What's in Between the Lines: Assessing the Readability, Understandability, and Actionability in Breast Cancer Survivorship Print Materials

Educational print materials for young women breast cancer survivors (YBCS) are supplemental tools used in patient teaching. However, the readability of the text coupled with how well YBCS understand or act upon the material are rarely explored. The purpose of this study was to assess the readability, understandability, and actionability of commonly distributed breast cancer survivorship print materials. We used an environmental scan approach to obtain a sample of breast cancer survivorship print materials available in outpatient oncology clinics in the central region of a largely rural Southern state. The readability analyses were completed using the Flesch-Kincaid (F-K), Fry Graph Readability Formula (Fry), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were analyzed using Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). The environmental scan resulted in a final sample of 14 materials. The mean readability of the majority of survivorship materials was "difficult," but the majority scored above the recommended 70% in both understandability and actionability. The importance of understandability and actionability may outweigh readability results in cancer education survivorship material. While reading grade level cannot be dismissed all together, we surmise that patient behavior may hinge more on other factors such as understandability and actionability. Personalized teaching accompanying print material may help YBCS comprehend key messages and promote acting upon specific tasks.

Barriers and solutions to implementing a pragmatic diabetes education trial in rural primary care clinics

INTRODUCTION

The purpose of this report is to describe barriers and solutions to the implementation and optimization of a pragmatic trial that tests an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care in rural primary care clinics.

METHODS

The two-arm pragmatic trial has been implemented in six rural family medicine clinics in Arkansas. It tests a self-management education and counseling intervention for patients with type 2 diabetes compared to enhanced usual care. Barriers and solutions were identified as issues arose and through interviews with clinic directors and clinic administrators and a focus group, interviews, and tracking reports with clinic health coaches who delivered the intervention.

RESULTS

Barriers to optimizing enrollment, intervention delivery, and data collection were addressed through targeted education of and relationship building with leadership, changing enrollment oversight, and ongoing training of health coaches.

CONCLUSIONS

Successful implementation and optimization of this pragmatic clinical trial in rural primary care clinics was achieved through establishing common goals with clinic leadership, minimizing demands on clinic staff and administration, frequent contact and ongoing support of health coaches, and collaborative troubleshooting of issues with delivering the intervention.

Implementation of a health-literate patient decision aid for chest pain in the emergency department

OBJECTIVE

The aim of this study was to investigate the implementation of a new health-literacy-tested patient decision aid for chest pain in Emergency Department (ED) patients. Outcomes included disposition, knowledge, decisional conflict and satisfaction prior to discharge. Patient health literacy was explored as a factor that may explain disparities in sub-group analysis of all outcomes.

METHODS

A health-literacy adapted tool was deployed using a pre/post intervention design. Patients enrolled during the intervention period were given the adapted chest pain decision aid that was used in conversation with their emergency medicine physician to decide on their course of action prior to being discharged.

RESULTS

A total of 169 participants were surveyed and used in the final analysis. Patients in the usual care group were 2.6 times more likely to be admitted for chest pain than patients in the intervention group. Knowledge scores were higher in the intervention group, while no significant differences were observed in decisional conflict and patient satisfaction, or by patient health literacy level.

CONCLUSION AND PRACTICE IMPLICATIONS

Using the adapted chest pain decision tool in emergency medicine may improve knowledge and reduce admissions, while addressing known barriers to understanding related to patient health literacy.

Development and Implementation of the How to Talk to Your Doctor HANDbook Health Literacy Program in Rural Counties

Background:

Improvements in health literacy are unlikely without intervention in community settings. However, interventions appropriate for delivery in these settings are lacking, limiting reach to rural adults who are disproportionately affected by low health literacy and poor health outcomes. The How to Talk to Your Doctor (HTTTYD) HANDbook Program was developed through a research-practice partnership to educate rural residents to effectively advocate and participate in their own health care.

Brief Description of Activity:

We describe development of the HTTTYD HANDbook Program delivered through the Cooperative Extension Service to educate adults who are eligible for Medicaid and have low health literacy. HTTTYD HANDbook implementation is described using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework (and specifically the reach, adoption, implementation, and maintenance dimensions).

Implementation:

The HTTTYD HANDbook was developed using health literacy best practices with user-centered design, and it was field tested with community members with varying levels of health literacy. Reach, adoption, implementation, and maintenance of the HTTTYD HANDbook were assessed by tracking distribution of HTTTYD HANDbook Program materials, return submission of evaluation and tracking instruments, adherence to program and data collection/submission protocols, and program continuation.

Results:

Overall reach into the population was 6 per 10,000; about 25% were Medicaid recipients and 28.2% had low health literacy. Most participants were age 65 years or older. Of the 72 counties with program access, 52.7% requested HTTTYD HANDbook Program materials; 31% adopted the program, but only 30% of these counties adhered to program implementation and data collection protocols. Reach and adoption were higher among rural counties, and rural counties were more likely than nonrural counties to maintain the HTTTYD HANDbook Program.

Lessons Learned:

The HTTTYD HANDbook Program addresses barriers to engagement in patient-provider communication for rural, low-income community members. Programs can be implemented in community settings through established local organizations, such as county extension offices, to increase access for rural adults. Implementation barriers included staff turnover and transportation of program materials. Online facilitator training availability had little impact on adherence to program protocols. Organizational context and established procedures for program delivery and evaluation should be considered in adoption decisions and integrated into implementation protocols. [HLRP: Health Literacy Research and Practice. 2019;3(3):e205–e215.]

Plain Language Summary:

The How to Talk to Your Doctor HANDbook Program was created with people from the community to help patients prepare for doctor visits. The How to Talk to Your Doctor HANDbook Program helps patients to overcome barriers to talking to their doctor so that they can better understand how to get healthy and stay healthy.

Screening Patients Who Speak Spanish for Low Health Literacy

Background:

Inadequate health literacy is a national health problem that affects about 90 million people from all racial and ethnic groups in the United States. Conceptual and empirical models of health literacy position language as one of the most significant contributors to health literacy.

Objective:

A validated Spanish health literacy screening question asks how confident patients are at filling out medical forms, but it does not clarify whether the forms are in English or in Spanish, contributing to ambiguity and potentially affecting validity. The purpose of this study was to compare responses to questions that clarified the language of the forms referenced in the validated screening question; to explore how the clarified items predicted scores on a measure of health literacy; and to compare the predictive ability of the clarified health literacy items to that of a question about patients' self-reported English proficiency.

Methods:

Participants who speak Spanish (N = 200) completed the following surveys: Spanish Health Literacy Screening Question that clarified “English forms” (HLSQ-E) and that clarified “Spanish forms” (HLSQ-S), self-reported English proficiency (SEP), demographic questions, the Short Test of Functional Health Literacy for Adults Spanish (S-TOFHLA-S), and the Newest Vital Sign-Spanish (NVS-Spanish).

Key Results:

Participants reported less confidence with English medical forms than Spanish forms. The sensitivity of screening approaches varied; each predicted inadequate health literacy on the NVS-Spanish and S-TOFHLA-S with different levels of sensitivity, specificity, and accuracy. In general, the HLSQ-E was a better predictor of inadequate health literacy than the HLSQ-S; however, the SEP performed nearly as well as the HLSQ-E.

Conclusion:

“How confident are you at filling out medical forms in English…” more appropriately identified patients with inadequate health literacy who speak Spanish. Health literacy screening practices should consider the patient's language and the language of the health care system and use questions that are less ambiguous. [HLRP: Health Literacy Research and Practice. 2019;3(2):e110–e116.]

Plain Language Summary:

This project focused on patients who speak Spanish and who have a hard time understanding health information. We wanted to find out the best ways to identify these patients so that doctors and nurses can be sure to give them information in ways that they can understand. We tested screening questions that can identify these patients.

Evaluating the Effectiveness of the How to Talk to Your Doctor HANDbook Program

Background:

Millions of Americans have low health literacy, potentially leading to a number of issues including medication errors, hospital admissions, unnecessary emergency department visits, skipped screenings and shots, and misinterpretation of treatment plans. People with low health literacy have less knowledge of illness management, less ability to share in decision-making, and poorer self-reported health status. Addressing health literacy is necessary to improve health care quality, reduce costs, and reduce disparities.

Objective:

The How to Talk to Your Doctor (HTTTYD) HANDbook Program addresses health literacy among rural participants who have low incomes, with a focus on improving health communication among populations that are medically vulnerable by using the HANDbook tool.

Methods:

Participants were recruited from 55 rural counties by county extension agents (CEA) to participate in the 1-hour HTTTYD session. Pre- and post-test surveys were completed. A subset of the sample completed a 3-month follow-up survey.

Key Results:

Of the 548 participants who fully completed the survey, a Wilcoxon Signed-Rank Test was performed on 484 of the participants who completed both the pre- and post-test. A statistically significant median increase in overall confidence among the participants from pre- (M = 15.99) to post-test (M = 17.76), (z = 13.454, p = .000), was noted. A subset of 166 participants also completed the 3-month follow-up survey. A significant increase in health literacy after participation in the HTTTYD HANDbook program from pre-test to 3-month follow-up was noted; effect sizes ranged from moderate to large.

Conclusion:

The HTTTYD HANDbook program meets recommendations for successful health literacy programs; significant positive outcomes demonstrate program effectiveness. HTTTYD HANDbook program delivery in rural communities by CEAs demonstrates access to understudied and often difficult-to-reach populations. [HLRP: Health Literacy Research and Practice. 2019;3(2):e103–e109.]

Plain Language Summary:

The How to Talk to Your Doctor HANDbook program delivered by county extension agents in rural communities showed capacity to access understudied and often difficult-to-reach populations. The significant, sustained improvement in health literacy noted among program participants demonstrated program effectiveness among those with low health literacy.

Health Literacy Evaluation of Opioid Patient Education Materials for Orthopaedic Surgery

Increased opioid use in the United States has resulted in greater incidence of misuse. Orthopaedic patients are more likely to be prescribed opioids for pain. Low health literacy is related to opioid misuse; therefore, orthopaedic patient education tools on use of opioids must be easy to read, understand, and use for patients of all skill levels to be effective. This project aimed to review a broad array of opioid patient education tools and evaluate them from a health literacy perspective. Content evaluation revealed that not all tools expressed the same essential messaging. The mean readability score of the tools assessed was 9.5 grade; higher than the national and recommended 8th-grade reading level. Therefore, many opioid patient education tools may be difficult for patients to read and understand. Improvements in readability and other health literacy best practices are recommended to improve reading, comprehension, and use of opioid patient education tools. (Journal of Surgical Orthopaedic Advances 28(3):232-236, 2019).

Health literacy and surgery expectations in total hip and knee arthroplasty patients

OBJECTIVES

This study assessed patients' health literacy and expectations for total hip (THA) and total knee (TKA) replacement surgery, and compared health literacy levels of patients and their caregivers.

METHODS

A convenience sample of 200 THA/TKA participants, patients and their caregivers, participated in this study.

RESULTS

Results demonstrated no statistical difference in health literacy between patients and their caregivers. However, patients with lower health literacy had significantly lower expectations for walking after surgery.

CONCLUSIONS

Practices should be aware that caregivers may not be any better equipped to consume and use complicated patient education materials than the patient they are assisting. Additionally, lower health literacy, rather than or in addition to race or social factors, may contribute to disparities in opting for THA/TKA because of lower expectations for walking after surgery.

PRACTICE IMPLICATIONS

Healthcare practices should develop patient educational materials that are easy for all patients and caregivers to understand, especially those with low health literacy. Additional patient education and counseling may help patients with low health literacy realistically align their expectations and mitigate barriers to consenting to surgery due to low expectations.

Rationale and development of a randomized pragmatic trial to improve diabetes outcomes in patient-centered medical homes serving rural patients

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes.

Readability of Patient Educational Materials for Total Hip and Knee Arthroplasty

This study aimed to evaluate patient education materials that are focused on total hip arthroplasty (THA) and total knee arthroplasty (TKA) using health literacy best practices and plain language principles as frameworks. Readability assessments were conducted on a sample of nine patient education documents that are commonly given to THA and TKA surgery patients. Mean readability scores were compared across the sample. The mean readability grade level for the nine arthroplasty educational documents analyzed in this study was 11th grade (10.5). The mean readability ranged from 9th to 12th grade. The documents in this study were written at levels that exceed recommendations by health literacy experts. Health literacy best practices and plain language principles were suggested to reduce the demands on patients so that the documents are easier to understand. Incorporating health literacy best practices into patient education materials for THA and TKA can contribute to improved communication with patients that is necessary for patient understanding and satisfaction. (Journal of Surgical Orthopaedic Advances 27(1):72-76, 2018).

Readability of Human Subjects Training Materials for Research

Institutions are required to ensure that persons involved in human subjects research receive appropriate human subjects protections training and education. Several organizations use the Collaborative Institutional Training Initiative (CITI) program to fulfill training requirements. Most researchers find the CITI program too complex for community members who collaborate with researchers. This study aimed to determine the readability of CITI modules most frequently used in community-based participatory research (CBPR). The mean readability level of the CITI modules is 14.8 grade; CBPR readability levels ranged from 11.6 to 12.0 grade (sixth- to eighth-grade reading level is recommended). With a baseline objective measure, modifications can be made to improve the plain language quality and understandability of human subjects training modules for community members.

Health Literacy and Opioid Use in Orthopaedic Patients

Opioid misuse has been linked to patient health literacy. This study aimed to estimate the prevalence of low health literacy in a sample of orthopaedic patients on opioids. Data were extracted from an electronic medical record database using queries that included an 8-month time frame, active status in an orthopaedic clinic, ICD-10 codes for opioids, and health literacy screening results. In the study sample of 8963 orthopaedic patients, 7103 had opioids in their current chart. Of those patients with opioids in their chart, 1547 had inadequate health literacy as measured by a validated health literacy screening question. Because approximately 22% of orthopaedic patients on opioids may also be at high risk for low health literacy, practices should consider identifying these patients and following national recommendations to tailor patient education so that these patients can better understand the risks, benefits, and dosing of opioids.

Promoting Tdap immunization in pregnancy: Associations between maternal perceptions and vaccination rates

OBJECTIVE

Tdap vaccine uptake among US pregnant women is low despite current recommendations. This study evaluated if a Tdap vaccine information statement (VIS) affected overall perception, vaccination intention, and components of a health behavior model associated with Tdap vaccination rates.

METHODS

A randomized, prospective study was conducted among pregnant women receiving care at two women's clinics in May-August 2014. Verbally consented participants were randomized to receive either the standard CDC Tdap VIS (sVIS) or a modified version (mVIS) before completing the first multi-part survey (T1). After T1, participants read their assigned VIS then completed the second part (T2). A 2015 chart review identified vaccinated participants. A health behavior model was hypothesized using the Reasoned Action Approach and Health Belief Model. Logistic regression, path analysis, and chi-square tests were used in the analysis.

RESULTS

279 surveys were analyzed. Average age of the participants was 26.4 years (SD=5.7) with average gestational age of 25.9 weeks (SD=9.2). 13% self-reported receiving Tdap vaccine prior to the survey. Overall perception scores significantly increased (3.1-3.4, p<0.001) after VIS review. A chart review showed that 131 (47%) received the vaccine post study. There was no significant difference in vaccination rates between the sVIS and mVIS groups (45% vs. 49%). Perceived benefits (B=0.315) and self-efficacy (B=0.197) were positively associated with the overall perception (T1), while perceived barriers (B=-0.191) were negatively associated with the overall perception (T1). Social norms (B=0.230), self-efficacy (B=0.213), and perceived benefits (B=0.117) were positively associated with vaccination intention (T1). The vaccination intention (T2) was positively associated with participants' decision to receive Tdap vaccine (B=0.223).

CONCLUSION

A VIS improved overall perception of the Tdap vaccine. Vaccination intention was a predictor of Tdap vaccination. It is crucial to provide information about immunization benefits to promote maternal Tdap vaccination.

Health literacy training for health professions students

OBJECTIVE

This pilot project assessed the effectiveness of training health professionals in (1) readability assessment of written health materials, (2) plain language editing, and (3) formatting materials so they are easy to understand and use.

METHODS

Over six semesters, five students participated in the project. Students were trained to assess document readability, confirm and interpret readability results and "stamp" the documents with results. Students then edited documents under supervision, via revised documents were re-assessed for readability and approved. Training was assessed through readability score comparison and exit interviews with students.

RESULTS

Most original readability scores were 10th grade to college level. After editing, the average reading level of 73% was 6th grade or better. Students and supervisor rated skill levels as "proficient" at the end of the semester.

CONCLUSION

To address the gap between document reading level and patients' reading ability, health documents should be assessed and edited for plain language. Working with patient documents from various health fields, our program effectively trained health professions students in these skills.

PRACTICE IMPLICATIONS

Training health professions students in readability assessment and plain language editing can reduce literacy demands on patients and address the need for professionals with these skills.