[MUSIC] Next I will describe a methodology for low literacy evaluation and adaptation. We'll start with information processing. This is what underlies our ability to understand process and use health information, which is the definition of health literacy. First, let's take a look at the normal information processing cycle and then we'll take a look at how low literacy disrupts the process. Our task when doing literacy adaptations is to help ensure that this information processing can occur well. When health information is presented, the first step is perception. It may be presented visually, as in a brochure or a form to be filled out or verbally, as when the doctor gives instructions allowed. To the extent that persons with lower literacy may be less inclined to visually take in words on a piece of paper with little white space. Or may be less inclined to keep listening to a string of words or phrases that sound like scientific jargon, this first step can be disrupted. So the some can occur right here at the beginning with information not being taken in. Information that is taken in or perceived moves on to registering with the person, this requires attention. There is selective registration or blocking what gets in, depending on importance. So here too, to the extent that a person with lower health literacy, for example, may deem what's being said as less important or unimportant, that information will be lost. After registration comes short term memory, we humans have only 30 seconds to hold on to information in short-term memory before we move it on for longer storage. We only put into longer storage information that's deemed high priority information. So here too is an opportunity where persons with lower literacy or health literacy may classify information as lower priority and, therefore, not maintain it long enough to get to the next step, which is working memory. Working memory requires that we keep that information in our heads for 10 to 20 minutes. And in general, we have a limited capacity, we can hold onto seven chunks of information. If we're able to keep manipulating that information in our head for 10 to 20 minutes, we can actually have memory for that information for 18 to 36 hours. But it requires being able to understand the information that we're holding in our heads, it has to have meaning and it has to be accurate in order for us to continue holding on to it and manipulating it properly. So here too, in the doctor's office, when a doctor asks a patient to repeat what was said, they may be able to repeat what was said in those next seconds. But in order for that information to get stored and held onto so that they can use it when they get home, it has to go through short-term memory and working memory which require their understanding it and finding it meaningful. And it's only after that stage that information hits long-term memory where it gets stored and you can pull it back out whenever you may need it. So our task when we are adapting materials for people with lower literacy is to ensure that the information is obtained, it is usable, it is understood and it is meaningful at every step along this process. For the adaptation method I'm describing, there are a couple of resources that you can refer to for more information. One of them is this paper, which appears in Diabetes Care in 2008. In this paper, you will be able to find the set of 32 consensus criteria that are available for making material suitable for low literacy. The sources of those criteria are the CDC, the National Cancer Institute and Doak, who is a long-standing reference in the world of lower health literacy. In that paper, you'll find an online appendix as well that describes the methods and operational definitions in more detail than we'll be able to go into during this presentation. Here are the 32 consensus criteria for lower literacy patient health education materials. There are several categories to be attentive to, the first is word usage, reading level and sentence length. Here you will find the criterion that is now accepted in the United States as the reading grade level for public information less than or equal to fifth grade. You will see also in this category recommendations, such as avoiding scientific jargon, a sentence length, a maximum of 15 words per sentence, for example. The next category is typography, it matters how print is displayed and how you are able to highlight and emphasize words and phrases. And so you will see such things as the font size, typographic hues for emphasis and how many characters and spaces even for line length for understandability. The next category is graphics, illustrations and tables. How the graphics are used, where they are placed on the page, what's emphasized in the graphics all have meaning to help people understand the information being presented. Layout space and paper is another category. You've all heard such things as white space is important, contrast is important, visual cueing devices that are listed here are important. Finally, we have content, scope and organization. The scope is very important, limiting the scope of the information presented directly to the purpose intended. And ensuring that when information is presented, at least 50% of it is behaviorally focused, meaning information people can act upon. In addition, there are recommendations regarding ensuring information is likely to promote engagement, interaction and action facilitation. Here you'll see recommendations, such as the behaviors are specific. For example, the information is presented in a step-by-step manner. How to information should be provided, not just what is important to do for your health for example, but how to do what is important for your health. And then audience relevance and appropriateness. This one is all about ensuring that the information that is presented meets the needs of the audience itself. So within the context of the targeted audiences culture, values, and beliefs, language, and experiences, and ensuring that the audience you are targeting is able to see themselves represented in what's being presented to them. So the 32 criteria that we just reviewed should each be used when developing new health information for the public or for targeted audiences. But often there is a need to evaluate and to adapt existing materials, and for that purpose my research group identified five criteria that when modified, can reliably result in less than fifth grade readability. So the paper you see here can serve as a resource regarding that five step methodology, with the key factors that you can modify in order to reach that less than fifth grade reading grade level. And the process I affectionately refer to as the Five-Step LEAP, Literacy Evaluation and Adaptation Process. So now let's walk through the five steps in the process. Step one is a readability evaluation of the original text or document. When you're going to modify a document, it's important to know where you're starting. And you'll see here, there are three levels of evaluation that are going to be important document level readability statistics. And here we use the Flesch-Kincaid grade level and passive sentences. Average number of sentences per paragraph, average number of words per sentence, and average characters per word. In addition to document level, you'll need to go to a paragraph level and sentence level readability statistics, and let me show you why. Here is an example of the readability statistics for an overall document, and very often I think we're tempted to get the reading grade level just for the document as a whole. This does provide you with some information, for example here, it's at a reading grade level of 10.6 or 10th grade readability. However, the overall document statistics don't tell you what needs to be modified, or where you'd need to make adaptations in order to reach the less than fifth grade readability. Here is an example of a document with what I call our coding strategy embedded, what you're looking at is both sentence level and paragraph level reading statistics. You'll see on that first paragraph right after each sentence we have our coding, and that key stands for active versus passive. So there you'll see an A or a p, reading grade level, so you will see in this instance in that first sentence, it's an eight point three reading grade level. You will see the number of words per sentence and the numbers of characters per word. Here I have highlighted the reading grade level for a few of the sentences. So you'll remember that the overall document had a 10th grade reading grade level. But what is almost always the case in documents is that there will be a wide range of readability. So as you see in the first sentence, it's an eighth grade reading level. But in that next circled reading grade level 15.9, almost 16 years of education required to be able to understand that sentence. Meanwhile in the next paragraph, you'll see a 5.7, just over fifth grade readability. And so when you're doing the original document readability statistics, you must not only overall document, but paragraph and sentence level, because now it tells you where to hone in to make the changes. Step 2 is identifying medical terminology and scientific jargon in the original document. And here you want to go through, you want to identify what would be considered medical terminology, that would not be commonly used and understood words and any scientific jargon, and you want to see how concentrated the document is. I have highlighted words that would be considered medical terminology or scientific jargon, to your average layperson. And now you will see an example of an adapted version. So where the scientific or medical word is used. The goal is always to use common words to explain the meaning of the medical terminology, followed by that medical term in parentheses. The reason that you start with the description of the term is because as people are reading a sentence, you don't want them to stop because they're unable to get the meaning. So complete the sentence with words that describe the information and make the medical term parenthetical. It's almost incidental to what's being presented here. It's often good to introduce medical terms. However, we don't want the medical terminology to take precedence over the flow of meaning. You'll see also here that we have reformatted the text, in the original you'll see that the medical terminology ketoacidosis and hyperosmolar coma are presented as an action item. However, the words that describe it, so that people would know what to do come second. In our adapted version again, our information processing cycle tells us that we want them to get the flow of what it is they need to understand and do, and afterwards we can tell them the medical terminology that goes along with it. Step three is the literacy adaptation process itself. Now you've seen some of it, for example, the using of common words in order to help explain medical terminology. It's not only medical terminology that necessitates common words, often words may be used with multiple syllables that are not needed, and so wherever possible the recommendation is avoiding words that are more than two to three syllables. Here too, you'll see the sentence length kept to less than 15 words, writing in the active versus passive voice, and again use of formatting to help improve readability, for example, using bullets or tables and headers. This is an example of an original text and if you read it through you'll see at the end the readability statistics. This paragraph has a reading grade level of 14.7 or almost 15 years of education required. The first sentence reads, diabetic retinopathy, the most common eye complication and leading cause of blindness among US adults, damages the retina, the light-sensitive nerve tissue at the back of the eye that transmits visual images to the brain. That's a 20.2 reading grade level. So that's beyond graduate degree education. This damage is caused by changes in the tiny blood vessels that supply the retina. And if you use the key criteria for lower readability that was on the previous slide, you could end up with something like this, which is a 4th grade reading level. Notice there is a header, diabetic retinopathy, followed by, this is the most common eye problem from diabetes. It is the leading cause of blindness among US adults. Diabetes can damage the retina. This is the nerve tissue at the back of the eye. This tissue is sensitive to light, and it sends visual images to the brain. Changes in the tiny blood vessels that send blood to the retina caused the damage, okay? Much easier to read. Step 4 is readability evaluation of the adapted document or text. So you may feel fairly confident that you have used common words and that your sentences are shorter. But it's critical to ensure that is the case. So here again, I'm presenting that original text with its readability statistics. And here is the adapted text that you saw previously, now with the adapted readability statistics embedded. Have we hit our goal? You will note that for each of the sentences, there is active rather than passive voice. And note that the reading grade level is now less than 5th grade for each of the sentences, and in ranges from 3.7 to 4.9. And the final step, step 5, is comparison of the pre and post adaptation readability. You do want to make a direct comparison of the readability statistics of your original document and now, your adapted document. Here, you will see an example of the direct comparison of those readability statistics. And you can do this now at the document level. You have gone through sentence by sentence to ensure you've hit the criteria. So when you're doing your final comparison of your adapted document, it is fine now to use the overall document statistics. Here, you will see the difference between the original and the literacy adapted document in reading grade level going from a 15.3 to a 4.3, hitting are less than 5th grade. As well as the improvements in percent of passive sentences, numbers of sentences per paragraph, words per sentence, and characters per word. In the article on the five-step methodology, you will see a table shown here that is our direct comparison of original and adapted versions of several articles that were from the American Heart Association, the American Diabetes Association. And you're able to see that we've taken from 15 through, some of these articles started with the 7th grade reading grade level, all ending after adaptation with less than 5th grade, again, ranging from 3.9 to 4.3. For this particular article, we did do our statistics and calculated whether there was a statistical significant difference between the readability statistics of the original and adapted documents. And in fact, there is. But more important, this was more to look at the reliability of the methodology itself. For us, of course, more important than the statistical significance of the difference is the meaningfulness and usability of the adapted documents for our targeted populations. In summary, literacy is a proxy for socio-economic status. And the US population declines in literacy necessitate widespread attention to plain language and lower literacy adaptations. The five-step methodology can reliably produce low literacy adaptations at the less than 5th grade reading level. The method does require training and practice. You will find that initially, it may not feel easy to get to those common words, But with practice, certainly, it can be improved. Studies using adapted materials have resulted in knowledge gained learning and improved clinical outcomes within populations with low health literacy. And importantly, persons with low literacy and persons with average literacy have rated materials adapted using this methodology high in ease of use, and ease of understanding, as well as satisfaction. Thank you. [MUSIC]
