Improving Healthcare Literacy Through Plain Language

Plain language is one of the most important health literacy tools for the clinician to use. Regardless of education or reading level, plain language engages patients and helps everyone understand and use information. The key is to present information in a clear, effective, and easy way for most patients to use and comprehend. Utilizing plain language in spoken and written communication is important to ensure patient understanding. While plain language speech and plain language writing are similar, there are also key differences. 

• Plain language speech presents information so listeners can use and understand information the first time they hear it. 
• Plain language writing and design presents information so readers can find, use, and understand information the first time they read it. 

The creation of plain language written materials involves multiple writing and design concepts to engage the reader. Health literacy specialists are trained in these concepts and can help healthcare organizations develop plain language materials that engage patients and improve patient understanding. 

Reading Difficulty

Factors that may contribute to patients’ reading difficulty include:

• Using fonts smaller than 12-point. 
• Providing extra information, including information other than what the patient needs to know. Although clinicians may think the extra information is important, readers may have difficulty processing it. 
• Employing vague and complex terms that healthcare professionals may use in daily practice, but the average person neither recognizes nor uses.
• Using words longer than two syllables. 
• Using synonyms. 

Readability Formulas

Readability formulas, such as Flesch Reading Ease, objectively measure the difficulty of reading written material by generating a score based on word, sentence, and syllable counts. These tools can be helpful but have limits in determining patient understanding. For example, two-syllable words like “oral” or “optic” score well on readability formulas but can be difficult for patients to understand. Using the plain language terms “mouth” or “eye” make information easier for patients to understand.
 

Plain Language Assessment Tools

There are assessment tools available that can measure the use of plain language writing and design principles in health materials. Two examples are below:

• The CDC Clear Communication Index.
• The Patient Education Materials Assessment Tool (PEMAT) and User’s Guide.

While these tools take readability into consideration, they are a better gauge for evaluating plain language writing and design with an eye toward the reader’s ability to understand and use the information. Both tools above are validated, widely accepted, and available free online with accompanying user guides. 

Numeracy

Numeracy is another important health literacy concept. The Centers for Disease Control and Prevention (CDC) reports that “numeracy plays a critical role in people’s ability to make informed decisions about their health.” Numbers are crucial in relaying the probability of a risk occurring. Using numbers in a way that patients understand is imperative for shared decision-making. Studies have shown that patients can better comprehend risk when clinicians display it by using pictographs or icon arrays in sequential order. 

Risk Recommendations

 

Train Clinicians How to Engage Patients With Plain Language
 

Speak in plain language. Teach clinicians to:

• Keep it short. 
• Present information in a logical way. 
• Speak slowly and clearly in a friendly tone.
• Avoid using unfamiliar abbreviations and acronyms. 
• Use familiar objects for comparison. 
• Use analogies to explain complicated concepts.
• Use familiar words. 

Present numbers clearly to maximize patient understanding. Encourage clinicians to review the Agency for Healthcare Research and Quality’s The SHARE Approach – Communicating Numbers to Your Patients: A Reference Guide for Health Care Providers. 

Use icon arrays in sequential order to display risk. Show clinicians how to access a web-based application like iconarray.com to develop and download tailored icon array graphics. 

Use plain language written materials. Provide clinicians with an overview of plain language writing and design concepts to give a clear understanding of why and how plain language writing and design improves readability and promotes health literacy. 

Use teach-back to confirm patient understanding. 

Develop a Process for Writing and Designing Plain Language Materials
 

Consider utilizing a health literacy specialist when developing any patient-facing materials and forms, including consent forms. If the organization currently does not have a health literacy specialist, consider identifying someone who has an interest in health literacy and providing additional training to develop these skills. 

Employ basic plain language writing and design principles.

• Limit paragraph depth and group information.
  • Keep paragraphs short (ideal depth is 4-5 lines).
  • Group like information into logical groups or chunks. 
• Use headings, subheadings, or short titles. 
  • Use bolded or enlarged headings and subheadings to highlight key messages and make information easy to find and follow. 
  • Use short sentences, phrases, or a single word. 
• Use vertical lists with bullets, letters, or numbers. 
  • Break dense text into vertical lists to limit concept density and make information easier to find and follow.
  • Limit the number of items or concepts in a list to seven.
  • Break longer lists into logical groups or chunks to avoid overwhelming the reader.
  • List items using parallel structure (same grammatical form). For example, use all verbs or nouns as the first word for each item on the list. 
  • Use alphabetical order when items or topics are equally important. 
  • Use numerical order when items or steps need to be presented in a particular sequence. 
  • Allow the use of a single bullet within a larger list to provide consistency when only one point is being made. 
• Use action verbs for directives. Action verbs are explicit and clear rather than implied. For example, the phrase “do not smoke” is much clearer and more directive than “you should not smoke.” The idea is to quickly get to the point and tell the reader what to DO. These are subtle differences that significantly impact the reader. 
• Identify complex information. Look for words that are:
  • Different but mean the same thing. 
  • Longer than two syllables. 
  • Technical, unfamiliar, or uncommon to the general population. 
  • Vague or complex. 
• Make content easier to read.
  • Try to use familiar one or two syllable words. For example, use the term bad instead of adverse. 
  • Use the simplest form of a word and stick too it rather than exchanging it with a different word that means the same thing. 
  • Recognize that sometimes the best word choice or most familiar term may be longer than two syllables. For example, consent is a two-syllable word that healthcare professionals frequently use, but it is not an everyday word for most patients. Further, it may sound like legalese or jargon to the patient. On the other hand, permission is an everyday word that most people understand. 

Use caution with readability formulas. Recognize their limitations in evaluating patient understanding. 

• Evaluate written materials using a plain language assessment tool. 

Resources

• Institute for Healthcare Advancement, Health Literacy Month, Health Literacy Specialist Certificate Program
• AHRQ, The SHARE Approach – Communicating Numbers to Your Patients: A Reference Guide for Health Care Providers
• CDC, Everyday Words for Public Health Communication
• National Institutes of Health, Plain Language: Getting Started or Brushing Up
• University of Michigan Medical School’s Center for Bioethics and Social Sciences in Medicine, Pictographs/Icon Arrays