Improve compliance, write to literacy level

Check demographics, use audience as test group

A young mother brought her asthmatic 2-year-old to the emergency department when the child was undergoing a mild attack. Physicians on duty gave her a prescription for a nebulized bronchodilator, antibiotics, and an oral corticosteroid. The next day, the child’s condition had worsened, so the mother took the child to another hospital. The medical evaluation showed that the mother had filled the prescriptions but had not given the child the medications because she did not understand the meaning of the words "nebulized" or "oral." Hospital staff had to show her how to administer the medications.

About 90 million Americans, or half the adult population, have low literacy skills according to the 1993 National Adult Literacy Survey — and that could be hazardous to their health.

Although many health care professionals are aware that a good portion of their patient population has low-literacy skills, they haven’t successfully addressed it, says Audrey Riffenburgh, MA, a reading specialist and president of Riffenburgh and Associates in Albuquerque, NM. In 1994, she collected more than 100 pieces of patient education materials from her health care community and did a readability analysis on them. She discovered that 95% of the material was written at a level that only 20% of the general population would understand.

The key to alleviating the problem is understanding your patient population, says Riffenburgh. To do this, gather government census data on your community, and then compare the break out to population groups identified as likely to have low-literacy skills. For example, three-fourths of the seniors in the 1993 National Adult Literacy Survey, funded by the U.S. Department of Education, performed in the two lowest of five skill levels on literacy tasks. About 43% of those who live in poverty function in level one, according to the survey. So, if your hospital is located in the inner-city or you serve a large elderly population, you might select reading materials that target people with low-literacy skills.

Although several tools for evaluating a patient’s health literacy level on an individual basis have been developed, Riffenburgh does not recommend their general use but encourages the method of analyzing demographics instead. "Health care professionals are not trained to evaluate reading skills," explains Riffenburgh. (For an example of literacy evaluation tools, see the list of resources, p. 43.)

She recommends writing patient education materials for the general public at the seventh- to eighth-grade reading level. If your patient population has a high proportion of elderly or patients in a low socio-economic level, write the material at a fourth- or fifth-grade level. And keep in mind that a severe illness can also affect a person’s functioning literacy level.

Use simple language

Another issue to consider when creating medical brochures is that the general public is not familiar with many health care terms. No matter what grade level the information is written for, people won’t understand the message if they don’t understand the terms. Riffenburgh says this point became very clear to her one day when a colleague called to tell her that he couldn’t understand a computer manual he was trying to read. He had completed a reading analysis on the manual and discovered that it was written at a fifth-grade reading level. The problem was that he was not familiar with the jargon, she explains.

In a study published in December 1995, researchers at Grady Memorial Hospital in Atlanta found that 35% of patients tested couldn’t adequately understand written medical information including directions on a medicine label.1

To avoid health care jargon when writing materials, use words that you hear in normal conversation as much as possible. To determine if your patient population can understand the material, form a group from your target audience to review the publication. "Get them talking so you can hear the expressions they use and how they would explain the procedure to a family member," advises Riffenburgh.

Once the material is written, conduct a readability analysis to make sure it is at the appropriate grade level. Readability formulas are often included in books on writing for patients with low literacy. The authors of these books not only give the formulas but also describe how to do the analysis. (For information on readability formulas, see source list, above.)

Riffenburgh recommends that patient education managers do one readability analysis by hand and another on a computer to avoid mistakes. Most word processing programs have assessment tools built into the grammar-checking function. However, if your software has the Flesch-Kincaid reading level, make note that it scores three grade levels too low, warns Riffenburgh.

It is possible to communicate with patients who have low-literacy skills by providing educational materials that have lots of illustrations and are written at the appropriate grade level. However, the materials must complement effective teaching, says Riffenburgh. (For information on teaching low-literacy patients, see story, above.)

[Editors note: Audrey Riffenburgh, MA, president of Riffenburgh and Associates, conducts seminars on educating low-literacy patients, does consulting, and edits and designs materials at a reduced reading level for health care facilities. Her book, Health Care Providers Guide to Plain English, will be published this fall. For more information write: 1990 Cherokee Road NW, Suite A, Albuquerque, NM 87107. Telephone: (505) 344-0299. Fax: (505) 344-0279. E-mail:]


1. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals.JAMA1995; 274:1,677-1,682.