Facilitating Behavior Change with Low-Literacy Patient Education Materials

This article describes a process for developing low-literacy health education materials that are designed to increase patients' knowledge and motivate them to adopt healthier behaviours. The authors illustrate this process by describing the development of a printed diabetes self-management guide in the United States; however, many of the principles are also applicable to web-based, telephone, and other interactive health education innovations.

As noted here, all health behaviour theories consider adequate knowledge of the benefits of healthy behaviours to be a prerequisite for behaviour change. Another concept is that of self-efficacy, which in the health care context refers to one's confidence in successfully organising and executing the courses of action necessary to manage one's health care needs - for example, adhering to a diabetic diet. Furthermore, social cognitive theory suggests that patient education materials designed to activate patients toward healthier behaviours ought to: improve knowledge of the health effects of behaviour change; positively influence outcome expectations; emphasise facilitators to behaviour change; address impediments to behaviour change; and enable the creation and achievement of short-term goals.

Drawing on these theories, the authors describe 6 steps for developing low-literacy education materials to activate patients toward healthier behaviours. In summary, these steps include:

1. Convene a multidisciplinary creative team and solicit input early - e.g., through focus groups - from health care providers, patients, families, and caregivers.
2. Identify 2 or 3 key concepts to be communicated, seeking focus group feedback.
3. Map concepts to a behavioural theory, such as social cognitive theory, and construct a brief intervention to support the use of written materials: "Short-term goals, developed to work toward achieving long-term goals, offer daily incentive to change....For example, the patient who is interested in losing weight as a long-term goal may create as an action plan 'I will walk around the block before I sit down to watch television 3 times during the next week.'"
4. Carefully design materials using low-literacy principles, including: shortening words; substituting general terms for jargon; simplifying sentence structure; using the active voice; eliminating extraneous words; replacing abstract principles with concrete suggestions; featuring drawings and photographs that emphasise key concepts; and using a large and clear font, a logical flow of information, flags to draw attention to important text, headers to orient the reader to new topics, and adequate white space.
5. Refine materials using input gathered through in-depth, semi-structured interviews with the intended population.
6. Assess the success of the patient education materials in the intended audience and learn from failures, gauging not only knowledge improvement but also changes in self-efficacy, outcome expectations, and actual behaviours.

The authors next describe how they used this 6-step process to design a guide for patients with low literacy skills entitled Living with Diabetes: An Everyday Guide for You and Your Family. Various lessons learned through the process are described. For example, focus groups indicated that using the patient's voice - rather than the physician's voice - to offer concrete behaviour change suggestions would be most effective. Also, "[w]ritten health education materials used in isolation are unlikely to be adequate for activating patients, particularly those with low literacy skills, to achieve difficult behavior change." So, nonmedical personnel in the clinical setting provided 5-10 minutes of orientation to the guide and instruction about how to generate an action plan. The authors of the guide also called patients on the phone 2, 4, and 12 weeks after receiving the guide to assess success with their action plans and facilitate the creation of new action plans.