Health literacy means different things to different people. Some people equate health literacy with the ability to read. Their assumption is that if one can read, one can understand health information. However, this assumption is not necessarily valid. Neither a high school education nor advanced reading skills guarantee that a person will understand health information (Nielsen-Bohlman, Panzer, & Kindig 2004). For example, the term “myocardial infarction” may not be understood by a person who has had a college education but who lacks knowledge of healthcare terms. However, a person who has difficulty reading may understand this term if a friend or family member has had a heart attack and the term was used during that experience.

...it is important to write in a manner that everyone can understand – the simpler and more straightforward, the better. Health literacy has many definitions. Healthy People 2010 has defined health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (Ratzan & Parker, 2000). A key point in this definition is the behavioral component associated with health literacy. Not only do people have to be able to understand the words, but they have to be able to critically assess the information and take appropriate action. Therefore it is important to write in a manner that everyone can understand – the simpler and more straightforward, the better. Written documents must be easy to read, simple to understand, and lead to appropriate action.

More than half the adults in the United States (US) may have difficulty understanding health information. As many as 90 million people in this country read at less than a fifth grade level (Kirsch, Jungeblut, Jenkins, & Kolstad, 2003), and 36% have only basic or below basic health literacy skills (Kutner, Greenberg, Jin, & Paulsen, 2006). Low health literacy in the US costs the healthcare system anywhere from $106 to $236 billion dollars a year (Vernon et al., 2007). Those with poor literacy skills have trouble navigating the healthcare system; obtaining, understanding, and using their health insurance plans appropriately; reading, understanding, and acting correctly on medical instructions; taking their medications as prescribed; and actively participating in their healthcare decisions (Rudd, Kirsch, & Yamamoto, 2004). Hence, those with poor literacy skills are not receiving quality healthcare and typically overuse high-cost healthcare venues, such as emergency rooms and hospitals. They are also frequently rehospitalized for failure to correctly follow discharge and after-care instructions (Villaire & Mayer, 2007). Solving the health literacy problem is key to avoiding this economic waste.

In this article we will provide readers with tips and tools to ensure that the written health education materials they are distributing are written and designed at a level that allows the recipient to read and comprehend them. We will describe how to write and design printed patient education materials to make them more understandable and usable. First we will provide a review of reading tests to determine grade level and design appropriateness. Then we will offer a comprehensive guide for writing patient education materials, including tips, such as use short sentences and active voice and avoid jargon, and present design considerations, including appropriate use of illustrations. Finally, we will discuss the need for continuous evaluation of written materials.

Readability Tests

It behooves all health professionals to understand the nature and scope of health literacy issues. One issue is that of the grade level of health-teaching materials. Creating and using printed material that is written at a reading level no higher than a 3^rd to 5^th grade level is essential. However, most patient educational materials and instructions currently are written at an 8^th -12^th grade reading level (Nielsen-Bohlman et al., 2004). Although some patients and/or their family members may understand these written materials, the majority of patients will not be able to do so. Furthermore, even those who are able to understand the higher level materials will not be upset with materials written at a lower grade level, and they may even prefer such materials. Several tests are available to judge the grade level of a written document.

One such test is the Flesch-Kincaid Reading Ease test. The Flesch-Kincaid test actually comprises two tests: the Flesch-Kincaid Reading Ease test and the Flesch-Kincaid Grade Level Formula. The Reading Ease test scores text on a scale of 0 – 100. The higher the score, the easier the text is to read. For text to be considered as being at an eight-grade reading level, it must score 60 or higher on the test. The Flesch-Kincaid Grade Level Formula translates the Reading Ease test into a U.S. grade level. The Flesch-Kincaid Grade Level test can be automatically calculated using the Microsoft Word software toolbar and may be available in your version of Microsoft word. If not, an open source application to download at no cost is also available (Flesh, 2007). Although the test has been validated (Kincaid, Fishburne, Rogers, & Chissom, 1975), there is some controversy about the computerized version. The original formula scores up to grade level 16 or 17, while the Microsoft version only reports scores up to grade 12. Because of this discrepancy, this function should only be used as a rough guide, not as a final score (Doak & Doak, 2004). The McLaughlin Simplified Measure of Gobbledygook (SMOG) readability formula (McGraw, n.d.; McLaughlin, 1969) is a quick, consistent, easy-to-use tool which allows one to approximate the readability levels of written materials. However, it may yield scores one to two grades higher than the actual grade reading level (Friedman & Hoffman-Goetz, 2006).

The Fry Formula (Fry, 1968; Fusaro, 1988; Schrock, 1995) is very popular and considered extremely accurate. Although this tool may be a little tedious to use, it can be completed while sitting at a desk with no additional equipment needed. The Fry Formula involves counting words, sentences, and syllables; performing simple calculations; and graphing results on a grid.

The Suitability Assessment of Materials (SAM) tool was created by Cecilia and Leonard Doak. This test assesses not only the readability of the material but also the usability and suitability for a low literate user (Doak et al., 1996). Using a standardized scoring sheet, the SAM test allows the evaluator to score printed materials in the following six categories:

• Is the purpose of the piece immediately evident? Does it deal in specific terms with behavior? Is the scope limited, and a summary or review included?
• Literacy demand. Is the reading grade level appropriate? Does the writer use an active style and voice? Is the vocabulary simple and clear, without jargon? Is context for the information provided? Are learning aids or organizers, such as headers, provided?
• Graphics. Do graphics match the purpose of the piece? Are they simple and straightforward without distracting elements? Are tables/charts/lists explained? Are they useful and easy to use?
• Layout and typography. Does the layout promote navigation and understanding? Does it follow graphic standards for enhancing comprehension?
• Learning stimulation. Are desired behaviors modeled? Are there interactive components? Is motivation provided?
• Cultural appropriateness. Is there a good cultural match between the logic, language, and experience of the printed piece and the intended audience? Are the images and examples culturally appropriate?

After completing the assessment a percentage score falls into one of three categories: superior, adequate, or not suitable.

All these tests are readily available in the literature and can be used to assess the appropriateness of reading material. However, these tests are typically used on existing printed material. When creating one’s own material, or when choosing existing printed material to use in one’s setting, it is important to ask the right questions. Below are the questions we like to ask before preparing/selecting materials:

• What role will the printed piece play in the overall communication plan? Written material is not enough to educate patients and families about their health and plan of care.
• How will the information be utilized?
• Will there be follow up on the initial education?
• Who is the target audience?
• Who will review the information and how will it be distributed?
• Is there a budget for the materials and educational process?
• How much time is available to get the materials ready and tested?
• Once the material is distributed, how will it be tested and evaluated?
• Who will do the evaluation and who will review and update the materials if needed?

These are important questions to answer to assure that your health education materials will be effective.

Writing the Materials

Although some written education materials are suitable for everyone, in many instances materials offered are not appropriate for the given audience. Such materials may fail to limit the number of objectives, use common words, give examples of medical terms that are used, use the active voice, use short words/sentences, use appropriate illustrations and/or uses appropriate designs. In the following sections, we’ll provide steps to use while planning and writing the materials that will help to ensure that your documents meet the needs of the intended recipients.

Define the audience

...the trend in health literacy is to use Universal Precautions...one is encouraged to plan all materials at a low reading level. Including a planning phrase in preparing educational materials is essential. During the planning phase, the audience age, gender, and cultural background need to be identified. It is important not to assume the health literacy level of the audience. Rather the trend in health literacy is to use Universal Precautions. When using Universal Precautions for infection control, healthcare providers do not use infection control practices, such as hand washing and gloves, only when caring for HIV patients; rather they use these precautions when caring for all patients. In terms of health literacy, Universal Precautions means to assume each patient has a low level of health literacy and “err on the side of caution in making clear communications and plain language standard practice in all patient encounters” (The Joint Commission, 2007). Because using easy-to-read material is generally preferred, one is encouraged to plan all materials at a low reading level. Seldom do people complain that the material they have been given is “too easy to read and use” (Davis et al., 1994). You will also want to consider in your planning phrase the illustrations or graphics you will want to use. This will enable you to develop your materials in such a way that your graphics support your text.

Limit objectives

...focus on the “need to do” rather than on the “nice to know.” Behavioral objectives are most effective when they are few in number and when the needed action is clearly stated. Limit the objectives of the message to two or three important points (Sanner, 2003). It is better to have two or three targeted brochures that are understandable than to have one brochure that tries to address all aspects of a given condition and is ignored because it results in information overload for the patient. In planning the content it is important to think through what the patient should be able to do after reading the educational piece. A brochure should focus on the most important activity the patient needs to perform, rather than provide details about the nature and etiology of a particular condition. In other words, focus on the “need to do” rather than on the “nice to know.” Secondary information about the pathophysiology and causes of the disease is not as important as the action(s) to take to control the disease. This secondary information should not be included in the primary brochure that describes specific actions to take. Assume that the patient does not possess any previous knowledge. If you are teaching a patient about taking medication for high blood pressure, it is important that the patient understands how to take the medication. For example, if the medication is to be taken every day at a certain time, even if the patient feels fine, then this is what needs to be stressed. Guidelines describing what to do it the patient forgets to take a dose (e.g. should they take two the next day or call their provider?) should also be explained clearly.

Use common words that are carefully selected

Healthcare professionals need to be able to translate medical jargon into understandable, everyday language... People often have difficulty understanding healthcare information even when common, known terms are used; but when medical jargon is used, even people who may read well may have difficulty understanding the directions. For example, a patient may have difficulty understanding what it means to “take with food.” Does this mean that they should put the pill in some food and take it that way rather than with water?Jargon is terminology that everyone in a particular profession understands, but which may not be understood by those outside of the profession. Medical jargon is a code that facilitates a more streamlined communication between people within the profession. The advantage of using medical jargon is that it is a shorthand language with standardized definitions that facilitates communication.

People outside of the profession, however, are at a disadvantage when they are not familiar with this medical code terminology. If patients do not understand what they have been told or the meaning of a written word, they cannot follow the action suggested. This may result in the patient and/or family feeling stupid and being too embarrassed to ask for further explanation. If the patient/family caregiver does not understand the healthcare information provided, a barrier and distance may be established between the patient/family and the healthcare professional. Healthcare professionals need to be able to translate medical jargon into understandable, everyday language for the sake of quality healthcare. Table 1 demonstrates some typical medical jargon words that patients may not understand, along with their common translation.

Table 1. Medical Jargon and Simpler Alternatives.

Word choice is also important in creating material. In one study involving senior citizens, it was found that people responded negatively to the phase ‘exercise’ but were very positive about the term ‘physical activity’ (Sanner, 2003). You may wish to utilize a focus group that represents the target audience of your educational material when developing materials so you can ask them about different word choices you are considering. Doing so will help you to identify either positive or negative connotations patients may have regarding these words under consideration.

Give examples of medical terms

Use medical terms only if a substitute phrase is either not available, or is more difficult to understand than the term itself, or if the patient will understand the word because of previous experiences. Sometimes words that are ‘simple’ to the provider are not clear to the patient. One term that may require an explanation is the term ‘pregnancy.’ It may be necessary to explain this term to the patient so she understands that the term refers to a woman who is going to have a baby. Likewise a patient may need help to understand the term ‘cholesterol.’ A pamphlet encouraging patients to eat a low-fat diet probably cannot avoid using the word cholesterol. If the pamphlet explains that cholesterol is a type of fat that is produced by the body and that is also found in animal products, the patient may understand what the term means. However, the best way to teach about a low-cholesterol diet would be to provide a list of foods that are high in cholesterol and hence should be avoided, along with a list of foods that are low in cholesterol.

Another word that, when used in a medical context, may not be clear, or may have the opposite meaning from what is common in regular conversation is the word ‘negative.’ When we speak casually to one another, the word ‘negative’ has a bad connotation, e.g., it may mean “She is a negative person.” However, in a clinical context the comment, “Your test results came back negative,” has a positive connotation. Not all patients will understand this. Similarly, a word such as ‘benign’ is not universally understood and may also have a negative connotation. Hence, a statement such as, “Your tumor is benign,” may be taken as bad news.

Use active voice

Content written in the active voice, i.e., content in which the subject of the sentence is the doer, is much easier to read. (Doak et al., 1996). A sentence utilizing the active voice very clearly states what behavior the person is expected to perform. A passive voice typically has the verb “to be.” Examples of both active and passive sentences are included in Table2.

Table 2. Examples of Active and Passive Voice. (Mayer & Villaire, 2007)

Use short words and sentences

The more syllables there are in a word, the more difficult it is for people to understand. In addition to the use of active voice, the use of short words and short, conversational-style sentences are generally recommended. For example, the word ‘doctor’ is easier to grasp than the word ‘physician.’ Short words tend to be easily understood and are preferred in easy-to-read material (Doak et al., 1996). The more syllables there are in a word, the more difficult it is for people to understand. That is why the word ‘shots’ is typically more widely understood than the word ‘immunization.’

However, an exception to this advice to use short words involves the use of anatomical words. Although there are some short words that describe parts of our anatomy, a longer description of an anatomical part may be easier to understand. For example, the word ‘quadriceps’ may be unfamiliar to many people; describing that part of the body as ‘the large muscles on the front of your thighs’ may be easier for patients to read and understand. In summary, use short words, unless the short word is more difficult to understand.

Just as short words are typically easier to understand than long words, shorter sentences are easier to understand than those containing more words (Osborne, 2005). Shorter sentences are better for communicating complex information than long ones because they present the information in smaller, easier-to-digest chunks. Poor readers tend to lose the point of the sentence if it goes on too long, or if many clauses and commas are used. Sentences of 15 words or fewer are acceptable, but sentences of fewer than 10 words are even better.

Again, however, sentence length should not take precedence over conversational style. Although short sentences are easier to read, do not let a focus on keeping sentences short lead to “choppy” writing (Mayer & Villaire, 2007). This means that if it is more natural to express an idea in a longer sentence, do so. In such cases, using examples and explanations can make the ideas contained in the longer sentence easier to understand.

Use appropriate illustrations

Illustrations are used to support, enhance, and explain the written word. They present key messages visually so the reader/viewer can grasp the key ideas from the illustrations alone. Illustrations do not have to be expensive or complex to achieve their purpose. Patients may decide to read a pamphlet based on the cover’s design. A superior cover is friendly, attracts attention, and clearly portrays the purpose of the material inside. When planning your illustrations, it is important to avoid clutter and to keep the illustration simple and meaningful. Simple drawings in black and white or color can promote the topic more effectively if there are no distracting details. In contrast to illustrations, photographs may include too many items that are irrelevant to the topic. If photographs are used, make sure they do not contain superfluous information or too many details. Be sure to identify the purpose of the illustration or photograph and to keep that purpose in mind when taking the photograph or securing a line drawing.

...photographs may include too many items that are irrelevant to the topic. Illustrations are useful when showing elements of a whole. For instance, an illustration of the organs or bones in the body is useful because one cannot see these body parts for oneself. Think of the adage “A picture is worth a thousand words.” Often a simple illustration that shows at a glance what you want the reader to grasp can replace three, or four, or five sentences of explanation. If you are teaching how to give an insulin injection, a simple line drawing can illustrate how to hold the syringe and the position of the hands and body when the injection is given.

Abstract concepts should never be used in illustrations as they tend to be confusing. For instance, when teaching an abstract concept, such as the concept that blood is used to deliver nutrients to parts of the body via blood vessels, one might be tempted to use a highway, truck, and load as an illustration (metaphor) for blood vessels, blood, and nutrients. However, the meaning of the metaphor, if taken literally, may confuse the recipient. Always ask yourself the question, “Does this drawing show exactly what was just written? Does it support the written content, clarify it, and/or make the content more clear?” If you can answer yes to each of these questions, then the drawing will most likely be helpful.

Design the material to make it easy to read

Overall visual appeal of the written materials is important. The appearance of the piece will be enhanced by leaving a considerable amount of white space on the pages. Furthermore, the writing itself should not be too dense. Using 13 or 14 point type size is better than a smaller type size. Serif typefaces, such as Times New Roman, in body text are easier to read than sans serif typefaces, such as Arial. Serifs are the little finishing flourishes on the bottoms and tops of the letters (Mayer & Villaire, 2007; Rudd 2005; Wheildon, 2005).

There are few, if any, instances in which using all upper case letters in a written pieces is advised. Since all words are rectangular in shape, the reading cues provided by word shapes are lost when using all upper case letters. However, judicious use of boldface words, or a cluster of words, is an appropriate way of calling attention to a section. Italics are difficult to read and should be avoided.

Another helpful tip is to use groupings which make it easier to remember the content. Illustrations should be placed close to the written words they are addressing. Headers help to group items together under a common headline, and bullets serve to cluster or “chunk” like information together.

Evaluation

Focus groups...can be a tremendous help when testing the effectiveness of written materials. After completing the written material, it is important to evaluate and revise it based on suggestions from potential readers. Focus groups having representative members of the intended audience can be a tremendous help when testing the effectiveness of written materials. Seeking the advice of certified educators and other professionals is also helpful. Creating health education materials is an ongoing, iterative process. The final written product is never a perfect piece; rather it needs to be evaluated and updated periodically. Feedback from users and other professionals provides information that can be used in revisions and updates to enhance the effectiveness of the written communication.

Summary

How something is written is just as important as what is written. The following passage is written at an 11^th grade level:

Fortunately, gastroenteritis usually has a limited life span. As long as fluid balance is maintained through adequate replacement, even complete lack of solid nourishment for a day or two won’t harm your unborn baby (Mayer & Rushton, 2002).

Here’s the same passage, written at a 4^th grade level:

The stomach flu can last up to 3 days. Try to drink eight glasses of water or juice a day and your baby should be okay. This is true even if you can’t keep food down (Mayer & Rushton, 2002).

Although the content is the same in both of these passages, the readability is markedly easier to understand when the content is written at the 4^th grade level.

This article has provided readers with tips and tools to ensure that the health education materials they are distributing are written and designed at a level that allows the recipient to read and comprehend them. We have reviewed the use of readability tests and given you some caveats on their use. We have discussed how to convey your message effectively by limiting your “need to do” points, using common words, giving examples of medical terms used, and using an active voice along with short words and short sentences. We have also offered tips addressing illustrations and material design and noted the importance of an evaluation process. The items on the Reference List below can provide you with additional information describing best practices in preparing educational materials. Also feel free to contact the authors at the emails listed below if you have additional questions.

Authors

Gloria Mayer, EdD, RN, FAAN
E-mail: gmayer@iha4health.org

Dr. Gloria Mayer is the President and CEO of the Institute for Healthcare Advancement (IHA), a non-profit organization dedicated to empowering people to better health. IHA operates the Friends of Children Health Center (FOC) which is a community-based school clinic and a family resource center. IHA is also a leader in health literacy, producing educational materials aimed at providing those with limited reading skills the health information they can use.

Mayer has extensive publications on a number of clinical and management topics. Her most recent publications include three of the five books in the What To Do For Health series: What to do When You’re Having a Baby, What To Do When Your Child Gets Sick, and What To Do For Teen Health. She is co-author, along with her husband, Thomas Mayer, M.D., of Goldilocks on Management, classic fairy tales revealing contemporary management principles. Her most recent publication is Health Literacy in Primary Care, A Clinician’s Guide. Dr. Mayer is co-author of the forthcoming low literacy self-help health book, What To Do For Heavy Kids, due out in December 2009 by IHA.

Dr. Mayer received her B.S. degree from the University of Miami, an M.S. from the University of Maryland, and her Master’s and Doctorate in Education from Columbia University in New York City.

Michael Villaire, MSLM
E-mail: mvillaire@iha4health.org

Michael Villaire is Director, Programs & Operations, for the Institute for Healthcare Advancement, a nonprofit healthcare foundation dedicated to empowering people to better health. One area of IHA’s emphasis is on health literacy.

His background includes 20 years in various Editor roles in healthcare publishing, including peer-reviewed journals in nursing, hospital publications, physician news magazines, and an online healthcare portal experiment. He has helped redesign and launch several medical and nursing journals, and managed the development of a multimedia, interactive curriculum in critical care.

Michael has produced and led several annual medical symposia, including an annual conference in the complementary/alternative medicine field, and in his current position, IHA’s annual Health Literacy Conference. He has written numerous articles on various aspects of health literacy, and lectures on several topics in health literacy, including designing and printing health education materials for a low literacy audience. He is co-author of the textbook, Health Literacy in Primary Care: A Clinician’s Guide, published in 2007 by Springer Publications and of the forthcoming low literacy self-help health book, What To Do For Heavy Kids, due out in December 2009 by IHA.

Michael earned a B.A. in English and a B.A. in Communications from Western Michigan University, Kalamazoo, Mich., and a Master of Science degree in Organizational Leadership and Management from the University of La Verne, La Verne, Calif.

© 2009 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2009