Background Document on Literacy and Health

1.5 The focus on plain language

An important and more common response of the medical establishment has been to evaluate the readability of health materials and to recommend the use of plain language. These materials include health pamphlets, booklets, basic medical instructions and self-care information. A large number of articles in American medical journals repeatedly confirm that health education material is written at a level far above average patient reading ability. A typical suggestion is that health education materials be written at three grade levels below the educational level of the target population. Researchers generally recommend that health materials be written at a 5th or 6th grade level.

The use of plain language in written health materials has been promoted as a tool for creating more open lines of communication between patients and the health care system. The National Literacy and Health Program of the Canadian Public Health Association (CPHA) has been a champion of plain language through its publications, conferences, training programs, directories, and by advocating plain language across the country. In 1999, it produced the Directory of Plain Language Health Information that gives guidelines on how to assess materials (the S.M.O.G. Readability Formula or Simple Measure of Gobbledegook) and how to produce plain language materials, and indicates where to find existing appropriate materials. CPHA has also produced, among others, a resource entitled: Creating Plain Language Forms for seniors: A Guide for the Public, Private and Not-for-Profit Sectors. Experience has shown that patients of all reading levels and all socio-economic levels prefer shorter pamphlets written in plain language. The work done by the CPHA appears to be paying off; more and more Canadian health education material is written in plain language. Still, much remains to be done. According to the CPHA, the use of plain language is uneven across Canada, within regions, and even within large health-care centres.

An evaluation model for health materials was developed in the United States: SAM or Suitability Assessment of Materials (Doak, et al., 1996, p.49). SAM lists factors to be rated: consent, literacy demand, graphics, layout and typography, learning stimulation and motivation, cultural appropriateness. For each factor, SAM assigns a numerical score, the weighting of which leads to a rating of superior, adequate or not suitable.

Many organizations, both in Canada and the United States, advocate the use of plain language in the production of health care materials and in the dissemination of public information in general. Studies in the United States and Britain have shown that plain language writing saves money. Many writers offer concrete and useful tips on how to present information, how to design visuals and how to choose appropriate language (for example, Doak, et al., 1996; Mayeaux, 1996).

The consensus is that to be effective, patient education materials should include short and simple information, be written in simple language, contain culturally sensitive graphics and focus on the desired behavior of the patient (Mayeaux, 1996).

1.6 Oral communication and more effective patient education

Researchers and practitioners recognize the need for more effective patient teaching. Apart from recommendations on written material, health literacy studies and manuals also recommend techniques to improve oral communication between hard-to-reach patients and health care professionals, although this is less common in the literature than information on plain language. These techniques typically include:

1. Limiting teaching objectives.
2. Giving many examples that have meaning to the patients.
3. Demonstrating procedures such as measuring dosages and counting pills.
4. Making learning participatory. Ask patients to restate instructions in their own words.
5. Repeating the information several times.
6. Organizing your instruction so the most important messages are presented both first and last.
7. Including family members or other caregivers in the education process (Mayeaux, 1996).

The issue of training health care providers is also discussed. In some cases, practice is changing. For example, a model for teaching oral communication skills to health care providers who deal with low-literate adults was developed a few years ago in the state of Maine in partnership with their largest rural health centre delivery system (Plimpton, 1994).

The need to develop non-written means of communication, including methods of conveying information such as audiovisual materials and storytelling, is mentioned in the literature. Guides exist on how to assess and produce effective health education videos. According to Mayeaux, et al. (1996), combining easy-to-read written patient education materials with oral instructions in simpler language has been shown to greatly enhance patient understanding. They stress that adults learn best when information is relevant to their lives, when they know the purpose of the information in their lives, when they have a specific educational plan or program and when evaluative feedback is given. Motivation is also a key factor that may be enhanced by involving family members in the patient education process and giving feedback.