1. Centrality of Pt. Ed to Effective Clinical Practice & Achievement of Desired Health Outcomes
   1. Def: Patient/Client Related Instruction:
      1. The process of informing, educating, or training patient/clients, families, significant others & caregivers is intended to promote & optimize PT services
   2. Instruction may be related to:
      1. – Current condition – specific impairments, functional limitations, or disabilities – POC – need for enhancement performance – transition to a different role or setting – risk factors for developing a problem or dysfunction – need for health, wellness, or fitness programs
   3. Healthy People 2020:
      1. Overarching Goals
         1. – Attain high-quality, longer lives free of preventable disease, disability, injury & premature death – achieve health equity, eliminate disparities, & improve health of all groups – create social & physical environment to promote good health for all – promote quality of life, healthy development & healthy behaviors across all stages of life
      2. Selected Health Communication & Health Info Technology Objectives Box 12-1 p. 201
2. Scope & Magnitude of the "Literacy Problem" in the US
   1. def: general Literacy:
      1. Using printed & written info to function in society, to achieve one's goals & to develop one's knowledge & potential
   2. – The first nationwide assessment of adult literacy, the National Adult Literacy Survey (NALS) conduced in 1992 and the 10-yr follow up study, the 2003 National Assessment of Adult Literacy (NAAL), revealed a high prevalence of illiteracy & low literacy in the US
   3. in the 2003 NAAL, the literacy skills were measured in 3 domains which rep 3 functional tasks that individs would need to assess, understand & use information
      1. Prose Tasks
         1. The knowledge & skills needed to understand & use info from text material such as newspapers, magazines, books, brochures
      2. Document Tasks
         1. The knowledge & skills needed to find, interpret, & use info from document such as applications, forms, maps, transportation schedules, charts etc.
      3. Quantitative Tasks
         1. The knowledge & skills required to read, interpret & work with numerical information & apply mathematics to calculate or reason numerically such as reading nutrition labels & calculating calories, computing restaurant bills & tips, balancing a checkbook etc.
   4. Findings from 2003 NAAL Table 12-1 p. 202
      1. 55% = determined to be at basic or below basic level for quantitative tasks
      2. 43% = determined to be at the basic or below basic level for prose tasks
      3. 34% = determined to be at basic or below basic level for document tasks
      4. Those at the basic or below basic level (55% & 43%) might experience significant difficulty completing intake forms, comparing drug plans, ID what they may or may not drink or eat before a medical test, or following written instructions on prescriptions to determine correct dosages
   5. Def: Health Literacy:
      1. The degree to which individuals have the capacity to obtain, process, & understand basic health information & services needed to make appropriate health decisions
   6. The Health Literacy Tasks in the NAAL were distributed across 3 Domains of health care services or information:
      1. Clinical care
         1. Understanding health or medical dosing instructions or filling out a form
      2. Prevention services & Info:
         1. Following guidelines for prevention services such as immunizations
      3. Navigation of the health care syst:
         1. Understanding an insurance plan or determining eligibility for assistance
   7. Findings of Pub'd 2006 Health Literacy results of NAAL:
      1. 36% = Basic or below basic levels of health literacy; thus overall literacy skills were about an eighth grade level or below
         1. Of the 36%, 14% were measured at the below basic level & would be considered functionally illiterate when dealing with health information
      2. 53% = rated in the intermediate level of health literacy (about 10 – 12 grade level)
      3. 12% = proficient
3. Implications of Low Literacy for Individual & Public Health
4. What can we do to be Effective Communicators & Teachers & Foster Pt. Learning
   1. Recognizing Populations at Risk, Risk Factors & Health Literacy Challenges
      1. Older Adults
      2. Ppl w/low incomes or living @ or below poverty line
      3. Ppl w/less than high school degree
      4. Racial & Ethnic minorities
      5. Non-native speakers of English
      6. Male Gender
      7. Persons on Medicare, Medicaid, or uninsured
      8. Individs w/chronic disease or disability
   2. Assessing Health Literacy: Informal Assessment
      1. – Need to develop strategies for assessing & addressing literacy concerned by creating clinical environment & encounters that are "shame free" Emerson reduce the potential for embarrassment or humiliation – stress associated with illness, injury & disability, in & of itself, can create barriers to communication & understanding of complex health information – oral communication skills may be far better than reading skills for individuals with low literacy
      2. Red flags: Reading Behaviors, Self-care behaviors, communication behaviors
      3. Informal Methods for Assessing Literacy Skills:
         1. Use Social Hx & Subjective Portion of the Exam to screen
            1. be alert for risk factors and if present, be extra alert for the red flag behaviors
         2. Complete a Medication Review with the Pt.
            1. – Can be an invaluable clinical & literacy screening tool – requires that you ask patients to bring their medications to therapy & then spend time talking with your patients about their medications to assess the patient's understanding of what medications they are taking, why they are taking them, when they are taking them & how they are taking them etc
      4. Just asking the Pt's highest school grade completed/educational level ISN'T ENOUGH!
         1. B/c there can be a 2-5 yr discrepancy between grade level attained & pt's true reading abilities (Pt can graduate 10th grade and have a 5 grade reading level)
   3. Assessing Health Literacy: Formal Assessments
      1. 2 Brief & EAsy tools to use in Clinical Settings:
         1. The Newest Vital Sign (NVS)
            1. – Quick screening for literacy in primary care settings – could be included in routine intake assessments – reliable & accurate measure of literacy with high sensitivity for detecting persons with limited literacy – consists of an ice cream nutrition label that the patient is asked to review & then answer a series of 6 questions regarding information in the label – it assesses all 3 dimensions of literacy: prose, document, quantitative (or numeracy) – 3 minutes to administer
         2. Rapid Estimate of Adult Literacy in Medicine (REALM)
            1. – Original = 66 item instrument the patient is asked to read where the terms were listed in 3 columns and tester scored patient based on his/her ability to read & correctly pronounce the words on the list – revised abbreviated form: REALM-R (2003)=only 8 items & took 2 mins, included terms: osteoporosis, allergic, jaundice, anemia, fatigue, directed, colitis & constipation – shortened version: REALM-SF (2008)= only 7 items –SAHLSA-50: short assessment of health literacy for Spanish adults – for both items = excellent agreement with the longer 66 item REALM instrument in terms of grade level assignments
      2. Other Assessment instruments: Appendix 12-A p. 215
5. Developing Appropriate Educational Interventions & Materials
   1. Other strategies/techniques you can use to enhance communication, learning, & understanding for your patience in face-to-face encounters & through the development or identification of appropriate, accessible, easy to read patient educational materials
   2. Face 2 Face Communication & Teaching Strats
      1. – Patients may hide their lack of understanding resulting in poor health outcomes from both the provider & patient perspectives
      2. To be MOST effective in communication w/ pts w/low literacy skills we need to:
         1. Create shame free & patient centered environments
            1. – Be attentive to the continuum of the experience of the patient in the healthcare system (from the initial referral & scheduling of an appointment with a provider, the check-in procedures, through the clinician-patient encounter itself, & to follow-up procedures) – make changes to decrease the stress associated with just getting to a clinic appointment – i.e. colored strips on walls or floors or other visual images that direct patients to various areas of the hospital or clinic – reception staff these to be aware of patient populations that might be at risk for literacy concerns – offer to assist patient and completion of forms in a private area away from the immediate waiting room area – reevaluate the forms to be filled out by patients during check-in & simplify them as much as possible by using plain language & formatting them to make them easy to read
         2. Adopt approaches to interaction & teaching that diminish the potential for patient embarrassment or humiliation
      3. Communication & teaching strategies that can be employed to help patient feel comfortable & facilitate learning & understanding :
         1. 2 most important: Plain Language & Teach-Back Technique
      4. Plain Language
         1. – Important to limit the amount of new information provided to the patient and one teaching session; try to determine what is essential – what the patient truly needs to know or do RIGHT NOW – when delivering new information/instructions, use short & simple terms that would be familiar to the patient & use in their everyday language – use analogies to name & describe exercise your teaching the patient – what the patient daily exercise using their own words once they understand the movement you are asking them to perform. "If you were naming this exercise, what would you like to call it?" – Helpful to repeat & were phase information to assure that the message was received as intended – use of demonstration, visual images or models, audiovisual resources & written materials – don't ask you have any questions at the end of the session instead say: "I have given you a lot of information today! What questions do you have for me now?" – Verify understanding of information using a teach back technique
         2. Ask Me 3 Intervention=a clear health communication initiative focusing on encouraging Pt questions about their health care:
            1. What is my main problem? (focus on dx or major prob)
            2. What do I need to do? (focus on instructions or interventions)
            3. Why is it important for me to do this? (focus on creating a context for instruction & adherence
      5. Teach-Back Technique
         1. Is a strategy you can use to assess or verify a patient's understanding of instructions or information you have provided to them
         2. 5 Steps Box 12-5 p. 209
            1. 1. Clinician explains new concept 2. Clinician assesses patient recall & comprehension 3. Clinician clarifies & Tailor's the explanation to the patient 4. Clinician reassesses patient recall & comprehension 5. Patient correctly recalls & comprehends the instruction
6. Designing & Evaluating Pt. Ed Materials: Helping Ur Pts. to Learn from Written Materials
   1. Written materials are resources for your patient can come in many forms, & should be easy to read, accessible & understandable for your patience, such as: – patient information sheets or brochures – HEP – activity or exercise logs – audiovisual materials
   2. 3 types of assessments you can use to abide with the clarity, difficulty, & suitability of patient education materials:
      1. The use of checklists of attributes of written materials
      2. Some commonly used readability formulas to determine literacy demands & grade level estimates of textual materials
      3. Suitability Assessment of Materials (SAM)
   3. Checklists of Attributes of Written Materials
      1. Help you assess attributes of written materials and 4 general categories:
         1. 1. Organization of materials (including amount of info provided) 2. Writing style (including use of active voice & plain language) 3. Appearance (including print type & size & use of illustrations) 4. Appeal & suitability
   4. Readability Assessments: The SMOG and FRY Formulas
      1. – Readability formulas can help you to specifically assess the reading difficulty written materials & most formulas are easy to use
      2. Usually looks at 2 Key features of text:
         1. Vocabulary Difficulty as assessed by the number of polysyllabic words
         2. Sentence Length
      3. 2 common & easy to use tools (Readability Formulas)
         1. Simple Measure of Gobbledy-gook (SMOG)
         2. FRY Readability Test/Graph
      4. SMOG Grading Formula Box 12-6 p. 210
         1. – One of the easiest, fastest & most accurate predictors of readability – can be applied to longer texts (30 sentences or greater) & shorter text (less than 30 but greater than 10 sentences) – Calculated by hand in a short amount of time or by a SMOG calculator
      5. FRY Graph Readability Formula Box 12-7 p. 212
         1. – Assesses reading levels ranging from grades 1 – 17 – easy to use & can be completed manually and less than 15 minutes – looks at similar features of text materials (word syllables & sentence length), but grade levels are assessed by putting values on a FRY Readability Graph
   5. Suitability Assessment of Materials Table 12-4 p. 212
      1. – Is a comprehensive, systematic process & scoring instrument that can be used to evaluate several factors (& related criteria) that can affect whether print materials are appropriate, attractive, & readable for target audiences – evaluation 6 primary factors that influence the suitability & potential effectiveness of written materials for various patient populations – then the evaluator will calculate numerical percentage score for the material that will fall into one of the following categories: superior (70% – 100%), adequate (40% – 69%), or not suitable (0% – 39%)