How to make teaching materials that work
Conversational language and common words help
In a report titled Low Health Literacy: Implications for National Health Policy, issued by the University of Connecticut in Storrs, the authors state that at every point of securing health care services, patients are required to read and understand important information.
However, those with poor reading skills have difficulty understanding forms of consent, pamphlets on how to manage a chronic disease, and specific instructions on self-care after a treatment procedure. It is important that written materials are understood by all patients, regardless of reading ability.
To address this problem, patient education managers are making sure that teaching materials are written at a grade level that is suitable for the patient population the institution serves.
Reading level for all written information can be determined by using a readability scale.
Diane C. Moyer, BSN, MS, RN, program manager of consumer health education at The Ohio State University Medical Center in Columbus prefers to use the Fry readability scale.
Using this method, you select three, 100-word sections in the document at the beginning, middle, and end. You count the number of sentences in each section of 100 words and the number of syllables in each 100 words. You then find the average number of sentences and the average number of syllables, and with this information and the use of a Fry graph, you determine the reading level.
Moyer says a good resource for readability tools is the book "Teaching Patients with Low Literacy Skills" by Doak, Doak, and Root (available as a free download at www.hsph.harvard.edu/healthliteracy/doak.html).
"It can take 10-15 minutes to do a manual Fry calculation, but once you have done it a few times, you get much faster. I generally take about five minutes if I am not interrupted in my counting," says Moyer.
To determine the reading level of materials used at Phoenix Children's Hospital, Fran London, MS, RN, health education specialist at The Emily Center, prefers the Suitability Assessment of Materials (SAM score). This, too, can be obtained from the book authored by Doak, Doak, and Root in chapter four, "Assessing Suitability of Materials."
"The steps involve calculating a score for each dimension including organization, writing style, appearance, and appeal and then totaling the SAM score for the piece. If the material has too high a grade reading level or is culturally inappropriate, it is not suitable for use," says London.
The process of filling out the SAM can take some time initially, but once you've used it a few times, it goes much quicker, adds London. "An experienced person can glance at a document and know if it needs to be edited for readability," she says.
Clues to easy-to-read manuscripts
There are clues that indicate material is easy to read and understand. For example, easy-to-read material is made personal by using the pronoun "you" and using a conversational style. Rather than using medical generalizations, concrete recommendations are given, says Sandra Cornett, RN, PhD, director of the AHEC Clear Health Communication program at The Ohio State University College of Medicine in Columbus.
In a document issued by the AHEC program, illustrations are provided of how material written at about a 12th-grade level was rewritten at an 8th-grade level and then a 4th-grade level.
Here are the examples:
Original copy: It makes good sense that premature births and newborn illnesses are decreased by early pregnancy care. The doctor is actively involved in testing the pregnant woman for pregnancy-induced diabetes and a host of other problems that would not be detected by the patient alone. We know that these problems cause premature births and illness in newborns. It certainly makes sense that early detection and treatment of these problems by the doctor results in healthier babies.
Copy at 8th-grade level: If you are pregnant or think you may be pregnant, call for an appointment right away. Getting care early in your pregnancy will help you have a healthy pregnancy and healthy baby. Your doctor will give you a complete check-up and will also do certain tests to make sure everything is going well. If there are any problems, it's good to find them early for the best chance for a healthy baby.
Copy at a 4th-grade level: (Readability has been lowered by using shorter sentences and eliminating most words with more than two syllables.) If you are pregnant or think you might be, go to the doctor as soon as you can. If you start your care early, things will go better for you and your baby. Your doctor will give you a first exam. Tests each month will let you know if all is going well. If there is a problem, you will know it right away. Then we can do what is needed to keep you healthy. Early care is the best way to have a healthy baby. Your baby counts on you!
According to London, if the grade reading level is too high, the word choices are too sophisticated and/or the sentences too long. She suggests the following steps for reducing the reading level:
- Think about what the writer is trying to say. What is the reader supposed to learn or do? Convey the same message using words that are normally used in conversation.
- Use common words of one or two syllables whenever possible.
- Convert long, complex sentences into lists.
- When medical terms are used, describe them first in the sentence, then put the sophisticated term (jargon) in parentheses after the definition.
- Break up content into chunks and put a subheading on each chunk.
- Recheck the grade reading level and repeat steps if necessary.
Moyer says when the reading level is too high, she usually starts with complex sentences and tries to break those down into more simple sentences. Also, she looks at the larger words in the document.
"Do you really want to use 'cardiac' when 'heart' may work? Use more common language and be sure the message you want to convey is clear and focused on only two or three points," she advises.
In addition to simplifying the text, make sure the font size is at least 12 and use Times or another serif font, she adds. Also the material should be written in a more active voice rather than passive and the page should have plenty of white space. If illustrations are used, make sure they add to the message and are clearly labeled, says Moyer.
To ensure foreign language materials are not written at too high a grade level, start with an English version at a lower reading level. Work with the translators to have them use more conversational language rather than professional language, says Moyer.
SOURCES
For more information about assessing the reading level of written materials, contact:
- Sandra Cornett, PhD, RN, director, OSU/AHEC Health Literacy Program, Office of Health Sciences, The Ohio State University, 218 Meiling Hall, 370 West 9th Avenue, Columbus, OH 43210-1238. Phone: (614) 292-0716. E-mail: [email protected].
- Fran London, MS, RN, health education specialist, The Emily Center, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016-7710. Phone: (602) 546-1408. E-mail: [email protected].
- Diane Moyer, BSN, MS, RN, program manager, consumer health education, The Ohio State University Medical Center, 1375 Perry Street Rm 524, Columbus, OH 43201. Phone: (614) 293-3191. E-mail: Diane. [email protected].
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