Health Literacy Training
Program for the Arkansas
Department of Health, Local
Health Units
Cathy A. Irwin, PhD, RN
University of Arkansas for
Medical Sciences (UAMS),
Center for Rural Health
Sherian Kwanisai, RNP
Arkansas Department of
Health
Objectives
1. Describe the implementation of the Health
Literacy Training Program, using the
Health Literacy Universal Precautions
Toolkit in the Arkansas Department of
Health, Local Health Units.
2. Discuss the evaluation plan, instruments,
and data analyses for the Health Literacy
Training Program and implications
for improving health literacy practices in
the Arkansas Department of Health, Local
Health Units.
Purpose of the Health Literacy
Universal Precautions Toolkit
• Complicated medical care: Patients struggle
with understanding medications, self care
instructions, and follow-up plans
• The toolkit helps health professionals take a
systematic approach to reducing the
complexity of health care—ensure patients
can succeed in the health care environment
• Provides step-by-step guidance and tools for
assessing your practice and making changes
so you connect with patients of all literacy
levels
Benefits of the Health Literacy
Toolkit
• Improved patients’ understanding of
medications, self-care
• Improved medication adherence
• Decreased patient phone calls,
hospitalizations and health care costs,
returned appointments
• Improved efficiency and quality of care,
increased patient satisfaction and safety
• Testimonials from clinical practices: “We
realized that toolkit is not adding more, it is
about learning how to do things differently.”
Development and Testing of the
Health Literacy Toolkit
• Website:
http://www.ahrq.gov/qual/literacy
• Developed by: Agency for Healthcare
Research and Quality (AHRQ) and The
Cecil G. Sheps Center for Health
Services Research, UNC at Chapel Hill
• Testing of toolkit in 8 clinical practices
What is Health Literacy?
“Health literacy is the capacity to
obtain, communicate, process, and
understand basic health information and
services to make appropriate health
decisions.”
Health Literacy Skills
• Ability to interpret documents
• Read and write prose (print literacy)
• Use quantitative information
(numeracy)
• Speak and listen effectively (oral
literacy)
• Internet
Literacy in Arkansas
• Among Arkansas adults, 20% read at or
below a 5th-grade level, which affects
their ability to understand written
information.
• 14% lack basic prose literacy skills.
• 76.5% working-age adults (18-65 y.o.)
have not completed any college.
• 15.5% of these have not completed
high school.
(Arkansas Literacy Councils, retrieved January 6, 2012 at http://www.arkansasliteracy.org/; NAAL,
NCES 2003; 2008, Council for Adult & Experiential Learning, www.cael.org).
Limited Health Literacy is
Associated with:
• Increased hospitalizations/costs
• Greater emergency room use
• Less likely to engage in disease
prevention behavior
• Poorer health outcomes
• Poorer medication adherence
• Inadequate care for chronic diseases
• Increased risk of mortality
Red Flags for Low Literacy
•
•
•
•
•
•
•
•
Frequently missed appointments
Incomplete registration, history forms
Medication non-compliance
Difficulty with understanding
medication dosages, instructions on
labels
Discharge instructions, consent forms
Information on self-management of
diseases
Ask fewer questions
Lack of follow-through on tests,
referrals
A Hidden Problem
• Low health literacy is often undetected
(not just education!).
• People who are confused about health
information may feel ashamed.
• They may mask their shame to maintain
their dignity.
Organizational Health Literacy
Practices
• Health literacy affects chronic disease care
and self-management
• Patient-provider communication
• Patient safety and health-care quality
• Access to health care and preventive services
• Health literacy interventions are most
effective when addressed at an
organizational level causing systematic
change to improve health literacy practices.
Universal Precautions
• Taking specific actions that minimize
risk for everyone when it is unclear
which patients may be affected
• Health Literacy Toolkit offers health
professionals a means to structure
services, patient interactions to
minimize the risk that any patient will
not understand health information.
• Allowing patients to make informed
decisions about their health care
Why Take Universal Precautions?
• Providers don’t always know which patients
have limited health literacy.
• Some patients with limited health literacy
• Have completed high school or college
• Are well spoken
• Look over written materials and say they
understand
• Hold white collar or health care jobs
• Function well when not under stress
• Clear communication practices will improve
care for all patients, regardless of their level
of health literacy.
Health Literacy Universal
Precautions Toolkit
Health Literacy Universal
Precautions Toolkit
Offers 20 tools to promote health
literacy practices in 4 change areas:
 Spoken communication
 Written communication
 Self-management and empowerment
 Supportive systems
Self-Management and
Empowerment
• Toolkit tools can be used to help
patients manage their chronic
conditions—Empower patients to take
care of themselves
• Improve health care access
• Health knowledge
• Behavior change
• Health outcomes
6 Steps for Improvement in
Health Literacy Practices
1. Watch Health Literacy Video (6 min;
ACP)
2. Form Your Team, Tool 1
3. Tool 2, Assess Your Practice
4. Choose Tools, Limit Number
5. Raise Staff Awareness about Health
Literacy in Clinical Practice (Tool 3)
6. Plan and Test Your Changes
Health Literacy Training Program
• To begin Fall 2013 (week of September 9th)
• To include one to two LHUs in each region
• Multidisciplinary staff to include Nurses and Clerical
staff as a constant in each LHU and Administrators,
Disease Intervention Specialist, Environmental
Health Specialist, and Nutritionists where available.
• Implement tools in the Health Literacy Universal
Precautions Toolkit
• Provide tools and guidelines for making
improvements in health literacy practices
• Program evaluation system to allow LHUs to
identify areas for improvement in spoken and
written communication, patients’ self-management
of diseases and supportive systems
ADH Regions Map
Health Literacy Training and
Implementation of Tools
• Three 1-hour Training Sessions: Education
on 11 toolkit tools
• Interactive video for some of the LHUs
• Tools will be selected based on pretest
assessment of health literacy practices—
Focus on areas with greatest need for
improvement
• Facilitator in clinical setting
• Establish Teams: Each team will focus on
implementing 1 new tool in clinic each month
• Assign 5-6 tools to implement over a 6-month
period
Health Literacy Training Program
First Session
• Overview of Health Literacy Toolkit, training program,
evaluation plan; Health Literacy Video; Pretest Health
Literacy Assessment Questions
Second Session
• Report Results of Pretest Health Literacy
Assessment Questions
• Form health literacy teams, team leaders
• Signs of low literacy
• Tools for improving spoken communication
• Tools for improving written communication
Third Session
• Teach-back method, Teach-Back Video
• Tools for improving patients’ self-management and
empowerment
• Tools for improving patients’ supportive systems
• Process evaluation meetings by interactive video
Key Change 1: Tools to Improve
Spoken Communication
Tool 4, Communicating Clearly
• Warm greeting: Smile, Welcoming attitude
• Eye contact
• Plain, non-medical language
• Slow down; Limit content to 3-5 key points
• Repeat key points, summarize
• Graphics: Draw pictures, use models
• Encourage questions, “What questions do
you still have?”
• Teach-back: Confirm patients’ understanding
Communication Skills:
Reminders, Track Your Progress
• Hang poster in various locations
• Communication Self-Assessment:
Complete after one patient encounter
a day, during the week
Tool 14: Encourage Questions
Ask Me 3 Program: Encourage
patient to know 3 things before
leaving encounter
• What is my main problem?
• What do I need to do?
• Why is it important for me to do
this?
• Emphasize benefits to patient
Tool 14: Encourage Questions
• Invite questions using body language
• Sit at same level as patient
• Look at patient when talking, listening
• I have the time to listen to your
questions.
• Solicit questions
• What questions do you still have?
• That was a lot of information. What do
I need to go over again?
Tool 14: Encourage Questions
• Encourage patients to bring a relative or
friend to clinic visit to help remember
information, write down questions
• Involve entire staff in soliciting questions
• Checkin: Clinical staff talk about
patients’ questions while taking vitals
• Nurses, health educators, medical
assistants: Encourage questions
• Checkout: Ask each patient if their
questions were answered
Tool 14, Encourage Questions:
Track Your Progress
• Ask as patients exit, Did you get a chance
to ask all your questions?
• If patients answer no, ask whether the
doctor/nurse said they would address
some questions later.
Tool 8: Brown Bag Medication
Review
• Encourages patients to bring all
medications and supplements to
medical appointments
• Answer patients’ questions
• Verify what patient is taking
• Identify and/or avoid medication errors,
drug interactions
• Assist the patient to take medications
correctly, improve adherence
Tool 8: Medication Review
• Get patients to bring in their medications
• What to bring: All prescription meds., overthe-counter meds. regularly taken, vitamins
and supplements, herbal meds.
• Ways to remind: appt. card, appt. reminder
call, during visit, hang posters
• Set out the medications in exam room
• Offer praise to patient for bringing meds.
• Stress importance of bringing meds. to every
visit
Tool 8: Medication Review
• Review the medications
• Purpose of the review
• Patients’ questions
• Some helpful questions
• Are you taking any new medications?
• Have you stopped taking any meds.
since your last visit?
• How many of these pills do you take
each day?
• What do you take this medication for?
Tool 8: Medication Review
• Clarify medication instructions
• Confirm patient’s understanding: I want
to make sure I explained your medicine
correctly. Can you tell me how you will
take your medicine?
• Update medications in patient’s chart
• Provide patient with updated list of
meds.
• Bill for medication review: Select ICD-9
V58.69 to bill patient’s insurance
• Document med. review in patient’s
record
Tool 8, Medication Review: Track
Your Progress
• Document in medical record
whether or not a medication review
occurred at the visit
• At the end of a day or week,
identify the % of patients who had a
medication review completed
Tool 5, Teach-Back Method
• Not a test of patient’s knowledge
• Test of how well you explained the
health information
• Shame-free way to assess
understanding
• Polite request that the patient state in
their own words key points of
information
• Demonstrate back a skill
Tool 5, Teach-Back Method: Tips
• I want to be sure that I did a good job
explaining your medication, because this
can be confusing. Can you tell me how
you are going to take this medication?
• We covered a lot today about your
diabetes, and I want to make sure that I
explained things clearly. So let’s review
what I discussed. What are 3 things that
will help you control your high blood
sugar?
Try the Teach-Back Method
• Start slowly—try with last patient of day
• Plan your approach: What is the most
important thing for the patient to know
or do?
• Why is it important for the patient to do
these things?
• Use handouts—review written materials
to reinforce the teaching points
• Practice
Teach-Back Method
• “Chunk and Check”approach: Limit to 1-3
concepts/ideas at a time, Explain
• Ask patient to state in their own words key
points of information
• Listen—Patient recall and comprehension
• Affirm understanding
• Say it again, Rephrase—Don’t just repeat
• Ask patient to try teach-back again
• May need to clarify several times
• Use plain language
• Action messages: “What you need to do is…”
• Go slowly, pause often
Teach-Back Video, 5-minutes
What teach-back strategies did you
observe that were helpful for
ensuring the patient’s
understanding about the
medication changes?
Teach-Back Method: Track Your
Progress
• Teach-Back Self-Evaluation Log
Tool 10: Culture and Other
Considerations
• Learn about your patients’ health beliefs and
cultural practices
• I am not familiar with your cultures and health
beliefs. Can you teach me what I need to know
so I can better treat you?
• Causes and treatment of diseases
• Ethnic customs
• Religious beliefs: Refusing contraception, blood
transfusions, etc.
• Interpersonal customs: Eye contact, touch
• Resources in Toolkit—See Handout on Culture
Cues, website on other cultures, Tool 10, p. 47
Tool 10, Culture: Track Your
Progress
• Include assessment of health beliefs
and customs in electronic medical
record
• Randomly select some records and see
what % have notes on patients’ health
beliefs and customs
Key Change 2, Written
Communication: Tool 13, Welcome
Patients
• Create a friendly environment
• Easy to navigate
• Evaluation: Patient and staff walkthrough to
assess feel and navigation at front desk area,
waiting room, and signs
• Front Desk: Help with forms, assess language
preferences, obtain interpreter; practice
brochure
• Waiting Room: Bulletin Boards—Target patient
population, limit to 4 points of interest, easy-toread, update regularly
• Signs: Easy-to-read, clearly visible, identify
locations, English/Spanish, simple words
Tool 13, Welcome Patients: Track
Your Progress
• Patient and staff walkthrough to assess
feel and navigation at front desk area,
waiting room, and signs
• After making changes, conduct another
walkthrough and compare results
Tool 11: Design Easy-to-Read
Material
• Clearly state how to prevent and
manage disease without a lot of extra
information
• Use headings and subheadings
between sections—a lot of white space
• Use short sentences and paragraphs
• Use one- or two-syllable words
• Use large fonts (minimum 12 point)
• Use lists in bullet form
• Underlined or bold print for key words
Tool 11: Easy-to-Read Material
• Write at a reading level of 6th grade or
below –HL Toolkit, Free Readability
Formulas
• CRH, Readability Project, Dr. Kristie
Hadden, Health Literacy Advisor:
www.healthliteracyinnovations.com/prod
ucts/hla
• Word choice: Limit the use of medical
jargon, define any terms used
• Use common medical terms—HL
Toolkit, Plain Language List
Tool 11: Design Easy-to-Read
Material
• Use graphics and visuals to enhance
understanding about action to take
• Patient Forms: Help patient fill out forms
• Check boxes
• Don’t know options
• Bold key words
• See HL Toolkit for Example Forms:
Adult History, Consent to Treat, Lab,
Appt.
Tool 11: Design Easy-to-Read
Material
• Cultural appropriateness
• Action steps, desired behaviors: Take
your medicine with your meals
• Test educational material and forms
with patients, get feedback
• Simple, plain language material can
benefit all patients.
Tool 11, Design Easy-to-Read
Material: Track Your Progress
• Every 4 months, do a tally of what
written materials have been reviewed
and revised using plain language
guidelines with Tool 11
• See if percentage goes up over time
Tool 12: Use Health Education
Material Effectively
• Use in conjunction with spoken
instruction
• Review the material with the patient—
ensure understanding, repeat back
• Repeat and follow-up with phone
contact, in future visits
• Use videos for patient education
• Manage materials: Location,
organization, supply, updated, training
for staff on development and use of
materials
Key Change 3, Self-Management:
Tool 16, Medication Adherence
• Help patients organize medications
• Educate on medications, purpose
• Ask patients how they remember to take
medications
• Do you have a way to remember to
take medications?
• Everyone forgets to take their
medicine from time to time. When
was the last time you forgot to take
any of your medicines?
Tool 16: Medication Adherence
• When prescribing medicines, write precise
instructions: Take 1 pill in morning, 1 pill at
bedtime
• When switching from brand name to generic
medicines, tell patient the color, shape, and
size of pill may change.
• Different methods of managing medications:
Med Card, Pill Chart, Pill Cards, Pill Boxes
• Filling Pill Boxes: Use Teach-Back Method
to assure they understand how to fill boxes
• Involve family members—helpful with older
adults
• Home Health agencies
Tool 16, Medication Adherence:
Track Your Progress
• Reminders: Medication Aid Poster—display
in exam rooms
• Patient’s record: Method patients use to
remember how to take medicines—nurses
and physicians document
• At end of first week: Identify % patients that
had a reminder strategy noted in their record
• Check again in 2, 6, 12 months
• Aim to have notes on reminder strategies for
90% of patients within 12 months
Tool 15: Make Action Plans
Use Action Plans
•
•
•
•
•
Diet changes
Smoking cessation
Increase physical activity
Reducing stress
Improving sleep habits
Tool 15: Make Action Plans
• Motivation: If patient does not express
motivation to change, patient is not ready for
action plan—Focus on risk factors
• Created by patient: Determine goal with
provider’s guidance
• Small and realistic steps to achieve goal
• One step at a time
• Fill out the form—See Example
• Assess confidence—Should feel confident
(7 or higher on scale 0-10); Revise goal if
needed
• Make a copy of the action plan for patient
and document action plan in patient’s record
Tool 15: Make Action Plans
• Follow-up: Lets patient know you are
interested in helping them achieve behavior
changes
• Follow-up: Phone call, during office visits
• If goal was not achieved: Follow-up can help
to re-define goal, result in progress
• If goal was achieved: Praise patient, work
with patient to make next goal
• Reminders to use action plans:
• Place them in folder or drawer in exam rooms
• Make it available in electronic medical record
• Copy on colored paper so they stand out
Tool 15: Track Your Progress
• Document in patient’s record whether
action plan was created or reviewed
• At end of first week, identify % patients
with action plan created
• Check again in 2, 6, and 12 months
• Aim to create action plans for 90% of
patients with chronic health problems or
unhealthy behaviors within 12 months
Key Change 4, Supportive
Systems: Tool 18, Link Patients
to Non-Medical Support
• Assess the problem: Take time to
listen about patients’ needs for
non-medical support—critical for
optimal health
• Involve current support systems:
Family, friends, case manager,
social service agency
Tool 18: Link Patients to Non-Medical
Support
Develop a community resources list
• Contact Chamber of Commerce or
city/county government agencies for list of
services/programs
• Food pantries, goodwill locations
• Transportation services
• Domestic violence shelters
• Employment assistance program
• Teen pregnancy programs
• Support groups
• Services for hearing or visually impaired
• Aging and caregiver services
Tool 18: Link Patients to Non-Medical
Support
• Organize resources
• Train everyone on use of resource guide
• Internal referral form—Make referral
appointment for patient, if needed
• Follow-up if referral was completed—Followup with patient and service provider
• Document results in patient’s record
• Adjust staff responsibilities—Staff person take
on role of helping patients with non-medical
problems; Social Worker on staff
Tool 18: Track Your Progress
• Conduct a spot check of your charts:
Choose 10 charts at random, and see
if patients’ non-medical problems and
support systems are documented with
referrals made
• Repeat chart review again in 3
months, and see if charts are more
complete with referrals made
Tool 20: Use Health Resources
in the Community
Community Health Resources and
Programs
• Diabetes Education
• Smoking Cessation Programs
• Support Groups
• Weight Management
• Exercise/Fitness Programs
• Stress Management Programs
Tool 20: Use Health Resources
• MedlinePlus: National Library of
Medicine, National Institutes of Health
• Free health education materials, online
• Hundreds of diseases
• English and Spanish
• Links to health info. in 40 languages
• Plain language, easy-to-read material
• Senior Health topics
• Incorporated in EHR, patient portal
Tool 20: Use Literacy Resources
in the Community
• Literacy Directory—Local resources;
help with reading, math, English for
speakers of other languages
• Ask about difficulty reading—Have you
ever had a problem with reading?
• Ask if they have an interest in improving
–Would you be interested in a program
to help improve your reading?
Tool 20: Track Your Progress
• Track how many health and literacy
referrals are made in a month and then
again after a few months of
implementation.
Evaluation Plan
• One-group pretest and 6-month follow-up
design
• Training Program Participants: One to two
LHUs in each region
• Multidisciplinary staff: Nurses and Clerical
staff in each LHU and Administrators,
Disease Intervention Specialist,
Environmental Health Specialist, Nutritionists
• Data collection: Begin September, 2013
• Outcomes: Perceptions of health literacy
practices
• Perceptions of successes and problems
with implementing the health literacy tools
• Program satisfaction
Process Evaluation
• Reporting of and interviews with clinical
staff
• 1-month, 3-month, and 6-month followup meetings by IAV—30 minutes
• Assess Health Literacy Toolkit activities:
Toolkit action plans, staff training, toolkit
strategies and tools
• Identify successes, benefits, barriers,
and problems with implementing health
literacy tools
Instruments
Health Literacy Assessment Questions
• 49-items, 15-20 minutes to complete
• Assesses clinical staff’s perceptions of health literacy
practices: Spoken and written communication, selfmanagement and empowerment, and supportive
systems
• Response choices: Doing well, needs improvement,
not doing, not sure or N/A
• Scores range from 0, not doing to 100, doing well
• Higher scores indicate doing better with using health
literacy practices in the clinic.
• Developed by authors of the Health Literacy
Universal Precautions Toolkit, Tool 2
• 6-month follow-up instrument: Revised to include 4
additional items with open-ended responses to
describe what the staff have done differently to
improve health literacy practices in the 4 change
areas
Instrument Testing: Pretest Health
Literacy Assessment Questions
Principal Components Factor Analysis
• N = 214, UAMS Family Medical Centers;
clinical staff, faculty, and residents
• Strong construct validity: Total scale and
subscales on spoken and written
communication and supportive systems
Strong Internal Consistency Reliability
• Cronbach’s alpha = 0.95, total scale
• Cronbach’s alpha = 0.85-0.88, 4 subscales
Instruments
Plan-Do-Study-Act (PDSA) Worksheets for
Process Evaluations—1-mo, 3-mo, 6-mo FU
• Method to test a change that is implemented
• Breaking down the task into steps
• Evaluating the outcome
• Improving on it
• Testing again
• Having them written down often helps people
focus and learn more.
• Used in the Institute for Healthcare
Improvement by hundreds of health care
organizations
• Health Literacy Toolkit, Appendix Items
Plan-Do-Study-Act Worksheets
Plan
• I plan to: See if team members are
performing teach-back with one patient in
each week.
• I hope this produces: We hope that each
of the team members will have performed
teach-back on at least 3 of their patients
during 3 weeks (measurement/outcome).
• Steps to execute: Team members will
count the number of patients they
performed teach-back on during 3 weeks.
• Team members will inform Team Leader if
teach-back was useful and if they will use
it again.
Plan-Do-Study-Act Worksheets
Do: What did you observe?—team members
and patients’ reactions, modifications
Study: What did you learn? Did you meet your
goal?
Act: What did you conclude from this cycle?—
Problems, successes with tool (Revised items)
What can you do differently to address
problems with tool?
• Teach-back is being used, maybe not as
readily as anticipated.
• Put a sign in clinic rooms, offices to remind
team members to use teach-back
• Will measure outcome again in 2 months
Instruments
Satisfaction Evaluation at 6-month follow-up
• 12 items
• Evaluates program satisfaction regarding
knowledge, use of information in practice to
enhance patient care, program quality, and
convenience of technology
• Demographic information, Discipline
• Likert-type response scale: Strongly disagree
(1) to strongly agree (5)
• Demonstrated adequate internal consistency
reliability (Cronbach’s alpha = 0.91) and
construct validity (N = 45,996)
Data Analysis
•
•
•
•
•
SPSS Version 19
Means, standard deviations, frequency %
Paired t-test and McNemar test
One-way analysis of variance (ANOVA)
T-test for independent samples
• Instrument testing: Principal components
factor analysis (construct validity), internal
consistency reliability
• Qualitative research procedures: Coding data
for open-ended responses for Process
Evaluations
Implications
• Results can be used to identify needs for
improvement in health literacy practices in the
LHUs.
• Pretest and FU assessments will promote
increased awareness of health literacy
practices.
• Health Literacy Toolkit Tools will be useful in
further developing a Patient Centered method
of information delivery for these LHUs.
• This Program provides a model for health
literacy training programs in other LHUs and
other health care facilities.
Cathy Irwin, PhD, RN
UAMS Center for Rural
Health
4021 W. 8th St., slot 599
Little Rock, AR 72204
479-684-5189
cirwin@uams.edu
Sherian Kwanisai, RNP
CLPH Nursing Director
Arkansas Department
of Health
4815 W. Markham, Slot
21
Little Rock, AR 72205
501-661-2796
Sherian.Kwanisai@ark
ansas.gov
Questions and Discussion