Creating Your Own Health Literacy Program: Tools from the What To Do For Health Book Series

Gonzalez_smDiana Gonzalez, MPH, CHES
Institute for Healthcare Advancement

This pre-conference session will discuss lessons learned from programs implemented in 2015 surrounding IHA’s “What To Do” book series. We will explore the programs that were developed for the books “What To Do for Senior Health, “What To Do For Your Teen’s Health”, and “What To Do When Your Child Gets Sick”. Participants will learn health literacy tools and tips that could be used to develop new programs or enhance existing ones.

In this workshop, Diana provides an in depth look into how programs can benefit from health literacy principals. Participants were engaged in the workshop content through interactive group discussions and workshop participation. Items discussed included simple health literacy principals, provided examples of programs that include health literacy principals, how to apply health literacy principals to current programs.

Health literacy is defined as the degree to which individuals has the capacity to obtain, communicate, process and understand basic health information services to make appropriate health decisions.

Design Strategies


Patient information should we easy to read, simple, and clean. The following are myths (which are also mistakes) that individuals tend to believe are best when developing patient information.

  • More is better
  • White space is meant to be filled up
  • Fancy and fun font types are cool and good to use
  • Style should be formal
  • Art provides effective communication


The reality is that less is better, the more white space the easier it is to read and follow, stick with simple font types, style should be informal and written at a 3-5th grade reading level, although graphics are ok they must be limited and to ensure the item is conveying the right message.

5 Design Strategies

  1. Type  – the best font type is Serif for the body, San serif for the headings, at 12-14 font size, Avoid “ALL CAPS”, make use of high contrast
  2. Paragraphs – Use 1.2 to 1.5 spacing between lines, leave the right margin jagged, block paragraphs with no indents are best, one line return between paragraphs
  3. Chunking – helps to organize, keep similar ideas together, write things in a logical order, and use clear headings.
  4. Graphics – use to help in understanding, need to be simple and clear, not abstract, provide captions when appropriate, table and charts should also be simple
  5. White space – makes handouts less intimidating, helps to give the eyes a rest, use white space around paragraphs, graphics and pictures, etc.

Helpful Tips

Avoid ghosting – Ghosting is similar to using “watermarks”. Avoid using ghosting since it is not easy on the eyes and not easy to read.  Avoid reverse type – when white print is used on a colored background.

Writing Strategies

  • Use everyday words – plain language, kitchen talk, has a thesaurus and guidelines to help you
  • Avoid long, complex sentences – use about 10-15 words per sentence , if sentences are too long you lose the reader
  • Explain technical terms and use examples – sometimes you just can’t use plain language, but you can use a definition written in plain language to explain the meaning of the technical term, and perhaps give an example about that term.
  • Write in the active voice – active sentences are stronger, shorter and clearer. The person/object comes before the action.

Implementing health literacy principles

Senior Health

  • Belvidere, Illinois – Boone County Council on Aging requested a 1 ½ program about medi-care, fall prevention and home safety.
  • Used IHA’s booklet, developed into a power point
  • Conducted a train the trainer training (for Seniors)
    • Senior learning styles – identify your audience, who is your audience, who is going to be receiving this information, learning styles, what do they need, i.e. Seniors. Collect primary data if possible – go directly to the community (Seniors) ask what they need, what do they want to see, what would make them feel comfortable to sit in a classroom.
    • Tips for presenting: A good idea to get someone that identifies with that population/community.
    • Practice trouble shooting – met with the trainer and looked at goals together, asked what worked or didn’t work
    • A quiz was provided
      • What worked: handed out surveys, put the questions on the power point and questions were read out loud.
      • What didn’t work: it was too time consuming but beneficial for collecting the necessary data
    • Lessons learned – participants enjoyed the class, seniors enjoyed having a felling Senior facilitator, wanted more details on Medicare but there was only so much information than can fit in an 1 ½ workshop.

Teen Health – Using IHA’s “What To Do For Youth Teen Health” Book and “We Thrive” Curriculum

       Teen Health Book

  • Phone number list – front page for immediate reference, and easy to access, emergency/hotline phone numbers
  • How parents can help teens – provides information about how parents can help teens through the issues they may encounter
  • Teen issues – comprehensive list of teen issues such as:
    • Dating and sex
    • Teen Safety


The We Thrive curriculum uses IHA’s “What To Do For Your Teen’s Health” Book, the Adult Learning Theory, the Health Belief Model to help parents shift their way of thinking and behavior about their parenting style, also uses Health Literacy principals, and uses the five Youth Thrive Protective and Promotive Factors Framework.

The power point doesn’t use more than 5 bullet points per slide.

Youth Thrive Protective and Promotive Factors

  • Developed by the Center for the Study of Social Policy that demonstrates these are the factors needed to be considered successful and healthy
  • Youth Resilience
  • Social Connections
  • Concrete Support in Times of Need
  • Knowledge of Adolescent Development
  • Cognitive and Social Emotional Competence

Each of the above protective factors are difficult concepts and written in a high literacy level. The curriculum has rewritten them using health literacy principals. For instance, Social Connections is called Healthy Relationships in this curriculum.

This curriculum offers fun and interactive group activities that provide opportunities for parent participation, team building, conversation, role playing, and more.

Pilot Program – the La Habra Family Resource Center

  • 10 week program, small sample size of 6 participants, dinner and daycare provided
  • Lessons Learned – participants have a tendency to tell not ask, need to leave ample time for discussion, parents enjoyed speaking with other parents

Sick Child – Using IHA’s “What To Do When Your Child Gets Sick” Book

Sick Child Book

  • Different ways to search – headings and table of content that are easy read and use
  • Ages 0-5
  • Ears and nose
  • Mouth and throat
  • Stomach

Train the trainer training

  • At the 2015 IHA conference, with 30 participants, 4 hour session, class setting on how to use the book
  • Kansas Head Start: video was created and provided by the Kansas Head Start Association
  • Provides hands on practice
  • Uses a 5 step format
  • Lessons learned – can use more practical tools, participants enjoyed the video, want to know about programs for other books


Implementing the “Always Use Teach-Back” Training Program

Abrams_smMary Ann Abrams, M.D., MPH
Nationwide Children’s Hospital

Do you struggle with these challenges in your health care setting? How can I get everyone to use teach back? Why don’t patients do what we ask them? There’s just not enough time…this interactive workshop will use the “Always Use Teach Back! Tool kit” as a foundation to strategize on making teach-back an “always event”.

In this workshop, Dr. Abrams gives audience members the opportunity to begin thinking about steps that they could use to encourage their organizational leaders to promote health literacy and teach back.

This workshop also provides opportunities for group discussions about shared ideas, steps, successes and failures of using teach back.

Using Teach Back

Building it, creating it, refining it, evaluating it, seeing how well it works, and helping it sustain and actually make a difference on the front lines of patient care, how to get traction, and one that a lot of use deal with a lot is the resistance to push back and the fear of taking too much time.

After the training program, you will feel more empowered to advocate for health literacy and teach back. To help make that case, these are key elements of patient safety and quality care. To be able to use this Teach Back Toolkit and to build that into initiatives that you are using to make your organization a more health literate healthcare organization, and to support your colleagues and each other in changing individual provider behavior as well as organizational behavior when you increase use of Teach Back.

Making the Case & Leverage
Health Literacy 101

The chronology of building and integrating teach back in your organizational structure. To do this is through Health Literacy 101. Health literacy, the degree to which individuals have the capacity to obtain, process, understand, use health information to make appropriate health decisions.

According to the National Assessment of Adult Literacy Data, a third of adults have basic or below basic health literacy; only about 90% people lack proficient health literacy. The health system that we have is not well designed for 90% of people to use and function. Proficiency is not a high level of literacy, rather they are skills of things that are involved in assessing that are in the “now” or “everyday things” such as going out  seeing how much you need to pay for your insurance premium if you are a family of 4.

Low Health Literacy & Poorer Health Outcomes

This leads to less healthy behaviors, preventative care, personal health knowledge, and understanding of treatment choices. Poorer ability to demonstrate taking medicines appropriately, interpret labels and health messages, greater use of emergency care, excess hospitalization, increased mortality and poorer health outcomes. Higher health care costs from $106 billion to $238 billion, 17.6% of all Medicare admissions are readmissions within 30 days can cost up to $15 billion.

As a result of this data, health literacy is improving the skills of the heath care system collectively and recognizing that it is our (the health care industry’s) problem, not the patient alone.

Quality – A frame work for health literacy

Triple Aim is a framework to look at quality healthcare. Work to optimizing the performance by simultaneously pursing three dimensions: improving the patient experience of care; improving the health of populations and reducing the per capita cost of health care. The six dimensions (aims) that the Institute of Medicine report on patient safety, described safe and high quality care is: being safe, effective, patient-centered, equitable, timely, and efficient. Also seeing how health literacy intersects with those areas.

Drivers in the Transforming Health Care System

These drivers include the Affordable Care Act related initiatives, Accrediting & Regulatory Authorities, AGCME – all 6 competencies especially interpersonal and communication skills, Quality care & patient safety, and Risk Management. These are areas that are ideas needed to begin some conversations as to where you can gain some leverage and traction from leadership to implementing teach back.

Health Literacy: Quality & Safety

The AHRQ , Joint Commission, and the National Quality Forum  are some high level agencies and authorities, explicitly speaking about health literacy, and its relation to seeing effective care.

According to the Institute of Medicine Chasm Report, Health literacy is fundamental to quality care and relates to three of the six aims of quality improvement. These are safety, patient-centered care, and equitable treatment. Furthermore, the Priority Areas for National Action (for the U.S. healthcare system) identified that self management & health literacy are cross-cutting priorities for improving health care quality & disease prevention. These are some things to consider when planning your strategy to implementing teach back in your organization. Data also shows that low health literacy is more common among racial and ethnic minority groups; we are all increasingly seeing more diversity in our patients referred in our workforce which is another area of leverage that can be used.

What are some ideas you see for quality and safety and health literacy?

Ideas included medication management, self care instructions; i.e. chronic disease, and fall prevention, and discharge processes. Other ideas include readmissions, outpatient, care coordination, reducing health disparities, etc.

10 Attributes of Health Literate Health Care Organizations (Institute of Medicine Roundtable)

  • Leadership that makes health literacy a priority
  • Integrating health literacy into planning, evaluation, safety and quality efforts
  • Create a shame-free environment to meet the needs of patients
  • ensure easy access to health information and services; and navigation support
  • Communicate health insurance and health care cost information clearly
  • Include consumers in design, implementation and evaluation efforts
  • Prepare the workshops to be health literate and monitor progress
  • Use health literacy strategies in interpersonal communication to ensure and check patient understanding
  • Address health literacy at high-risk points
  • Design and use information that is easy to read, understand and use

Offering Solutions – Teach Back

Teach back is:

  • Asking people to explain what they learned in their own words what they need to know or do, in a friendly way
  • Not a test of the patient but a measure of how well you explained something
  • A way to check for understanding and, if needed, re-explain, then check again

Teach back – Quality & Safety

Several research studies have demonstrated successful results when using teach back. The Agency Health care Research for Quality, for instance, found that “asking patients to recall and restate what they have been told” is one of 11 top patient safety practices based on strength of scientific evidence. Others include:

  • Schillinger, et al., 2003 Closing the Loop
  • Bennett, et all., 2009 J Am Coll Radiol
  • Fink, et al., 2010, Annals of Surgery
  • Press, et al., 2010, J Gen Intern Med
  • Griffey, et al., 2015, J Commun Healthcare

Teach-back – Examples

Switching from YES/NO questions to Teach-back questions, such as:

  • YES/NO: Do you have your follow-up doctor appointment scheduled?
  • Teach-back:  Please tell me when your next appointment with your doctor is?

Teach back – is Everyone’s Job

This is not just for clinical providers, it’s important for everyone to know. Everyone that works in the health care industry need to use teach back in order to better help a patient through the journey of the healthcare system.

Unable to Teach Back?

If someone isn’t able to Teach-back:

  • Make sure they are using their glasses, hearing aids, or other assistive devices
  • Ask if they want to include family member or friend
  • Check for language, literacy, cultural barriers
  • Ask another health care team member to help
  • Schedule another visit or call

Then pass this information along to other members of the healthcare team, so that they are aware of the patient’s difficulty with teach back.

Changing Behavior

Never to Always

  • Never Event: adverse events are unambiguous, serious, and usually preventable (AHRQ).
  • Always Event: Aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time (IHI).

Make Use of teach-back an “always event”

  • Help all health care providers learn to use teach-back – every time it is indicated, to support patients and families throughout the care continuum, especially during transitions within and between care settings.

Making Teach-back an Always Event

  • High reliability organizations – organizations or systems that operate in hazardous conditions but have few than their fair share of adverse events: they are resilient, have a culture of safety.
  • Telling people to work harder doesn’t lead to lasting improvement
  • Education necessary but not sufficient: leads to low level reliability at 80-95% success rate so we want to make teach back a highly reliable intervention
  • Must use effective change strategies, as the individual and the organization.

Theoretical Models:

Transtheoretical Model of Behavior Change – worth applying this, so patients can be moved from the stage of pre-contemplation (to never hearing of teach back) to contemplation (willing to explore and think about it), then from contemplation to preparation (moving from Maybe to ok ), then from preparation to action to implement, revise/reform plan, (Ok I will use teach back). There is possible relapse and recycle piece with this model, therefore the need to go back to help though that issue.

IHI Model for Improvement – another approach for organizational change

This involves setting aims, establishing measures, and selecting changes to achieve that aim and making use of small tests of change. By starting small you avoid resistance. You are not setting high unrealistic expectations for the organization to implement of teach back.

The Always Use Teach-back! Toolkit

What Is In This Toolkit?

  • Introduction on Using the Teach-back Toolkit
  • Interactive Teach-back Learning Module
  • Coaching is Always Use Teach-back
  • Readings, resources and videos
  • Tools and Videos:
    • 10 Elements of Competence for Using Teach-back Effectively (PDF)
    • Why Use Teach back? A Patient Story – Inadvertent Overdose (Video)
    • Toolkit Background and Purpose (VIDEO)

Helping People to Always Use Teach-back

Raising Awareness & Changing Behavior – Applying Tips from the Toolkit

Traditional Methods

How to integrate traditional methods of implementing the tool kit:

  • Make it personal – connect to their experience or setting, a personal adaptation
  • Power of stories – talk about the successes
  • Close with a “call to action” – examples:
    • What can you DO by Tuesday?
      • Could you try using this plain language hand-out during discharge for one patient?
      • Would you be willing to try using teach-back with your last patient tomorrow?
      • Could you ask a family member for feedback to help you improve your registration process?

Marketing Strategies – an alternative to leadership resistance to teach-back

  • Explain the benefits – Highlight the importance of teach back
  • Then ask the questions:
    • How do you feel when patients don’t keep their follow up appointments?
    • Where do you see using teach-back as being most helpful?
    • How do you see yourself using this?
  • Handle objections – this is ok
    • They are interested enough to listen & think about it
    • Then restate it, reframing it
    • Clarify, if needed. Address concerns. Support your point. Validate their concerns
  • Close with a “call to action”: Willing to use it? Willing to try it?
  • Conduct some follow-up?

Coaching – Straight from the toolkit

  • Build motivation
  • Respecting and honor current work – all the hard work everyone is doing already
  • Understand and recognize that change is hard
  • Resistance is natural
  • Foster new skill development
  • Build confidence to integrate new habit into work plans
  • Make it a reliable process,  standard work; reminders; default; appropriate redundancy
  • Manage relapses: follow up coaching; share questions and problems; recognize and reward

Right Intervention for the Right Issue at the Right Time

  • Assess conviction and confidence
  • Create context to explore ambivalence
    • That’s interesting, tell me more
    • What makes you say that? Do that? Ask that?
  • Listen to and categorize resistance so you can respond appropriately

Overcoming Resistance

Right Intervention for the Right Issue at the right Time

  • Listen to and evaluate concerns to respond appropriately
    • If there is a lack of understanding, then explain, educate, check understanding
    • If they have a different perspective, then understand, acknowledge, perspective, address importance and inspire.
    • If there are competing priorities, validate, problem solve together
    • Focus on barriers, understand specifics, focus on their own behaviors, and seek their solutions, feedback. Formulate action plan.
  • Teach-back is an investment, it is NOT an add-on
    • Concerns about time – takes approximately 1.8-4.3 minutes more to the patient visit
  • Investment
    • Trade-offs/ Patterns/Habits – other people can help with teach back, have less interruptions, less non-compliance, less phone calls from people that don’t understand
    • Opportunities to improve outcomes

8 Steps for Organizational Change include:

  1. Establish sense of urgency
  2. Create guiding coalition
  3. Develop change vision
  4. Communicate the vision for buy-in
  5. Empower team and remove barriers
  6. Generate short term wins, communicate success
  7. Never let up
  8. Incorporate changes into the culture

Making it Stick

Sustain Improvement – adding teach back to parts of standards of care and clinical competencies which can be done in the following areas:

  • Position descriptions and performance reviews
  • Orientation and credentialing
  • Training and education
  • Build into care processes and competencies
  • Begin at admission, discharges are confusing
  • Order sets
  • Documentation systems for work flow, data feedback

Organizational Level

  • Quality meetings
  • Performance scorecards
  • Communication –related adverse events
  • Lay reader review in materials development
  • Faculty teach, model, and evaluate for learns
  • Recognize leaders and champions
  • Engage community teach how to elicit teach back

Focus on high-risk situations such as medications, transitions


  • Know when and how to access and work with trained interpreters
  • Passes along need for clear communications (SBAR)
  • Can “stop the line” if they sense a patient/family member doesn’t understand
  • Ensures understanding with teach back

Using Teach Back Well

Chunk and Check

  • Teach 2-3 main points for the first topic
  • Check for understanding with teach back
  • Then go on to the next topic
  • Support teaching with reader-friendly print materials
  • Use teach back for all key patient education and communication
  • Document use of and response to teach back