WN6

See below

Rubric #8, Patient Education Pamphlet (M6)

Area Evaluated
20 points

Accomplished Proficient Needs Work Unacceptable

Thesis/organization

7 points

*Clearly written,
visually appealing
*Good use of
white space,
bullets, and
graphics
*Good use of
chunking and
subheads
*Order of topics
is logical
*Font use is
appropriate and
readable
*Stays within the
one-page limit

*Writing style is
mostly easy to
read but places
where bullets etc.
would simplify
*Decent use of
chunking and
subheads
*Font use is
appropriate but
size varies at
times
*Stays within
one-page limit
but pushes the
margins

*Poorly
organized.
*Cluttered
looking
*Very little use of
chunking or
subheads
*Illogical order of
information
*Font too small.
*Poor use of bold,
italics, etc.
*Graphics are
minimal or little
connection to
text

*Poorly organized
and visually
cluttered
*Order of
information is
confusing
*Graphics not
appropriate
*Poor use of font,
italics, bold,
chunking, or
subheads

Content

6 points

*Appropriate and
accurate
information
*Purpose is clear
*Link between
information and
graphics is clear

*Covers most of
important and
necessary points
*Purpose is clear
but not
immediately
obvious
*Some links

*Misses 2 or
more important
points
*Purpose is not
clear
*Some content or
language does
not fit

*Misses 3 or
more important
points
*No obvious
purpose
*Link between
content &
graphics poor

Audience

5 points

*Language used is
at appropriate
level of
readability for
defined audience
*Culturally
appropriate
language and
references
*Correct
audience is
clearly addressed

*For the most
part the language
used is
appropriate
*Culturally
appropriate in
most instances
*Intended
audience can be
inferred
*Mostly clear and
is likely to be
understood

*Language is
about 50%
appropriate
*Cannot identify
the specific
audience
*Not culturally
correct in some
places
*Not very clear
and could be
easily
misunderstood

*Language not
appropriate for
the audience or
for the format
*Cannot identify
the audience
*Easily
misinterpreted or
misunderstood

MUGS
2 points

No more than 2
errors

No more than 5
errors

No more than 8
errors

More than 8
errors

Interpretation of Final Points Accomplished: 20.00 – 18.01 points
Proficient: 18.00 – 16.01 points
Needs Work: 16.00 – 14.00 points
Unacceptable: Less than 14 points

What You Need to Know About Opioids
What are opioids?

Opioids are a class of prescription medicine used to
treat pain. Common opioid medicines include:

• Percocet® (oxycodone and acetaminophen)
• Oxycontin® (long acting oxycodone)
• Vicoden®, Norco® (hydrocodone and

acetaminophen)
• Morphine
• Fentanyl
• Dilaudid® (hydromorphone)

Let’s focus on opioids

Opioids may be called painkillers, narcotics or
Schedule II controlled substances (CII). The U.S. Food and Drug Administration (FDA) and U.S. Drug
Enforcement Administration (DEA) have determined that these medicines carry serious risks of
addiction and overdose, often with prolonged use. The government closely monitors and regulates
manufacturing, prescribing and dispensing of opioids.

When are opioids prescribed?

Opiods are used to treat moderate to severe pain. Pain can be acute or chronic. Acute pain means it
will only last a short time (like after surgery). Chronic pain is pain that lasts longer. It occurs with
diseases like cancer or arthritis. Opiods are used as a last resort, meaning that other pain medicines
and therapy (like physical therapy) are not working.

Prescribing restrictions

Because of the risks, only prescribers who have a special license from the DEA can prescribe
controlled medicines. Opioids require a new prescription each time they are filled at a pharmacy.
Prescriptions for opiods may not be refilled. Many insurance companies place restrictions on the
strength of opioids you may receive, how often you may receive them and for how long you may
receive them.

What is the Colorado PDMP?

In addition, be aware of your seizure
triggers and avoid them when possible.
Triggers vary from person to person, but
some of the most common include lack
of sleep, emotional stress and hormonal
swings.

Treating epilepsy correctly also means
taking care of yourself. Be sure to get
enough sleep, exercise regularly and eat
well-balanced meals at regular intervals.
Find strategies to help you to cope with
stress, such as yoga or relaxation tech-
niques. Depression and anxiety are
possible side effects of some AEDs and
can also stem from the emotional stress
of dealing with epilepsy. Be sure you
have a strong support system and let
someone know if you’re feeling hopeless
or depressed. Above all, continue to
take your medication, even if you
haven’t had a seizure for a long time.

Beyond this, there are special consid-
erations for women with epilepsy in
various stages of life.

Epilepsy And Late Adolescence

Adolescence can be a pivotal time for
people who were diagnosed with
epilepsy as children. Young women face
a number of choices about their pending
independence, including college, future
employment, sexual relations and birth
control. Epilepsy needs to be factored
into these decisions.

An important issue to consider is
continuity of care as you transition from
pediatric care to adult care. You should

1. Will I experience a change in
seizure frequency now that I’m
approaching menopause?

2. The AED that I take causes side
effects that interfere with my life.
I’ve been seizure-free for years, so
I’m afraid to make a change.
What are my options?

3. I’m 35, and I want to try to have a
child. What do I need to know
about pregnancy and managing
epilepsy?

4. I know I’m supposed to keep
notes about when I have a
seizure and how long it lasts.
What other things should I track?

5. My mother is 75 and still experi-
ences seizures occasionally. What
can I do to help? Should her AEDs
be changed?

Whether or not your condition
is under control, it is wise to
wear a medical ID and carry a
first aid card in your wallet.

talk with your parents and your current
health care provider about finding a new
“medical home.” You will want to find a
doctor who understands your condition
and can see you whenever necessary.
You may not need to worry about
finding your own health insurance until
well after college and/or your first job.
Recently enacted health care legislation
will allow parents to keep their children
on their health insurance plans as
dependents up to the age of 26.

As you head off to school or into the
workplace, be careful to avoid possible
seizure triggers or lifestyle choices that
may not be compatible with your condi-
tion. Get enough sleep and develop

Epilepsy is a common neurologic
condition characterized by two or more
unprovoked seizures. It affects about
one in every 100 people. Worldwide,
there are more than 50 million individuals
living with epilepsy.

Women with epilepsy deal with
unique issues because epilepsy and
related treatments can affect or be
affected by the menstrual cycle,
contraception, pregnancy choices and
menopause. Because of this, you not
only need to be aware of the best
general strategies to manage seizures,
but you may want to make treatment
and management decisions in the
context of your reproductive life stage.

You should seek care from a physician
who fully understands your condition—
a neurologist or an epileptologist. An
epileptologist is a neurologist who
specializes in epilepsy.

For the majority of people with
epilepsy, seizures can be controlled with
antiepileptic drugs (AEDs). Individuals
with controlled epilepsy can do almost
anything someone without epilepsy can
do. Communicating with your health
care team is essential. You and your
health care provider need to work
together to find the optimal treatment
plan to control seizures with minimal
side effects. If you’re experiencing
seizures, bring a family member or care-
giver who has witnessed these events to
medical appointments, so they can
describe what you may not remember.

Whether or not your condition is
under control, it is also wise to wear a
medical ID and carry a first aid card in
your wallet so people know what to do
if you experience a seizure.

Living Well With Epilepsy

Presented by HealthyWomen

© 2010 National Women’s Health Resource Center dba HealthyWomen

HealthyWomen 157 Broad Street, Suite 106, Red Bank, NJ 07701 Toll-free: 1-877-986-9472 www.HealthyWomen.org

Questions to Ask Your

Health Care Professional

strategies for coping with emotional
stress. In addition, review with your
health care professional the facts about
alcohol and recreational drug use and
epilepsy. These substances are not only
common seizure triggers but can also
be dangerous in combination with
many antiepileptic drugs.

If you are seizure-free, you can
choose whether to discuss epilepsy with
new friends. However, if you still experi-
ence seizures, friends, colleagues and
teachers should be made aware so they
know what to do if a seizure occurs.

If you are considering birth control,
discuss your options with your doctor.
Some forms of hormonal birth control
(birth control pills, injections, implants
and the progestin intrauterine system/
IUD) are less effective when they inter-
act with certain AEDs.

Epilepsy And Pregnancy

Most women with epilepsy are able
to successfully get pregnant and give
birth to healthy children.

Before you attempt to get pregnant,
speak with your neurologist and
obstetrician/gynecologist about how
pregnancy may affect your treatment
plan. Discuss the AEDs that you are
taking. When possible, doctors avoid
changing AEDs during pregnancy, as the
change may put you at greater risk for
uncontrolled seizures. However, your
neurologist may need to adjust the dose
of your AED during pregnancy to ensure
that the amount of drug in your body
stays consistent. Most women with
epilepsy have uncomplicated pregnan-
cies. In addition, the risk that you might
pass epilepsy on to your child is small.
However, some women choose to speak
with a genetic counselor before getting
pregnant.

Epilepsy And Midlife

Midlife can be a challenging time for
women with epilepsy. Juggling work
and family responsibilities may make it
difficult to prioritize your own health.

Women with epilepsy tend to go

through menopause three to five years
earlier than average, which is age 51 in
the United States. The hormonal changes
of the transition to menopause may
affect seizure control. During menopause,
about 40 percent of women experience
worsening of seizures. Menopausal
hormone therapy (HT), a common treat-
ment for menopause-related symptoms,
can also increase seizure frequency and
should only be used with close monitor-
ing by your doctor.

In addition, the long-term use of
many AEDs can harm bone density. This
means that, as women with epilepsy
get older, they are at increased risk of
fractures, osteoporosis and osteomalacia
(a softening of the bones due to lack of
vitamin D). If you have epilepsy, you
should have your bone density monitored
regularly. Weight-bearing exercise and
taking calcium supplements with vitamin
D may help prevent these problems.

It is also important to pay close
attention to your overall health at this
time in your life. Continue to get
enough rest and minimize emotional
stress. Regular physical exercise can be
especially beneficial because it con-
tributes to overall health and may
decrease seizure frequency and counter
some of the bone loss caused by AEDs.

Epilepsy Over 70

The incidence of epilepsy peaks in
older adults, affecting 1.5 percent of the
population over 70. Whether you were
recently diagnosed or have been living
with epilepsy for years, it is important to
maintain ongoing communication with
your health care provider. While AEDs
are still the most effective way to
manage epilepsy in older women with
epilepsy, these individuals tend to take
medications for multiple conditions.
For this reason, drug interactions are a
concern. In other words, one drug may
reduce the effectiveness of another drug
or cause negative side effects. To avoid
drug interactions, tell your health care
provider and pharmacist about all of the
medications that you are taking.

In addition, older women with
epilepsy face an increased risk of frac-
tures, osteoporosis and osteomalacia.
This is due to (1) bone loss associated
with the postmenopausal state and with
taking certain AEDs for a number of years,
(2) changes in balance and gait stability
and (3) the subtle effects of seizures
and/or medications on coordination.

Living Well With Epilepsy

For women of all ages, epilepsy is a
condition that can usually be controlled.
Provided you take care of yourself and
communicate with your health care
provider, epilepsy should not stand in
the way of a rich and fulfilling life.

One key to success is to establish
frequent and ongoing communication
with your health care team and make
sure they are talking to each other
about your care. The medical experts
you choose to manage your medical
care should clearly communicate with
you about your care regardless of your
stage in life.

For people living with epilepsy, it is
important to involve a caregiver or family
member in medical appointments. They
may see something that happens during
a seizure that you are not aware of.
Sharing this information with your
physician can result in more informed
treatment decisions at each life stage.

For more information on this and other women’s health and lifestyle topics,
visit www.HealthyWomen.org, or call toll-free: 1-877-986-9472.

Resources

Centers for Disease Control and
Prevention—Epilepsy
1-800-232-4636
www.cdc.gov/Epilepsy

Epilepsy Advocate
www.EpilepsyAdvocate.com

Epilepsy Foundation
1-800-332-1000
www.EpilepsyFoundation.org

National Institute of Neurological
Disorders and Stroke
1-800-352-9424
www.ninds.nih.gov

Women Succeeding with Epilepsy is sponsored by UCB, Inc.

LWEFF7.10

[Typetext]

FACT SHEET #1

CHCS Center for Health Care Strategies, Inc.

What is Health Literacy

?

Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate health decisions.”1

Health literacy refers to the skills necessary for an individual to participate in the health care system and maintain good
health. These skills include reading and writing, calculating numbers, communicating with health care professionals,
and using health technology (e.g., an electronic diabetes monitor).

HEALTH LITERACY SNAPSHOT

Sherry, 53, is referred to a clinic for care
following a four-week hospitalization.
Upon discharge, she is provided with a
handwritten list of medications. When
asked by clinic staff why she was
admitted, Sherry says, “I had a bad
cold.” Her hospital records, however,
show an admission for pneumonia
complicated by congestive heart failure
and diabetes. Although Sherry’s hospital
physicians said they communicated
these diagnoses, she left the hospital
without a full understanding of her
condition.

Who has Low Health Literacy?

An estimated 90 million Americans have low health literacy,2 including
many:

With lower socioeconomic status or education;
Who are elderly;
With low English proficiency (LEP) and/or who are non-native

speakers of English; and

Who are receiving publicly-financed health coverage or other
socio-economic assistance.

The burden of low health literacy does not lie only on the individual.
Health care organizations must also be health literate to reduce the
demands placed on individuals.3

Why is Health Literacy Important?

People make choices about their health every day: what to eat, when to see a doctor, whether or not to smoke. In order
to stay healthy, individuals must know how to read the labels on food and medicine, locate the nearest health center,
report symptoms to health professionals, understand insurance paperwork, and pay medical bills. These can be
complicated tasks and the skills to achieve them are not explicitly taught by the health care system or other
educational and social institutions.

The consequences of low health literacy are felt by:

Individuals, families, and communities struggling to access quality care or maintain healthy behaviors;
Health care delivery systems unable to provide safe and effective services; and
Governments, employers, insurers, and patients facing higher costs.

This is one in a series of health literacy fact sheets that address topics like identifying low health literacy and improving
print and oral communications, produced with support from Kaiser Permanente Community Benefit. For more
information, visit www.chcs.org.

What is the Impact of Low Health Literacy?

Low health literacy can result in:

Compared to those with proficient
health literacy, adults with low health
literacy experience:

• 4 times higher health care costs
• 6% more hospital visits
• 2 day-longer hospital stays

Source: Partnership for Clear Health Communication at the National Patient
Safety Foundation.

Medication errors;
Low rates of treatment compliance due to poor communication

between providers and patients;
Reduced use of preventive services and unnecessary emergency

room visits;
Ineffective management of chronic conditions, due to

inadequate self-care skills;
Longer hospital stays and increased hospital re-admissions;
Poor responsiveness to public health emergencies; and
Higher mortality.4 , 5

Through all its impacts – medical errors, increased illness and disability, loss of wages, and compromised public health –
low health literacy is estimated to cost the U.S. economy up to $236 billion every year. 6

What are Ways to Address Low Health Literacy?

Solutions for addressing low health literacy rely both on individual health care consumers as well as broader societal
structures like the health care system, educational institutions, and the media. Interventions in the health system fall
into three broad categories:

1. Making print, oral, and electronic health information easier to understand (e.g., at a fifth-grade reading level);
2. Providing education to improve literacy skills and empower individuals; and
3. Reforming health care delivery to be more patient-centered.

RESOURCES

Visit the hyperlinks below for more information.

The Health Literacy of America’s Adults – Results from the 2003 National Assessment of Adult Literacy by the National
Center for Education Statistics.

Health Literacy: A Prescription to End Confusion – The landmark report on health literacy from the Institute of Medicine.

Health Literacy Interventions and Outcomes – Agency for Healthcare Research and Quality systematic review.

Health Literacy Fact Sheets – A series of health literacy fact sheets produced by CHCS that provide guidance in identifying
and addressing low health literacy.

© Center for Health Care Strategies 2013 October 2013

1 S.C. Ratzan and R.M. Parker. Introduction, National Library of Medicine Current Bibliographies in Medicine: Health Literacy. (Bethesda, MD: 2000).
2 L. Neilsen-Bohlman, A.M. Panzer, and D.A. Kindig. “Health Literacy: A Prescription to End Confusion.” (Washington, DC: National Academies Press, 2004).
3 C. Brach, B. Dreyer, P. Schyve, L.M. Hernandez, C. Baur, A.J. Lemerise, and R. Parker. “Attributes of a Health Literate Organization.” IOM Roundtable on
Health Literacy. (Washington, DC: National Academy of Sciences, 2012).
4 Neilsen-Bohlman et. al., op cit.
5 N.D. Berkman, et al. “Literacy and Health Outcomes.” (Rockville, MD: Agency for Healthcare Research and Quality, 2004).
6 J. Vernon, A. Trujillo, S. Rosenbaum, and B. DeBuono. “Low Health Literacy: Implications for National Health Policy.” University of Connecticut; 2007.

http://nces.ed.gov/naal/health.asp

http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx

http://www.ahrq.gov/clinic/epcsums/litsum.htm

http://www.chcs.org/publications3960/publications_show.htm?doc_id=291711

[Type text]

This is one in a series of health literacy fact sheets that address topics like improving print and oral communications
and the role of culture in health literacy, produced with support from Kaiser Permanente Community Benefit. For
more information, visit www.chcs.org.

FACT SHEET #2

How is Low Health Literacy Identified

?

Low health literacy can seem invisible, but it is present among patients seeking care and made worse
by the complexity of services provided by health care organizations.

Health care organizations should assume that every individual may have difficulty understanding health care
information. They can use universal precautions1 to reduce the complexity of their verbal and print communications to
reach all patients more effectively. However, organizations that want to prioritize interventions for patients with the
poorest levels of health literacy – and health status – may benefit from using some informal and formal health literacy
assessments to identify these individuals and develop appropriate services and supports.

Informal Patient Assessments
Adults with low health literacy report feeling a sense of shame and may
hide their struggles with reading or health vocabulary.2,3 There are,
however, informal ways to identify individuals who may be at higher risk
for low health literacy. Such patients may:

 Frequently miss appointments;

 Fail to complete registration forms;

 Be unable to name medications or explain their purpose or
dosing;

 Identify pills by looking at them, not reading label;

 Be unable to give coherent, sequential medical history;

 Show lack of follow-through on tests or referrals; and/or

 Repeatedly use statements such as “I forgot my reading glasses,” “I’ll read through this when I get home,” or
“I’m too tired to read,” when asked to discuss written material.

During conversation, the following questions may help a provider or health administrator assess the health literacy
needs of an individual:

 Medical terms are complicated and many people find them difficult to understand. Do you ever get help
from others in reading prescription labels, completing insurance forms, or using health materials?

 A lot of people have trouble reading and remembering health information because it is difficult. Is this ever
a problem for you?

 What do you like to read? (Newspapers are generally at 10th-grade reading level and news magazines are at the
12th-grade level). What do you rely on most to learn about health issues? Everyone has a unique source. TV?
Radio? Internet? Friends and family?

HEALTH LITERACY SNAPSHOT

A primary care physician finds that
many of her diabetic patients do not
schedule follow-up appointments and
often miss their scheduled foot,
cholesterol, and eye exams. The
physician feels she can only do so much
in brief appointments if patients do not
speak up about their needs. Her clinic
leadership is asking her to identify high-
risk patients for a new diabetes quality
improvement program.

Center for Health Care Strategies

© Center for Health Care Strategies 2013 October 2013

Formal Patient Assessments
Formal assessments can help organizations systematically address health literacy in their quality improvement
processes. Assessments can be administered separately or portions can be incorporated into existing tools such as
performance metrics, patient and staff satisfaction surveys, and focus groups.

Below are three common tools used by organizations to identify individuals with low health literacy by assessing their
word recognition and reading comprehension (visit the hyperlinks for more information):

 REALM/D (Rapid Assessment of Adult Literacy in Medicine/Dentistry): Measures ability to read common
medical words.

 SAHLSA (Short Assessment of Health Literacy for Spanish-speaking Adults): Form of the REALM for
adults who speak Spanish as a primary language.

 TOFHLA (Test of Functional Health Literacy in Adults): Measures reading and numeracy using common
medical scenarios and materials. Assigns inadequate, marginal, or adequate health literacy scores to users. Also
available in a shortened seven-minute s-TOFHLA version (original version is 22 minutes long).

Organizational Assessments

Health care organizations can also use the following tools to identify areas for improvement in their services and
communication approaches (visit the hyperlinks for more information):

 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Item Set for Addressing Health
Literacy (31 supplemental items for use with the CAHPS Clinician and Group Surveys);

 Health Literacy Assessment Questions (for primary care practices);

 Health Plan Organizational Assessment of Health Literacy Activities; and

 Is Our Pharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy Assessment Tool User’s Guide.

1 Agency for Healthcare Research and Quality (AHRQ). “Health Literacy Universal Precautions Toolkit.” Accessible at: http://www.ahrq.gov/qual/literacy/
2 M.S. Wolf, M.V. Williams, R.M. Parker, N.S. Parikh, A.W. Nowlan, and D.W. Baker. “Patients’ Shame and Attitudes Toward Discussing the Results of Literacy
Screening.” Journal of Health Communication, 12, no.8 (2007), 721–732.
3 D.W. Baker, R.M. Parker, M.V. Williams, K. Ptikin, N.S. Parikh, W. Coates, et al. “The Health Care Experience of Patients with Low Literacy.” Archives of
Family Medicine, 5, no.6 (1996), 329–334.

KEY CONSIDERATIONS WHEN IDENTIFYING LOW HEALTH LITERACY

 Use a combination of informal and formal measures to gain a more nuanced understanding of individuals’ abilities.

 Conduct assessments in private settings, and with sensitivity and respect, to ensure that patients do not feel ashamed,
inferior, or like “targets of study.”

 Distinguish low literacy skills from cognitive decline, developmental disability, or mental health disorder.

 Differentiate English proficiency from literacy. Individuals who are more – or highly – proficient in a non-English language do
not necessarily have low literacy.

http://www.adultmeducation.com/AssessmentTools_1.html

http://www.ahrq.gov/legacy/populations/sahlsa

http://cumc.columbia.edu/dept/nursing/ebp/HealthLitRes/assessTool.html

https://www.cahps.ahrq.gov/content/products/HL/PROD_HL_Intro.asp?p=1021&s=215

https://www.cahps.ahrq.gov/content/products/HL/PROD_HL_Intro.asp?p=1021&s=215

http://www.nchealthliteracy.org/toolkit/tool2

http://www.ahip.org/Issues/Documents/2010/Health-Plan-Organizational-Assessment-of-Health-Literacy-Activities.aspx

http://www.ahrq.gov/professionals/quality-patient-safety/pharmhealthlit/pharmlit/index.html

http://www.ahrq.gov/qual/literacy/

[Type text]

This is one in a series of health literacy fact sheets that address topics like identifying low health literacy and improving
print and oral communications, produced with support from Kaiser Permanente Community Benefit. For more
information, visit www.chcs.org.

FACT SHEET #3

CHCS Center for Health Care Strategies, Inc.

Health Literacy and the Role of Culture
Individuals’ social and cultural contexts are inextricably linked to how they perceive and act on health
information.

HEALTH LITERACY SNAPSHOT

A young Latina woman is told by her
physician she needs to lose 30 lbs to
lower her risk of diabetes and heart
disease. Her family cannot afford a
gym membership and she is too
embarrassed to play sports at school,
where she is often teased. Her
physician told her simply to “improve
her lifestyle and run outside,” but she
does not feel safe running in her
neighborhood, where crime rates
have been rising.

An individual’s perception of his or her health is shaped not only by
personal convictions, but also by the beliefs of his or her racial, ethnic,
religious, social and/or linguistic communities. These personal and
collective values can be summed up as culture, and they influence an
individual’s health literacy. Culture can impact how individuals:

Define what they feel is a health problem;
Express concerns about the problem or report symptoms;
Decide what type of service should be obtained, when, and from

whom; and
Respond to treatment guidance.

If cultural norms do not match up with the dominant values of the health
care system, an individual – even with adequate reading, writing, and numeracy skills – can have trouble accessing
health services, communicating with providers, and pursuing effective self-management. Such cultural mismatches –
along with low socio-economic levels and historic discrimination – have contributed to disparities in health and health
care experienced by individuals in racial, ethnic, and linguistic minority groups.

Low health literacy is both a key cause and effect of these disparities. National estimates suggest that minority
populations tend to have greater rates of low health literacy. 1 Further, studies show that when controlling for health
literacy, racial and ethnic disparities in health care quality and outcomes often disappear.2

Cultural Competency

Cultural competency refers to the “practices and behaviors that ensure that all patients receive high-quality, effective
care irrespective of cultural background, language proficiency, socioeconomic status, and other factors that may be
informed by a patient’s characteristics.”3 Improving the cultural competency of health materials, personal interactions,
and services is an important step toward addressing low health literacy among diverse populations.

National Standards for Culturally and Linguistically Appropriate Services

In 2000, the Office of Minority Health developed National Standards on Culturally and Linguistically Appropriate
Services (CLAS) to provide a common understanding and consistent definition of culturally and linguistically
appropriate services in health care. These standards are designed to offer a practical framework for providers,
payers, accreditation organizations, policymakers, health administrators, and educators. Learn more about the
CLAS guidelines at https://www.thinkculturalhealth.hhs.gov/Content/clas.asp.

https://www.thinkculturalhealth.hhs.gov/Content/clas.asp

© Center for Health Care Strategies 2013 October 2013

Strategies to Improve Cultural Competency in Health Organizations

Provider-Patient Communication

Give guidance on nutrition and lifestyle that aligns with patients’ cultural, dietary, and/or religious values;
Respect cultural norms around body language, clothing, and gender during appointment interactions; and
Be sensitive when asking questions to clarify understanding or dispel pre-conceived notions.

Care Management

Include diverse backgrounds and skill sets in care teams to meet patients’ range of medical and social needs;
Provide culturally-relevant education and management tools to facilitate self-care and shared decision-making; and
Link patients with community-based services and supports outside of the clinic.

Health Information

Reduce the use of health industry jargon;
Translate health materials into multiple languages and provide interpreter services for in-person encounters;
Represent racially and ethnically diverse groups in the images and content of materials; and
Tailor prevention and health promotion messages to diverse communities using social marketing strategies.

Workforce Training

Increase racial, ethnic, and linguistic diversity among professional and paraprofessional providers (e.g., physicians,
physician assistants, nurses, behavioral health specialists, community health workers, peer navigators, etc); and

Train providers and front-line staff in cross-cultural communication, trust-building, and motivational interviewing.4

SPOTLIGHT ON LIMITED ENGLISH PROFICIENCY

More than 23 million Americans have limited English proficiency (LEP). While their lack of skills in English drives their low health
literacy, it is important to differentiate literacy from English-language proficiency. For example, some individuals with adequate
health literacy may be more adept at a non-English language than English, and there are many individuals who have inadequate
health literacy, even though English is their primary language. Individuals with LEP experience similar problems to those with low
health literacy, such as delay or denial of services, issues with medication management, and underutilization of preventive
services. 5 Translation and interpretation services are recognized as best practices in engaging individuals with LEP.6 Title VI of the
Civil Rights Act of 1964 requires all entities (e.g., state agencies, hospitals, providers) receiving federal funds to provide these
services. 7

Resources for Providing Culturally Competent Care

Visit the hyperlinks for more information.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence Item Set: Survey
instruments that assess provider cultural competency. Part of the suite of CAHPS Clinician & Group Surveys
developed by the Agency for Healthcare Research and Quality.

Health Resources and Services Administration – Culture, Language and Health Literacy: Resources such as
tools, assessments, and articles for health care providers, particularly those serving the uninsured, isolated or
medically vulnerable, such as Federally Qualified Health Centers, Essential Community Providers, Rural Health
Centers, and Community Health Centers.

DiversityRx: Resource website for delivering health care to minority, immigrant, and indigenous communities.

1 L. Nielson-Bohlman, A.M. Panzer, and D.A. Kindig (Eds.) Health Literacy: A Prescription to End Confusion. (Washington, DC: The Institute of Medicine & The National
Academies Press, 2004).
2 A.E. Volandes and M.K. Paasche-Orlow. “Health Literacy, Health Inequality and a Just Healthcare System.” The American Journal of Bioethics, 7, no.10 (2007), 5-10.
3Office of Minority Health, Department of Health and Human Services. What is Cultural Competency? Accessible at:
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=11
4 M.K. Paasche-Orlow, D. Schillinger, S.M. Green, and E.H. Wagner. “How Healthcare Systems Can Begin to Address the Challenge of Limited Literacy.” Journal of
General Internal Medicine, 21, no.8 (2006), 884–887.
5 M. Youdelman. “The Medical Tongue: U.S. Laws and Policies on Language Access.” Health Affairs, 27, no. 2 (2008): 424–433.
6 A. Sampson. National Health Law Program (2006). “Language Services Resource Guide for Health Care Providers.” Available at:
http://www.healthlaw.org/images/pubs/ResourceGuideFinal .
7 M. Au, E. Taylor, and M. Gold. “Improving Access to Language Services in Health Care: A Look at National and State Efforts.” Mathematica Policy Research, April 2009.
Available at: http://www.ahrq.gov/legacy/populations/languageservicesbr .

https://www.cahps.ahrq.gov/clinician_group/cgsurvey/aboutculturalcompetenceitemset

http://www.hrsa.gov/culturalcompetence/index.html

http://www.diversityrx.org/

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=11

http://www.healthlaw.org/images/pubs/ResourceGuideFinal

http://www.ahrq.gov/legacy/populations/languageservicesbr

[Type text]

This is one in a series of health literacy fact sheets that address topics like identifying low health literacy and the role
of culture in health literacy, produced with support from Kaiser Permanente Community Benefit. For more
information, visit www.chcs.org.

FACT SHEET #4

CHCS Center for Health Care Strategies, Inc.

Improving Print Communication

to Promote Health Literacy
While most health care materials are written at a 10th-grade reading level, the average American reads
at only a 5th-grade level.1 Materials that are simple, attractive, and relevant are more likely to
effectively reach patients.

Key Components of Effective Print Materials

Individuals rely on print materials when they are unable to speak directly with a health care professional, or when they
are unable to engage fully in a verbal encounter. Materials that effectively communicate health messages will generally
adhere to the following principles:

1. Plain and clear language is used and content is relevant to the audience.

Assumes minimal background knowledge.
Sentences are short. Messages are simple.

HEALTH LITERACY SNAPSHOT

A 30-year-old Vietnamese-
speaking man applies for Medicaid
after a devastating assault leaves
him with a disability. The local
Medicaid office does not have
application materials in Vietnamese
so he attempts to use the English
version, although he is not
proficient. Due to errors in his
application, he never receives
coverage.

Presents numbers and percentages simply. Does not require extra
calculation.

Uses commonly understood words. Minimizes multi-syllabic words.

2. Ideas are organized clearly.

Provides background information or needed context.
Contains logical flow of information.
Groups information into meaningful sections with clear headings.
Uses key points, summaries, and highlights to emphasize main points.

3. Layout and design facilitate reading and comprehension.

Lot of white space (fewer words or less dense text).
Bullets and/or Q&A format used to break up text, and graphics used to clarify text.
Dark text (preferably black) on a light or white background.
Large and familiar font. Consistent use of font sizes and styles throughout document.
Upper and lower case letters (use of all caps can make text difficult to read).
Left-justified margin.

Testing and Improving Print Materials

Health care organizations can use quality improvement processes to help create materials that will be most useful for
patients. These involve getting input from patients, creating materials, testing them with patients, and refining the
materials to ensure they are effective.

© Center for Health Care Strategies 2013 October 2013

PROCESS FOR DEVELOPING EFFECTIVE HEALTH COMMUNICATION MATERIALS

Step 1. Define the key health problem or areas of interest (e.g., low use of preventive services) and identify your
intended audience (e.g., Hispanic and African-American women).

Step 2. Engage the intended audience. Focus groups, surveys, patient advisory councils, or community advisory
boards can be good mediums to seek input. Determine the audience’s needs, beliefs/values, level of
knowledge, and perceived barriers related to the identified health topic.

Step 3. Determine key concepts and messages based on your knowledge of the audience.

Step 4. Design a draft of the materials.

Step 5. Pilot materials with the intended audience, or an available subset. Patient volunteers or community partner
organizations may be good sources for a pretest audience. Incentives such as gift certificates might help gain
their participation.

Step 6. Revise draft according to feedback from the pretest audience.

Step 7. Publish and distribute materials.

Step 8. Evaluate the audiences’ satisfaction and understanding, using focus groups, surveys, and related tools.

Using Instruments to Assess Print Materials

Grade-level readability is a common metric for print materials. It is based on the number of difficult words (usually
words with three or more syllables) and the length of sentences. However, even materials written at a low reading
level may be difficult to comprehend if content is poorly organized or not designed well. The following instruments
may help organizations assess their materials (visit the hyperlinks for more information):

Flesch-Kincaid Grade Level and Flesch Reading Ease Score: Analyzes readability based on the number of
syllables per word and words per sentence in addition to other measures.

FOG (Frequency of Gobbledygook): Assigns a grade level based on sentence length, number of words, and

number of polysyllabic (>3) words.

Fry Readability Formula: Measures readability of small documents using sample sizes of 100 words. Identifies
more difficult words or sentences.

SMOG (Simple Measure of Gobbledygook): Analyzes reading level of prose in sentence and paragraph

format.

SAM (Suitability Assessment of Materials): Measures readability based on content, literacy demand,
graphics, layout, learning stimulation, and cultural appropriateness. Can also measure audio-visual materials.

PMOSE/ IKIRSCH Document Readability Formula: Assigns a grade-level to charts, tables and other non-

prose documents.

1 National Patient Safety Foundation. Health Literacy Statistics At-A-Glance. Accessible at: http://www.npsf.org/wp-
content/uploads/2011/12/AskMe3_Stats_English

http://www.usingenglish.com/glossary/flesch-kincaid-index.html

http://www.usingenglish.com/glossary/fog-index.html

http://www.readabilityformulas.com/free-fry-graph-test.php

http://www.hsph.harvard.edu/healthliteracy/files/2012/09/smogoverview

http://aspiruslibrary.org/literacy/SAM

http://www.hsph.harvard.edu/healthliteracy/files/2012/09/pmose

http://www.npsf.org/wp-content/uploads/2011/12/AskMe3_Stats_English

http://www.npsf.org/wp-content/uploads/2011/12/AskMe3_Stats_English

[Type text]

This is one in a series of health literacy fact sheets that address topics like identifying low health literacy, improving
print communications, and the role of culture in health literacy, produced with support from Kaiser Permanente
Community Benefit. For more information, visit www.chcs.org.

FACT SHEET #5

CHCS Center for Health Care Strategies, Inc.

Improving Oral Communication

to Promote Health Literacy

Health information that is delivered in a clear, engaging, and personally relevant manner can promote
understanding, action, and self-empowerment, no matter the literacy level of the recipient.

Oral communication, particularly between providers and patients in a medical setting, is a critical medium through
which vital information is shared and decisions are made. The following strategies should be used to promote health
literacy:

 Create a safe and respectful environment. Greet patients
warmly. Make eye contact. Take the time to get to know the
patient and earn his or her trust.

 Use speech that is easy to understand. Slow down your speaking
pace. Limit content to a few key points. Be specific and concrete,
not general. Use words that are simple and familiar. Avoid
complex technical jargon or acronyms (see Simplified Language
examples in the box below).

 Keep the individual engaged in the conversation. Use pictures,
physical models, videos, or interactive media to aid technically
complex conversations. Ask open-ended questions to facilitate
discussion. Get to know what the patient cares about most –
family, friends, work, hobbies – and incorporate those into your health discussions.

 Confirm patient understanding. Ask the individual to “teach back” the information you have imparted.
Remind the individual that many people have difficulty understanding the materials. Summarize key points.

For more, see: http://stacks.cdc.gov/view/cdc/11500/

Simplified Language Swap-Outs

Common Term Modification

Eligible → Qualified, or able to get
Hormone → Natural or manmade chemical that can impact your energy, mood, and/or growth
Hypertension → High blood pressure
Infection → Problem caused by germs; reason you clean open wounds
Pulmonary → Related to breathing
Supplement → Add to, in addition to

HEALTH LITERACY SNAPSHOT

An older Asian-American man cannot
understand the dosage label on his
medication. For fear of taking the
wrong dosage, he does not take it at
all. His back pain gets worse and he is
not able to go into work for a whole
week. He recalls being rushed through
his appointment and unable to
understand the doctor’s accent. He left
without being able to ask any other
staff for help as they seemed too busy.

Center for Health Care Strategies

http://stacks.cdc.gov/view/cdc/11500/

© Center for Health Care Strategies 2013 October 2013

Preparation for Health Care Encounters

To improve the quality and content of in-person encounters, providers, care managers, health plan administrators, and
other professionals can ask patients to prepare for their medical visits by:

 Making a list of two or three questions they want answered;

 Bringing in a list of all medications (prescription, over-the-counter, vitamins/herbal) or the actual bottles;

 Bringing copies of recent test results or reports from other health care providers, including any personal health
records;

 Asking a family member or friend to accompany them to help write down information or remember what was
said; and/or

 Reporting all symptoms and anything that does not seem quite right during their office visit, and asking the
provider to repeat instructions at the end of the visit.

Supports in the Medical Office Environment

Beyond the interactions with health care professionals, other aspects of the medical office environment – unreadable
signage, complicated layouts, or chaotic environments – can impact patient experiences. Individuals with lower health
literacy may feel intimidated in professional health care environments. This may lead hem to avoid seeking out
services, asking clarifying questions, challenging a provider’s assumptions, or sharing vital personal details during
medical appointments.

Health care institutions can pay attention to the following to help ensure that individuals with low health literacy will
successfully participate in health care services:

 The facility’s name is clearly displayed outside the building and entry signs are visible.

 The signs use plain, everyday words such as “Walk-in,” in addition to “Ambulatory Care.”

 Maps, including handheld ones, are available to navigate the premises.

 Overhead signs use large lettering and are in languages of major population groups.

 Color codes or symbols are used consistently on walls and floors to mark paths.

 All staff wear a form of identification such as a uniform, nametag, or button.

 There is a welcome or information desk with friendly personnel.

 Multilingual and racially/ethnically diverse providers and administrative staff are available.

MOTIVATIONAL INTERVIEWING: Helping Providers and Patients Reach Goals Together

Motivational interviewing is a patient-centered method of engagement and ongoing communication that is based
on meeting patients in a comfortable, familiar environment; addressing goals defined by the patient; and
gradually helping patients work toward more ambitious goals. It is a promising technique that is increasingly used
by providers to support patients with complex chronic conditions and significant social barriers. Providers looking
to better address the needs of individuals with low health literacy can use this model, or incorporate its elements
into care delivery. For more information: www.motivationalinterview.org.

http://www.motivationalinterview.org/

[Type text]

This is one in a series of health literacy fact sheets that address topics like identifying low health literacy and improving
print and oral communications, produced with support from Kaiser Permanente Community Benefit. For more
information, visit www.chcs.org.

FACT SHEET #6
CHCS Center for Health Care Strategies, Inc.

Health Literacy: Policy Implications and Opportunities
Health care policymakers nationwide are seeking to expand insurance coverage, improve care, and
control costs. To meet these goals, health care programs must focus on the cultural, linguistic, and
social barriers facing vulnerable populations, including those with low health literacy.

Affordable Care Act

The Affordable Care Act (ACA)1 is the most significant piece of health
care legislation in recent history. Though there are only four explicit
mentions of the term “health literacy” in the law, the ACA indirectly
addresses this topic in the following areas:2

1. Coverage Expansion: Millions of Americans will gain insurance

through the state-based exchanges and Medicaid beginning in 2014.3
For such expansion to be successful, outreach efforts and enrollment
methods must be streamlined, easy to understand, and coordinated
with other social services and community programs.

2. Equity: Moving toward universal coverage and creating the same “floor” for the lowest-income populations should
help address some of the fundamental disparities in access to care, but only if there is attention to culture, language,
and literacy.

3. Workforce: Provider training and diversity provisions in the ACA will help build a workforce with the background,
cultural competency, and patient-centered orientation to adequately meet care needs across all levels of patient
health literacy.

4. Health Care Information: From medication management to provider performance rating, patient information must
be presented in a way that is accessible to the millions of Americans with low literacy skills.

5. Public Health and Wellness: The development of consumer information – whether in print, electronically, or
otherwise – on issues ranging from prevention to emergency preparedness must be done with low literacy in mind,
and in partnership with local communities.

6. Quality Improvement: The promotion of payment and delivery system redesign models such as health homes and
accountable care organizations, and emphasis on quality measurement and reporting presents many new
opportunities for making the business and policy case for investments in health literacy.

Additional Federal Policy Efforts Related to Health Literacy
National Action Plan to Improve Health Literacy

The National Action Plan to Improve Health Literacy, released in 2010 by the U.S. Department of Health and Human
Services, outlines seven goals that address the importance of health and safety information that is accurate, accessible,
and actionable. It addresses how payers, the media, government agencies, health care professionals, and community
institutions can work together to tackle the national problem of low health literacy.4

HEALTH LITERACY SNAPSHOT

A young, unemployed mother is
unable to obtain coverage for her
children because she cannot read the
Medicaid application and feels
uncomfortable asking for help. She
and her family continue to go without
care.

Center for Health Care Strategies

© Center for Health Care Strategies 2013 October 2013

Plain Writing Act of 2010

This legislation requires the federal government, including all health agencies, to use “plain writing” guidelines in
every covered document – both print and electronic. This includes every document that agencies issue or substantially
revise, including letters, publications, forms, notices, or instructions. It also includes any document necessary for the
public to obtain a federal government benefit or service; file taxes; or comply with federal requirements.5

Healthy People 2020

Healthy People 20206 is a set of 10-year goals for improving the health of Americans. It provides national benchmarks
for meeting specific aims around health promotion and disease prevention. Several objectives explicitly speak to health
literacy principles.7

National Resources to Address Health Literacy

Following are a variety of resources available to health care policymakers, providers, and administrators looking to
address health literacy (visit the hyperlinks below to access each resource).

 Health and Human Services (HHS)

Overview and Resources
Health Literacy Action Plan

A Guide to Writing and Designing Easy-to-Use Health Web Sites
Expanding the Reach and Impact of Consumer e-Health Tools

 Center for Disease Control (CDC)
Health Literacy Resources

 National Institutes of Health (NIH)
Clear Communication: A NIH Health Literacy Initiative

 Health Resources and Services Administration (HRSA)
Free Online Course for Health Professionals and Students

 Agency for Healthcare Research and Quality (AHRQ)
Health Literacy Universal Precautions Toolkit

 Institute of Medicine (IOM)
Roundtable on Health Literacy

 Surgeon General
Improving Health by Improving Health Literacy

 The Joint Commission
Improving Health Literacy to Protect Patient Safety

1 U.S. Congress, “H.R. 3590: Patient Protection and Affordable Care Act.” 11th Congress, 2009 – 2010. Signed into law March 23, 2010. Available at:
http://www.govtrack.us/congress/bill.xpd?bill=h111-3590.
2 S.A. Somers and R. Mahadevan. Health Literacy Implications of the Affordable Care Act. Center for Health Care Strategies. November 2010
3 Banthin J and Masi S. (March 2013). How Has CBO’s Estimate of the Net Budgetary Impact of the Affordable Care Act’s Health Insurance Coverage
Provisions Changed Over Time? Congressional Budget Office. Available at: http://www.cbo.gov/publication/44008.
4 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy.
Washington DC, 2010.
5 U.S. Congress. “H.R. 946: Plain Writing Act of 2010.” 111th Congress, 2009 – 2010. Signed into law October 13, 2010. Available at:
http://www.govtrack.us/congress/bill.xpd?bill=h111-946.
6 Healthy People 2020. Federal Government website managed by the U.S. Department of Health and Human Services, Washington DC, 2010. Available at:
http://www.healthypeople.gov/2020/default.aspx
7 Healthy People 2020: Health Communication and Health Information Technology. Federal Government website managed by the U.S. Department of Health
and Human Services, Washington DC, 2010. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HealthCommunication

“Health literacy is the
currency for everything

we do.”

Dr. Howard Koh
Assistant Secretary for Health,

U.S. Department of Health and Human
Services, 2010

http://www.health.gov/communication/literacy

http://www.health.gov/communication/HLActionPlan

http://www.health.gov/healthliteracyonline

http://www.health.gov/communication/ehealth/ehealthTools/default.htm

http://www.cdc.gov/healthliteracy

http://www.nih.gov/clearcommunication/healthliteracy.htm

http://www.hrsa.gov/publichealth/healthliteracy/

http://www.ahrq.gov/qual/literacy/

http://www.iom.edu/Activities/PublicHealth/HealthLiteracy.aspx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966655/pdf/phr125000784

http://www.jointcommission.org/assets/1/18/improving_health_literacy

http://www.cbo.gov/publication/44008

What is Health Literacy
What is Health Literacy?
Who has Low Health Literacy?
Why is Health Literacy Important?
What is the Impact of Low Health Literacy?
What are Ways to Address Low Health Literacy?

How is Low Health Literacy Identified
How is Low Health Literacy Identified?

• Health Literacy Role of Culture

Improving Print Communication
Improving Oral Communication
Beyond the interactions with health care professionals, other aspects of the medical office environment – unreadable signage, complicated layouts, or chaotic environments – can impact patient experiences. Individuals with lower health literacy may fee…
Health care institutions can pay attention to the following to help ensure that individuals with low health literacy will successfully participate in health care services:

• Health Literacy and Policy

Health Literacy: Policy Implications and Opportunities
National Action Plan to Improve Health Literacy
Plain Writing Act of 2010
Healthy People 2020

WWW.CDC.GOV/FLU

nfluenza (flu) is a contagious
disease that can be serious.
Every year, millions of people get
sick, hundreds of thousands are
hospitalized, and thousands to
tens of thousands of people die
from flu. CDC urges you to take
the following actions to
protect yourself and
others from flu.

#F

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Overview:

Useful resources

Variety of educational materials are available at:

www.cdc.gov/dhdsp/materials_for_patients.htm

This is an opportunity to create a document of your own design with the intention of teaching laypeople in the country you selected and that addresses the chosen health issue.

Review the examples that are available in the Instructional Materials folder for Module 6. Use the samples and any other health education materials from the clinical setting, in the community, or online as resources

Instructions

1. Choose the type of educational material you wish to design. It may be a patient education pamphlet, a poster, or a fact sheet that addresses a defined educational need of laypeople in relation to the chosen health issue. Remember you are working with individuals in the selected country.

2. The following audience characteristics must be addressed in the educational material you are creating. 

2. Adults in the country you selected in Module 1 (or revised by Module 3).

2. English is the second language of these adults. Kenya people speak Swahilli

2. The adults are laypeople

1. Address the following items.

3. The purpose of the pamphlet/poster/fact sheet is clear

3. Use visuals when appropriate and make sure the visuals are appropriate for the purpose you have specified

3. Use language appropriate for the identified audience (remember that material for the general US population needs to be between the 6th and 8th grade reading level).

3. Avoid inclusion of items that might frighten or upset the layperson but make sure the document is informative

1. Make sure that the educational document is only one (1) page. Documents that are more than one (1) page will receive an immediate five (5) point deduction.

1.
Remember, this is informative, educational material. It should inform, but should also be visually appealing and not all words. Include color/graphics/images/bullet points, etc. Make it easy for the reader to understand and catch their eye.

1. There should not be a lot of white space, but it should not be excessively busy. It should be understood by someone with a 6th-8th grade reading level.

1. It should be geared to the intended population

1. -Laypersons

1. -Adults

1. -English is second language

1. This should be about YOUR selected health concern in YOUR chosen country.

1. Make sure that the pamphlet/poster is only 1 page. Documents that are more th