Special Report: Annual 2008 Salary Survey

Going beyond clear language when writing patient education materials

Consider such factors as scientific, civic and cultural literacy

Delivering health information in simple, clear language is important for comprehension. However, the use of plain language and employing a low reading level are not the only factors that determine comprehension.

"There are all kinds of issues involved in what causes people to really understand and engage with the information," states Christina Zarcadoolas, PhD, an associate clinical professor at Mount Sinai School of Medicine, Department of Community and Preventive Medicine in New York.

Simplifying information does not always make it understandable and usable, she adds. While fundamental literacy, or the ability to read, write, speak, and work with numbers, is key to understanding health messages, it is not the only factor in comprehension. Therefore, readability, good layout, and clear language are only part of the focus when writing materials.

What other factors should be considered when creating educational handouts? According to Zarcadoolas, when writing materials it is important to consider how literate a person is scientifically, civically, and culturally.

She discusses these issues in detail in a book she has co-authored with Andrew F. Pleasant and David S. Greer titled Advancing Health Literacy: A Framework for Understanding and Action.

"Less than 20% of adults in the United States know anything about the scientific method or how science works - and that science evidence is always changing and is dynamic," says Zarcadoolas. Yet an understanding of basic science often improves their ability to comprehend a health message.

Scientific evidence is addressed all the time in health information, she adds. Handouts include the percentage of people with diabetes in a certain state or warnings of a possible flu epidemic and how to avoid getting sick. Zarcadoolas says she uses an example in her book about readers confused by a message that was designed to teach people not to ask for antibiotics to cure the common cold, which is a virus. The confusion was caused by the fact that most did not understand the difference between a virus and bacteria.

Zarcadoolas describes scientific literacy as "the skills and abilities to understand and use science and technology, including some awareness of the process of science."

In her book she suggests that authors of health education handouts ask two questions about the scientific literacy of readers when writing health education materials.

1. What science must a person know to comprehend and decide to act on a specific health message?

2. What assumptions about the listeners' scientific literacy are made by developers of health messages?

Another factor that affects a person's ability to understand health information is civic literacy. Zarcadoolas describes it as "skills and abilities that enable citizens to become aware of public issues, participate in critical dialogue about them, and become involved in decision-making processes."

This component has to do with how a person judges the source of information and determines whether it is reliable, she explains. People's civic literacy provides a good indicator of how they will receive health messages and engage with them by changing their behavior.

In Advancing Health Literacy, Zarcadoolas states that civic literacy covers a range of understanding that includes: "judging the sources of information; judging the quality of information; knowing where and how to access information; knowing how to advocate for oneself and others; and understanding the relationship between one's actions and the larger social group."

An example of a person acting for the greater good of a social group would be parents keeping a sick child home from day care so as not to expose other children to a cold or flu.

"When we look at people's civic literacy, we get a very good indicator of how they are going to receive health messages and trust them enough to engage with them and change their behavior," says Zarcadoolas.

Many factors affect point-of-view

The fourth component that must be considered when writing understandable patient education materials is cultural literacy, according to Zarcadoolas. Culture is "the shared and dynamic characteristics of a group of people, which may include language, patterns of behavior, beliefs, customs, traditions, and other modes of expression."

People who are culturally literate not only recognize their cultural beliefs but recognize that the authors of health information have a professional culture as well. According to the authors of Advancing Health Literacy"the communicator should understand aspects of the culture of the recipient, and the recipient should understand aspects of the professional culture of the sender."

In their book, the authors discuss information on medication coverage provided by a health care insurance provider that assumes the reader has a basic understanding of industry practices. Yet the insured party needs to know that the company does not necessarily cover all drugs that might be prescribed by a physician in order to understand the message.

To create messages people will act upon requires an awareness of the cultural beliefs people have, says Zarcadoolas. It includes values, perceptions, and actions.

For example, the fact teenagers are at a stage in life where they are building an identity and have confidence in their immortality makes lessons on HIV medication adherence difficult. Teens are notoriously noncompliant because they do not want to be identified as sick people, says Zarcadoolas. Thus, the health care providers must find a way to deliver the message that works.

In this particular situation, options to consider might be the use of trusted sources to deliver the message, or people who have gone on to accomplish and build strong identities in spite of being HIV positive, she says.

Writing patient education materials in simple language is the first step in clear communication; however, authors must also take into account the reader's cultural literacy, science literacy, and civic literacy as well, according to Zarcadoolas.

Therefore, when creating written materials for a patient population, Zarcadoolas advises authors to give thought to four areas: fundamental literacy (a person's ability to read, write, speak and work with numbers), scientific literacy, civic literacy, and cultural literacy.


For more information about consideration of the four areas of literacy when writing heath education materials, contact:

• Christina Zarcadoolas, PhD, Health and Environmental Literacy Initiative, Associate Clinical Professor, Mount Sinai School of Medicine, Dept. of Community and Preventive Medicine, Box 1057, One Gustave. L. Levy Place, New York, NY 10029. Telephone: (212) 824-7061. E-mail: Christina. zarcadoolas@mssm.edu.