A process for creating data report-back tools to improve equity in environmental health.

BACKGROUND: Although there is increasing interest in reporting results of environmental research efforts back to participants, evidence-based tools have not yet been applied to developed materials to ensure their accessibility in terms of literacy, numeracy, and data visualization demand. Additionally, there is not yet guidance as to how to formally assess the created materials to assure a match with the intended audience. METHODS: Relying on formative qualitative research with participants of an indoor air quality study in Dorchester, Massachusetts, we identified means of enhancing accessibility of indoor air quality data report-back materials for participants. Participants (n = 20) engaged in semi-structured interviews in which they described challenges they encountered with scientific and medical materials and outlined written and verbal communication techniques that would help facilitate engagement with and accessibility of environmental health report-back materials. We coupled these insights from participants with best practice guidelines for written materials by operationalizing health literacy tools to produce accessible audience-informed data report-back materials. RESULTS: The resulting data report-back materials had a 7th -grade reading level, and between a 4th -8th grade level of overall document complexity. The numeracy skills required to engage with the material were of the lowest demand, and we incorporated best practices for risk communication and facilitating understanding and actionability of the materials. Use of a rigorous assessment tool provides evidence of accessibility and appropriateness of the material for the audience. CONCLUSIONS: We outline a process for developing and evaluating environmental health data reports that are tailored to inspire risk-reduction actions, and are demonstrably accessible in terms of their literacy, numeracy, and data visualization demand. Adapting health literacy tools to create and evaluate environmental data report-back materials is a novel and evidence-based means of ensuring their accessibility.

Communication between Health Professionals and Community Residents in Fukushima: A Focus on the Feedback Loop.

Interactive communication and the ability to consider feedback are critical for linking health professionals and the community. Goto and colleagues developed and conducted health literacy training workshops for public health nurses after the 2011 nuclear accident in Fukushima to improve their communication skills. The present study aimed to examine the association between past workshop attendance and nurses' attitudes toward feedback from community residents. We conducted a questionnaire survey with 723 public health nurses in Fukushima and analyzed differences in feedback acceptance, work environment, basic characteristics, and health literacy levels between health literacy workshop attendees and non-attendees. Among 582 respondents, 19.4% were past attendees and showed a higher likelihood of accepting feedback from community residents (amount: adjusted odds ratio [aOR] = 1.87, 95% confidence interval [CI]: 1.21-2.88; specificity: aOR = 1.69, 95%CI: 1.09-2.61; satisfaction: aOR = 2.34, 95%CI: 1.50-3.65) than did non-attendees after adjusting for other variables. Furthermore, work engagement was associated with positive feedback acceptance (amount: aOR = 1.43, 95%CI: 1.03-1.98; specificity: aOR = 1.57, 95%CI: 1.12-2.20; satisfaction: aOR = 1.97, 95%CI: 1.38-2.81). We note the importance of creating a better work environment as well as a training system at the organizational level that encourages public health nurses to learn about health literacy and to improve their communication skills. This could improve professional/community relationships, increase the accessibility of health information for the public, and ultimately improve community health.

Expanding Environmental Health Literacy-A Focus on Water Quality and Tribal Lands.

Environmental health literacy (EHL), an evolving concept, has potential for significant public health impact. However, complex skills are needed to access and use information, to study and document hazards, to link findings to health outcomes, and to understand the complexities of regulations and laws needed to take efficacious action. Because water issues are creating headlines world-wide, we draw from several water-related cases on American Indian tribal lands to examine some of the complexities associated with building needed skills, obtaining accessible information, and navigating the layers of laws and regulations that enable or inhibit efficacious action. Each case highlights the importance of partnerships, skill building, and collaborative action to redress environmental assaults. For our analysis, we draw from and expand upon Nutbeam's typology of health literacy which includes functional, interactive, and critical stages to derive lessons from each of the EHL cases. Community partnerships engaging in EHL efforts still face many challenges, including enhancing skills for community members as well as professionals, clarifying scientific processes and findings, articulating and respecting cultural practices and needs, and translating policies and laws for community accessibility and collaborative action.

Literacy analysis of National Comprehensive Cancer Network patient guidelines for the most common malignancies in the United States.

BACKGROUND: Cancer information is of critical interest to the public. The National Comprehensive Cancer Network (NCCN) offers a series of comprehensive patient guidelines on the management of the most common cancer diagnoses. This study was aimed at assessing the health literacy demands of NCCN patient guidelines for the most common malignancies in the United States. METHODS: The American Cancer Society's most common malignancies by annual incidence in the United States and their corresponding NCCN patient guidelines were identified. Four validated tools were used to evaluate literacy levels: 1) the Simple Measure of Gobbledygook, 2) the Peter Mosenthal and Irwin Kirsch readability formula (PMOSE/IKIRSCH), 3) the Patient Education Materials Assessment Tool (PEMAT), and 4) the Clear Communication Index from the Centers for Disease Control and Prevention (CDC). RESULTS: The average reading grade level was 10.3, which was higher than the recommended 6th-grade level. The average PMOSE/IKIRSCH score was 11; this corresponded to moderate complexity and required some college-level education for interpretation. Only 1 tool, the PEMAT, yielded scores above the benchmarks for high-quality materials. The PEMAT's understandability, actionability, and overall scores were 94%, 83%, and 91%, respectively. The average CDC index was 85%, which was below the recommended 90% for an appropriate health literacy demand. CONCLUSIONS: Overall, the assessment indicates high demand scores for the readability and complexity of the NCCN patient guidelines and thus that the materials are not quite suitable for the general US adult population. Further input from patient focus groups to address appropriateness and usefulness is critical. Cancer 2018;124:769-74. © 2017 American Cancer Society.

Collaborative Processes of Developing A Health Literacy Toolkit: A Case from Fukushima after the Nuclear Accident.

Following the Fukushima nuclear accident in 2011, the central government provided health and radiation-related information that was incomplete, difficult to understand and contradictory, leading to widespread distrust in the community. Thus, from 2013 to 2014, we developed and implemented a series of health literacy training workshops for local public health nurses, often the first health care professionals with whom members of the community interact. The results from our program evaluation revealed that the task of paraphrasing professional terms and skills related to relaying numeric information to the community were difficult for the nurses to acquire. In 2016, to further support the communication efforts of public health nurses, we developed a pocket-size "health literacy toolkit" that contained a glossary explaining radiation-related terms in plain language and an index to measure the accessibility of both text and numerical information, so that nurses could calibrate and appreciate the literacy demand of information. This case study documents an interprofessional collaborative effort for the development of the toolkit, and highlights the iterative process of building health literacy skills in health care professionals.

Health Literacy Training for Public Health Nurses in Fukushima: A Multi-site Program Evaluation.

Public health nurses (PHNs) are community residents' access points to health information and services in Japan. After the Fukushima nuclear accident, they were challenged to communicate radiation-related health information to best meet community needs. We previously developed and evaluated the outcome of a single-site health literacy training program to augment PHNs' ability to improve community residents' access to written health information. This paper presents an evaluation of an identical training program using data combined from multiple sites, and further included proximal and distal evaluations to document the impact of health literacy training in a post-disaster setting. A total of 64 participants, primarily experienced PHNs, attended one of three multi-session health literacy workshops conducted in multiple sites across Fukushima. Quantitative and qualitative data on PHNs' training satisfaction, self-evaluation of achievements regarding training goals, and application of learned skills were collected and analyzed. Each workshop consisted of two 2-hour sessions introducing health literacy and assessment tools and developing skills to improve written materials, followed by a one-month follow-up assessment on PHNs' application of the gained skills in the field. Post-training evaluations on the appropriateness and usefulness of the workshop were highly positive. At the end of the one-month follow-up, 45% of participants had gained confidence in assessing and revising written materials and had applied the skills they had gained to develop and communicate health information in various settings and modes. This increase in confidence was associated with further application of the learned skills at the municipal level. However, participants reported difficulties in explaining risks, and the need to learn more about plain language to be able to paraphrase professional terms. This paper highlighs the positive outcomes of health literacy training among PHNs. Practical strategies to reinforce their skills to use plain language and communicate the epidemiological concept of risk are also recommended.

Health literacy environmental scans of community-based dental clinics in Maryland.

OBJECTIVES: We conducted health literacy environmental scans in 26 Maryland community-based dental clinics to identify institutional characteristics and provider practices that affect dental services access and dental caries education. METHODS: In 2011-2012 we assessed user friendliness of the clinics including accessibility, signage, facility navigation, educational materials, and patient forms. We interviewed patients and surveyed dental providers about their knowledge and use of communication techniques. RESULTS: Of 32 clinics, 26 participated. Implementation of the health literacy environmental scan tools was acceptable to the dental directors and provided clinic directors with information to enhance care and outreach. We found considerable variation among clinic facilities, operations, and content of educational materials. There was less variation in types of insurance accepted, no-show rates, methods of communicating with patients, and electronic health records use. Providers who had taken a communication skills course were more likely than those who had not to use recommended communication techniques. CONCLUSIONS: Our findings provide insight into the use of health literacy environmental scan tools to identify clinic and provider characteristics and practices that can be used to make dental environments more user friendly and health literate.

Leveraging public health nurses for disaster risk communication in Fukushima City: a qualitative analysis of nurses' written records of parenting counseling and peer discussions.

BACKGROUND: Local public health nurses (PHNs) have been recognized as the main health service providers in communities in Japan. The Fukushima nuclear disaster in 2011 has, however, created a major challenge for them in responding to mothers' concerns. This was in part due to difficulties in assessing, understanding and communicating health risks on low-dose radiation exposure. In order to guide the development of risk communication plans, this study sought to investigate mothers' primary concerns and possible solutions perceived by a core healthcare profession like the PHNs. METHODS: A total of 150 records from parenting counseling sessions conducted between PHNs and mothers who have attended mandatory 18-month health checkups for their children at the Fukushima City Health and Welfare Center in 2010, 2011 (year of disaster) and 2012 were examined. Discussion notes of three peer discussions among PHNs organized in response to the nuclear disaster in 2012 and 2013 were also analyzed. All transcribed data were first subjected to text mining to list the words according to their frequencies and inter-relationships. The Steps Coding and Theorization method was then undertaken as a framework for qualitative analysis. RESULTS: PHNs noted mothers to have considerable needs for information on radiation risks as they impact on decisions related to relocations, concerns for child safety, and experiences with interpersonal conflicts within the family owing to differing risk perceptions. PHNs identified themselves as the information channels in the community, recommended the building of their risk communication capacities to support residents in making well-informed decisions, and advocated for self-measurement of radiation levels to increase residents' sense of control. PHNs also suggested a more standardized form of information dissemination and an expansion of community-based counseling services. CONCLUSIONS: Inadequate risk communication on radiation in the Fukushima nuclear incident has resulted in multiple repercussions for mothers in the community. Empowerment of local residents to assume more active roles in the understanding of their environment, increasing PHNs' capacity in communication, and an expansion of health services such as counseling will together better address risk communication challenges in post-disaster recovery efforts.

Health literacy training for public health nurses in fukushima: a case-study of program adaptation, implementation and evaluation.

Health literacy comprises not only an individual's ability to gain access to, understand and use health information, but also health care providers' ability to make health information accessible and usable. The Fukushima nuclear accident has posed challenges related to the communication of radiation-related health information. Public health nurses are gatekeepers of community health in Japan, and have primary responsibility for communicating this complex information about science and risk to lay members of the community. A health literacy training program was designed to augment communication skills of participating nurses with two primary goals: changing communication practices and norms among public health nurses, and improving access to information for community residents. Training content incorporated an overview of health literacy skills (including numeracy), processes for assessing written materials and visual displays, as well as guidelines for text improvement. The workshop was spread across two days with two-hour sessions each day. A proximal post-training evaluation survey was conducted, followed by a more distal one-month follow-up evaluation to assess the application of learned skills in practice. Twenty-six nurses in Fukushima City attended the first trial. Post-training evaluations were highly positive, with agreement from 85-100% of participants on the appropriateness and usefulness of the workshop. During a one-month follow-up, the nurses reported applying new knowledge and skills to develop written materials. However, they faced difficulties sharing their new skills with colleagues and challenges changing work norms. Participants also encountered difficulties using graphics and explaining risks in practice. This paper highlights the importance of providing health literacy training opportunities for professionals to strengthen health system's ability to accessible information and services. This program also serves as important reference for future disaster management efforts.

A Call for More Rigor in Science and Health Communication.

Successful dissemination of scientific knowledge relies on the ability of the writer, speaker, and designer to provide information and data that is both available and accessible to the audience for whom it is intended. Scientific rigor, uniformly applied to the development of medicines, products, and devices must be applied, as well, to communications-spoken, written, posted, or displayed. Rigorous development and design protocols call for formative research data gathering, careful pilot testing with members of the intended audience, needed revisions, and rigorous assessments. Guidelines and tools developed for health literacy applications can be adopted and adapted for environmental health research and educational efforts in the design of questionnaires, instructions, education and report back materials, as well as for public discourse.

Characterizing the Environmental Health Literacy and Sensemaking of Indoor Air Quality of Research Participants.

This study is based on in-depth semi-structured interviews with the participants of an indoor air quality monitoring study. The purpose of the interviews was to capture participants' perceptions of indoor air quality and engage them in a discussion of those factors that influenced their behavior. Interview study participants (n = 20) noted the importance of family health concerns and their own sensory awareness of possible contaminants. They discussed their level of personal control over their home environment as well as their access to needed resources. This study is based on grounded theory and applies interpretivist epistemological methods. Study findings offer insights into how people perceive their home environment and what influences their decision making and action. Analyses indicate that perceived agency, risk perception, access to resources, and information all influenced participants' sense of ability to take action as well as their interest in taking action. These insights serve to challenge some of the current work in environmental health literacy which tends to focus on and measure an individual's knowledge or skills. Our analysis suggests that consideration be given to a number of factors that include perceived agency, access to resources, and the quality of information provided.

An assessment of printed diabetes-prevention materials available to a Northern Plains tribe.

The purpose of this study was to characterize the literacy demands of print materials used to encourage diabetes prevention on the Crow Reservation. Diabetes-prevention materials included pamphlets, booklets, and fact sheets provided to Crow people. Readability was assessed using the SMOG formula. Diabetes related vocabulary was assessed to determine whether medical/scientific words were used and if they were defined. Numeracy demand was assessed by counting the number of times different numeracy concepts were used in each material. Lists, charts, and graphs were assessed using the PMOSE/IKIRSCH tool. We found that materials were written at a readability level higher than recommended. Across all materials, vocabulary terms were used often but not always defined. Numeric terms were not often used, but when used they were not defined. Most of the materials required the reader to read numbers or count. However, overall numeracy demand was relatively low. The PMOSE/IKIRSCH scores for materials were adequate. The authors found a mismatch between the level of skills required in some of the materials and the skills of the average person, including adults on the Crow Reservation. This study highlights the need for designing materials specifically for the intended audience, including rigorous pilot testing of materials.

Cancer screening among Native Americans in California.

OBJECTIVE: To determine the factors associated with cancer screening adherence among Native Americans living in California. PARTICIPANTS: 2,266 Native Americans identified from the California Health Interview Surveys during 2001, 2003, and 2005 eligible for cervical, breast, or colorectal cancer screening. METHODS: We fit multivariable logistic regression models to identify demographic and healthcare access predictors of adherence to cancer screening. RESULTS: The presence of a recent physician visit was significantly associated with cervical (odds ratio [OR] 7.34, 95% confidence interval [CI] 4.27, 12.6), breast (OR 3.29, 95% CI 2.0, 5.42), and colorectal (OR 3.02, 95% Cl 1.74, 5.23) cancer screening adherence. The report of a usual source of care was similarly positively associated with cervical, breast, and colorectal cancer screening adherence. Additional predictors for colorectal cancer screening included higher educational attainment (OR 1.56, 95% Cl 1.07, 2.28), and the presence of a comorbid condition (OR 1.54, 95% CI 1.16, 2.05). Experiencing discrimination (OR .42, 95% Cl .20, .89) and never being married (OR .49, 95% CI .27, .89) were negative predictors of breast cancer screening, while having insurance (OR 2.00, 95% CI 1.27, 3.15) was a positive predictor. Cervical cancer screening was positively associated with living at or above 300% of the federal poverty level (OR 2.69, 95% CI 1.50, 4.85). CONCLUSIONS: Regular access to health care and a physician are the most consistent predictors of cancer screening adherence among Native Americans and should represent a focus of activities to improve screening rates in these communities.

Quantifying word use to study health literacy in doctor-patient communication.

Most health literacy research to date has assessed health literacy using either general reading tests or text-based appraisals of reading and numeracy skills, yet the definition of health literacy includes domains beyond reading ability. Effective oral communication between doctor and patient is an important component of health literacy, but only recently have efforts been made to develop measures that tap into domains beyond those that can be assessed with text-based measures. Focusing on oral exchange, this article describes computer-assisted approaches to quantifying word use and the development of three word-use measures that can be used to study health literacy in transcripts of clinical encounters. The measures can be used to assess either the expressed literacy level of patients or the aural literacy demands made by doctors. Importantly, the computer-assisted quantitative measures described here make it possible for word use to be analyzed at a level of detail that human raters would be hard pressed to attain.

Medical word use in clinical encounters.

OBJECTIVE: Doctors often use medical language with their patients despite findings from a variety of studies that have shown that patients frequently misunderstand medical terminology. Little is known about the patterns of medical word use by doctors and patients during clinical encounters. METHODS: A content analysis of 16 verbatim transcripts of first clinical encounters between rheumatologists and newly referred patients was conducted to assess how doctors and patients introduced medical words. Medical words were identified via a computer program using a defined list. RESULTS: Doctors did not introduce or use more medical words than patients, but the types of words that doctors and patients introduced did differ. The majority of patient-initiated medical words occurred during the history taking (94%). Doctors did not explain, or use as part of an explanation, the majority (79%) of the medical words they introduced, and patients seldom responded in a way that would indicate whether or not they had correctly interpreted those terms. There was relatively little repetition of medical words within or even across encounters. CONCLUSIONS: This study provides insights into how the use of medical terminology could contribute to misunderstanding. Findings suggest that steps already promoted in the literature to improve doctor-patient communication may also ameliorate potential problems arising from the use of medical terminology.

Health Literacy Considerations for a New Cancer Prevention Initiative.

Cancer prevention efforts are newly focused on the older adult population. Adult literacy and health literacy findings and suggestions can help shape more efficacious health communication strategies and thereby increase the "accessibility" of important health information and the potential for healthful action. National and international surveys of adult literacy skills have consistently offered problematic findings that older adults have more limited proficiencies than do younger working adults and face difficulties using commonly available materials to accomplish everyday tasks. Clinical as well as population-based studies of health literacy similarly find limited health literacy among a majority of U.S. adults and even poorer health literacy among older adults. This is of concern because health literacy studies have established clear links between limited literacy and poor health outcomes as well as diminished participation in activities related to disease prevention. Literacy experts note difficulties associated with abstract concepts and with sophisticated numeracy tasks, both associated with disease prevention. Health literacy findings and insights are important considerations in the development of health messages and materials to promote cancer prevention among older adults.

Lingering health-related anxiety about radiation among Fukushima residents as correlated with media information following the accident at Fukushima Daiichi Nuclear Power Plant.

Following the March 2011 accident at Fukushima Daiichi Nuclear Power Plant, many residents of Fukushima have faced anxieties about the health impacts of radiation exposure. Considering that source of information may influence resident anxiety, this study aimed to elucidate the correlation between the two. In addition, a health literacy query was included to examine a possible relationship between anxiety and health literacy skills. A mail survey was conducted in August 2016 among 2000 residents of Fukushima Prefecture aged 20 to 79 years. Survey items included questions about current health anxieties caused by radiation, trusted sources of information about radiation, and media used to obtain information on radiation. The survey valid response rate was 43.4%. Results of multiple linear regression analysis revealed that anxiety was significantly higher for the groups indicating "trust in citizen groups" and "use of internet sites." Anxiety was significantly lower for the groups indicating "trust in government ministries," "trust in local government," and "use of local broadcast television." Also anxiety was significantly lower for groups with higher health literacy. It was found that the significant relationship to anxiety varies depending on the sources of trust and media used. There is a possibility that this was caused by the difference between the contents of each information and media reports. In preparation for any future nuclear accident, government may consider action to improve the media literacy of residents. In addition, improving health literacy of both the recipient and the sender of information can improve access to information and thereby safeguard the health and well-being of the public.