Can Clients Understand Our Instructions?

This study was designed to determine whether or not clients in an ambulatory care setting read at a level that allowed them to comprehend the written materials available for patient education. First, 106 adults waiting for clinic appointments were interviewed, and their reported and actual reading levels were compared. Reported reading levels, indicated by the clients' last grade completed in school, were significantly higher (mean—3.1 grades) than their actual reading levels, indicated by scores on the Wide Range Achievement Test (WRAT). Second, the readability levels of written materials available for patient education were evaluated. The mean readability level for the 28 instructional texts examined was 11.2 grades. The majority (54.7%) of study participants read at levels that did not allow them to comprehend any of the patient education materials available at their site of primary care. In addition, 25 percent of the texts examined were beyond the comprehension of all participants.     

Neurology patient education materials: do our educational aids fit our patients' needs?

The purpose of this study was to assess the suitability of various neurology patient education brochures, as well as neurology information on the World Wide Web, to determine whether they were appropriate for patients with low literacy. A convenience sample of 520 patients in university-based public and private neurology clinics participated. In this cross-sectional study, the patients' reading levels were assessed by using the Rapid Estimate of Adult Literacy in Medicine. Forty-three patient education materials were assessed for reading level by using the Fog Index and for suitability characteristics (including content, type and relevance of graphics, layout, type size and fonts, and motivating qualities) by using the Suitability Assessment of Materials. The mean education level of patients was 12th grade; however, the mean reading level was 7th-8th grade. Of the assessed materials, 91% were written at a 9th-grade level or above, even though only 58% of patients read at a 9th-grade level. Only 14% of the materials were considered to have superior suitability, whereas 58% were adequate, and 28% were determined not suitable. Thus, the available neurology patient education aids are not matched to the patient population or to the average U.S. reading levels. Ideally, information needs to be written at a 9th-grade level or below. Instructional graphics, simpler words, patient interaction, and cultural sensitivity improve material suitability.     

Discrepancy between older clients' ability to read and comprehend and the reading level of written educational materials used by occupational therapists.

OBJECTIVE: The match between the reading level of occupational therapy education materials and older clients' reading ability and comprehension was determined. The sociodemographic and literacy characteristics that influenced clients' reading ability and comprehension were investigated. METHOD: The reading level of 110 written education materials (handouts, brochures, and information leaflets), distributed to older clients (65 years of age and older) by occupational therapists working in Queensland hospitals, was analyzed using the Flesch formula. The reading ability of 214 older persons (mean age 77 years, 63% female) was assessed using the Rapid Estimate of Adult Literacy in Medicine. Participants' comprehension of information of increasing reading difficulty was measured using the Cloze procedure. RESULTS: The written materials required a mean reading level between the ninth and tenth grades. Participants' mean reading ability was seventh to eighth grade. Therefore some materials may have been too difficult for participants to read and understand. Participants with a managerial or professional or clerical background (p= 0.001) and those who perceived they read well (p= 0.001) had a significantly higher reading ability. Older age was significantly related to poorer comprehension (p = 0.018), with participants 75 years of age and over having a mean comprehension score of 25.6 compared to 30.3 for those 65 to 74 years of age. CONCLUSION: Occupational therapists must analyze the reading level of the written education materials they develop for and use with clients by applying readability formulas. There should be a match between the reading level of written materials and clients' reading ability. Clients' reading ability may be assessed informally by discussing years of education and literacy habits or formally using reading assessments. Content and design characteristics should be considered when developing written education materials for clients.     

Readability of printed patient information for epileptic patients

BACKGROUND: Written information can be a valuable tool in patient education. Studies evaluating written information for various disease states have frequently demonstrated that the majority of literature is written at a readability level that exceeds that of the average patient, and it has been recommended that written communications for adult patients should be provided at a fifth-grade level or lower. OBJECTIVE: To assess the readability of printed patient information available to patients with epilepsy. METHODS: Samples of written patient information (n = 101) were obtained from various sources. The information was classified based on source, content, and intended audience, and readability was assessed using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) score. RESULTS: The mean FRES and FKGL score for all samples were 50.2 and 9.4, respectively. Significant differences were observed in both the FRES and FKGL score of material obtained from different sources; however, no differences were observed when material was analyzed according to content. The mean FRES and FKGL score for materials intended for adults were 49.6 and 9.5, respectively. In comparison, mean FRES and FKGL scores for materials intended for children/adolescents were 78.9 and 5.3, respectively. CONCLUSIONS: The majority of information tested was written at a level that exceeds the reading ability of many patients. The information intended for children is actually written at the appropriate level for an adult. Efforts should be taken to develop written teaching tools that target low-level readers, especially for a disease state that affects many children.     

Measuring patients' ability to read and comprehend: a first step in patient education

Recent reports released by the U.S. Department of Education indicate that approximately 90 million adults have poor reading and comprehension skills. This information highlights the importance of considering the literacy level of clients when planning patient education programs. The purpose of this investigation was to measure, in urban public clinics, the discrepancy between a self-report of the highest grade completed in school and the actual reading and comprehension levels of patients, measured by the WRAT and CLOZE. Twenty-five subjects, 22 African Americans and 3 Caucasians, participated in this study. The findings indicated that, even though the self-reported highest grade completed showed a mean of twelfth grade, the actual mean reading level was below eighth grade. The results on comprehension showed that 52% (N = 13) of the subjects needed additional instructions after reading materials and 24% were unable to comprehend what they read. The demographics of people with poor literacy skills suggests that they represent a significant proportion of health care consumers who visit health departments, primary care facilities, and community-based health centers (Baker, Newton, & Bergerstresser, 1988).     

Assessing the readability statistics of national consent forms in the UK

Introduction: When obtaining consent for an invasive procedure, the patient needs to understand what is happening to them in broad terms. Best medical practice advocates that written consent is given to acknowledge patient agreement. Across the UK, the Department of Health has provided standard consent forms for obtaining consent in all situations. Potentially these written sources of information may not be comprehended by patients and thus invalidate consent. Method: Consent forms were assessed by the Flesch readability and Flesch‐Kincaid grade formulae and compared with the national reading age, the recommended level for patient medical information, three newspaper articles and a journal article. Results: The consent forms have acceptable statistics [average Flesch readability 61.1 (range 57.2–66.1) and Flesch‐Kincaid grade 7 (range 6.3–8)]. This grade, however, is above the recommended level of patient health information (Flesch‐Kincaid grade 6). When the patient statements are isolated the reading statistics worsen [average Flesch readability 52.6 (range 41–62.6) and Flesch‐Kincaid grade 9.6 (range 7.9–11.1)]. Conclusion: Consent forms should be used as adjuncts to detailed conversations, describing what a procedure involves to ensure that a patient understands, in broad terms, what is happening to them. The patient’s statement section of the form may be being written at a level above patient comprehension currently and thus could invalidate any consent given. We would advocate a documented conversation with patients to ensure they have a broad understanding of the procedure and using the consent form as an adjunct to this discussion. The patient’s statement section should be re‐written to avoid invalidating consent.     

Can Easy-to-Read Immunization Information Increase Knowledge in Urban Low-Income Mothers?

This article describes a pilot study that (1) assessed the self-report of highest grade completed in school and the actual reading and comprehension skills of low-income mothers whose children receive immunizations in urban public clinics and (2) tested the effectiveness of a nursing intervention on immunization knowledge using revised easy-to-read written education materials. Thirty-seven mothers were randomized either to a control group (asked to read the standard vaccine information sheets) or to an experimental group (asked to read the revised immunization pamphlets). Although there was a modest increase in immunization knowledge for both groups, it was not significant. Thus, simplifying information alone may not increase parental knowledge.     

Health literacy: the gap between physicians and patients

Health literacy is basic reading and numerical skills that allow a person to function in the health care environment. Even though most adults read at an eighth-grade level, and 20 percent of the population reads at or below a fifth-grade level, most health care materials are written at a 10th-grade level. Older patients are particularly affected because their reading and comprehension abilities are influenced by their cognition and their vision and hearing status. Inadequate health literacy can result in difficulty accessing health care, following instructions from a physician, and taking medication properly. Patients with inadequate health literacy are more likely to be hospitalized than patients with adequate skills. Patients understand medical information better when spoken to slowly, simple words are used, and a restricted amount of information is presented. For optimal comprehension and compliance, patient education material should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. All patients prefer reading medical information written in dear and concise language. Physicians should be alert to this problem because most patients are unwilling to admit that they have literacy problems.     

Readability of Invasive Procedure Consent Forms

Background

Informed consent is a pillar of ethical medicine which requires patients to fully comprehend relevant issues including the risks, benefits, and alternatives of an intervention. Given the average reading skill of US adults is at the 8th grade level, the American Medical Association (AMA) and the National Institutes of Health (NIH) recommend patient information materials should not exceed a 6th grade reading level. We hypothesized that text provided in invasive procedure consent forms would exceed recommended readability guidelines for medical information.

Materials and methods

To test this hypothesis, we gathered procedure consent forms from all surgical inpatient hospitals in the state of Rhode Island. For each consent form, readability analysis was measured with the following measures: Flesch Reading Ease Formula, Flesch–Kincaid Grade Level, Fog Scale, SMOG Index, Coleman–Liau Index, Automated Readability Index, and Linsear Write Formula. These readability scores were used to calculate a composite Text Readability Consensus Grade Level.

Results

Invasive procedure consent forms were found to be written at an average of 15th grade level (i.e., third year of college), which is significantly higher than the average US adult reading level of 8th grade (p < 0.0001) and the AMA/NIH recommended readability guidelines for patient materials of 6th grade (p < 0.0001).

Conclusion

Invasive procedure consent forms have readability levels which makes comprehension difficult or impossible for many patients. Efforts to improve the readability of procedural consent forms should improve patient understanding regarding their healthcare decisions.     

The impact of medical terminology on readability of patient education materials

Most health-related literature is written above the reading ability of the lay audience; however, no studies to date have identified the impact of medical terms on readability of health education materials. The purpose of this study was to identify whether there was a change in calculated reading levels of patient education brochures after medical terms were removed from analysis passages. The reading levels of 5 patient education brochures were analyzed before and after removal of medical terms, using both the Fry and Simple Measure of Gobbledegook (SMOG) readability formulas. Results indicated that the reading levels for all brochures were significantly lower after removal of medical terminology, but they remained above the 5th to 6h grade level recommended by health education experts. Findings hold implications for healthcare professionals in relation to the development and evaluation of patient education materials.     

The Impact of Medical Terminology on Readability of Patient Education Materials

Most health-related literature is written above the reading ability of the lay audience; however, no studies to date have identified the impact of medical terms on readability of health education materials. The purpose of this study was to identify whether there was a change in calculated reading levels of patient education brochures after medical terms were removed from analysis passages. The reading levels of 5 patient education brochures were analyzed before and after removal of medical terms, using both the Fry and Simple Measure of Gobbledegook (SMOG) readability formulas. Results indicated that the reading levels for all brochures were significantly lower after removal of medical terminology, but they remained above the 5th to 6h grade level recommended by health education experts. Findings hold implications for healthcare professionals in relation to the development and evaluation of patient education materials.     

Literacy in the health care system: a study on open heart surgery patients

PURPOSE: To determine if patients recovering from open heart surgery were able to read and understand written discharge instructions and further to analyze the level of difficulty of standard discharge instructions and consent forms for open heart surgery. DATA SOURCES: After screening for visual acuity and efficiency, literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine test (REALM) and comprehension was tested by a post-test of five questions based on the discharge instructions. Flesch-Kincaid scores were calculated on four sets of standard written discharge instructions and consent forms. CONCLUSIONS: Results from the study indicated that the REALM test was more accurate than the reported grade level and that reading skills are needed to understand and comprehend information needed for post-operative care. The study further substantiated that health care facilities are not providing written instructional material that is within the reading level of the patient. IMPLICATIONS FOR PRACTICE: Illiteracy can have a major impact in the health care system. Low reading skills can disempower and can prove to be costly for patients who are requiring health care services. Further investigation is needed on the impact of patients' reading skills on the health care system.     

Evaluating patient choice of typeface style and font size for written health information in an outpatient setting

Objectives: This study sought to explore patients’ choice of typeface style and font size for written health information.Participants and setting: Men and women attending an outpatient setting in a teaching hospital in Hamilton, Ontario, Canada.Method: All patients who consented to participate first completed the REALM test to assess their literacy level. Patients were then asked to select which typeface style (Times New Roman or Arial) and font size in that style (12 or 14 point) they preferred. Patients then read a handout in the typeface style and font size they had selected. They were then asked to answer questions about the information they had read to assess their reading comprehension.Results: 191 patients agreed to participate but 5 were eliminated as they could not answer the comprehension questions. Of the remaining 186 participants, 131 (70%) preferred Arial font style and 155 (83%) preferred 14-point font size. Individual predictors of preference such as age, gender, REALM grade equivalent, reported education or income were tested using logistic regression but were not found to be significant.Conclusions: Results demonstrate the need to evaluate patient preference when developing written materials for patient education.     

MDA and AAEM informational brochures: can patients read them?

The purpose of this study was to assess patient literacy and the readability of patient education brochures from the American Academy of Electrodiagnostic Medicine and Muscular Dystrophy Association. Materials with the appropriate readability and suitability are more likely to provide instruction patients will understand. The readability of the brochure was assessed with Grammatik (Fry, 1977), the literacy of the participants with the Rapid Estimate of Adult Literacy (REALM) in Medicine test, and the suitability of the brochure was tested with the Suitability Assessment of Materials measure (Doak, Doak, & Root, 1993). The average REALM score for participation in this study correlated with a reading level of 7th-8th grade. All six brochures were found to be too difficult for many patients. Readability levels in four of the brochures were at 11th- or 12th-grade levels, one at 9th grade, and one at 10th grade. Materials with readability levels for 9th grade or higher should be rewritten to be understandable by most Americans, or supplemental instruction should be given. Readability and suitability assessments should be made to determine whether educational materials are appropriate for patients.     

Readability and Reading Level of Behavior Treatment Plans in Intellectual Disabilities

Behavioral treatment plans are developed and implemented to enhance an individual’s skills or reduce maladaptive behavior. Often, they are written by doctoral-level psychologists and implemented by direct care staff. However, recent research on readability suggests that behavioral plans may not be implemented as designed because the direct care staff that implements them may not be able to fully understand or read the plans as they are written. The purposes of our study were to analyze the readability and reading level of 20 behavior treatment plans written by professional staff and to determine if the plans were understandable and written at an acceptable reading level. We used the RAIN to assess 20 randomly selected behavioral treatment plans for readability and the SMOG formula to assess reading level. Results showed that none of the treatment plans met all 12 criteria for readability examined by the RAIN. Further, reading levels of the plans measured by the SMOG ranged from 12 to 16 suggesting that an average reading level of 14 was required to read them. These results suggest that behavioral treatment plans are not being written in a manner that facilitates understanding by direct care staff and are written at six grade levels higher than the reading level of an average American. Our findings indicate an urgent need for psychologists to write behavioral treatment plans at least at the reading level of the staff who are entrusted to implement them.