Strategies and Materials for Health Education

Health Literacy Assessment

Abstract

Educating patients is an integral part of a nurse’s job. While this might seem to be a simple task, it can, in fact, be quite challenging. As nurses, we care for patients from a wide variety of ages. Although a patient’s age can be a barrier to their ability to learn and/or understand what is being taught to them, it is not the only factor that must be considered. The nurse must consider other factors as well, such as the patient’s level of education, cultural background, and perhaps even what type of career the patient has. Regardless of what type of materials a nurse uses to educate his or her patients, it is helpful for the nurse to know what the patient’s level of health literacy is. There are many tools available today to help nurses assess their patients’ health literacy, such as Rapid Estimate of Adult Literacy in Medicine – Short Form (REALM-SF), Short Assessment of Health Literacy – SAHL – English, and Spanish, and the NVS – Newest Vital Sign Tool/Test. In this paper, I will discuss how my institution creates and reviews health promotion and/or educational materials for patient education; I will discuss the results of the health literacy assessment I performed on a non-health professional, which tool I used to conduct my assessment and why I chose that specific tool; I will discuss a specific piece of health promotion education material used by my institution and its appropriateness; and finally, I will reflect on my experience.

SSM St. Clare Health Center is a 154 – bed hospital, located in Fenton, Missouri. It was built in 2009 to replace the former St. Joseph Hospital in Kirkwood, Missouri. St. Clare is a Level 1 Stroke Center. Strokes can be devastating and therefore, it is imperative that we properly and thoroughly educate our patients and their families so that we may, perhaps, prevent additional strokes from happening. Part of the education process at St. Clare includes giving written educational materials to our patients and their families. To find out about the process involved in creating these educational materials for SSM, I recently contacted and interviewed Ms. Maureen Bell, one of the SSM STL stroke coordinators at St. Clare Health Center. Ms. Bell answered the following questions for me:

1. Who (individuals or professional groups) has input into creating patient education (brochures, instructions for follow up care, or disease education? The SSM STL stroke coordinators meet annually to review the Stroke Education Binder that is given to each stroke/TIA patient. The stroke coordinators review the latest guidelines, which come mainly from the AHA/ASA (American Heart Association/American Stroke Association), and the latest Clinical Practice Guidelines. They make any appropriate changes based on the evidence and guidelines. If the information is related to another discipline, they involve them as well (i.e. changing the diet guidelines would involve obtaining input from clinical nutrition).
2. What is the process for health teaching information approval? At SSM, regarding stroke, requests come to the stroke coordinators and are added based on the latest guidelines/research. The stroke coordinators decide if it would be beneficial to add the requested information to the Stroke Binder. There is a potential to overload the booklet with information so additional information is reviewed carefully for its added value.   
3. Who evaluates documents for health literacy reading levels, and readability? Many of the forms within the booklet come for the AHA/ASA website (they are documented as such) and already have been designed at a fifth-grade reading level. Information that is not already reviewed for its reading level is reviewed by the stroke coordinators.
4. Is there a process for review of existing written materials? Annually, the stroke coordinators review the booklet before we order the supply for the upcoming year for appropriateness of information.
5. Who in your organization is responsible for assessing individual patient’s health literacy (not the documents) when they are admitted to the hospital? It is the responsibility of many: the admitting nurse, the registrar, and the case manager. Upon admission, however, we ask them if they do better with handouts or verbal instructions. Not every patient is forthcoming with this information either, so we try and explain every form we either have them sign or give to them. We also try to reaffirm the understanding of the information. (M. Bell, personal communication, February 4, 2019).

Next, I interviewed two non-health professionals of different age groups for health literacy using a literacy assessment tool. I chose to use the Short Assessment of Health Literacy – SAHL tool (English version) to conduct an assessment test of my clients’ literacy levels because of the three tests offered, I felt this one was the most pertinent to a health literacy assessment, as it contains medical terms. To administer the test, a set of 18 flashcards was

created. Each flash card contained three words, one at the top of the card, and two words underneath that. First, the instructions were read to the client. Next, the first card was shown to the client and he or she was asked to read the top word out loud. Then, I read the other two words on the card to the client. The client was then instructed to tell me which of the two words I read was more closely associated with the top word. The client was instructed to answer, “I don’t know” if he or she did not know the answer. This process was repeated for each of the remaining flash cards. I recorded the answers on a score sheet which was kept out of the client’s view. The clients were awarded one point for each correct answer. For this test, a score between zero to fourteen on the test suggests a low level of health literacy.

The first individual I interviewed was a 53-year old married man named Bill Young who lives at home with his wife and children. He has a high school education and his occupation is rebuilding automobile transmissions. Bill was able to read and pronounce all words without difficulty and he correctly matched seventeen out of the eighteen words. He said the test was easy. (B. Young, personal communication, February 2, 2019)

My second client was a 19-year old female college student name Jessica Boyer, who lives at home with her parents and siblings and works part-time at a local grocery store. Jessica also had no difficulty reading and pronouncing all the words and she correctly matched sixteen out of the eighteen words. (J. Boyer, personal communication, February 2, 2019).

One possible drawback with the Short Assessment of Health Literacy tool is that the words on the test are very common and are understood by most people. Since doctors and other health professionals sometimes use medical “jargon” or more difficult words when discussing health issues with their patients, I feel this test might be good for assessing a client’s general literacy level, but I do not feel that it is appropriate for assessing a client’s health literacy level. 

When asked how they felt about taking this test, both of my clients reported feeling very comfortable during the assessment. The main reasons they said they felt comfortable were that the test was given by someone they know, and the test was given in a familiar environment, so they did not feel intimidated. Also, no one else was present when the test was administered. Clients might feel uncomfortable for many reasons, such as: if they were tested in an unfamiliar environment, if the interviewer was unfamiliar, if the interviewer is more educated than they are, if others were present during the assessment, or if they have difficulty reading and/or writing. Although my clients reported feeling comfortable during the assessment, I did sense that they both seemed to feel a little embarrassed when they weren’t sure about their answers. I felt very comfortable assessing my clients because I am familiar with them, because I am accustomed to frequently and routinely assessing patients, and because I interact well with others in general.

Overall, the main thing I learned from this activity is that it is important for health care professionals to create an open and shame-free environment for their patients (Health Literacy Video, 2010). Patients need to know that they are not being judged and that you are there to help them. If patients feel comfortable, they will be more open and honest with you and they will be more apt to ask questions and/or admit when they do not understand something. This allows for the opportunity to better educate the patient. 

As a registered nurse, I spend a fair amount of time educating patients. Since SSM St. Clare Health Center is a level I stroke center, for part three of this assignment, I chose to review our patient education materials regarding strokes for part three of this assignment. The pamphlet I reviewed is titled, “Depression & Stroke” (SSM Health, 2015). To determine the readability of 

my document, I used the SMOG Readability Formula (ReadabilityFormulas.com, n.d.). The process of determining the readability included submitting a portion of my document on the SMOG Readability Formula website. Once submitted, the website generated several different scores which determined the level of difficulty and the grade level of the material I submitted. My results were as follows: Flesch Reading Ease score = 47.7, which, according to their grading scale, is “difficult to read”; Gunning Fog score = 11.1, which is considered “hard to read”; Flesch-Kincaid Grade Level = 9.5 (tenth grade level); The Coleman-Liau Index = 14 (college level); The SMOG Index = 8.9 (ninth grade level: Automated Readability Index = 10.1 (14-15 years old/ninth-tenth grade level);  and Linsear Write Formula = 7.1 (seventh grade). From these results I have concluded that this document may not be very easy for my patients to understand, depending on their age, level of education, and literacy level.

 Patient education materials should be assessed for design appropriateness and plain language. Design appropriateness has to do with the appearance of the document, making it appealing to the reader. Not only is it important to attract the reader, but it is also important to keep them interested. The following elements should be considered when designing a document: use headings and subheadings to separate and identify key components in the document; use appropriate font types and sizes so the document has a clean appearance and is easy to read; use a combination of upper and lower-case letters to help convey meaning of the material presented; justify the left margin to keep the document uniform; use short, bulleted lists to separate key points or ideas; be mindful of your use of white space so the document looks well balanced; use elements of contrast, such as different fonts, bold lettering, pictures, and colors to grasp and hold the reader’s attention; and keep the document subjective (Osborne, Ch. 9).

The pamphlet I reviewed displays three different sized fonts, three different colored fonts, three bulleted lists. The white balance is a little bit off and could use fewer words to balance it out. Most of us have heard people say, “can you explain that to me in plain English?”. Well, what exactly is plain English? Plain English, also known as Plain Language, is a way of writing that simplifies what is being said so that anyone who reads it will be able to understand it. It differs from design appropriateness in that design appropriateness is about the presentation and/or appearance of the document, making it look appealing to the reader; plain language is about the way the document is written. When using plain language, organization is key. The writer should choose a main topic or message and support that message with key points, but not too many. The writer needs to be careful not to include trivial or unnecessary information because if the document is too long the reader will lose interest. It is also important to inform your readers of why your information or message is beneficial to them.  Using common words that most people are familiar with and can pronounce without difficulty is very helpful; readers are not likely to continue reading something if they do not understand it or cannot pronounce the words. Writers should also try to use the same words throughout the document instead of using different terms for the same thing because this confuses readers. Contractions should be avoided because not only do they look unprofessional, but people with low literacy levels might not understand their meanings. Lastly, writers should also avoid using choppy sentences and should stick to using one main topic per sentence so as not to confuse the reader (Osborne, Ch. 28). According to the SMOG Readability Formula results, the pamphlet I reviewed is difficult to read. It does contain some of the elements I have discussed here, such as different sized fonts, however, the writer

used some very difficult words and one of the bulleted lists was rather long. Also, the author did not list any benefits or advantages for the reader. Chapter 21 talks about knowing your audience and what their literacy level is. It suggests the use of common words and using materials that are easy to read. One thing mentioned, that I think is a great idea, is offering non-written options. The SSM Health Stroke pamphlet seems to use a lot of large, uncommon words, which could be difficult for laypeople and stroke patients to understand. Some of the material discussed, such as vascular depression could be very confusing to someone with a lower literacy level. It would be beneficial to include some visual images of vascular depression. The pamphlet does list several websites that readers can go to for more information and it does list a couple of phone numbers readers can call if they would rather speak to someone over the phone, but perhaps it would be beneficial if the author offered a link for a video or podcast for the readers to watch (Osborne, Ch. 21).

 In conclusion, I have not personally used the pamphlet I reviewed for this assignment in my nursing practice. The reason I haven’t used it is that most of our stroke patients either go to the neuro floor or the ICU. Also, we have a stroke educator who speaks with the stroke patients and hands out these pamphlets. While I do believe this document is informative, I do think it would be more difficult than not for patients to understand it, especially if the patient has any residual from a stroke. Some changes I believe are needed to make this document more useful to patients would be to include less information in this pamphlet and perhaps create a second pamphlet to go along with this one. Maybe include more graphics/visual images in the pamphlet since some patients have cognitive difficulties and/or a decreased literacy level after a stroke.

Captions could be included with the images to help convey what the writer is teaching the patient. The pamphlet could also use a little more contrast to make visuals easy to see, and

perhaps changing the color of the paper the pamphlet is printed on could help make it easier to follow. “Many people enjoy and learn from visuals. This includes visual learners (those who learn best when seeing, reading, or being shown) as well as people with limited literacy or language skills who benefit from illustrations, not just words” (Osborne, Ch. 38). No matter what type of document you are using to educate your readers, it is always important to confirm that they understand what you taught them so it would also be beneficial to include a few checkpoints with questions throughout the pamphlet to check and see that the patient is understanding what they have already read before going on to finish the rest of the document.

 In the future, I plan to focus a lot more on patient education and ask my patients more open-ended questions to make sure they understand what I am teaching them, regardless of what the subject is. I also plan to try to manage my time better so that I might possibly have more time to spend with my patients for educational purposes. I also plan to review some websites and online videos for use with my patients.

References

• AMA Foundation. (2010, August 27). Health literacy and patient safety: Help patients understand . Retrieved from http://youtu.be/cGtTZ_vxjyA
• Automatic Readability Checker (n.d.) in Readability Formulas. Retrieved February 4, 2019, from www.readabilityformulas.com/free-readability-formula-tests.php.
• Health Literacy Measurement Tools (Revised) (n.d.) in Agency for Healthcare Research and Quality. Retrieved February 2, 2019, from https://www.ahrq.gov/professionals/quality-patient-safety/quality-resource
• Osborne, H. (2018). Health Literacy From A to Z. Lake Placid, NY: Aviva Publishing, chapters 1, 2, 3, 9, 16, 19, 21, 28, 38.
• SSM Health (2015) Depression & Stroke [Pamphlet] SSM Health: St. Louis, Missouri.