Health literacy demonstrator site - Headline report three

Posted by Dr Phyllis Easton on 16-01-2017
Health literacy demonstrator site - Headline report three

Meaningful communication before medical procedures

The issue

In some healthcare settings patient instruction prior to medical interventions may primarily or exclusively depend on written materials containing complex requirements ranging from strict adherence to dietary restrictions. The success of some procedures is dependent on the quality of patient preparation. The readability of relevant written information is therefore an important issue in ensuring that patients are appropriately supported to carry out any necessary preparation. Such information written beyond the reading and comprehension skills of the target audience may not serve its intended purpose.

We considered that endoscopy provided a good example where patients are sent instructions for the bowel preparation required prior to the procedure.

What we did

The readability levels of the written information leaflets for various endoscopy procedures, namely gastroscopy, same day flexible sigmoidoscopy and barium enema, upper gastro-intestinal endoscopic ultrasonography, flexible sigmoidoscopy and colonoscopy were tested in two ways:

  • Computer software based readability measures Simple Measure of Gobbledygook (SMOG) and Flesch-Kincaid Grade Level (FKGL) were used to assess readability of the leaflets send out prior to procedures
  • Adult learners who had sought help with literacies assessed the appointment letter and leaflets for readability and comprehension


What we learned:

The readability estimates of the leaflets using the FKGL ranged from 7.4 to 8.8 with overall Mean score of 8 [95% CI 7.3 to 8.7], which is equivalent to 7th -9th grade or school age 12-15.

For the same leaflets, the readability grade level estimate using the SMOG index ranged from 12.16 to 12.63, with overall Mean score of 12.39 [95% CI 12.1 to 12.7] which is above the 12th grade or school age 15-17.

Not surprisingly, adult learners reported, that medical jargon in the leaflets was difficult to understand e.g. CJD or vCJD; Sedation; Sedative; Cannula. However, this exercise highlighted that words or phrases that are not necessarily medical jargon can still be difficult to understand. Examples from the gastroscopy leaflet were:

Word/phrase in patient information leaflet Alternative suggested by learners

Discontinue - Stop
Prior to - Before
Potentially - Possibly
We are working to the principle of providing -  We provide; or We aim to provide
Following - After
Significant - Important

Other unclear, ambiguous words and phrases were identified.

In general, some learners said that, prior to their present learning, they would have needed someone to read the leaflet and explain it to them. Adult learners stated that they:

“would have signed the consent form but would have lied about understanding the information given.”

The standard appointment letter was also assessed by the adult learners. It was considered to be too long; it had 2 paragraphs of explanation about the conditions around guarantee to be seen within a certain time; and the instructions for what to do were unnecessarily complex e.g. “If you know of anything that may prevent you from attending your appointment ...” It was suggested that the letter could be laid out more simply with instructions in short sentences and plain language.

Conclusion and next steps:

This example is not unique to the clinical area it focused on. Clear and meaningful patient-provider communication before and after medical interventions can remove literacy barriers, improve shared decision making, and ultimately improve health outcomes in individuals at all literacy levels. Having adequate reading and writing skills does not mean that the content of written material can be interpreted appropriately. In this project, the software was useful in assessing grade level. However, the algorithms used do not measure comprehension or how information may be interpreted by different people. The input from the adult learners in this case was invaluable and gave us suggestions for improvement rather than highlighting the problems only.

There are several guidelines relating to the production of patient information but testing the final product with real people from various backgrounds will help ensure that instructions are clear and appropriate.  It is hoped to continue this work through testing different ways of communicating information with a variety of participants.

This project was the subject of a Master of Public Health dissertation at Dundee University.

Resources and further information

Plain English Free Guides

Patient Information Forum Quick Guides

Written by Dr Phyllis Easton

Health Intelligence Manager

NHS Tayside