Recap-Wednesday May 9, 2012

National Action Plan to Improve Health Literacy
Nationwide Live Virtual Event
Michael Villaire, MSLM and Cynthia Baur, Ph.D.

The IHA Health Literacy Conference team presented their second annual live virtual event, with Facebook and Twitter participation, and a remote video hookup. The purpose of the event was to highlight how various organizations are implementing the seven points of the National Action Plan to Improve Health Literacy.

Michael Villaire and Cynthia Baur moderated the lively discussion in which many people were eager to share their stories. Villaire is the Chief Operations Officer for IHA; Baur, works as Lead Author for developing and maintaining the National Action Plan to Improve Health Literacy at the Centers for Disease Control. In her opening dialogue, Baur points out the purpose and relevance for developing the plan, which is to unite various healthcare related disciplines and provide them with guidelines to proactively and strategically identify and improve health literacy within their organization. Baur communicated that in order for the plan to be truly effective; an organization needs to embrace it as an initiative that's a part of their "culture" and present it in a way that's accountable, assessable and actionable.

Following Villaire and Baur's opening, a variety of attendees offered their own National Action Plan story-sharing stories of best practices, challenges and outcomes.

Approximately 100 people were there in person for the event and over 50 watched the live video stream via the Twitter feed. (You can watch an archived video of the entire event here and read a transcript of the Twitter feed here.) If you have a National Action Plan that you'd like to share, IHA would love to hear your story.

Write Your Own National Action Plan Workshop
Michael Villaire, MSLM

Following up on the successful National Action Plan virtual event, in which attendees learned what various organizations and individuals have done to fulfill the Plan, Michael Villaire hosted a nuts-and-bolts workshop to show how to create your own Plan.

Before getting into the Plan development, Villaire explained why you would want to create a Plan in the first place. The National Action Plan creates value by:

Helping organizations to create health literacy culture and identity. This allows for the field to grow and expand.
Allowing you to answer questions others may have. This sets up your organization as a key resource for health literacy.
Challenging your organization to ask and answer the "bigger questions" about healthcare, such as how to reach as many people as possible with your message.
Establishing a heath literacy culture and identity. This raises the credibility of the field not only among other professionals, but also among the general public.

In Villaire's presentation, he communicated that starting from scratch is not always necessary. You can work the Plan into your existing organization by targeting the needs that your organization already fulfills. Think about which areas you want your Plan to focus on. See what other people have done and what is already out there. This will avoid duplication of efforts.

Creating a plan may seem daunting, but it can be done. However, you need to establish accountability within your organization. This means outlining which person will be responsible for which tasks, and then making sure they complete those tasks. Building a roadmap helps with this, as it allows you to break down the entire Plan into manageable pieces.

In order to do this, you need to have both leaders and advocates. Villaire explained that leaders are those people within the organization who take responsibility for the objectives and goals set up for your Plan. They are the people who make timelines, assign tasks and verify that those tasks have been completed in a timely fashion.

By comparison, an advocate is somebody who can help you remove barriers to achieving your objectives. Villaire added that one of the strongest advocates you can have is somebody within senior management: "Getting senior managements buy-in will help you in clearing roadblocks and give you the support you need."

Attendees appeared eager and enthusiastic to further work on the Plans they had started during the session once they got home. Villaire reminded them that having these Plans in place was proof that their organizations were "walking the talk" of health literacy.

How to Write for a Low Literacy Audience
Gloria Mayer, RN, Ed.D., FAAN

Writing for a low-literacy audience seems pretty simple, right? Well, not always.   As a writer, you may be delivering a message in a style that's not completely clear to the reader.   In turn, readers may disregard information or (even worse) take action that could be detrimental to their health.

Gloria Mayer, CEO for the Institute for Healthcare Advancement, led the discussion with a variety of written examples, both good and bad.   Mayer provided examples for attendees to critique. In many cases, the language was not simple enough. In other cases, there were confusing graphics that detracted from the message. One particularly striking example was a flyer offering a class in "Spanish language class" --written entirely in English. Mayer added, "I'm not sure who they think will show up for a Spanish-only class if they don't advertise it in Spanish."

She started by discussing key concepts for participants to consider when writing for a low literacy audience.   First, remember that is reader is unique. Some may have learning difficulties. Others may have been taught English as a second language.

Before you start writing, think about your audience and consider who they are, if they have a language preference, what they need to know and the best vehicle for delivering that message.

Mayer shared a few key concepts to keep in mind when developing your communication:

Limit your message to one or two items. The fewer the messages, the greater the chance of understanding the message.
Focus on action items, or developing a "call to action." This tells the reader to take action.
Explain the benefit of taking action.
Make sure your message is consistent with your other messages. This provides continuity and reduces confusion.

Always start your message with the most important point. Mayer states, "If people don't understand the first sentence, they won't read any further." She also recommends using subtitles and grouping like items together.

In looking at word choices, the most important item to avoid is jargon. Mayer also suggested using contractions and personal pronouns, as well as one- or two-syllable words when possible.

In closing, Mayer reminded attendees to test messages with others or a focus group before finalizing your communication-this will provide various viewpoints and validate/correct any assumptions you are making. Why run the risk of wondering whether your message is effective? Test, test, test.

10 Tips to Make Your Health Website Easier to Use for People with Limited Health Literacy Skills
Stacy Robison, MPH; Xanthi Scrimgeour, MHEd

Stacy Robison and Xanthi Scrimgeour from CommunicateHealth led a powerful and interactive workshop that provided 10 research-based tips for making your health website more user-friendly, particularly for people with limited health literacy skills. Topics included content strategy, design, navigation and how to involve clients/patients with limited health literacy skills in testing and improving your site.

Robison pointed out that several factors affect how well users with limited health literacy skills can find, understand and use information on the web, including:

Access to computers and experience online
Ability to read and understand printed text
Complexity of information on the web
Usability of the web in general and websites specifically

Studies show that uncluttered content and user-friendly navigation will dramatically improve the performance and experience of web users, particularly for those with limited health literacy skills. Clean layouts and familiar language are more usable for everyone.

When developing content, you must put yourself in the mind of the user. What are their needs and wants? Outline them, and write health content your users need and in words they understand. Make content easy to find and organize it in a fashion that puts their needs first and foremost.

Scrimgeour sites research that shows that highly targeted health information is more effective in getting users' attention and promoting learning. If you are talking to people in their teens, be sure to use images, language and topics that are relevant to their age.

There are 10 key factors that you must consider when building web content:

Involve users-feedback and suggestions from users are invaluable.
Start with the homepage design-this is the foundation for your website and the first impression that users will see
Review content strategy-most web users go to the web already having an idea of what type of information they need. If you are answering health information, you need to address questions quickly and succinctly.
Write clearly-plain language is not enough. Tell them what actions they need to take and outline the necessary steps
De-clutter-too much info is too much info. Don't overwhelm users. Keep it straight and to the point.
Simplify your navigation-try and help readers find the content that they need without having to jump through numerous pages. Remember, you only have their attention for a short time.
Strengthen your organization-create information categories in a way that's clear and specific
Improve search results-allow for common misspellings while searching for content, limit the number of search results, use clear titles and avoid long URLs.
Make it interactive-interactive tools will help you to increase user engagement and create a "voice" for users to become involved.
Test and revise often-test, revise and repeat. If you want people to come to your site, content needs to be user-friendly, relevant and current.

In closing, Robison and Scrimgeour provided examples of good and bad website and discussed feedback with the audience. Attendees left the presentation well-prepared in developing their own web content.

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

The popular "Health Literacy 101" rounded out the preconference sessions. This beginner's course, taught by Michael Villaire, provided not only data to support health literacy, but clips from a powerful video from the AMA Foundation.

Villaire opened his presentation by defining health literacy:

Health Literacy: "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Ratzan and Parker, Introduction to National Library of Medicine Current Bibliographies in Medicine: Health Literacy, 2000)
Health Literacy: "The ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials required to successfully function as a patient." (AMA Council of Scientific Affairs, 2000)

He added that the problem with most definitions of health literacy, like the ones above, is that they put the responsibility on the patient. The problem is, "There is no class on being a good patient. We learn by trial and error."

By comparison, Villaire shared his preferred definition from the Calgary Charter on Health Literacy that puts the responsibility on the healthcare providers:

"Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improve the ability of people to act on information in order to live healthier lives. These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills."

In order to act on this responsibility, healthcare providers must take into account several components. These include reading and writing, verbal communications and listening skills (both provider and patient), cultural or belief systems, and understanding any provider/patient mismatches.

To demonstrate his point about the need for health literacy, Villaire then took the audience through an exercise. He read a paragraph from a very complicated academic article on nuclear physics. He then asked the audience what it meant. As expected, nobody could understand what he had just read. Villaire noted that this example proved the point that if patients can't understand what their healthcare providers are saying, they won't follow through properly.

Villaire then showed the AMA video and asked afterward for audience reaction. People mentioned that there was a huge sense of shame with not being literate. The patients in the video mentioned that they did not feel they could easily ask questions of their providers. Some even would avoid going to the doctor's altogether out of a fear that their low literacy would be revealed.

Villaire also highlighted some of the biggest health literacy myths. Among them:

Writing at a low grade reading level or using plain language is "dumbing down"
Using plain language that is easy to read is unprofessional and insulting
Writing at a lower grade level is easy to do
Why do this? Most people understand what we send to them

Villaire then moved into a discussion of other health literacy statistics. One study cited the fact that 44% of Americans have either basic or below basic literacy skills in reading words. Thirty-four percent have low literacy when it comes to reading forms or documents. Finally, an astonishing 55% have low literacy when it comes to numbers. In comparison, only 12% were found to have proficient health literacy skills.

In looking at who has poor health literacy, Villaire noted:

Nearly 60% of those age 65 or older have either basic or below basic skills
Those with employer health insurance have higher health literacy
Those with Medicare, Medicaid or no insurance have lower health literacy
43% of those living below the poverty level have below basic skills
75% of those who said they had poor health had below basic skills

Poor health literacy is very costly to the healthcare system. Villaire cited one study that estimated $73 billion in annual unnecessary health costs due to low health literacy. Another study estimated an even higher annual amount of somewhere between $106 billion and $238 billion.

Once the audience understood the full scope of the problem, Villaire then went on to discuss possible solutions. One of the most important is what he called "Universal Precautions." This involves, among other things:

Assuming that all patients read at about a 5th grade level.
Limiting to three "need to know" messages.
Using the phrase, "What questions do you have?"
Don't ask "Do you have any questions," as patients are likely to simply say "no," even if they don't understand.

Another important solution is using plain language. Villaire supplied a list of common medical jargon terms, along with possible alternate words. For example, you can use the phrase "throw up," instead of "vomit." Essentially, it involves using what Villaire terms "living-room language." This would be the level of conversation you might have among family or friends on a daily basis.

Finally, use various teach-back techniques. Explain the concept to the patient. Have them repeat back in their words what you told them. Go back and forth until you are confident the patient understands.

Villaire mentioned one example of such a technique, known as the "brown-bag test." Have the patient bring in all their medications in a brown bag. Ask them to identify each medication, along with how often they take it and what they take it for. This can also serve as a quick literacy test, since patients who cannot read the instructions on the label will instead look at the medication itself to identify it.

In closing, Villaire recounted the story of former New York Mayor Rudy Giuliani's reaction to finding out his prostate cancer test was positive. Giuliani assumed that this was good news; that he did not have cancer. Villaire gave this example to show that even a very intelligent man such as Giuliani cannot necessarily understand complex health concepts. He commented, "The word 'negative' is considered bad in every context except healthcare."


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