Creating Educational Materials for Patients with Low Literacy Levels

Rehabilitation

Carol Page, PT, DPT, CHT
Department of Rehabilitation
Hospital for Special Surgery

  1. The Issue
  2. Who Is Affected?
  3. Patient Education Materials
  4. Recognizing Literacy Problems
  5. Tips for Recognizing Literacy Problems
  6. Possible Signs of Low Literacy and Illiteracy
  7. Tips for Creating Easy-to-Read Materials
  8. Determining Readability of Education Materials
  9. Examples
  10. Conclusion

The Issue

When educational materials are too complex, patients fail to understand what is being asked of them. Worse, their safety may be placed at risk, according to a recently released policy paper from The Joint Commission.{26} Some health care providers may not be aware of the extent of low literacy levels.

The 2003 National Assessment of Adult Literacy {1} determined that 30 million adult Americans (14%) lack the skills to perform simple, everyday literacy activities. An additional 63 million lack literacy skills beyond the basic level. These 93 million adults are able to read and understand only short, simple prose texts and documents, at best. Average prose and document literacy has not improved since the 1992 survey. The gap between literacy levels and the readability of patient education materials is a critical healthcare issue.

Who Is Affected?

Individuals with low literacy are found throughout all segments of the population. Some groups particularly at risk are the elderly, individuals with low socioeconomic status, and adults without a high school degree or GED.{1,4,26} Even health care providers not routinely working with at-risk groups are likely to encounter patients with low literacy.{10,17}

Patient Education Materials

Most adults read between the 8th and 9th grade level.{17} Those at the lowest literacy level read at the 5th grade level or lower.{17} Because most health care materials are written at the 10th grade level or higher,{9,10} a mismatch occurs.

People of all levels of education and literacy have been shown to prefer materials that are easy to read.{9,10} Patients of higher literacy levels do not appear to be offended by simply written health care information.

Recognizing Literacy Problems

This widespread problem is difficult to recognize. Most people with low literacy experience feelings of shame. Therefore, they may learn to hide their difficulties with reading, even from their spouses.{2,20}

Tips for Recognizing Literacy Problems

  • Increase your awareness of the issue.
  • Don’t assume level of literacy based on appearance, intelligence, socioeconomic status, race, ethnicity, or age.
  • Take grade completed in school into consideration, but realize that it is usually 2 to 5 years higher than literacy level on objective testing.{27}
  • Consider using screening tests, for example:
    -Wide Range Achievement Test (WRAT)
    -Test of Functional Health Literacy in Adults (TOFHLA)
    -Rapid Estimate of Adult Learning in Medicine (REALM)

Possible Signs of Low Literacy and Illiteracy

  • Poor compliance with treatments and appointments
  • Watching and mimicking others
  • Not knowing the names of regularly used medications
  • Making excuses for not reading, e.g., forgetting glasses, etc.
  • Bringing someone who can read to appointments
  • Vocalization or subvocalization when reading
  • Confusion or frustration when reading.

Tips for Creating Easy-to-Read Materials

Content

  • Define your purpose
  • Limit content to the key information
  • Emphasize specific actions the patient should take

Linguistics

  • Choose simple, familiar words
  • Use short sentences with simple grammatical structure
  • Use the active voice and present tense
  • Use the pronouns “you” and “your”
  • Make positive statements when possible
  • Use meaningful topic headings

Design

  • Select an easy-to-read type style and size
  • Use uppercase and lowercase letters for headings
  • Use bold type, not italics, for emphasis
  • Use ample white space
  • Include clear visuals

Determining Readability of Educational Materials

Before using patient education materials, check the grade level or “readability”. To be effective for individuals with a wide range of literacy abilities, they should be written at no greater than the 5th or 6th grade level. Commonly used formulas for checking the readability of documents include the Flesch formula, FOG Index, Fry formula, and SMOG.

To learn how to check grade level using word processing software, search the program’s help files using the keyword “readability.” For example, in Microsoft Word go to “tools,” “options,” “spelling & grammar,” and “show readability statistics.” Check the document by highlighting it then selecting “spelling & grammar” on the standard toolbar to display grade level. Once set up, the grade level of a document will be displayed each time you check spelling and word count.

Examples

I analyzed the 53 patient education handouts used at the Hand Therapy Center of the Hospital for Special Surgery Rehabilitation Department. The handouts were written at the 5th grade leel on average.  However, difficulty ranged as high as the 9th grade level, too high for comprehension by patients with low literacy levels.

As an example for the staff, I rewrote the most complex handout from the 9th to the 5th grade level. I accomplished this by using simpler words and shorter phrases. See the following links to view both versions of the handout:

Handout at 5th grade level (pdf)
Handout at 9th grade level (pdf)

Also see the poster in the right hand column at the top of the page.

Conclusion

Educational materials should be written at no greater than the 5th or 6th grade level, since low literacy is found throughout all segments of the U.S. population. Once aware of the literacy issue, health care providers can easily create more effective patient education materials.

Simple strategies include performing computerized assessment of the readability of all patient education materials, and using short sentences with short, familiar words to create easy-to-read materials.

 

References

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2. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329-334.

3. Bastable SB. Literacy in the adult patient population. In: Bastable SB, ed. Nurse as Educator. Sudbury, Mass: Jones and Bartlett Publishers; 2003:189-231.

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15. Gunning R. The Technique of Clear Writing. New York, McGraw-Hill, 1974.

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21. Parker RM, Baker DW, Williams MV, Nurss JR. Functional health literacy of patients at two public hospitals. J Gen Intern Med. 1994;9:106.

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25. Weiss BD, Coyne C. Communicating with patients who cannot read. N Engl J Med. 1997;337:272-274.

26. What did the doctor say? Improving health literacy to protect patient safety. The Joint Commission. 2007;1-60.

27. Winslow EH. Patient education materials: can patients read them, or are they ending up in the trash? Am J Nurs. 2001;101:33-38.