Maximizing Comprehension of Health Messages for Different Literacy Levels

Working in health care, you’re likely to care for patients across a range of literacy levels—depending on their native language, education level and ability to comprehend complicated or unfamiliar health information.
It’s impractical to assume that a patient is able or willing to take notes during the office visit. To ensure your patient is leaving with the facts they need, a written health education tool is a great way to reinforce clinical visit information and instructions. The goal is to create a resource the patient can refer to for clarification of their condition and what to do when they need help.

One way to ensure patient comprehension of these tools is to develop your content at the most appropriate literacy level. While you likely have a great literacy-level tool readily available—via Microsoft® Word readability statistics—the only way you can increase comprehension is to use a manual method. For instance, the Simple Measure of Gobbledygook (SMOG) method (McLaughlin, 1969) can help you find the areas in your document that unnecessarily increase its literacy level, thus reducing its comprehension level. Usually these will be things like sentence length and use of polysyllabic words (more than three syllables). The key is to decrease word and sentence length without compromising the intent of the material or the reader’s intelligence.

Here are the steps I’ve used for more than 17 years:

SMOG Literacy-Level Testing Steps (Hopp, 1993)

Step One: Select three sample sections of 100 words each in different parts of your document. Write “100” next to each of the chosen sample sections.

Step Two: Count the number of sentences in each sample section. Write the number next to that sample section.

Step Three: Count the number of words that have more than three syllables. Write that number next to that sample section. Don’t count names or words that are normally less than three syllables but become longer because it changes form—for example, respectable, strengthening, assessment, instructions, etc. Keep in mind that some words have more than three syllables but are well-known by most populations so you won’t have to change them. Understand is one of those words. As a result, the grade level may appear higher.

Step Four: Now for the math. For each section:

A. Divide 100 by the number of sentences.
B. Add that number to the total number of words with more than three syllables.
C. After you have completed A and B, add each of the sample sections together to get a sum.
D. Divide the sum by three (because there are three sections) and obtain a product.
E. Multiply that number by .4 to get the literacy level. That number represents the grade level. The desired grade level will depend on your target audience—be sure not to offend their intelligence if the level is too low.

Step Five: Literacy level depends on the target audience. When working with lower educational-level populations, it’s recommended that materials be written between the fourth and sixth grade reading level. To adjust the literacy level you’ll need to do one or all of the following:

Shorten sentences. Break up long sentences into shorter ones, or simply reduce the number of words in them. The more sentences you have in a 100-word sample the lower the literacy level, which is the goal.
Decrease number of words with more than three syllables. Use a thesaurus to find simpler ways of describing a lengthier word. For example: “The efficacy of this statement has yet to be proven” can be simplified as this: “It’s not yet known if this statement is true and will work.”
Do the math again to see if the literacy level has changed. If not, continue to find ways to make the document easier to read by shortening sentences and making words simpler. 

Step Six: Field test with your target audience.

There are other methods that can help you improve clinician/patient interactions that will result in excellent patient compliance, comprehension and retention. While I enjoy using the SMOG method, you should consider the various websites and toolkits available to you at no charge.

The resources listed below are specific to health care professionals:

California Health Literacy Initiative

Food and Nutrition Information Center - Health Literacy Resource List for Educators 2007

National Center for the Study of Adult Learning and Literacy

Agency for Healthcare Research and Quality

You’re in health care to make a difference in the lives of others. By taking the time to ensure your patients fully understand your health care literature and instructions, you help improve the quality of their lives.

References

Friedman, D.B. and Kao, K. (2008, January). A comprehensive assessment of the difficulty level and cultural sensitivity of online cancer prevention resources for older minority men. Preventing Chronic Disease, 5(1), A07.

Hopp, H. (1993). Health Education and Curriculum Design. Loma Linda, CA: Loma Linda University.

McLaughlin, G.H. (1969). SMOG grading: A new reading formula. Journal of Reading, 12, 639–640.