The Institute for Healthcare Advancement's
Twelfth Annual Health Literacy Conference:
"Operational Solutions to Low Health Literacy"

Recap of Wednesday May 8, 2013

How to Write for a Low Literacy Audience
Michael Villaire, MSLM

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Michael Villaire set the tone for the conference with a hands-on, fundamental session of how to write for a low literacy audience to accomplish the goal of improving health literacy and understanding. He began his session explaining the key point when writing for a low literacy audience, “For a message to be readable, understandable and comprehensible you must remove the barriers for poor readers. Removing the barriers increases the likelihood that the reader will get the message.”

There are many avenues by which poor readers can be challenged: low motivation or interest, limited vocabulary, age, education, and first language spoken. These challenges are confounded by typical document problems of high reading levels, too many words, jargon, formal style, passive writing, long sentences, and either no visuals or inappropriate graphics.

However, there are tools of the trade to overcome these challenges. Villaire compared creating a good, plain language document to preparing a fine meal; it is a process that takes planning and effort to meet your goal and purpose. The process begins by clearly stating the purpose and defining the main message.

1. Create your menu – Who is invited as your audience? What will they benefit from your message?
2. Make your shopping list – What do they need to know? Do you have all the information you need? What do you want your final piece to look like?
3. Go to the market – Identify key informants, find someone who can tell you something about your target group. Proof readers to review the grammar, editors make suggestions, peer reviewers look at the accuracy of your information and each skill set is necessary to your message.
4. Assemble your ingredients – As you begin to organize your document, remember your purpose goes first. Don’t make assumptions about what you think your audience knows, instead sequence the information. Divide your information into short sections and headings. There is great value in short headings; it can be the difference in whether your audience gets to the next step.
5. Cook your meal – This is where you use the tools of the trade: active voice, short sentences and simple words, positive tone, interactive voice using “you” and “your”, and be direct and specific.
6. Wine pairings – Compliment your document with stories, examples, navigational aids, graphics to explain the text and processes, use bullet points for like material, and use interactive devices like quizzes and lists.
7. Taste your cooking – Tap into your focus group for a test of your final version, especially if you have created a translated document.
8. Set an appealing table – Leave plenty of white space, use size 12-point or larger with limited bold and italics, double-spaced, use upper and lower case, and block paragraphs with headings.
9. Do the dishes – Look closely at your final document with one last review, edit, proof, and peer review.  The hard part is done, now it’s time to test, review, and one last test.

Attendees took a shot at rewriting sample documents that were written at a 9th grade level and worked in groups to rewrite them at a 3rd to 5th grade level. Groups presented their rewritten document to the class and were given a critique by Michael.



Using Social Media to Promote Your Organization and Health Literacy
Samuel Pettyjohn, MPH

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This year at the session on promoting your organization and social media Sam Pettyjohn focused on several fun and interesting topics. A main goal was to provide the participants with steps they could take to move forward in some way with social media in their own organization.

Pettyjohn started the session with introductions and a general overview of all of the different types of social media that are now available to organizations. Pettyjohn commented “I think participants were shocked at the number of choices available to them.” He covered everything from Facebook to Tumblr and Instagram and really wanted to make sure that participants understood that there is a channel for any effort they want to put forward.

The focus then shifted to sharing good and bad examples of social media use out in the field. This lead to much feedback and participation from the audience. Pettyjohn noted that at times the participants had better examples of social media at work in their communities than he did.

After looking at some examples, participants were given time to work on planning their own social media efforts when they returned to their organization. Pettyjohn also made sure to make himself available throughout the conference so that people could check in with him for guidance in their efforts.

Pettyjohn said, “I look forward to seeing these organizations demonstrate their new social media prowess in the near future.”



Best Practices for Clear Communication
Cliff Coleman, M.D.

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Dr. Clifford Coleman, a health literacy veteran and tremendous resource, started his preconference session by divulging that he has attended the IHA Health Literacy Conference for the last 10 years.

“Unfortunately,” Dr. Coleman continued, “I predict that not many doctors are here among us today,” making a subtle point. “How many are there?” Two hands rose. When the exact same question was asked of nurses, a significant portion of attendees raised their hand.
Before delving into best practices, Dr. Coleman described the importance of a “universal precautions” approach to healthcare. With this approach, one assumes the risk of a patient misunderstanding despite what education level they are at and uses plain, simple language by default to communicate health information to all patients. This “universal precautions” approach starkly contrasts to the current culture of healthcare that places the burden of understanding on the patient rather than on the health professional. As of today, the healthcare system is set up to reward health professionals for poor communication. “As a physician my incentive is to follow my moral compass but my financial compass is to see as many patients on my clock such that if a patient doesn’t understand, the patient will come back for more visits.

And better yet, if the patient gets sick, the procedures required to treat that illness will bring even more bucks in!” As sad as this sounds this is the reality. A “universal precautions” approach of patient-centered care, plain language usage, and health professional accountability within a system that rewards clear communication is really our last hope to transform the system!

Dr. Coleman went over a number of best practices for clear, verbal communication, and below are some of his “must-knows” for daily conversation:

• Best Practice #1 – As a health professional, you must realize that patients prioritize their concerns differently.
• Best Practice #2 – Patient retention of information is extremely low especially when they are ill, so focus on 1-3 “need to know” items to narrow it down to the key message.
• Best Practice #3- Avoid medical jargon! Research shows that all patients prefer simple “plain language” health information.
• Best Practice #4 – Teach through multiple learning “channels” because everyone learns differently.
• Best Practice #6 – Elicit questions in a patient-centered manner. Framing the question in this manner shifts any ownership and blame to you as the health professional and implies that patients should have questions!Best Practice #7 – Use the “teach-back” method to assess the patient’s understanding.

Dr. Coleman ended his lecture stating, “In 2010, half of the medical schools taught health literacy on average for only about 3-4 hours throughout the 4-year program. However, in residency programs, approximately 300 hours were devoted solely to communication on average.” Realizing we still have a long way to go and much work to be done, we can take comfort in the fact that the ball has been set rolling and our first few baby steps have begun.

Dr. Coleman stated his goals and intentions right from the beginning: “I want this session to be more interactive. I plan to not lecture you the entire time, but rather provide you with the time and space to practice the tools, that from my experience help you to successfully communicate to patients clearly and simply, both in verbal and written forms every day.” This “interactive model” became the underlying theme for the rest of the session.



Health Literacy 101: An Introduction to the Field
Michael Villaire, MSLM

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Michael Villaire’s session opened the conference as an introduction to the topic of health literacy for the conference’s first-year attendees, or as a perfect refresher for the multi-year veterans.

Villaire began his talk by reviewing the definition of literacy as a means of distinguishing “literacy” from “health literacy.” Whether using Ratzan and Parker’s definition or the AMA definition of health literacy, both emphasized patients’ ability to obtain, use, and apply health information in their everyday life. “Notice,” he said, “this definition places the burden of understanding and using health information on the patients themselves, rather than the providers. Does anyone really know how to be a patient? As patients, we try to scrape by and learn from trial and error. We hope that we understand the information or instructions that are given to us, and better yet, we pray that we use that information correctly!”

He noted that the Calgary Charter better defines health literacy as, “Allowing the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information.” Favoring this definition, Villaire asserted, “We in the health care field are responsible. If we are the source of information on how to inform others on how to take care of themselves and manage their chronic diseases, our job is to convey the information we know in the best way possible so that they can understand too. But if I speak in Spanish to a person who doesn’t understand Spanish, or if I write at a 13th grade reading level for a person who doesn’t read at a 13th grade reading level, then we've already failed. Our job is to remove these communication barriers first and foremost and learn how to communicate in a way that can be used and understood by everyone.”

Villaire continued, “Unfortunately, communication is oftentimes a one-way education channel with the health professional talking at the patient as the patient just listens.” An alternative to this approach is to utilize the “teach-back” method. If you ask a patient to reiterate how to take and use the medication as if he or she was explaining the instructions to a relative, this method allows the health professional to assess the patient’s understanding of the information and enables the patient to confidently walk away from the visit with the knowledge of what to do. Building self-efficacy is the cornerstone to health literacy, and this is the mentality we want to bring to the health care field.

There are many components in health literacy that are continuously at play – reading, writing, listening, speaking, numeracy, self-efficacy and cultural and belief systems. “People will have different interpretations of the information you present to them; remember to always be mindful of that,” he said. He provided a number of examples to show how easy it is to misinterpret information on the part of the patient. The first example was something as simple as the doctor telling a patient to, “drink only 1 glass of alcohol a day,” but did not specify what size glass the patient could drink. The patient ended up using a glass that was ten times as large a normal-sized glass! The room howled with nervous laughter as the audience thought, “No way! How could that be?” Villaire’s point is that a patient’s interpretation of the instructions given to him or her should never be overestimated. “Specificity and detailed explanations is more often than not, required to get the message across!”

Mr. Villaire shared the AMA Foundation video of heart-jerking anecdotes of patients who we were victims of poor health literacy and some final remarks on the annual costs for poor health literacy amounting between $106-$238 billion. The session concluded with an energized audience ready to conquer the rest of the conference and all the work that must be done!



Health Literacy Association: Discussion Group
Michael Villaire, MSLM; Julie McKinney, MS; Sabrina Kurtz-Rossi, MEd

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Health Literacy Association Discussion Group

Conversations about forming a Health Literacy Association stirred about a year ago, right around the same time of the 2012 IHA Health Literacy Conference. Similar conversations continued at this year’s conference with Michael Villaire, Julie McKinney, and Sabrina Kurtz-Rossi moderating an open discussion on what the next steps should be for a Health Literacy Association becoming a reality.

The discussion opened with the question, “How many here tonight have a job position that has a title with ‘health literacy’ in it? About four raised their hands. Rossi acknowledged that many more in the crowd do health literacy work as some part of their job. “As health literacy continues to become a rising profession, it’s time to take the formation of an association seriously,” Rossi asserted. “Tonight is about discussing what types of things you would benefit from in having an association.”

McKinney reinforced, “We feel strongly about expanding this community. We don’t want people in their jobs feeling isolated because their company is not advocating for health literacy. We want our community members to feel supported and to have a space to discuss health literacy and to collaborate with each other.”

The session quickly fashioned itself into a town hall meeting where the ideas and thoughts of the community poured forth. Rossi and many others agreed that the association should be a “very large umbrella” that provides a community for people of various professions. “Nonetheless, we seek to standardize being a health professional, albeit certifications and/or tools that give people credibility for their health literacy expertise within the companies and organizations they work for.” McKinney added, “The idea that special interest groups from other associations become a part of the Health Literacy Association sprouted from the Listserv. Many people at this conference come from various groups, but we want to be able to centralize our supporters into an association that can produce research results, set standards, and ultimately, improve the quality of care.”

A few questions that were left unanswered:

• Would the association be more community-oriented or regulatory?
• If regulatory, what will be the standards of practice?
• If we are more community-oriented, what types of services are we going to provide?

Are we sure that we would like a new organization? Should we keep the possibility of merging with another organization open?

The community town hall concluded with Villaire’s adamant remark, “Our time is now. The trajectory starts here, and there will be so many potholes that could kill this idea altogether. First and foremost, we must get the ball rolling with work groups. Whoever feels very passionate about one issue area, can potentially be the spark and spearhead of a work group. Although there is much to be done, I am confident that we can get this done.”