully understand.Gently ask patients or family members to convey back in their own words. Note: Refer to page 3, Tool 7.

Training Guide Script

Say: We discussed interpreters and teach-back earlier in the module. Page 3 reminds us that using qualified medical interpreters for patients whose English proficiency is limited is vital for clear communication.

Also consider using teach-back as a good technique to expose any cultural misunderstandings. Remember nodding and saying "yes" doesn't always mean your patients fully understand. Gently ask patients or family members to convey back in their own words.

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  Slide 66: Work to build trust

Slide 66: Work to build trust. Recognize that in many cultures, family members are deeply involved in health decisions. Try to involve extended family members when planning care. Encourage your patients to ask questions.Explain that asking questions is a good way to learn about their health problems and treatment options. You might probe with, What questions do you have for me today? Create a welcoming environment. Put a Welcome sign in a variety of languages on the office door. Place a few magazines or other print materials in the patient’s native language. Note: Refer to page 3, Tool 7.

Training Guide Script

Say: The final area that I want to discuss from the tool is working to build trust, which is found at the bottom of page 3. Let's go over a few of these tips now.

Recognize that in many cultures, family members are deeply involved in health decisions. Try to involve extended family members when planning care.

In some cultures, it is not polite to ask questions.

Bullet 3 reminds you to encourage your patients to ask questions. You might probe with, "What questions do you have for me today?"

Finally, create a welcoming environment. You can even put a "Welcome" sign in a variety of languages on the office door. Place a few magazines or other print materials in the patient's native language in the waiting area. This will show a caring attitude.

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  Slide 67: Key takeaways

Slide 67: Key takeaways. Offer your patients appropriate decision aids when applying shared decision making. For example, use decision aids that are:Culturally sensitive. Easy to read.In multiple formats, such as print, video, and audio for people with communication challenges.

Training Guide Script

Say: Key information in Module 3 includes:

Offer your patients appropriate decision aids when applying shared decision making.  For example, use patient decision aids that are:

  • Culturally sensitive.
  • Easy to read.
  • In multiple formats, such as print, video, and audio for people with communication challenges.

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  Slide 68: Key takeaways

Slide 68: Key takeaways. Work with qualified medical interpreters when possible to ensure accurate translations and understanding when practicing shared decision making. Use universal health literacy precautions during shared decision making with all your patients because you can't tell by looking who has limited health literacy.

Training Guide Script

Say: Work with qualified medical interpreters when possible to ensure accurate translations and understanding when practicing shared decision making.

Use universal health literacy precautions during shared decision making with all your patients, because you can't tell by looking who has limited health literacy.

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  Slide 69: Key takeaways

Slide 69: Key takeaways. Follow the strategies for making numbers easier to understand when conveying benefits and risk and treatment options; even college graduates struggle with health numbers. Use teach-back to make sure you have conveyed your health message in a way that your patients can understand as you engage in shared decision making.Ask your patients about their health beliefs and cultural norms to build relationships based on trust and concern during shared decision making. Clear health communication is key to effective shared decision making.

Training Guide Script

Say: Follow the strategies for making numbers easier to understand when conveying benefits and risk and treatment options; even college graduates struggle with health numbers.

Use teach-back to make sure you have conveyed your health message in a way that your patients can understand as you engage in shared decision making.

Ask your patients about their health beliefs and cultural norms to build relationships based on trust and concern during shared decision making.

I encourage you to pull out Tools 3 through 7 in the next week to review the tips and information we addressed in Module 3. Look at the back of each tool for resources on finding decision aids and to learn more about the five topic areas in this module.

Remember, clear health communication is key to effective shared decision making.

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  Slide 70: Citations

Slide 70: Citations. Text description is below the image.

Training Guide Script

  1. National Assessment of Adult Literacy. National Center for Education Statistics; 2003.
  2. Disability Status Report United States. Employment and Disability Institute at the Cornell University ILR School; 2011.
  3. A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations. Office of Minority Health; 2005.
  4. Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality: Tool 9—page 43; 2010.
  5. National Assessment of Adult Literacy Survey. National Center for Education Statistics; 2003.
  6. Nielsen-Bohlman L, Panzer AM., Kindig DA (Eds). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press; 2004.

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  Slide 71: Citations

 Slide 71: Citations. Text description is below the image.

Training Guide Script

  1. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department of Education, National Center for Education Statistics; Washington, D.C.; 2006.
  2. Rudd RE, Anderson JE, Oppenheimer S, Nath C. Health literacy: An update of public health and medical literature. In J. P. Comings, B. Garner, & C. Smith (Eds), Review of adult learning and literacy. Mahwah, NJ: Lawrence Erlbaum Associates; 2007.
  3. Berkman ND, Sheridan SL, Donahue KE, et al. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Agency for Healthcare Research and Quality. Rockville, MD; 2011.
  4. Paling J. Strategies to help patients understand risks. BMJ 2003 Sept. 27; 316: 745-8.
  5. National Heart, Lung, and Blood Institute. What Are the Risks of Having a Stent; 2013. http://www.nhlbi.nih.gov/health/health-topics/topics/stents/risks.html.

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  Slide 72: Citations

Slide 72: Citations. Text description is below the image.

Training Guide Script

  1. Fagerlin A, Zikmund-Fisher B, Ubel P. Helping Patients Decide: Ten Steps to Better Risk Communication. JNCI J Natl Cancer Inst 2011; doi: 10.1093/jnci/djr318.
  2. Waters EA, et al. Formats for Improving Risk Communication in Medical Tradeoff Decisions. Journal of Health Communication 2006; 11, 2: 167–182.
  3. Fischhoff B, Brewer N, Downs J (Eds). Communicating Risks and Benefits: An Evidence-Based User's Guide. U.S. Food and Drug Administration; 2011.

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Return to SHARE Approach Workshop

Page last reviewed December 2014
Page originally created September 2014
Internet Citation: SHARE Approach Workshop Curriculum. Content last reviewed December 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/module3/shareworkshop-mod3guide.html