Promoting health literacy by using the Health Literacy Universal Precautions Toolkits: A reflection study

Brevidelli, Maria Meimei; Moura, Veronica Paula Torel de; De Domenico, Edvane Birelo Lopes

doi:10.1590/2177-9465-EAN-2024-0013pt

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RESEARCH • Esc. Anna. Nery 28 • 2024 • https://doi.org/10.1590/2177-9465-EAN-2024-0013en linkcopy

Promoting health literacy by using the Health Literacy Universal Precautions Toolkits: A reflection study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives To describe the Health Literacy Universal Precautions Toolkits document and reflect on its applicability in promoting health literacy in different contexts.

Method This is a reflection that synthesizes the dimensions and action strategies, as well as presents a summary of the implications for clinical practice.

Results The toolkits are organized into five dimensions: preparation for improvement, verbal communication, written communication, self-management and empowerment, and support systems. Each dimension is subdivided into 21 tools, accompanied by their respective action strategies. Studies on the applicability of these toolkits in clinical practice indicate a preference for more concise and easy-to-use instruments, and also reveal that implementing changes took more time than originally anticipated. Identified limitations include the need for planning, reorganization of the physical environment, adjustment of service flow, and training of the staff in communication skills.

Final considerations and implications for practice The value of this framework lies in the collection of evidence-based recommendations that can be used to promote effective interactions with health care users.

Keywords: Health Communication; Health Education; Health Literacy; Empowerment; Self-management

Dimension	Tools	Main action strategies
Initiating improvement path	Tool 1: Form a Team	These tools aim to organize the resources and actions necessary to implement the others. They offer instruments and strategies to initiate the process, which includes: (1) forming and organizing a work team, (2) developing an action plan based on selected improvement dimensions, (3) organizing the necessary resources to implement the action plan, and (4) training the team to improve health literacy.
	Tool 2: Develop a Health Literacy Improvement Plan
	Tool 3: Raise Awareness
Improving verbal communication	Tool 4: Communicate clearly: Oral communication strategies	Maintain eye contact; have a friendly attitude; listen attentively; use simple language; speak slowly; limit and repeat content; avoid vague/subjective terms; use explanatory images; demonstrate how to do something; encourage listener participation and questions; use the teach-back method; discuss these strategies with the work team.
Improving verbal communication	Tool 5: Use teach-back method: a way of checking the person’s understanding, asking them to explain in their own words what they need to know and do to take care of their health	Use a warm tone of voice; show welcoming body language and make eye contact; ask the person to explain what was taught in their own words; plan how to ask questions; ask open-ended questions, avoid yes/no questions; clarify points not understood and ask again; use printed materials to aid understanding; ask the person to demonstrate what they understood, in the case of a procedure or technique.
Improving verbal communication	Tool 6: Follow up on users: Contact the person being assisted to assess the progress of treatment since the last visit, in order to identify doubts and/or make adjustments.	Define reasons for follow-up, such as monitoring health, reinforcing knowledge and action plans, confirming medication use, scheduling returns, communicating test results, confirming referrals. Ask the user to record monitored information. Identify professionals who will follow the user in different treatment instances. Choose the follow-up method: phone, email, text message, electronic systems, etc. Organize and supervise follow-up.
	Tool 7: Improve telephone access: Make it user-friendly to facilitate access to the health service.	Evaluate the phone system (busy signal, wait time, time to access desired information, transfer to different channels). Decide on implementing an automatic or personal phone system. Consider using service menus. Improve how the health team communicates by phone. Guide the user on the phone system.
	Tool 8: Assess “brown bag medicine”: a practice that involves encouraging the user to bring the medicines and supplements in use to each appointment, with the aim of reviewing correct use and identifying possible errors.	Identify which medications the user should bring. Remind the user to bring them (reminders on appointment cards or when confirming the appointment; posters in the environment). Plan how and when to conduct the assessment. Clarify correct use. Record the process. Provide an updated list of medications. Help the user remember how and when to take the medications.
Improving verbal communication	Tool 9: Consider language differences: to include these differences in the communication of health information with foreign users, in order to increase health literacy.	Evaluate preferences and needs for linguistic assistance. Use reliable linguistic assistance services (translators, multilingual professionals, telephone interpreters). Plan interpreter services in advance. Provide written materials in the user’s preferred language. Seek funding sources for linguistic assistance (health insurance, community organizations, shared contracts, public funding).
Improving verbal communication	Tool 10: Consider culture, customs, and beliefs. Understand how these aspects affect people's understanding of and use of health information.	Include aspects related to beliefs, customs, and values in data collection. Avoid judgments. Seek resources to acquire cultural competence (courses, videos, community organizations). Develop cultural competence among health team professionals. Hire people who represent the cultural diversity of the population served.
Improving written communication	Tool 11: Evaluate, select, and create easy-to-understand materials. Making written materials (forms or health education resources) understandable, even in the face of limitations in health literacy	Train team members to assess the quality of materials provided to users. Evaluate readability and comprehensibility of materials. Involve users in the evaluation. Choose or develop easy-to-understand materials. Use guidelines to create, evaluate, and rewrite educational materials (e.g., Harvard School of Public Health Guidelines for Creating, Assessing, and Rewriting, PEMAT, or CDC-CC Index).
Improving written communication	Tool 12: Use health education materials effectively. Use only as a resource to assist in the process of health education, seeking understanding and behavior change.	Consider that received material is not always read. Highlight or emphasize the most relevant points of the material during the educational process. Personalize the material by adding specific information (e.g., name, medications). Use the teach-back method to assess understanding. Use the material as a resource during verbal instructions. Check if the user knows how to use audiovisual or digital resources. Train the user to use these resources. Obtain user feedback. Organize and manage resources.
Improving written communication	Tool 13: Welcome users - useful attitudes, signs, and more: make the environment welcoming, receptive, and easy to navigate.	Guide the user through the environment. Evaluate the visibility and readability of signs. Train the team to welcome users warmly. Offer help to fill out forms. Create a brochure with contact information, services offered, what the user should bring to appointments. Use the waiting room to disseminate important information, such as educational content, names and titles of health team members, and posters encouraging reflection and action. Use written or audiovisual materials.
Improving self-management and empowerment	Tool 14: Encourage questions: Create an environment where people do not feel embarrassed or inhibited to ask questions as a way to actively engage in their care.	Encourage simple questions with open-ended prompts. Ask if the user has any doubts during the appointment. Use non-verbal language to encourage questions (stay seated, close to the person; observe and be attentive to everything said; do not interrupt). Encourage the health team to answer all questions. Remind the user to record questions that may arise outside the appointment.
Improving self-management and empowerment	Tool 15: Develop action plans: Plan health goals with the user to improve self-management of chronic disease, change diet, quit smoking, increase physical activity, reduce stress, improve sleep patterns, take medications correctly.	Obtain user consent to discuss health behaviors, such as weight loss. Observe if there is motivation to change lifestyle. If not, identify the user's perception of difficulties and benefits of behavior change. Ask the user to set goals that are important and motivating to them. Offer options for behavior changes (do not give suggestions). Help the person break down a goal into small, realistic steps. Use an appropriate form to record. Assess the person's confidence to follow the plan using a numerical scale. Identify barriers or difficulties in following the plan. Help the person plan the next step when the plan is achieved.
Improving self-management and empowerment	Tool 16: Help users remember how and when to take medications: reduzir erros no uso de medicamentos, ajudando o usuário a entender seu regime terapêutico	Ask how the person usually remembers to take their medications. Offer a list of medications or a form with names and schedules. Evaluate the possibility of using online tools for medication management (lists with simple explanations about the purpose of the medication; tutorials to help the person know how to take them; emails or text messages to remind the person to take them). Include precise instructions on how to take the medications. Inform which oral medications may change in color, shape, and pill size. Offer pillboxes and guide how to organize them based on the prescription. Involve family members to help with proper medication use. Record the strategies used and agreed upon with the user.
Improving self-management and empowerment	Tool 17: Obtain user feedback: Obtain user evaluation on difficulties faced during the appointment (e.g., filling out forms, understanding health information, navigating the system).	Make a health team member available to accompany the user and get their perspective on the service. Conduct a guided tour to get user feedback on the physical environment. Observe how the user utilizes the resources offered by the health service’s online site. Ask the user to evaluate forms and other written materials. Provide a suggestion box. Conduct methodologically sound surveys with users (sampling, reliable instruments, and analyses).
Improving support systems	Tool 18: Link users to support systems: Guide and supervise referrals to available community resources.	Assess access to community resources for each user (e.g., difficulties in general health care, problems obtaining healthy foods). Identify available community resources. Direct the user to the resources they need.
	Tool 19: Provide easy access to medications: Facilitate access to free or low-cost medications.	Assess the user’s ability to purchase medications. Check if this cost is covered by health insurance. Refer the user to medication assistance programs.
	Tool 20: Refer users to literacy resources: Refer users to learning centers to improve literacy and math skills.	Assess reading comprehension and numeracy skills. Identify community resources for this purpose. Help the user connect to the resource.
	Tool 21: Facilitate referral to other services: Increase the chances of treatment follow-up.	Increase the chances of treatment follow-up. Develop and maintain relationships with teams from other services. Establish a formal referral network, determining participation rules. Share information directly with the other service. Include information about the user's need for linguistic assistance. Explain to the user the reasons for the referral. Provide clear information. Monitoring the referral process.

Patient Education Materials Assessment Tool (PEMAT)	Clear Communication Index (CCI)
Understandability	Clear Communication Index (CCI)
Content: Ensure the purpose of the material is clear; do not include information that deviates from this purpose; use everyday language; avoid medical terms unless the intent is to educate; use active voice; use numbers only when necessary, without requiring mathematical calculations.	Main Message and Actionability: Describe the main message in one to three sentences; highlight it at the beginning of the text; use visual effects (e.g., bold, colored text, different font styles); complement or reinforce the message with images or figures; encourage the person to change a behavior, attitude, or seek more information.
Organization: Arrange information in short sections; use informative headings about the section's content; present information in a logical sequence; provide a summary of the main points covered.	Language: Use active voice (direct, clear, simple to understand); select familiar words and terms; avoid slang, colloquial language, metaphors, abbreviations, and culturally sensitive language; explain unusual words or expressions when used.
Layout andDesign: Use visual cues to draw attention to key points (e.g., arrows, boxes, bullets, bold, larger font, highlighting).	Information Structure: Break text into items or sub-items with bullet lists; divide long texts into blocks with short sentences and paragraphs; use headings to organize text blocks; connect the blocks for smooth reading; manage the amount of information (do not overload); present the most important information at the beginning (essential to know; interesting to know more; what can help; what can be done; action strategies and available community resources).
Acionability
Clearly identify at least one action the person can take.	State of scientific knowledge: Explain what reliable sources (experts, government representatives) know or do not know about the topic.
Directly address the user to describe actions.	Behavior recommendation (not applicable to all materials): Express one or more desired behavior recommendations; link the behavior to information about the consequences of performing or not performing it; include specific instructions on how to perform the behavior (sequential steps).
Arrange actions in feasible steps.
Provide concrete tools to help the user act (e.g., agendas, checklists).	Numbers (not applicable to all materials): Describe numerical information in common terms, with whole numbers, not decimals; use familiar expressions (e.g., 8 out of 10 people instead of 80%); provide context to explain numerical information, such as clarifying whether the value is higher or lower than expected or its significance individually or collectively; avoid qualitative expressions (e.g., high and low, small and large).
Present simple instructions or examples on how to perform calculations when applicable (e.g., how to calculate calories per meal; carbohydrate counting).
Explain how to use charts, tables, graphs, or diagrams to act.	Risks (not applicable to all materials): Explain the attributed meaning (probability of an event occurring, such as risk of contamination; threat or harm to an individual or group, such as health risk; result of a threat or harm, i.e., risk of getting sick); do not qualify as high or low, large or small; explain how the risk may affect the person, i.e., the relationship between risk and its effect (is the effect immediate or long-term? can the person get sick or die? what is the chance of the outcome occurring?); characterize the benefits versus risks relationship; describe probabilities with easily understood terms or images (e.g., 1 in 4 people get sick; there is a 6% chance of the disease occurring).
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