Design Your Handouts and Surveys for Low Health Literacy

The ability of any patient or caregiver to communicate ailments/symptoms, medical history (personal and family), and other medical information is vital to proper care. Similarly, while it is important to assess the patient and/or family’s experience of care, many satisfaction surveys used in healthcare settings are designed without attention paid to low literacy, language barriers, and culturally-based expectations of care. In fact, studies show many standard forms and surveys used in healthcare settings are incomprehensible for about 1/3 of the US adult population, who are functionally illiterate (National Adult Literacy Survey (NALS, 1992).  They are unable to comprehend, retain, and apply information acquired through reading, writing, and speaking (Davis, Meldrum, Tippy, Weiss, & Williams, 1996).  Moreover,  “patients are not likely to volunteer information that they have difficulty reading or understanding” (Davis et al., 1996, p. 96).  These communication factors can adversely affect the ability for patients to receive proper care.

1. 1. People develop coping mechanisms that hide their condition. In one study, two-thirds of those who admitted having reading difficulties had never told their spouse; 19% had never told anyone (Parikh, 1996). Because of the stigma associated with poor reading skills, most people won’t. Instead they’ll come up with strategies to avoid reading, like saying they’ve left their glasses at home or that they usually leave the work of filling out forms to a family member. Or, they leave forms sitting in an exam room without completing them.

1. Most poor readers also view their own reading skills as adequate. In the National Adult Literacy Survey, 66 to 75% of adults in the very lowest skill level described themselves as being able to read or write English “well” or “very well.” Of those in the next lowest skill level, 93-97% described themselves this way. [NAAL, 2003]

 Stress and time constraints affect cognition

When people are tired, under stress, or just plain busy, they may have fewer cognitive resources to bring to the task at hand. And that affects word recognition, inference, problem solving—all the skills you use for reading and understanding. One classic low-literacy behavior is picking the first plausible answer without confirming that it’s the correct or best answer.

 Retaining Little of What is Read

People with low literacy skills may not be able to store as much information in their short-term memory. Adults with adequate literacy skills can store around seven independent chunks of information at a time in short-term memory. The number for poor readers may be closer to five or fewer (Miller, 1956). That becomes a problem when you include lots of information and expect readers to remember it. So it’s not a good idea to include lots of information in text and hope that some of it will stick; it probably won’t.

 Communication Tips to Remember

Be consistent: What is often obvious to skilled readers—like using two different words to mean the same thing—requires more work for poor readers or people learning English. Examples:

• Using both “physician” and “doctor” at different points in a survey or in-take form
• Using both “dairy” and “milk” to describe dietary restrictions for a medication
• Using lotion, cream, or brand names like Vaseline  interchangeably

Use the common word:

• Use “doctor” instead of “provider”
• Use “nurse” instead of RN

Avoid passive sentences, use common words & active verbs. Better Eaxmple: “You must file your application by August 1, 2016.” Best Example: “You must send us your application before August 1, 2016. 

• Davis, T., Meldrum, H., Tippy, P., Weiss, B. D., & Williams, M. V. (1996). How poor literacy leads to poor health care. Patient Care, 30(16), 94-127.
• National Center for Education Statistics. (1992). National Adult Literacy .
• [On-line]. Available: http://nces.ed.gov/naal/naal92/Overview.html [1999, Nov 21]
• Miller G. (1956) The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychological Review, 63, 81-97.
• Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV (1996). Shame and health literacy: the unspoken connection. Patient Educ Couns. 1996 Jan;27(1):33-9.