Health literacy is demonstrated when individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions. Veteran health literacy is believed to be lower than the general population due to the aging and culturally diverse population. Veterans require adequate health literacy to manage their diverse high acuity physical injuries, psychological conditions, and chronic diseases. Clear communication between the clinician and veteran patient is essential to provide high quality health services. The objective of this quality-improvement project was to evaluate the ability of nurses in the ambulatory environment to identify low health literacy patients and to deliver an educational intervention focused on health literacy awareness and communication strategies. A pre-intervention Clear Communications Questionnaire (CCQ), a validated instrument, was delivered to 299 ambulatory nurses with a 20% response rate. The results from this questionnaire informed the development of a 40-minute educational program, multimedia and discussion format, provided to 200 nurses. Following the education program, the post-intervention CCQ was sent to the nurses, with a 30% response rate. Survey Monkey was utilized to collect the CCQ data and Minitab for the statistical analysis, including a pre- and post-intervention data analysis with a t test. While this project was unable to show a significant difference between the pre- and post-intervention CCQ, the individual survey items indicated increased awareness about the importance of health literacy and the ability to locate patient health literacy level in the medical record. Further work needs to be undertaken to assure veteran patients can actively engage in clear communication with clinicians, discern between treatment options, adhere to treatment recommendations, and develop health-seeking behaviors across their lifespans.

Plain language is defined in a variety of ways, but is generally understood to refer to language and design strategies that make texts easier for target audiences to understand and use. Research has helped demonstrate that plain language strategies work, not only to improve reader comprehension, but also to save individuals and organizations time and money. Most plain language research focuses on the outcomes of plain language texts; however, there are a variety of complex processes that happen behind the scenes as these texts are produced. To better understand the complexity of plain language work and the challenges of producing these texts, this dissertation studies plain language using rhetorical and sociolinguistic theories. This framework allows us to see how plain language produces meaning within complex social and cultural contexts. Using the rhetorical triangle as an organizing framework, this dissertation proposes three models of research for studying plain language, each emphasizing a different part of the triangle: readers, writers, and texts.

Obesity is one of the most pressing global population health issues, and importantly one that affects racial/ethnic minorities and those of low socioeconomic status disproportionately. Obesity tracks from childhood into adulthood and is related to serious medical and economic consequences throughout the life course. Childhood obesity is well recognized as a complex and multifaceted problem influenced by broader social, geographic and environmental factors. A social ecological framework that is transdisciplinary is needed to address individual-level influences and choices that lead to energy imbalance, but also to address the complex interactions among home and neighborhood environmental features that provide the context for health-related behavior change. The overall goal of this dissertation is to investigate multilevel factors that could influence outcomes of an intervention program aimed at addressing childhood obesity. Including studies that investigated the use of clear communication strategies to facilitate parents comprehension, home media environment related to change in children weight status and the neighborhood environmental context of families. This dissertation draws upon a social ecological model that acknowledges multiple levels of human interaction with the environment and represents a comprehensive approach to designing, implementing and evaluating interventions that which target multiple influences on health behaviors. The iChoose is a 3-month family-based childhood obesity treatment program developed under a community-based participatory research approach led by the Partnering for Obesity Planning and Sustainability (POPS) Community Advisory Board (CAB). The studies within this dissertation use clear communication evaluation and qualitative feedback from focus groups, intervention outcome data and home environmental surveys, as well as environmental audits of neighborhoods. To investigate multilevel factors could influence intervention outcomes, we used both multiple statistical analytical techniques and a Geographic Information System (GIS) spatial analysis to evaluate the iChoose program. / Ph. D.

The United States dedicates greater than 17% of its gross national product to healthcare. This percentage is expected to go up to 20% by 2018. Despite the high cost of care, the health care system remains inefficient and ineffective. Barriers include reduced access to care related to low health literacy. Complicating low health literacy is the high readability score of patient education materials. The high readability score is in part due to tools that are not standardized and measure different aspects of education materials creating varying readability scores. The purpose of this quality improvement project was to adopt a tool, the Clear Communication Index, which is evidence-based and standardized using the federal Plain Language Guidelines, to assess the reading score of educational materials in a 62-bed acute long-term care facility. The plan, do, study, and act model was used as a translational framework to guide this project, and the theory of goal attainment served as the theoretical support for the project. The Clear Communication Index worksheet was used to assess the readability of documents given to patients at discharge. Any score below 90% was considered difficult to understand and required revision. One month after implementation, patient satisfaction scores on 2 metrics showed improvement. The score for 'When I left the hospital, I clearly understood the purpose for taking each of my medications?' increased from 58.2% to 90.7%. The 2nd patient satisfaction survey metric, 'During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?,' increased from 73.1% to 83.3%. The results may promote social change by providing equal care access to all through readable educational materials.