What Reading Grade Level Should You Assume for All Patients

Health Literacy in Primary Care Practice

LAUREN HERSH, Doc; BROOKE SALZMAN, MD; and DANIELLE SNYDERMAN, Md, Thomas Jefferson University, Philadelphia, Pennsylvania

Am Fam Dr.. 2015 Jul fifteen;92(2):118-124.

Related editorial: Health Literacy: What Practice You Need to Do?.

CME This clinical content conforms to AAFP criteria for standing medical education (CME). Run into the CME Quiz Questions.

Author disclosure: No relevant financial affiliation.

• Abstract
• Epidemiology
• Implications of Limited Health Literacy
• Assessment
• Interventions
• Recommendations for Enhancing Communication with Patients
• Numerical Data
• References

Commodity Sections

• Abstract
• Epidemiology
• Implications of Express Health Literacy
• Assessment
• Interventions
• Recommendations for Enhancing Communication with Patients
• Numerical Information
• References

Health literacy includes a set up of skills needed to make appropriate wellness decisions and successfully navigate the health intendance arrangement. These skills include reading, writing, numeracy, communication, and, increasingly, the apply of electronic technology. National information indicate that more one-3rd of U.South. adults have limited health literacy, which contributes to poor wellness outcomes and affects patient safety, and wellness care access and quality. Although in that location are a number of tools that screen for limited health literacy, they are primarily used for enquiry. Routinely screening patients for wellness literacy has not been shown to improve outcomes and is not recommended. Instead, multiple professional organizations recommend using universal health literacy precautions to provide understandable and attainable data to all patients, regardless of their literacy or education levels. This includes fugitive medical jargon, breaking downward information or instructions into small physical steps, limiting the focus of a visit to iii fundamental points or tasks, and assessing for comprehension. Additionally, printed information should exist written at or beneath a 5th- to 6th-grade reading level. Visual aids, graphs, or pictures tin can heighten patient understanding, as can more physical presentation of numerical information.

Wellness literacy is the caste to which individuals have the capacity to obtain, procedure, and understand basic wellness information and services.1 The wide range of skills that contain wellness literacy and influence a patient's power to navigate the health care arrangement and make appropriate decisions almost his or her health include reading, writing, numeracy, communication, and, increasingly, the use of electronic technology.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Testify rating	References
Use universal health literacy precautions with all patients, regardless of their literacy or teaching levels.	C	10, thirty, 31
Prioritize and limit information to three key points for each visit.	C	30
Utilize the teach-back method to assess patient comprehension of information.	C	ten, xxx, 36
Simplify forms and offer assist with form completion.	C	10, 30

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More than than 1-tertiary of U.Due south. adults, an estimated lxxx million persons, have limited wellness literacy,ii,three making information technology more difficult for them to read, understand, and employ health information (e.grand., diction on medication bottles, nutrient labels, date slips, discharge instructions, informed consent documents, medical forms, insurance applications, medical bills, and wellness didactics materials). Although U.Due south. adults on average read at an eighth-grade level, more 75% of patient education materials are written at a high school or college reading level.iv

Physicians oftentimes overlook wellness literacy in routine patient care, overestimating patients' health literacy skills and incorrectly bold that health information and instructions have been understood.five,6 In addition, most patients fail to identify their ain deficiencies in comprehension and overestimate their remember of important data.7

Numerous policy and advocacy organizations have recognized the negative furnishings of limited health literacy on patient rubber and the quality of wellness care. As a result, wellness literacy has evolved from a poorly recognized "silent epidemic" to a major issue in wellness policy and reform.3,eight

Epidemiology

• Abstract
• Epidemiology
• Implications of Limited Wellness Literacy
• Cess
• Interventions
• Recommendations for Enhancing Communication with Patients
• Numerical Data
• References

The best population data on health literacy in the United states of america come from the 2003 National Cess of Adult Literacy (NAAL).2  Commissioned by the U.Due south. Department of Teaching, the NAAL categorizes health literacy into four tiers reflecting the ability of patients to undertake increasingly complex tasks within the health care organisation. Table 1 presents an overview of these tiers.2

Tabular array i.

Overview of the NAAL Health Literacy Tiers

Tier	Percentage of the U.South. population	Examples of key abilities	Associated health tasks
Below basic	14	Able to locate only straightforward pieces of information in short, simple texts or documents; some patients have even less ability because of nonliteracy in English language	Discover the date on a hospital engagement slip; identify what is permissible to drink before a medical test based on a brusque set of instructions
Basic	22	Observe more complex information in brusk texts and elementary documents that are somewhat longer and more complex than those at the below bones level	Give two reasons a person with no symptoms of a specific disease should exist tested for the affliction using information from a patient education handout
Intermediate	53	Interpret or apply data presented in complex graphs, tables, or other health-related texts or documents	Determine a good for you weight range for a person of a specified height, based on a graph that relates height and weight to body mass index; place substances that may have an agin interaction with an over- the-counter drug using information on a drug label
Proficient	12	Describe abstract inferences, comparing or contrasting multiple pieces of information within complex texts or documents, or employ abstract or complicated information from texts or documents	Evaluate applicability of a legal document in a specific health intendance situation; calculate an employee's share of almanac wellness insurance costs using a table that shows how the price varies based on income and family size

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Using the NAAL designations, 36% of the U.Due south. adult population has a basic or beneath bones wellness literacy and therefore may face serious challenges in understanding and interim on health information. Even patients categorized every bit having intermediate health literacy may have difficulty accomplishing tasks essential for managing their health (east.1000., correctly determining from instructions on a prescription bottle what fourth dimension to accept the medication based on mealtimes).2

Limited wellness literacy is more common in Hispanic (66%), black (58%), and American Indian and Alaska Native (48%) populations, and among those 65 years and older (59%). Express literacy rates are besides higher among those with less education, those who did non speak English before starting school, and those living below the poverty level.ii The NAAL also identified approximately 11 million adults as nonliterate in English, of whom iv million could not consummate the NAAL because of language barriers.

It is also of import to recognize that wellness literacy skills can vary within one individual and modify over fourth dimension. Performance on wellness literacy tasks may be influenced past emotional state, acute pain or illness, vision and hearing deficits, and cognitive harm.9

Implications of Express Wellness Literacy

• Abstract
• Epidemiology
• Implications of Limited Health Literacy
• Assessment
• Interventions
• Recommendations for Enhancing Advice with Patients
• Numerical Data
• References

Numerous studies with varying methodological strengths have shown that deficiencies in health literacy contribute to poor wellness outcomes (higher mortality rates and worse overall health status), health disparities, and increased costs.3,eight,10  The implications of wellness literacy (Table ii3,8,11–22) are amplified in an increasingly circuitous and fragmented health care system that places growing demands on patients for cocky-care, care coordination, and system navigation. Shorter hospital stays, polypharmacy, multiple health care providers, and the rising prevalence of chronic illness all contribute to the increasing role that patients have in managing their own care.10 With this increased responsibleness, express wellness literacy has been associated with decreased cancer screening and immunization rates, more emergency section utilize, and higher rates of medication errors.3,eight,xi–22

Tabular array 2.

Implications of Express Wellness Literacy

Implications	Research findings
Health organisation utilization
Access to intendance	Mixed results for association with number of physician visits
Access to insurance	Low parental wellness literacy associated with no health insurance for children
Emergency intendance and hospitalization	Increased utilize of emergency care, increased hospitalization rates
Health care costs	Studies have mixed results regarding differences in costs of health care by health literacy level
Personal health intendance
Adherence to intendance recommendations	Studies have mixed results depending on adherence measure out and disease country
Adherence to healthy lifestyle	Studies have mixed results
Interpreting health data	Difficulty understanding nutrition labels or a standard engagement slip
Medication use	Difficulty identifying medications, interpreting dosing, and administering medications correctly; higher risk of misunderstanding medication labels/directions
Preventive services	Decreased rates of mammography, flu vaccination, and screening for cervical and colon cancers
Wellness outcomes
Chronic disease outcomes	Studies have mixed results for chronic disease in general and for specific chronic diseases
Health status	Lower overall health status among older adults
Mental health outcomes	College rates of low
Mortality	Higher mortality rates in older adults

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Cess

• Abstract
• Epidemiology
• Implications of Limited Health Literacy
• Assessment
• Interventions
• Recommendations for Enhancing Communication with Patients
• Numerical Information
• References

Although there are several tools to appraise health literacy (Tabular array 3), they are mainly used in research.23–26 Studies accept found that patients will accept health literacy screening if presented in an appropriate, sensitive style and that such screening does not engender feelings of shame or mistrust.27,28 However, because there is no evidence that assessing wellness literacy skills in practice settings improves outcomes, it is not recommended as part of routine clinical care.29

Tabular array 3.

Commonly Used Health Literacy Assessment Tools

Tool	Measurement	Administration time (minutes)	Number of items
Newest Vital Sign	Reading and applying information	2 to 6	six questions based on information from a nutritional label
Rapid Guess of Developed Literacy in Medicine	Word recognition and pronunciation; provides an gauge grade level for reading ability	3	66 medical terms to be read out loud
Brusk Test of Functional Health Literacy in Adults	Reading comprehension and numeracy skills	vii to 12	2 prose passages and four items assessing numerical ability
Single Particular Literacy Screener	Identification of patients who demand aid with reading health-related data	1 to 2	1 question: How often exercise you lot need to have someone help you lot when yous read instructions, pamphlets, or other written fabric from your doctor or pharmacy?
Test of Functional Health Literacy in Adults	Reading comprehension and numeracy skills	22	3 prose passages followed by a l-particular reading comprehension section

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Interventions

• Abstract
• Epidemiology
• Implications of Limited Health Literacy
• Cess
• Interventions
• Recommendations for Enhancing Advice with Patients
• Numerical Data
• References

Research on health literacy interventions has shown inconsistent results well-nigh the extent to which they improve long-term health outcomes.iii,8,19 Withal, systematic reviews of interventions designed to improve different aspects of health literacy prove an overall benefit of clear health communication strategies to optimize patient care.3,8,18  These strategies entail improving verbal and written approaches, along with increased sensitivity to how numerical data are presented (Table iv).iii,8,10,16,30–33

Tabular array 4.

Strategies for Promoting Wellness Literacy in Clinical Practice

Component	Strategies	Tools
Exact communication	Use evidently, nonmedical language Utilise common words and/or words the patient uses in chat Slow downwards; speak conspicuously and at a moderate pace Limit content: prioritize and limit information to 3 key points Repeat key points Confirm whether the patient understands the data given	Teach-back: Ask patients to explicate a concept or plan in their own words (this is not a test of patient knowledge, simply a reflection of how well the concept or plan was explained) Example: "I reviewed options for colon cancer screening with you today. To brand certain I explained these options clearly, can you tell me in your own words what these options are?" Chunk and cheque: After giving each key signal, stop to solicit questions and have the patient repeat the textile dorsum to you
Written communication	Use easy-to-read materials that are at a 5th- to 6th-grade reading level or lower Use brusque, uncomplicated sentences Avoid words of more ii syllables Limit content to fundamental/well-nigh relevant information Limit medical jargon, and define terms Chunk information into clearly marked sections; bulleted lists are amend than blocks of text Review wellness education materials with the patient, and underline or circle key points On forms, apply cheque boxes instead of asking patients to write answers Include "don't know" options Bold key words on forms	Electronic assessments: Use electronic tools to appraise reading level of written material; a number of tools are available at http://www.readabilityformulas.com/complimentary-readability-formula-tests.php
Visual aids	Use visual aids; include simple pictures and avoid unnecessary details Apply models Use photonovelas (easy-to-read stories formatted like a comic volume, simply using photographs instead of drawings) Use videos	Online videos: Most patients accept access to the Internet; at that place are numerous online videos (e.g., YouTube) illustrating important and common patient education topics; an case of a humorous pedagogy video on colonoscopy preparation is available at https://www.youtube.com/watch?v=H7V5bmyk8BU
Patient cocky-direction and empowerment	Encourage patient participation; for example, enquire "What questions practice you have?" rather than "Exercise you take any questions?" Encourage patients to bring a list of 2 or 3 questions to appointments Assess understanding of medications and adherence Ask patients how they remember to have their medications Write precise instructions for taking a medication; for example, requite specific times instead of using vague instructions such every bit twice daily Provide written or typed medication lists Ensure medication review and/or reconciliation for all patients at all encounters Offering different methods for medication system, such equally pillboxes Create an activeness plan, outlining steps the patient can take to accomplish a health goal Ask for patient feedback	Ask me 3: Encourage patients to know three things earlier leaving the see: What is my chief problem? What practise I need to do? Why is it important for me to do this? Example: "Before you leave today, I desire you to tell me the main problem we talked nigh, what you need to do adjacent, and why it is important for you to do what we planned." "Chocolate-brown pocketbook" review of medications: Ask patients to bring in all of their medications and supplements to appointments so that you can verify what they are taking, answer their questions, identify any errors or interactions, and help with adherence
Supportive systems and caring environments	Link patients to nonmedical back up Link patients to health and literacy resource in the community Train all staff on health literacy sensation and communication principles Limit paperwork and redundant forms Utilize simple forms with articulate language Routinely offer assist with forms Provide clear referral instructions, and review them with patients	Bureau for Healthcare Research and Quality Wellness Literacy Universal Precautions Toolkit: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resource/tools/literacy-toolkit/index.html

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Organizations such equally the American Medical Clan and the Agency for Healthcare Research and Quality endorse adopting universal health literacy precautions (i.e., using like shooting fish in a barrel-to-understand concepts and terms with all patients instead of focusing only on those with low literacy) to minimize the run a risk that an individual patient volition not sympathise the information they are given.10,thirty,31

Recommendations for Enhancing Advice with Patients

• Abstract
• Epidemiology
• Implications of Limited Health Literacy
• Assessment
• Interventions
• Recommendations for Enhancing Communication with Patients
• Numerical Data
• References

VERBAL Communication

Clinician-patient advice is a key component of patient intendance. Patients empathize and retain near one-half of what is discussed in clinical encounters, and many exercise not feel comfortable request for clarification or reiteration.34,35 With this in mind, the following strategies can exist employed to promote clear and effective communication.

Avoid Making Assumptions Most Linguistic communication Preferences or Literacy Level. A patient's preferred language should exist ascertained from the patient. If a clinician is unable to communicate effectively in the patient'south preferred linguistic communication, a trained interpreter should be used rather than relying on family members or untrained bilingual staff. Considering literacy level cannot be determined by appearances, clinicians should never assume a patient'south level of understanding.10,30

Use Patently, Nonmedical Language. Clinicians ofttimes use medical jargon that patients do not empathise, particularly during critical moments of patient education or while developing a handling plan.36,37 Clinicians should speak slowly and conspicuously, and strive to mirror a patient's vocabulary.33,38  Even patients with high literacy skills may accept minimal understanding of medical terms. If a medical term is used, information technology should be conspicuously explained. Table v lists resources for improving communication in health care settings.

Speak Slowly and Break Downwardly Information into Pocket-sized, Manageable Steps. Circuitous instructions are more than challenging to understand, remember, and follow. Information or instructions should be simplified into individual steps or units and should be concrete and specific.10,16,xxx For instance, instead of telling a patient to eat a healthier diet, a physician tin can offering specific suggestions, such as telling the patient to eat five servings of vegetables a day and teaching about the plate-size method.39 Limiting the focus of each clinical encounter to well-nigh three key messages increases comprehension of both depression- and loftier-literacy patients.30,36,37

Confirm Patient Understanding. Patients rarely disclose whether they comprehend the information presented to them. One style to assure that patients have clearly understood the data is to use the teach-back method. This entails the patients explaining the new data in their own words, allowing the clinician to assess for comprehension. The teach-back method should exist framed to assess the effectiveness of the clinician'south communication rather than to test the patient's learning skills. This method has been shown to increase glycemic command in patients with diabetes mellitus36 and better comprehension of the informed consent process.40 Although the teach-dorsum method may meliorate patient understanding, it has not been shown to affect 30-day rehospitalization rates.41

PRINTED COMMUNICATION

Written materials should exist used to reinforce exact communication. A Cochrane review demonstrated that verbal and written information increases patient satisfaction and knowledge compared with exact information alone.42 Written materials should be at or below a fifth- to 6th-class reading level. Like shooting fish in a barrel-to-use tools to evaluate the reading level of written materials are bachelor at http://www.readabilityformulas.com/free-readability-formula-tests.php.

Written materials should be limited to key points, fugitive unnecessary detail. Visual aids, such as pictures, drawings, or graphs, can enhance patient understanding,43,44 particularly when communicating risks and probabilities.45

Numerical Data

• Abstract
• Epidemiology
• Implications of Limited Health Literacy
• Cess
• Interventions
• Recommendations for Enhancing Communication with Patients
• Numerical Data
• References

Quantitative or numerical data have a prominent role in health intendance discussions and decisions. These information include statistics near the benefits and risks of preventive behaviors, medications, and procedures, too as affliction risk and prognosis. Many physicians presume that the utilize of numbers will empower patients to make informed decisions and adopt healthier behaviors. However, many Americans have depression numeracy skills, or have difficulty understanding or processing numbers.46 A study of patients in an asthma dispensary found that two-thirds of all patients (not just those with express health literacy) did not understand what i% meant.47 Furthermore, the way in which numerical data are presented influences how patients understand and act on information.48  Although the near effective ways to communicate numerical data are unclear, several suggested approaches to improving patients' comprehension of health-related numbers are reviewed in Table 6.3,8,x,sixteen,xxx,46,49,50

Table 6.

Strategies to Address Limited Numeracy

Strategy	Example
Limited probabilities in terms of natural frequencies rather than percentages	"i out of 20 people (instead of five% of people) get colorectal cancer in their lifetime."
Provide absolute risks rather than relative risk; this is particularly important when gamble reduction is pocket-sized	"At your historic period and with your family history, the take a chance of developing this kind of cancer is most two out of 1,000, instead of one out of 1,000 for people without your family history," rather than maxim that the risk "doubles" or increases by 100%
Avoid using only positive (gain) or negative (loss) risk framing, and instead use both	"Pressure from the camera that passes through the whole wall of the colon is very rare. This happens in less than 1 out of 1,000 people. In other words, it doesn't happen in 999 people."
Keep time spans at about ten years if possible, rather than talking about lifetime risk	To a 60-yr-old human being: "i or 2 out of 10 men your age will go colorectal cancer in the next 10 years."

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Information Sources: A PubMed search was completed in Clinical Queries using the key terms health literacy, numeracy, interventions, and cess. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. We limited our search to articles written in English language. Nosotros also searched the Bureau for Healthcare Inquiry and Quality Evidence Reports, National Guideline Clearinghouse, Medline, and Google Scholar. There were no specific date parameters. Search date: November eleven, 2014.

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The Authors

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LAUREN HERSH, MD, is an teacher in the Department of Family and Community Medicine at Thomas Jefferson Academy in Philadelphia, Pa....

BROOKE SALZMAN, MD, is an associate professor in the Department of Family and Community Medicine at Thomas Jefferson University.

DANIELLE SNYDERMAN, Md, is an assistant professor in the Section of Family and Community Medicine at Thomas Jefferson University.

Writer disclosure: No relevant financial affiliation.

Address correspondence to Lauren Hersh, MD, Thomas Jefferson University Infirmary, 833 Chestnut St., Ste. 301, Philadelphia, PA 19107 (e-postal service: lauren.hersh@jefferson.edu). Reprints are not bachelor from the authors.

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