1. People who have problems reading and writing;
2. People who cannot follow simple directives, who do not understand oral and written information;

1. People with limited knowledge about their body, who lack insight into their health;
2. Patients who have difficulties understanding health informaiton such as side effects, why he or she needs to take this medication. They have problems with compliance.
3. People who are not medically aware of their needs, who do not know what is best for them. They cannot make decisions or solve problems regarding their health. They take a less active rple in their care than other patients.

1. Patients who will not read in front of a nurse, who will say they understand everything, who will say they will read it at home. They are very good at hiding the fact that they cannot read. They will use different excuses such as "I forgot my glasses";
2. Disadvantaged or poor patients, older patients, paatients who smoke and have bad health habits - patients who live in poor neighbourhoods;
3. Patients who are non-talkiative and very shy, or in some cases, who talk all the time and reveal inappropriate personal details.

1. Stick to the most crucial, minimal ("life and death") information. Repeat key points to patients (up to three times). Give only the most important information to avoid overload.
2. Explain clearly, one step at a time. Follow a more structured pattern to give the information (steps 1,2, 3…).
3. Say it in themost simle way possible, adapt the level of language.
4. Use key words, ex., cereal, dodos, and use very precise guidelines, for example a feeding schedule. Give practical information, for example where to find baby cereal in the supermarket.
5. Ask patients questions to check if he/she has understood key points. This can also be done by phone or during another home visit. Make the patient repeat it back.
6. Ask often if patient has understood, ask if patient has any questions.

The answers, while often referring to a specific unit, can be grouped into three categories:

Need for specific information

1. For Dialysis: more complete information (and better documentation) for patients to make an informed choice e.g. between peritoneal dialysis and hemodialysis;
2. For all Dialysis patients to attend the pre-dialysis clinic or a complete teaching session;
3. For Oncology Hematology patients: need to know why the treatment is done, about the side effects, how to take the anti-nausea medication, when they need to call for emergencies and what to do if they have a fever;
4. For Pre-op patients: need advice and information to find their way in the hospital; Pre-op staff take a lot of time to explain how to get to other parts of hospital;
5. For CLSC clients: education on common health problems, contraception and vaccines.
6. For CLSC clients who are immigrants or refugees: information on how the Canadian health system works. For example, as one informant explained, it can be difficult for these clients to understand that someone will call later to make an appointment, or that a card might be sent with the appointment information. It can make them very insecure. Some clients cannot understand a message left in English or French. They prefer to be given an appointment while they are at the CLSC.

Need for better adapted teaching material and hand-outs for patients

1. For Dialysis: better and easier material on peritoneal dialysis; visual material, ex. renal nutrition educational tool; need for simpler information using pictograms; need for information using colour codes, e.g. calendar with colour on days of medication;
2. Material translated in the languages of patients and caregivers;
3. Material in plain language;
4. Pre-op Centre: updated written material. Documents given to patients must be redone, corrected, updated, written in plain language, etc. This was an urgent need identified by the three nurses.

Need for a better, more thorough teaching process

1. More repetition, more follow-up, more validation that the information has been understood; need for the nurse to call up a few days after the treatment (for Oncology Hematology patients) to check that all is well and that patient has understood key points;
2. For Dialysis and Oncology Hematology: a nurse to follow the same patient to have continuity and better follow-up;
3. A family member to be involved in the teaching process; this is crucial for hard-to-reach patients who do not read and who face language barriers. It will also help patients in general since the family member can assist with the patient's care;
4. For Oncology Hematology : teaching to be done on different days and for teaching to be done in small doses, not all at once. Currently, patients receive the teaching during the first treatment when they are super-anxious and overwhelmed with information. One nurse said that probably 75% of the information does not get through to patients.

For one informant, the heart of this issue is that health care professionals take for granted that patients have understood the health information. Nurses and others must drop this assumption and take the time needed for validation.

Health care professionals were divided on this issue:

1. 2 of these informants did not answer.
2. Some informants gave specific examples of complicated information (a hand-out given to Dialysis patients for a 24-hour urine collection); some said they try to make it simple but the result is not always appropriate.

¹5 (33%) said "some do, some don't".

1. 1 did not answer.
2. Interviewees are aware that some hard-to-reach patients do not understand the health information given to them, either in writing or orally.

1. 2 did not answer.
2. One informant said that half the patients are very conscious of their health and do everything by the book. Many patients will do what they are told by someone in a position of power. The other half do not care about their health but will do the strict minimum.

1. 3 did not answer.
2. One informant explained that most people do not change: if they were engaged in their health before becoming ill, they are after (having cancer, being operated, coming to the hospital for their treatment) and if they were passive about their health before, they will be after.
3. Some informants believe that most patients want to make healthy changes to their lifestyle. Receiving health information and education can begin a process of patient education and involvement.
4. Many informants answered that this is the goal, what they are trying to achieve with patients.
5. One social worker commented that having choices is valued in our culture, but in other cultures, it creates insecurity and fear.

1. Need to have written material in Italian, Greek, Cree, Spanish, etc. on basic information and what to do in an emergency.
2. It is impossible to translate everything and the list of languages is long. Is it worthwhile and feasible to translate documents into Chinese, for example? We need to consider all the aspects, including cost.
3. Better cross-cultural knowledge
4. Need simpler material, better designed, well presented, colourful, pamphlets in plain language with large font. Pamphlets from pharmaceutical companies are useful but not always in plain language.
5. Need for specific written information tools to give to Dialysis patients, e.g. "How to take care of your fistula", "How to take care of your catheter", better document "Urine collection 24 hours"

The majority of informants (9 or 60%) indicated that they would like to have more time to assess the literacy and comprehension level of patients and to teach hard-to-reach patients (including time for validation). Some informants said they already simply take the necessary time. A nurse said that an important principle was that health care workers cannot predetermine the time needed to teach a patient since you have to know the patient's needs to do this.

A few health care professionals would like more quiet space allocated to teaching. Currently, the lack of space and intimacy often distracts patients from learning. Also, nurses need time to meet among themselves and maximise the quality of teaching. There is a need for uniform teaching by all nurses who educate patients.

11 (73%) (2D, 3O, 3P, 3 from the CLSC) said they need posters for teaching. These posters can be very effective and everyone can understand them. Patients will remember them better if they include a comic element.

10 (66%) (2D, 3O, 3P, 2 from the CLSC) said they need videos for teaching. According to informants, videos can be very useful for a cross-section of people. Health care workers need videos to lend to patients who can watch them at home with their family. Nurses can follow up with questions & answers the next visit. Because of the time and cost of producing videos, it would be helpful to find good videos from other hospitals and health centres. Specific content themes were mentioned: heart video, orthopedic video, chest tube video, video on pain management, video on taking care of incisions, video on birth and breast feeding, video on cholesterol, video on the Canadian nutrition guide, video on diabetes.

5 (33%) (3O, 2P) said they need audio tapes for teaching so patients could listen and then ask questions.

Dialysis staff talked about the need for making better use of the TV system (each hemodialysis patient has his or her own TV monitor). Patients could learn about different aspects of dialysis from an in-service channel while they are being treated. This could be highly effective because there is a captive audience. One informant concluded that the ideal would be to pick and choose among a variety of teaching tools and materials what is most appropriate for a particular patient.

In terms of process, hard-to-reach patients should be screened by nurses and put on the priority list to see the pharmacist. This would avoid having them miss their meeting and not seeing the pharmacist. It can be difficult for the pharmacist to give the key information to a hard-to-reach patient over the phone. And it could be a life or death issue, e.g. telling them about the need to stop aspirin 7 days before the operation but continue the cardiac medication.

Interviewees identified the need to allocate:

1. More human resources: more nurses cold mean more time to assess and teach hard-to-reach patients.
2. More financial resources: budgets for teaching tools, translation into other languages, rewriting documents into plain language, training health care workers, buying videos and visual material.
3. Two interviewees identified the need for a hospital-wide plain language policy.

The staff interviewed at CLSC Côte-des-Neiges said that their CLSC already does a lot for hard-to-reach patients; this CLSC, the largest in Québec, is the provincial leader on the topic of health of ethno-cultural minorities.

9 (60%) (2D, 3P and 4 CLSC) said they use computers in their work as health educators, but some said they do not like the Internet. 6 (40%) (2D, 3O, 1P) said they do not.