1. Professor Avril Taylor University of Paisley Does written hepatitis C information meet the needs of injecting drug users?

2. Background to Study Much information on HCV disseminated through written materials In 2003 an awareness campaign used cards and posters Knowledge evaluated pre and post campaign No difference in knowledge Other health literacy studies find discrepancy between literature and reading ability

3. Aims of the Study To assess the reading levels of injecting drug users To assess any association between reading level and risk behaviours To assess the readability levels of written harm reduction leaflets on HCV To assess sources of HCV knowledge To determine IDUs preference for knowledge acquisition

4. Method IDUs reading levels assessed using two validated tools (REALM and S-TOFHLA) Interviewed using structured questionnaire - drug use, risk behaviours, knowledge of HCV, sources of knowledge, preferred format Leaflets assessed using SMOG

5. REALM Rapid Estimate of Adult literacy in Medicine Assesses adults’ ability to read common medical words and lay terms for body parts and illnesses 66-item word recognition test One mark is given for each correctly pronounced word The REALM score is the sum of correctly pronounced words

6. REALM Scores and Reading Age REALM Score Reading age in years 0 – 18≤ 8 yearsWill not be able to read most low literacy materials. Will need repeated oral instructions, materials composed primarily of instructions, or audio/videotapes 19 - 449 – 11 yearsWill need low literacy materials. May not be able to read prescription materials 45 – 6012 – 14 yearsWill struggle with most patient education materials. Will not be offended by low literacy materials 61 – 66> 14 yearsWill be able to read most patient education materials (Davis T et al, 1991)

7. S-TOFHLA Short Test of Functional Health Literacy in Adults Respondents read out loud a number of sentences Fill in a missing word from a provided list

8. S-TOFHLA Your doctor has sent you to have a____________ X-ray. a. Stomach b. Diabetes c. Stitches d. germs You must have an_________ stomach when you come for_____. a. asthma a. is b. empty b. am c. incest c. if d. anaemia d. it The x-ray will____________ from 1 to 3 __________ to do. a. take a. beds b. view b. brains c. talk c. hours d. look d. diets

9. S-TOFHLA Grades and Literacy Level TOFHLA GradeScore Literacy Level Inadequate Health Literacy 0-16Unable to read and interpret health texts Marginal Health Literacy 17-22Has difficulty reading and interpreting health texts Adequate Health Literacy 23-36Can read and interpret most health texts

10. Leaflet Assessment 10 HCV leaflets distributed within GGHB and the recruitment centres were evaluated The SMOG (simplified measure of gobbledygook) Readability Formula determines the readability level of written material If someone has a reading age of, say, 12 years, they will understand 90-100% of material with a readability level of 12 Most people will understand a readability level of about 10

11. Sample characteristics 150 Glasgow IDUs 69% male Mean age = 32.02 years Mean age left school = 14.87 years Mean age first injected = 21.58 years 60% no qualifications 48 refused to take part

12. Results REALM scores 11 years 12 – 14 years > 14 years or less Total (n=150) 12 (8%) 34 (23%) 104 (69%) Males (n=104) 11(11%) 15 (14%) 78 (75%) Females (n=46) 1 (2%) 19 (41%) 26 (56%) Mean age 35.9 31.0 31.9 11years or less. At the very least will need low literacy materials 12-14 years. Will struggle with most patient education materials >14 years. Will be able to read most patient education materials

13. Results TOFHLA scores Inadequate Marginal Adequate Total (n=150) 19 (13%) 14 (9%) 117 (78%) Males (n=104) 16 (15%) 9 (9%) 79 (76%) Females (n=46) 3 (7%) 5 (11%) 38 (83%) Mean age 35.1 33.2 31.4 Inadequate. Unable to read and interpret health texts Marginal. Has difficulty reading and interpreting health texts Adequate. Can read and interpret most health texts

14. REALM and TOFHLA REALM 11 years or less12 – 14 years > 14 years ( n=12) (n=34) (n=104) TOFHLA Inadequate 9 (75%) 7 (21%) 3 (7.5%) Marginal 0 6 (18%) 8 (8%) Adequate 3 (25%) 21 (6%) 93 (89%)

15. Risk Behaviours – Injecting with used n/s 11 years 12 – 14 > 14 years Total or less years (n=12) (n=34) (n=104) (n=150) Ever share n/s 5 (42%) 15 (44%) 55 (53%) 75 (50%) Shared last 4 (33%) 6 (18%) 20 (19%) 30 (20%) 6 months

16. Risk Behaviours – other paraphernalia 11 years or less12 – 14 years> 14 years Total (n=12) (n=34) (n=104) (n=150) Ever share spoon 8 (67%) 20 (59%) 73 (70%) 101 (67%) Shared spoon 6 (50%) 14 (41%) 47 (45%) 67 (45%) last 6 months Ever share filter 8 (67%) 19 (56%) 74 (71%) 101 (67%) Filter last 6 months 6 (50%) 13 (38%) 49 (47%) 66 (44%)

17. HCV Knowledge Think easily transmitted 11 years or less12 – 14 years> 14 years Total Injecting with used n/s 11 (92%) 34 (100%) 101 (97%) 146 (97%) Drawing up used spoon 11 (92%) 34 (100%) 88 (85%) 133 (89%) Used filter 11 (92%) 32 (94%) 92 (89%) 135 (90%) Used flush water 10 (83%) 29 (85%) 90 (87%) 129 (86%)

18. How received Hepatitis C knowledge 11 years 12 – 14 >14 years Total or less years Verbal 10 (83%) 25 (74%) 81 (78%) 116 (77%) Poster 1 (8%) 8 (24%) 26 (25%) 35 (23%) Leaflet 6 (50%) 22 (65%) 76 (73%) 104 (69%) Other 1 (8%) 3 (9%) 14 (14%) 18 (12%) (TV, press etc)

19. Found source helpful/very helpful 11 years 12 – 14 > 14 years Total or less years Verbal 9 (90%) 22 (80%) 69 (85%) 100 (86%) Poster 0 5 (63%) 15 (58%) 20 (57%) Leaflet 0 5 (23%) 15 (18%) 20 (19%) Other 1 (100%) 3 (100%) 11 (79%) 15 (83%) (TV, press etc.)

20. Leaflet assessment 10 leaflets ranged between equivalent reading age of 13-17 years Mean readability level of 15-16 years Those with reading age of 12-14 years or less (31%) would have problems understanding most of the leaflets Some of those aged >14 years would have difficulty reading the leaflets

21. Would you like to know more about Hepatitis C? 11 years or less12 – 14 years> 14 years Total Know enough, don’t want to know any more 3 (25%) 10 (29%)42 (40%) 55 (37%) Know quite a lot, but would like to know a bit more 2 (17%) 5 (15%)23 (22%) 30 (20%) Know a little bit, would like to know a lot more 6 (50%) 18 (53%)36 (35%) 60 (40%) Don’t know anything 1 (8%) 1 (3%) 3 (3%) 5 (3%)

22. Leaflet assessment Leaflet Reading Age L1 14-15 L2 13-14 L3 13-14 L4 14-15 L5 13-14 L6 17-18 L7 13-14 L8 15-16 L9 17-18 L10 17-18 Aim is for readability of 10 or under

23. Preferred source of information 11 years 12 – 14 >14 years or less years Verbal 11 (92%) 29 (85%) 71 (68%) Leaflets/posters 1 (8%) 1 (3%) 23 (22%) TV/DVD/Web 0 3 (9%) 7 (7%)

24. Conclusion At least average reading age Risk behaviours continue despite widespread knowledge of injecting transmission factors At least one third would have difficulty reading current literature Only 19% of those who had read a leaflet found it helpful; only 18% of those with reading age of >14 found it helpful Only 23% had read a poster Preferred source of information was verbal communication for all reading groups 60% wanted to know more about HCV; 57% of >14 group Implications for staff training