Communication Strategies — Literacy Issues in Patient Care

November-December 2002


Ms. Weiss is a Santa Monica, CA–based health care consultant and speaker.

As many as one in three American adults has trouble understanding health care information. Of these, about half read at or below the fifth grade level.

"This translates into patients who can't read instructions on a prescription bottle, don't know what informed consent documents mean, can't adhere to self-care regimens for chronic diseases, miss follow-up appointments, and fail to properly prepare for medical tests and procedures," explains Gloria Gilbert Mayer, RN, EdD, president of the Institute for Healthcare Advancement in Whittier, CA.

Despite this fact, health care communications continue to puzzle their intended audience. Consider Mayer's example from a booklet describing the stomach flu to pregnant mothers: "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 baby."

As measured by the Flesch-Kincaid readability test, the above paragraph is at an 11.2 grade reading level. This information is complicated to most people who are not health care professionals, and it is completely foreign to someone with low literacy skills. An easy-to-read translation could be: "The stomach flu can last up to three days. Drink eight glasses of water or juice a day and your baby should be OK. This is true even if you can't keep food down."

Using the same readability test, the above paragraph is written at a 4.3 grade level. For the most part, however, health care communicators routinely write information at a seventh to ninth grade level, or even higher.

"For patients with low literacy skills, the instructions on a prescription bottle or the advice in a simple brochure can be extremely confusing," says Mayer. "Many patients can't read the information we give them, and they work hard to hide this fact. And as providers give patients more control of their care, we expect them to digest much more technical and clinical information."

Simply getting information into patients' hands is only half the battle. What's critical is ensuring that the information accomplishes what it's designed to help patients achieve.

Low literacy is harmful to one's health and expensive to society. "It is estimated that low literacy costs the health care industry $73 billion from longer hospital stays or rehospitalizations," adds Mayer. "People with limited reading ability suffer from poorer health status because they don't understand their illness, chronic disease, treatment, or the health care system in general. Can you imagine a low literacy person reading and understanding his or her health plan documents?"

What can we do? Mayer suggests tailoring educational materials to the populations served — real people with real health problems who may simply have trouble reading. Here are the eight steps they suggest to accomplish this goal:

1. Produce communications at the third to fifth grade reading level. Begin by profiling the target audience by age, sex, marital status, occupation, income, religion, ethnicity, language group, and experience. Determine their needs. "You are writing for these individuals and not to impress your colleagues, supervisor, or executives," warns Mayer. "Make sure you understand your audience and the subject matter." What are the key cultural health beliefs of the target audience? How are specific illnesses traditionally treated? Is the concept of preventing illness understandable within the cultural context? What about the significant family structures and values that affect health care? What customs and values affect their approach to health issues such as pregnancy, terminal illness, and death? Should the family be included in the session or just the patient and health care provider?

2. Talk to your audience before writing copy. Understand what they know and believe about the topic, rumors, or misinformation and the types of questions they have. Obtain this information through interviews and group sessions that offer topics and questions in advance and include individuals who share common age, sex, and socioeconomic status. "People are more relaxed among others with similar backgrounds," says Mayer. The facilitator should speak the language of the participants and have a thorough understanding of the issues presented.

3. Once you know the audience and what you want to communicate, determine how to say it. Mayer suggests using simple language, short words and sentences, an active rather than a passive voice, a 14- to 16-point typeface, plenty of white space in the layout, and language at the fifth grade level or lower. "Arrange information logically and effectively in a user-friendly fashion by prioritizing and repeating the most important points and including question-and-answer sections," she states.

4. Use line drawings, photographs, cartoons, and other art. Present one message per illustration and avoid charts and graphs. "Use appropriate colors for the culture because certain colors may have different connotations," advises Mayer. "And beware of humor — not all cultures perceive the same things as funny."

5. Pre-test your materials. Ask a focus group of the intended audience if the text and artwork are understandable and acceptable.

6. Ensure that your staff understands the information and is trained to use it effectively — before distributing the materials. "All staff must know why and how the materials have been prepared and how their use will make their jobs easier," says Mayer.

7. Explain each page of the materials to patients. Although mailing, handing out, or e-mailing the material is better than doing nothing, the more time you can take explaining the information to patients personally, the better the chance of them using it. "There is a lot of shame among patients who have trouble reading. They will not tell you they can't understand what you are giving them," says Mayer. "You may not be able to ask them about their reading ability because of embarrassment and trust issues. Therefore, the best patient approach is to have easy-to-read and easy-to-understand materials that you can review with them in a private place, leaving time for the patient to ask questions."

8. Verify the message has been received. Interview patients to determine their understanding, use, and recall of the materials as well as the actions taken to improve their health and wellness.

Developing, producing, and distributing patient education materials to a low literacy level population require a great deal of time and energy. Health care materials don't have to be complex, elaborate, or high-tech to achieve favorable outcomes. By paying careful attention to your patients' needs and by choosing words they can understand, your organization's communications efforts will see positive results.

Ms. Weiss is a Santa Monica, CA-based health care consultant and speaker. She can be reached at 310-393-5183.


Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Communication Strategies - Literacy Issues in Patient Care

Copyright © 2002 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.