when plain isn’t boring: using health literacy principles ... · 8 of 10 women? 80 of 100? .8 is...
TRANSCRIPT
When Plain isn’t Boring: Using Health Literacy Principles
to Create Engaging Communication Products
Cynthia Baur, Ph.D.
Office of the Associate Director
for Communication, CDC
National Action Plan to Improve Health Literacy
The most important actions you
can take to improve health literacy
Available at
http://www.health.gov/communicati
on/HLActionPlan/
People Want to Know
Why do I need a flu shot?
Is cholesterol important to me?
Where should I go in an emergency?
What exactly is “moderate physical activity?”
Does that recommendation about a mammogram
apply to me?
Is this moderate physical activity?
What is a 2 times greater risk for pneumonia if I don’t get a flu shot? Greater than what?
What do these rates mean
for me?
80% risk of what?
8 of 10 women?
80 of 100?
.8
Is one better than the other?
What is 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
4 actions
Obtain
Process
Understand
Decide
More than Reading and Writing…
Health Literacy includes:
Reading
Writing
Numeracy
Listening
Speaking
Cultural and conceptual knowledge
Factors that Influence Health Literacy
Communication and information-seeking skills Level of complexity of information Cultural and linguistic suitability
Location of information and services
Information channels
Existing public health infrastructure
“Do-ability” of recommendations
Health Literacy Levels by Self-Assessed Overall Health
Source: U.S.
Department of
Education, Institute of
Education Sciences,
National Center for
Education Statistics,
2003 National
Assessment of Adult
Literacy
Proportion of Adults by Literacy Type
Source: National
Center for Education
Statistics, Institute for
Education Sciences
National Profile of 8th Grade Mathematics Skills
Description % of 8th graders
Basic (at or above) Partial mastery 73
Proficient (at or above) Demonstrated
competency
34
Advanced Superior performance 8
Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics,
National Assessment of Educational Progress (NAEP), 2009 Mathematics Assessment.
Example: Medication Instructions
Multiple studies find medication
instructions are confusing and cause
errors
Best outcome: use concrete
instructions
Yes: Take medicine at 9 a.m., noon, 3
p.m. and 6 p.m.
No: take every 3 hours
Health Literacy Tools
Audits
http://www.ahrq.gov/qual/pharmlit/index.html
Universal Precautions
http://www.ahrq.gov/qual/literacy/
Clear Communication Guidance
http://www.cdc.gov/healthmarketing/pdf/Simply_Put_082010.pdf
Health Literacy Principles
Invest in knowing and understanding your audiences
Recognize and adjust communication for group and individual differences
Engage members of your target groups in the process
Applying the Principles
of Health Literacy
Presenter: Eileen Hanlon, MHS
This section
• Basic principles to guide your work
• Skill 1: Assessing readability
• Skill 2: Rewriting
• Skill 3: Reviewing design elements
Basic principles
in line with social marketing
• The purpose and audience are clear
• Messages are limited (3-5)
• Action and benefits are described
• Engages the reader
What is the action?
• Ensure your audience will do the behavior you want
them to
• Specific actions are easier to do
• Use easy to read language, support statements and
design to support the action
More than
90 million
Americans
would have
trouble with
this.
Reduce the content
• Less is more – focus on
desired action
• Cut unnecessary
information
• Limit the number of
messages
• More bullets; fewer
paragraphs
4 key strategies
• To make materials more understandable and
actionable:
• Use common words, conversational style
• Give examples
• Make it interactive
• Use visuals that support message
What are they saying?
• A perissodactyl ungulate may be propelled toward a
body of aqueous fluid, but such ungulate cannot be
compelled or forcibly induced to imbibe such fluid.
Readers at lower levels
• Read slowly
• Read each word separately
• Skip unfamiliar words; use other words as clues
• Take meaning literally; miss context/big picture
• Get tired quickly; may not finish reading long text
Readability
• Readability is a key component of health literacy:
o 75% of Americans can read at 6th grade level
o but 90% can read at the 3rd grade level
• Aim to write at 3rd – 5th grade level
Use clear, lay language
• Use short, simple sentences
• Use common words and analogies
• Avoid or explain medical terms
• Avoid statistics
Example
• 20th grade level: “Benzac is injected just under the
skin in the abdominal area. Benzac injections are well
tolerated with a low incidence of injection site
reactions. Another type of injection can be given
intramuscularly (into the muscle). Most patients find
both injection types of similar tolerability.”
• 2nd grade level: “Benzac is given with a shot.
You can get this shot in your belly, or in a muscle.
Most men have no problems either way.”
Source: MM&M article
Skill 1: Assess readability
• Readability is measured by assessing multi-syllable
words and sentence length
• Three common methods:
o Word processing software
o Fry
o SMOG
• Checking readability by hand helps you see where
problems are
14
MSWord: Spelling & Grammar check
Statistics: Commonly misunderstood
Most statistics are meaningless to consumers:
• Half of Americans cannot complete simple calculation
• Half cannot give simple probabilities (i.e., flip of a coin)
• Most interpret risk as higher or cannot put in context of
other risks or benefits
o Example: 5% risk of death seems scarier than 95% survival
Why use statistics?
• Define the purpose of using the statistics or numbers:
o Show how common/rare
o Establish community: “you’re not alone”
o Explain risk
o For self-monitoring
o Calculate dosing; give instructions like frequency
• Find out what numbers will be meaningful to the reader
to do the action
Skill 2: Rewrite statistics
• Use simple verbal interpretation (“there is a small
chance”; “you are at greater risk if…”)
• Give context; compare risk to more familiar events
• Use simpler numbers (1 in 4)
• Add a simple visual depiction
• Stick to one type of number representation (ie, do not
mix rates and percentages)
Skill 2: Rewrite statistics
• Look at text
o Who is the target audience?
o What is the desired action?
o What information is necessary for the reader to lead to the desired
action?
Rewriting text
Before:
• Achieving the A1c goal of
less than 7% is essential,
since every 1% increase
above 6% elevates the risk
of diabetes complications
and the risk of heart
attacks.
After:
• It’s so important to set
and meet your A1c goal,
because lowering your
blood sugar can reduce
your risk of complications,
such as blindness, loss of
limbs, heart attack, and
stroke.
Eliminated statistics
Included a specific action
Provided the rationale for consumers
Skill 2: Rewrite statistics
• Measles can be a serious disease, with 30% of
reported cases experiencing one or more
complications. Death from measles occurred in
approximately 2 per 1,000 reported cases in the United
States from 1985 through 1992. Complications from
measles are more common among very young
children (younger than five years) and adults (older
than 20 years).
Immunization Action Coalition, Measles: Questions and Answers.
Use design as a communication tool
• Look at more than language and reading level
• Design, layout, and color are important
• Ask: “Does this design element support the message
and drive behavior?”
Visuals aid understanding of instructions
A study of 234 patients given trauma care at home
Discharge instructions Text only Text + visuals
Read the material 79% 98%
Recalled the material 6% 46%
Followed instructions 45% 86%
Source: Academic Emergency Medicine, March 1996.
Skill 3: Design for clarity
and ease of reading
• Leave more white
space
• Use larger fonts
• Use color appropriately
• Avoid technical
graphics
• Make illustrations
relevant to the content
Choose a clear, serif typeface
• This is a serif font (Times Roman). It has
little “feet” that connect the letters, making it
easier to read, especially in large blocks of
text.
• This is a sans serif font (Arial). While it
may look “cleaner,” it requires the
reader’s eyes to work harder, especially
in large blocks of text.
Put body parts in context
Source: CDC (2010). Prevent and Control Diabetes Guide
Design guides the reader
Before: 36 page booklet After: 16 page booklet
Bold type conveys the key
messages of the booklet
Using content to create a tool
From blue-ribbon panel statement To pocket card
508 compliance
• Ensures that people of all abilities can access Web
and electronic materials
• 508-compliant material doesn’t look very different from
non-compliant materials, but the internal coding and
programming is designed to be accessible by all
www.tobacco-cessation.org
Todd Phillips – AED
Creating Materials to Help Smokers Choose
Evidence-Based Cessation Treatments
www.tobacco-cessation.org
www.tobacco-cessation.org
100
184
268
Some HS GED HS diploma Some college Associates College Post grad
Below
Basic
Inter-
mediate
225
Source: National Assessment of Adult Literacy 2003, The Health Literacy of American Adults, September 2006.
Basic
Health Literacy Scores by Education
www.tobacco-cessation.org
0
10
20
30
40
50
GED HS diploma Some college Associates College Post grad
Cu
rre
nt
sm
ok
ers
(%
)
Source: CDC, MMWR Tobacco Use Among Adults—United States, 2005. October 27, 2006.
Smoking by Education Level
www.tobacco-cessation.org
What Does This Tell Us
Millions of smokers may lack the skills to correctly use evidence-based cessation products and services
May partially explain the appeal of “cold turkey” and the use of non-evidence-based products (“Smoke Away,” herbal supplements, hypnosis, etc.)
Only 20-30% use evidence-based cessation treatment
www.tobacco-cessation.org 13-page fact sheet
www.tobacco-cessation.org 40-page booklet
www.tobacco-cessation.org
About NTCC
NTCC is a coalition of leading tobacco control organizations working together to advance tobacco cessation efforts
CDC, NCI, NIDA, RWJF, ACS, Legacy
Card development funded by RWJF
Goal: Get more smokers to use evidence-based treatments when quitting
Consumer Reports
www.tobacco-cessation.org
NTCC PHS Guideline Recommendations Outreach
In collaboration with RWJF and Dr. Michael Fiore, developed a “Consumer Reports” style card
Translated the recommendations for consumers
Provides objective and easy-to-understand information on cessation choices
Visually appealing and easy-to-read format
www.tobacco-cessation.org
Consumer Testing
6 triad discussions (small group discussions with 3 participants)
3 each in 2 phases of research; 1 low-education group in each phase
Current smokers interested in quitting smoking but not currently making a quit attempt.
www.tobacco-cessation.org
Phase I Concepts
www.tobacco-cessation.org
Phase I Concepts
www.tobacco-cessation.org
Phase I Findings
Positive response to cards overall
Participants found the cards informative, easy-to-understand, and helpful
Amount of information was ideal; not too overwhelming
Participants liked the design and colors
Pocket-sized format was useful
www.tobacco-cessation.org
Phase I Findings
Font size was too small
Lower education group wanted the cards to be more personal and wanted to see pictures and testimonials from smokers like themselves.
Some felt card was too “clinical” and would be something you would get in a doctor’s office
www.tobacco-cessation.org
Phase II
Feedback from Phase I was incorporated into new designs
To enlarge the size of the chart but still retain a pocket-sized product, folded cards were created.
Allowed for larger font as well as additional features, such as photos and quotes.
www.tobacco-cessation.org
Phase II Concepts
www.tobacco-cessation.org
Phase II Concepts
www.tobacco-cessation.org
Phase II Concepts
www.tobacco-cessation.org
Phase II Findings
Similar feedback as Phase I cards
Felt the photos/quotes were a way of “easing into” the information; not immediately overwhelmed by a lot of text
Felt the quotes were accurate statements about quitting
Participants thought the photos made the cards more personal and eye-catching
Response to actual images was mixed; some felt portrayed everyday life, but others felt the images were not realistic enough
www.tobacco-cessation.org
Phase II Findings
Participants preferred a combination of the three versions tested
The final version of the card is based on the blue card from Phase II
A additional fold was added to create a pocked-sized version
Photos/quotes were added to create a more personal feel
www.tobacco-cessation.org
Final Consumer Card
www.tobacco-cessation.org
Final Consumer Card
www.tobacco-cessation.org
Final Consumer Card
www.tobacco-cessation.org
Consumer Reports
www.tobacco-cessation.org
Final Consumer Card
www.tobacco-cessation.org
Website (whatworkstoquit.tobacco-cessation.org)
www.tobacco-cessation.org
Promotion/Distribution
Can be adapted by other groups
Distribute to doctors, clinics, retail outlets, pharmacies
Partnering opportunities
www.tobacco-cessation.org
Lessons
To support behaviors/action, people need tools, not just prose
Health literacy guidelines can greatly improve the utility of tools
Health literacy principles are particularly important for reaching lower SES audiences
www.tobacco-cessation.org
