Nurses provide a lot of written teaching material to their patients through brochures, booklets, diet lists, medication teaching cards, and questionnaires. Unfortunately, much of this literature goes unused because half of all Americans might not be able to read it.¹

Widespread illiteracy

A 1993 U.S. Department of Education<www.ed.gov> survey found that about 44 million adult Americans fell into the lowest of five categories of literacy skills. These people were functionally illiterate, reading below a fifth-grade level. When combined with those who read at the next higher level of ability (grade levels five through seven), the survey found that 90 million people — more than half of the adult population — had very limited reading abilities.²

People with poor reading skills have a difficult time in our society. They can’t read street signs or maps and must rely on television or other people to tell them what is occurring in the world. Barely 18% of adult Americans could comprehend a simple bus schedule that included five stops each way and 20 starting times.³ The National Center for Education Statistics found that adult’s ability to read and understand sentences has changed little between 1992 and 2003.⁴ Problems with literacy plague some of the same groups most in need of health care. For example, two out of five people who are 65 or older or belong to inner-city minorities are functionally illiterate.^3,4 Research conducted in Arizona with people ages 60 and older found their average reading ability to be at the fifth-grade level with 32% reading at or below the fourth grade. The percentage of poor readers was probably much higher because many people refused to participate in the study. Only 32% were found to have fully developed reading skills, which are eighth grade and above.⁵ Over 40% of people with some type of chronic illness are illiterate,6 and misunderstanding provided information can lead to further complications and treatments failing at an estimated cost of $73 billion.⁷

Health literacy

Health literacy is the ability to read, understand, and act upon health-related information.⁸ Many adults have difficulty understanding directions for taking medications and dealing with the intricacies in the healthcare system for themselves and their families. Health literacy not only involves being able to read a sentence but to understand directions and being able to act on them.

People with limited health literacy have less knowledge about their health in general, are less able to manage their condition, do not seek preventive services, and have higher hospitalization rates. Overall low health literacy is associated with poorer physical health, poorer mental health, and higher healthcare costs. People with inadequate health literacy have significantly higher rates of some chronic conditions, including hypertension, diabetes mellitus, heart failure, and arthritis. They are also less likely to tell their provider that they have symptoms of chronic bronchitis or emphysema.⁹

Handouts that can’t be read

Even though the average reading level of adults in the U.S. is between the eighth and ninth grades, most healthcare instructions are written at or above the ninth-grade reading level.³ A mismatch between the reading content levels of teaching materials and their intended readers ’ abilities have emerged in several healthcare settings and organizations.

• A 1992 study found that The Arthritis Foundation issued only one pamphlet written at the eighth-grade level; their other pamphlets included four at the 10th-, six at the 11th-, two at the 12th-, and two at the 13th-grade levels. Thirty-one percent of their clientele read below the seventh-grade level and would not be able to use any of the pamphlets. Fifty-one percent read at or below the 10th-grade level and would be able to use only five of the 15 pamphlets.¹⁰
• An analysis of material at an oncology clinic found that the reading content of 30 cancer-related handouts ranged between the sixth- and 16th-grade levels. However, 27% of the patients were reading at or below the sixth-grade level, 17% at the sixth- to eighth-grade level, 29% at the ninth- to 12th-grade levels, and 27% above the 12th-grade level. Only 27% of the clients would be able to understand all 30 handouts.¹¹
• A study of 136 HIV/AIDS-related handouts revealed that more than 50% of the material fell within the 10th- to 12th-grade and 13% within the 13th- to 16th-grade reading levels. Fewer than 10% fell within the third- to sixth-grade and 26% within the seventh- to ninth-grade levels. The mean grade level of all handouts was 11.¹²
• The reading level of 10 commonly used preprinted discharge instructions in an urban ED ranged from the eighth- to 14th-grade reading levels. Although the content level of the instructions matched the mean reading level of 82 tested patients, 12% of them were functionally illiterate. Approximately 45% of the patients would not be able to understand what they were to do once they left the ED.¹³

A hard reality for patients

Patients with poor reading skills may have difficulty using healthcare practices that are elementary to those of us who can read. For example, some patients may be unable to interpret self-help messages that caution against unprotected sex. They often can’t read a simple diet plan to lower their sugar, fat, or sodium intake or understand that a low-fat diet doesn’t necessarily mean that they must totally eliminate anything fattening, including potatoes, rice, and bread, from their diet.¹⁴ When it comes to medications, poor readers may be unclear about how to administer medications to a child twice a day or the difference between a teaspoon and tablespoon. By not being able to read and comprehend a route of administration, they can even have trouble deciding if a medication for an ear infection should be administered by mouth or directly into the ear.

Many patients are not able to read simple instructions distributed after outpatient surgery or ED visits. For example, nearly one-third of the patients in a Los Angeles ED were unable to identify the date of their follow-up appointment from a standard appointment slip. Another third could not understand instructions about preparing for a procedure, even though the material was written at a fourth-grade reading level.¹² Fifty-eight percent of the ED patients couldn’t even read the directions on a prescription label.¹⁵

Anecdotes underscore the dangers. One man who lived at home with his family was discharged from a hospital after recurrent congestive heart failure. A cardiologist instructed him to take digoxin (Lanoxin, Digitek), 0.125 mg PO, alternating with 0.25 mg PO every other day. The patient stated that he understood the directions and was given written instructions for reference. At the next visit, his digoxin level was well above therapeutic range. He had been taking both pills every day instead of alternating doses. He still had the written directions in his wallet, but admitted that he could not read them stating, “I don’t want anyone to know. They’ll think I’m stupid.” ¹⁶

Improving patient education

Improving the quality of a patient’s recovery as well as enhancing compliance with follow-up care often depends on well-written and easy-to-understand materials.^4,16 And readable literature is not an option, but a requirement: The Joint Commission mandates that patients be informed. One Joint Commission standard states that teaching should be provided in a comprehensible manner that takes literacy, educational level, and language into consideration.¹⁷

The good news is that nurses can make handouts more readable for patients with poor reading skills. The most important component is to match the reading level of the handout to the reading level of patients. This intervention involves a two-step process: First, test the reading skills of the patients who will be receiving the handouts. Then analyze the reading level of materials currently in use and rewrite them to reflect the true reading level of the patients tested in step one.

Assessing patients’ reading abilities

Nurses need to know the patients they serve. Different facilities may have patient populations with diverse reading levels. For example, a hospital in the suburbs may have patients who read at different levels than the clientele of some urban clinics.

Unfortunately, nurses cannot determine patients ’ reading levels simply by asking them what their last grade in school was, if they are a high school graduate, or if they understood a handout. The assumption that people who graduated from high school have a 12th-grade level reading ability does not hold true. On average, adults ’ reading levels are about five grade levels lower than the last grade completed.^3,18

Poor readers may not present a realistic appraisal of their skills. For example, one researcher found that two-thirds of those reading at the very lowest reading levels reported that they “read well” or “read very well.” ³ These same adults may be very intelligent but have not had a chance to acquire the necessary skills. They may feel a sense of shame and a lifetime of embarrassment. When asked to read, a poor reader may try to conceal the deficit by using an excuse, such as “I forgot my glasses.”

Such excuses mask an activity that can be stressful for some. Poor readers read differently than those who are more adept. Good readers read a sentence through completely and then decode the entire sentence to derive a complete thought. Poor readers read and decode each word individually in a sentence. By the time they decode the last part of a sentence, they may forget what the first part was about and become frustrated.

Two easy methods are available to test the reading level of patients: the Wide-Range Achievement Test (WRAT3) and the Rapid Estimation of Adult Literacy in Medicine (REALM). Nurses can learn how to administer WRAT3 in about an hour and an individual patient can be tested in about five minutes.³ Patients are given a card with lists of words of increasing difficulty. They read down the list until they have mispronounced 10 words, at which time the test is stopped and scored. Some experts suggest the test can even be stopped after five mispronounced words with equally accurate results.³

REALM is similar to WRAT3, but may be more acceptable to patients because the word list contains health-related words. This test can be administered in two to three minutes and is easily scored.¹⁹ Although some patients may become anxious, most will enjoy the attention they receive by participating in the test, especially if the nurse is honest in explaining its purpose — to make user-friendly handouts.

Matching the reading level

Ideally, every patient should be tested and then given handouts specifically matched to his or her reading level. However, a more realistic goal is to devise literature that can be used by as many patients as possible. Once the abilities of patients on a particular unit or setting have been assessed, a general range of reading levels can be identified. The reading level of handouts should be adjusted as low as possible to reach the maximum number of patients without giving up important information. Some nurses may feel that patients with higher reading levels might object to handouts several grades below their reading level, but people actually prefer material that is simpler to read.^3,14 To save time and money, it may be wise to have all materials set at the sixth-grade reading level, which is generally reasonable for all health-related handouts and allows for at least 75% of patients to be able to read them.³

The easiest solution is to buy already published literature at the required reading level. However, many nurses choose to develop their own material that is tailored to their practice settings or institutional policies. In this case, nurses need to analyze the reading level of handouts currently in use and change them to a more appropriate level. If these handouts are computerized, an easy way to assess them is to use a software program with reading analysis capabilities. At least a dozen computer programs, including those for word-processing and grammar-checking, such as WordPerfect^® and Microsoft Word^® , are currently available.³

If a computer solution is not available, the Fry Formula or SMOG Index works well. These formulas assess the reading level of text by using word and sentence lengths. To use the Fry Formula, a nurse selects three samples of 100 words each from different parts of the text.²⁰ The average number of syllables and average number of sentences are plotted on a graph that then shows the grade level.

The SMOG Index is less accurate than the Fry Formula, but easier to use. SMOG also uses the number of syllables in a given piece of text with a conversion chart that translates the score into a grade level.²¹ Both are free, easily used, and quickly mastered.

Improving patient handouts

Nurses are used to processing a great deal of information about health and illness. Although they may feel a need to impart all of that knowledge to patients, nurses should guard against producing handouts that are lengthy, complicated, and too comprehensive. Only essential information that patients need to know at a particular moment should be included in the material, and information should be prioritized. For instance, patients newly diagnosed with diabetes might need to know which foods they should avoid before they need to know the etiology of their disease. Once patients have mastered essential basic knowledge, they can build on that information.

Although graphics and pictures add impact and interest to handouts, they should be used cautiously. Anatomical drawings are too complicated and not suitable. Pictures should be simple line drawings that are specific to the message, so that poor readers can use them as clues to understand the information. Pictures should never be used as decorative ornamentation, but rather to demonstrate actions. For instance, a well-baby clinic might use a simple illustration to show mothers how to hold and feed newborns.

The font or typeface should be selected with care. Generally, a serif font at a size of 12 to 14 points or larger is a good choice. Serif fonts, used in books and newspapers, have little bars at the tops and bottoms of the letters that help patients read across a line of text. Sans-serif fonts do not have these bars, so patients have a harder time reading across a line of text. Sans-serif fonts can be used in headings, but serif fonts should be used exclusively in the body of the text. Fancy, hard-to-read script should be avoided, and text should never be presented in all uppercase letters. Titles or headings underlined or in bold should be used to introduce new sections. Poor readers use these as clues that a new topic is coming up.

Although nurses may be comfortable with technical terminology, common words are more appropriate with poor readers. Use two-syllable, uncomplicated, nontechnical words whenever possible. And the active voice is more effective than the passive voice. A statement, such as “Take one tablet before each meal” will be more effective than “It is better if this medication is taken before meals.”

If in doubt about the suitability of words or phrases, ask the patients. For example, they might not know what an “injection” is, but most know what it means to “get a shot.” Some might not recognize their “physician,” but everyone will know who their “doctor” is. Handouts should contain examples with which patients can identify, and accompanying directions that are simple and direct, such as “This means that you should not put any extra salt on your food at the dinner table.”

Targeting patients

By involving patients in the development of handouts, the material is more likely to be culturally appropriate, as well as reader friendly. All handouts should be pilot tested with a group of patients before final production. Handouts should use language and pictures familiar to the culture of the patients. For example, a clinic that primarily serves Hispanic patients should distribute handouts written in Spanish with pictures of Hispanic people. When teaching well-baby care in an Asian neighborhood, nurses could be more effective by using pictures of Asian mothers and children rather than those of Caucasians. Individual cultural groups are more likely to read handouts if they can identify with the material and perceive that the literature was produced for them.

When giving nutritional information, use foods that are familiar and relevant to the targeted cultural group, rather than using pictures of food that the group might not eat nor have available in their neighborhood stores. Suggestions should also be appropriate to the habits of the targeted group. For instance, when giving dietary advice to a group, be sure to know if members are likely to cook at home or dine out. If a person tends to frequent fast food restaurants or lunch carts, advice about what foods to choose might be more valuable than instructions about how to cook foods at home.

Literature should be age-specific as well as culturally appropriate. For example, handouts aimed at teenagers should feature pictures of their peers. A handout in a Hispanic neighborhood might show two Hispanic, teenage girls discussing abstinence as a way to avoid becoming pregnant.

Although patients with poor reading skills present unique challenges to effective teaching, nurses can do many things to make their handouts more useful. But the most important strategy is to adjust the reading levels of handouts to the reading levels of the patients.