Journal of Public Health Policy

, Volume 28, Issue 1, pp 71–93

Plain Language: A Strategic Response to the Health Literacy Challenge

Article

Abstract

Low health literacy is a major challenge confronting American and international health organizations. Research in the past decade has documented the prevalence of limited literacy and limited health literacy skills among adults worldwide. This creates a major policy challenge: how to create text-based health information – a common method of health communication – that is accessible to the public. Plain language is a logical, flexible response. While touted by American, Canadian, and European health policy makers, adoption and promotion of plain language standards and skills in health-focused organizations have lagged. Most text-based health information continues to be too hard for most adults to read. Barriers to more rapid diffusion of plain language are reflected in a set of myths perpetuated by critics. These myths are identified and refuted. While plain language is only one of many broad-based solutions needed to address low health literacy, the benefits to everyone demand increased use by health organizations.

Keywords

literacy health literacy low health literacy health communication plain language reading skills 

References

  1. National Institutes of Health, National Library of Medicine. Current Bibliographies in Medicine: Understanding Health Literacy and Its Barriers; May 2004. Available at: http://www.nlm.nih.gov/pubs/cbm/healthliteracybarriers.html, accessed 15 May 2006.
  2. Rudd R, Colton T, Schacht R . An overview of medical and public health literature addressing literacy issues: an annotated bibliography. NCSALL Report No. 14. Boston, MA: National Center for the Study of Adult Learning and Literacy; 2000. Available at: http://www.ncsall.net/?id=665, accessed 15 May 2006.Google Scholar
  3. Nielsen-Bohlman L, Panzer A, Kindig P, editors. Health Literacy: A Prescription to End Confusion. Washington, DC: Institute of Medicine (IOM), National Academies Press; 2004.Google Scholar
  4. Klare G . The Measurement of Readability. Iowa: Iowa State University Press; 1963.Google Scholar
  5. Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, et al. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87, AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality; 2004.Google Scholar
  6. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A . Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey (NALS). Washington, DC: National Center for Education Statistics, US Department of Education; 1993.Google Scholar
  7. Parker R, Ratzan S, Lurie N . Health literacy: a policy challenge for advancing high-quality health care. Health Aff. 2003;22:147–153.CrossRefGoogle Scholar
  8. Rudd R, Kirsch I, Yamamoto K . Literacy and Health in America. Princeton, NJ: Educational Testing Service; 2004. Available at: http://www.ets.org/Media/Research/pdf/PICHEATH.pdf, accessed 15 May 2006.Google Scholar
  9. Kutner M, Greenberg E, Baer J . National Assessment of Adult Literacy (NAAL): A First Look at the Literacy of America's Adults in the 21st Century. Jessup, MD: US Department of Education; 2005. Available at: http://nces.ed.gov/naal, accessed 15 May 2006.Google Scholar
  10. Gazmararian J, Williams M, Peel J, Baker D . Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51:267–275.CrossRefGoogle Scholar
  11. Scott T, Gazmararian J, Williams M, Baker D . Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care. 2002;5:395–404.CrossRefGoogle Scholar
  12. Kalichmann S, Ramachandran B, Catz S . Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14:267–273.CrossRefGoogle Scholar
  13. Baker D, Parker R, Williams M, Clark W, Nurss J . The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87:1027–1030.CrossRefGoogle Scholar
  14. Baker D, Parker R, Williams M, Clark W . Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13:791–798.CrossRefGoogle Scholar
  15. Schillinger D, Davis T . A conceptual framework for the relationship between health literacy and health care outcomes: the chronic disease exemplar. In: Schwartzberg J, VanGeest J, Wang C, editors. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago: AMA Press; 2005. p. 181–203.Google Scholar
  16. WHO. Global health promotion scaling up for 2015 – a brief review of major impacts and developments over the past 20 years and challenges for 2015 WHO Secretariat Background Document, Unedited Working Paper; 14-07-2005. Available at: http://www.who.int/healthpromotion/conferences/6gchp/hpr_conference_background.pdf, accessed 15 May 2006.
  17. High Level Group on Innovation and Provision of Medicines in the European Union: Recommendations for Action. European Commission Report; May 2002. Available at: http://ec.europa.eu/comm/health/ph/key_doc/key08_en.pdf, accessed 15 May 2006.
  18. Statistics Canada. Building on our Competencies: Canadian Results of the International Adult Literacy and Skills Survey; 2003. Available at: http://www.statcan.ca/english/freepub/89-617-XIE/89-617-XIE2005001.pdf, accessed 15 May 2006.
  19. Organization for Economic Cooperation and Development and Statistics Canada. Literacy, Economy, and Society: Results of the first International Adult Literacy Survey OECD and Statistics Canada. Catalogue No. 89-545E. ISBN 92-64-14655-5; Paris: France; 1995.Google Scholar
  20. Organization for Economic Cooperation and Development and Statistics Canada. Learning a Living: First Results of the Adult Literacy and Life Skills Survey. OECD and Statistics Canada; 2005. Available at: http://www.statcan.ca/english/freepub/89-603-XIE/2005001/pdf/89-603-XWE-part1.pdf, accessed 15 May 2006.
  21. Plain language guidelines. Available at: http://www.plainlanguage.gov, accessed 15 May 2006.
  22. Plain language guidelines. Available at: http://www.plainlanguagenetwork.org, accessed 15 May 2006.
  23. Plain language guidelines. Available at: http://www.cdc.gov/communication/resources/simpput.pdf, accessed 15 May 2006.
  24. Effective Communication: A Leading Indicator of Financial Performance, 2005/2006. Watson Wyatt Worldwide, Communication ROI Study, Catalog #W-868, p. 1.Google Scholar
  25. Vice Admiral R.H. Carmona United States Surgeon General. From Remarks Delivered to the American Medical Association House of Delegates Meeting, June 14, 2003. Available at: www.surgeongeneral.gov/news/speeches/ama061403.htm, accessed 15 May 2006.
  26. President William Clinton's Memorandum on Plain Language in Government Writing; 1998. Available at: www.plainlanguage.gov, accessed 15 May 2006.
  27. AMA, Ad Hoc Committee on Health Literacy. Health Literacy: Report of the Council on Scientific Affairs. JAMA. 1999;281:552–557.Google Scholar
  28. Schwartzberg J, VanGeest J, Wang C, editors. Understanding Health Literacy. Chicago: AMA Press; 2005.Google Scholar
  29. Information about the Partnership can be accessed at this website: http://www.askme3.org/PFCHC/, Accessed 15 May 2006.
  30. Information about Harvard's program can be accessed at this website: http://www.hsph.harvard.edu/healthliteracy, accessed 15 May 2006.
  31. The National Cancer Institute publishes a template for plain language consent forms for cancer clinical trials. Available at: http://www.cancer.gov/clinicaltrials/understanding/simplification-of-informed-consent-docs, accessed 15 May 2006.
  32. Wu H, Nishimi R, Page-Lopez C, Kizer K . Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy – A National Quality Forum Implementation Report; 2005. Available at: http://www.qualityforum.org/docs/informed_consent/webinformedconsentMember+public09-13-05.pdf, accessed 15 May 2006.
  33. Information about Pfizer health literacy efforts. Available at: http://www.pfizer.com, accessed 15 May 2006.
  34. Information about Canadian Public Health Association health literacy efforts. Available at: www.cpha.ca, accessed 15 May 2006.
  35. Information about the EU campaign. Available at: http://ec.europa.eu/comm/translation/en/ftfog/index.htm, accessed 15 May 2006.
  36. Information about Plain Language Association International. Available at: http://www.plainlanguagenetwork.org, accessed 15 May 2006.
  37. Jacobson T, Thomas D, Morton F, Offutt G, Shevlin J, Ray S . Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. JAMA. 1999;282:646–650.CrossRefGoogle Scholar
  38. Grotsky R . Plain language: its effect on organizational performance. Clarity. 2004;51:17–19.Google Scholar
  39. Bagin CB . Plain language pays off for the Social Security Administration. Clarity. 2000;45:2–4.Google Scholar
  40. Hibbard J, Peters E . Supporting informed consumer health care decisions: data presentation approaches that facilitate the use of information in choice. Annu Rev Public Health. 2003;24:413–433.CrossRefGoogle Scholar
  41. Strunk W, White EB . The Elements of Style 3rd edition. New York: Macmillan Publishing Co.; 1979.Google Scholar
  42. Authors' rewrite.Google Scholar
  43. Authors' rewrite. NIH publication, Understanding Alzheimer's Disease from which this passage was selected. Available at: http://www.nia.nih.gov/Alzheimers/, accessed 15 May 2006.
  44. Doak C, Doak L, Root J . Teaching Patients with Low Literacy Skills, 2nd edition. Philadelphia: JB Lippincott; 1996.Google Scholar
  45. National Cancer Institute, National Institutes of Health. Making Health Communication Programs Work 2nd edition, NIH Publication No. 02-5145. US Department of Health and Human Services, Bethesda: MD; 2002.Google Scholar
  46. Maiback E, Parrott RL, editors. Designing Health Messages: Approaches from Communications Theory and Public Health Practice. California: Sage Publications; 1995.Google Scholar
  47. Glanz K, Rimer B . Theory at a Glance: A Guide for Health Promotion Practice NIH Publication No. 95-3896. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Bethesda: MD; 1995.Google Scholar
  48. Knowles MS . The Modern Practice of Adult Education: From Pedagogy to Andragogy. Chicago, IL: Association Press/Follett; 1980.Google Scholar
  49. Frederiksen LW, Solomon LJ, Brehony KA, editors Marketing Health Behavior. New York: Plenum Press; 1984.CrossRefGoogle Scholar
  50. McGee J . Writing and Designing Print Materials for Beneficiaries: A Guide for State Medicaid Agencies. HCFA Publication No. 10145. US Department of Health and Human Services, Centers for Medicare and Medicaid Services; 1999.Google Scholar
  51. Parker R . Looking Good in Print, 4th edition. Arizona: The Coriolis Group; 1998.Google Scholar
  52. Williams R . The Non-Designer's Design Book, 2nd edition. Berkeley, CA: Peachpit Press; 2004.Google Scholar
  53. Kostelnick C, Roberts D . Designing Visual Language: Strategies for Professional Communicators. Boston: Allyn and Bacon; 1998.Google Scholar
  54. Lohr L . Creating Graphics for Learning and Performance: Lessons in Visual Literacy. New Jersey: Merrill Prentice-Hall; 2003.Google Scholar
  55. Krueger R, Casey MA . Focus Groups, A Practical Guide for Applied Research, 3rd edition. California: Sage Publications; 2000.Google Scholar
  56. Spyridakis J, Wenger M . Writing for human performance: relating reading research to document design. Tech Commun (2nd quarter) 1992;39 (2):202–215.Google Scholar
  57. Chall J, Dale E . Readability Revisited: The New Dale–Chall Readability Formula. Cambridge MA: Brookline Books; 1995.Google Scholar
  58. Ley P, Florio T . The use of readability formulas in health care. Psychol Health Med. 1996;1:7–28.CrossRefGoogle Scholar
  59. Pearson DP, Barr R, Kamil M, Mosenthal P, editors. Handbook of Reading Research. White Plains, NY: Longman Inc.; 1984.Google Scholar
  60. Schriver K . Dynamics in Document Design. New York: John Wiley & Sons; 1997.Google Scholar
  61. Committee on Communication for Behavior Change in the 21st Century, Institute of Medicine (IOM). Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: National Academies Press; 2002.Google Scholar
  62. Pichert JW, Elam P . Readability formulas may mislead you. Patient Educ Couns. 1985;7:181–191.CrossRefGoogle Scholar
  63. Klare GR . The Measurement of Readability. Iowa: Iowa State University Press; 1963.Google Scholar
  64. Klare GR . Readability. In: Pearson DP, Barr R, Kamil M, Mosenthal P, editors. Handbook of Reading Research. White Plains, NY: Longman, Inc.; 1984. p. 681–744.Google Scholar
  65. Young DR, Hooker DT, Freeberg FE . Informed consent documents: increasing comprehension by reducing reading level. IRB Rev Hum Subjects Res. 1990;12:1–5.Google Scholar
  66. Davis TC, Holcombe RF, Berkel HJ, Pramanik S, Divers SG . Informed consent for clinical trials: a comparative study of standard versus simplified forms. J Natl Cancer Inst. 1998;90:668–674.CrossRefGoogle Scholar
  67. Meade DC, Byrd JC, Lee M . Improving patient comprehension of literature on smoking. Am J Public Health. 1989;79:1411–1412.CrossRefGoogle Scholar
  68. Eaton ML, Holloway RL . Patient comprehension of written drug information. Am J Hosp Pharmacy. 1980;37:240–243.Google Scholar
  69. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S . Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. JAMA. 1999;282:646–650.CrossRefGoogle Scholar
  70. Kleimann S, Enlow B . Is plain language appropriate for well-educated and politically important people? Results of research with congressional correspondence. Clarity. 2003;50:4–11.Google Scholar
  71. Flory J, Emanuel E . Interventions to improve research participants' understanding in informed consent for research. JAMA. 2004;292:1593–1601.CrossRefGoogle Scholar
  72. Davis TC, Mayeaux EJ, Fredrickson D, Bocchini Jr. JA, Jackson RH, Murphy PW . Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics. 1994;93:460–468.Google Scholar
  73. Meade CD . Improving understanding of the informed consent process and document. Semin Oncol Nurs. 1999;15:124–137.CrossRefGoogle Scholar
  74. Kimble J . Answering the critics of plain language. Scribes J Legal Writing. 1994–1995;5:51–85.Google Scholar
  75. Health Promotion Council of Southeastern Pennsylvania. Literacy, Health and the Law. 1996 and 2002. Available from Health Promotion Council at: 215-731-6150 or email: hpcpa@phmc.org.Google Scholar
  76. ABA resolution. Available at: http://plainlanguage.gov/populartopics/regulations/aba.cfm, accessed 15 May 2006.
  77. Kimble J . The great myth that plain language is not precise. Just say no to that lawyerly concept of: “Why say something in five words when you could say it in 10?”. Business Law Today; July/August 2000. Available at: http://www.abanet.org/buslaw/blt/blt7-kimble.html, accessed 15 May 2006.
  78. Pew Internet & American Life Project. Digital Divisions. Report released October 5, 2005. Available at: http://www.pewinternet.org/pdfs/PIP_Digital_Divisions_Oct_5_2005.pdf, accessed 15 May 2006.
  79. Zarcadoolas C, Blanco M, Pleasant A, Boyer JF . Unweaving the Web: an exploratory study of low-literate adults' navigation skills on the World Wide Web. J Health Commun. 2002;7:309–324.CrossRefGoogle Scholar
  80. Birru M, Monaco V, Charles L, Drew H, Njie V, Bierria T, et al. Internet usage by low-literacy adults seeking health information: an observational analysis. J Med Internet Res. 2004;6:e25. Available at: http://www.jmir.org/2004/3/e25/, accessed 15 May 2006.CrossRefGoogle Scholar
  81. Nielsen J . Lower-Literacy Users. Alertbox, March 14, 2005 (web page). Available at: http://www.useit.com/alertbox/20050314.html, accessed 15 May 2006.
  82. Berland G, Elliott M, Morales L, Algazy J, Kravitz R, Broder M, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA. 2001;285:2612–2621.CrossRefGoogle Scholar
  83. Kaphingst K, Zanfini C, Emmons K . Accessibility of Web Sites containing colorectal cancer information to adults with limited literacy (United States). Cancer Causes Control. 2006;17:147–151.CrossRefGoogle Scholar
  84. D'Alessandro D, Kingsley P, Johnson-West J . The readability of pediatric patient education materials on the World Wide Web. Arch Pediatr Adolesc Med. 2001;155:807–812.CrossRefGoogle Scholar
  85. Krug S . Don't Make Me Think: A Common Sense Approach to Web Usability. Indiana: New Riders Publishing; 2000.Google Scholar
  86. Shaller D . Consumers in Health Care: The Burden of Choice. California: California HealthCare Foundation. Available at: http://www.chcf.org/documents/insurance/ConsumersinHealthCareBurdenChoice.pdf, accessed 15 May 2006.
  87. Entwistle V, Mello M, Brennan T . Advising patients about patient safety: current initiatives risk shifting responsibility. Jt Comm J Qual Patient Saf. 2005;31:483–494.CrossRefGoogle Scholar
  88. Maximus. The Health Literacy Style Manual (prepared for Covering Kids & Families); 2005. Available at: www.coveringkidsandfamilies.org, accessed 15 May 2006.
  89. Irvine C . Health and Literacy Compendium. Boston: World Education; 1999. Available at: http://www.worlded.org/us/health/docs/comp/compendium.pdf, accessed 15 May 2006.Google Scholar
  90. McKinney J, Kurtz-Rossi S . Culture, Health and Literacy. Boston: World Education; 2000. Available at: http://www.worlded.org/docs/Culture_Health_Literacy.pdf, accessed 15 May 2006.Google Scholar
  91. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Quick Guide to Health Literacy Available at: www.health.gov/communication, accessed 15 May 2006.
  92. Dignan M, Plomer K, Raich P, Schneider L, Barley G, Cifuentes M, et al. Standardized Patient Cases on Cancer Screening & Literacy Issues. Colorado: AMC Cancer Research Center and University of Colorado School of Medicine. Available by telephone request to the Center for Standardized Patients at the University of Colorado Health Sciences Center: 303-724-1216. Requested May 2006.Google Scholar
  93. University of Virginia Health System. School of Medicine Health Literacy Curriculum. 2003. Available at: http://www.healthsystem.virginia.edu/internet/som-hlc/home.cfm, accessed 15 May 2006.
  94. American Medical Association Foundation and American Medical Association. Health Literacy: Help Your Patients Understand. 2003. Video can be viewed at: http://www.ama-assn.org/ama/pub/category/8035.html, Accessed 15 May 2006. The toolkit that includes the video and A Manual for Clinicians, can be ordered here: http://www.ama-assn.org/ama/pub/category/9913.html.
  95. Stableford S, Blum J . Evaluating Health Literacy/Plain Language Training: Learning Results from the 2005 Health Literacy Summer Institute Unpublished paper available from the author.Google Scholar
  96. The Clear Language Group offers professional expertise in health literacy, plain language, and cross cultural communication. Available at: www.ClearLanguageGroup.com, accessed 15 May 2006.
  97. DeWalt D, Pignone M . Reading is fundamental: the relationship between literacy and health [Editorial]. Arch Intern Med. 2005;165:1943–1944.CrossRefGoogle Scholar

Copyright information

© Palgrave Macmillan Ltd 2007

Authors and Affiliations

  1. 1.AHEC Health Literacy Center, University of New EnglandBiddefordUSA

Personalised recommendations