|Plain Language: A Promising Strategy for Clearly Communicating Health Information and Improving Health Literacy||
PLAIN LANGUAGE: A PROMISING STRATEGY FOR CLEARLY COMMUNICATING HEALTH INFORMATION AND IMPROVING HEALTH LITERACY
This issue brief describes why plain language is a promising strategy for clearly communicating health information and improving health literacy.
The brief shows how plain language helps adults understand health information by
In its recent report on health literacy, the Institute of Medicine (IOM) finds that there is a major mismatch between the health information people receive and what they understand. But this lack of understanding is not primarily the fault of individuals receiving the information; nor is it solely or primarily the result of poor or limited literacy skills. According to the IOM, “Even highly skilled individuals may find the [healthcare] systems too complicated to understand, especially when these individuals are made more vulnerable by poor health” (1).
Four reasons why health information is difficult to use and understand are:
For example, the health literacy capacities of a 50-ish English-speaking woman with 2 years of college and a head cold who is buying a familiar over-the-counter medicine are different in that moment from the capacities of that same woman when she undergoes diagnostic tests, learns she has breast cancer, and has two different treatment options, neither of which she really understands.
The link between literacy skills and health literacy
Even though everyone may struggle to understand health information at times, the concept of “health literacy” recognizes that most health information is even more challenging for people with limited literacy skills. According to a 1992 study by the U.S. Department of Education, about 90 million English-speaking adults have literacy skills in the two lowest levels, affecting their ability to carry out everyday tasks. People with certain characteristics are more likely to have trouble reading and understanding health-related information. These include older adults, racial and ethnic minorities, people with low education or income levels, non-native speakers of English, and people in poor health (1).
The IOM and other organizations propose using plain language to address the needs of those with limited literacy skills, as well as those with limited health literacy skills. The idea is that plain language helps people understand health information because the writing style is clear, concise, organized, and jargon-free. Documents written in plain language are less complex and therefore easier for everyone to understand, including people who have limited literacy skills, limited health literacy skills, or both.
Defining the terms
People in the healthcare community often use the terms "plain language" and "health literacy" interchangeably or to refer to many of the same issues because they share a common interest in clear communication. One important shared concept is that people should be able to both understand and use the information presented. However, while the terms have points of intersection, they are not interchangeable. Therefore, it is useful to define and explain them.
Health Literacy – The widely accepted definition of health literacy comes from a 2000 National Library of Medicine bibliography (2), and was adopted by both Healthy People 2010 and the IOM. Health literacy is the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” This definition supports the Healthy People 2010 Health Communication Objective 11-2: Improve the health literacy of persons with inadequate or marginal literacy skills (3).
It’s crucial to recognize that health literacy capacities are broader than reading and writing skills, and include the ability to:
These skills must also include understanding numerical data such as percentages, ratios, and measurements, which can be crucial to making informed medical choices. Presenting quantitative data clearly can also help people understand how to weigh the risks and benefits of treatment options and prevention strategies.
Plain Language – This term was first used in the United States in the early 1950s. The Federal Government’s most recent plain-language initiative began in 1998, when President Clinton issued a Memorandum on Plain Language in Government Writing to the heads of executive departments and agencies. He said, “We are determined to make the Government more responsive, accessible, and understandable in its communications with the public. By using plain language, we send a clear message about what the Government is doing, what it requires, and what services it offers. Plain language saves the Government and the private sector time, effort, and money” (5).
There is no one generally accepted definition of plain language or plain English. But most experts in the field would agree that a plain-language document is one in which people can:
Key elements of plain language are to:
In addition to the key elements, there are dozens of plain-language guidelines and techniques such as using short sentences and active voice when possible (7) (see the Addendum). Document design principles highlight the importance of organization and format and enhance the impact of plain language. Good document design is “the act of bringing together prose, graphics…and typography for purposes of instruction, information, or persuasion. Good document design enables people to use the text in ways that serve their interest and needs” (8). Although findings are not consistent, research and experience do suggest that plain language may be remembered better and be more persuasive when it is enhanced with graphics and other visuals (9, 10).
The specifics of plain language depend on the information needs of the audience, so it is critical to test materials with the intended audience in order to implement plain language effectively.
Health information is also communicated verbally, especially between patient and healthcare provider. Because some people learn better by listening than by reading, speaking plainly is just as important as writing plainly. Many of the same plain-language techniques that make the written word understandable also work with verbal messages. These include avoiding jargon and using everyday examples to explain technical or medical terms the first time they are used.
In interpersonal communication situations, plain language combined with other good communication practices can increase the understandability of information. For instance, research shows that communication between healthcare providers and patients can be enhanced by using the “teach-back” method (11). People getting the health information are asked to restate it in their own words—not just repeat it—to ensure that it is understood and remembered. When understanding is not accurate or complete, the sender repeats the process until the receiver is able to restate the information needed. This iterative process is called the “interactive communication loop.” Patients can also be asked to demonstrate their understanding of critical concepts by acting out a medication regimen or showing how they would, for example, check and record their blood sugar levels (12, 13).
Dispelling the myths of plain language and low literacy
Plain language is not “dumbing down.”
People with low literacy skills are not illiterate.
Many people still believe the following myths about low literacy, and it’s important that they be refuted with evidence (9):
Everyone has difficulty understanding health information at some time.
By moving past the myths, senders and receivers break down barriers and enhance the likelihood of understanding each other.
When plain language isn’t enough
To ensure that the intended users of health information understand it, communicators must know how to reach them. Writing and speaking clearly are critical steps to achieve that goal. At the same time, communicators must also be aware of additional barriers to understanding. Intended users of the information may speak a different language or be unfamiliar with the situation; there may be critical cultural differences between sender and receiver; and intended users may have communication or development disorders.
Limited English Proficient speakers – Plain English won’t necessarily help individuals who do not speak English as their primary language and who have limited ability to read, write, speak, or understand English. Simply translating health information, such as written medical instructions, into a person’s native tongue does not guarantee that non-English speakers will be able to read or understand it. To better ensure understanding, health information for people with limited English proficiency needs to be communicated plainly in their primary language, using words and examples that make the information understandable in their language.
Cultural differences – Culture affects how people understand and respond to health information. In addition to the use of plain language, the cultural competency of health professionals can contribute to health literacy. The Office of Minority Health, U.S. Department of Health and Human Services, defines cultural competency as the ability of health organizations and practitioners to recognize the cultural beliefs, values, attitudes, traditions, language preferences, and health practices of diverse populations, and apply that knowledge to produce a positive health outcome. Cultural competency includes communicating in a manner that is culturally and linguistically appropriate.
Lack of knowledge and experience – People with limited health literacy skills often also lack knowledge or have misconceptions about critical health topics, such as the body, its functioning, and the nature and cause of disease. Without accurate and appropriate knowledge, they often fail to understand the importance of lifestyle factors—diet and exercise, for example. They may read commonly used directions, like “take on an empty stomach,” and not understand what the terms mean (17). Even with clear directions, if the audience has no context or prior experience, they can still misunderstand. For example, when instructions say, “Give two drops, three times a day for earache,” it may not be clear whether the drops should be swallowed or placed in the ear.
Communication and developmental disorders – Plain language and other clear communication techniques may not be effective or appropriate for audiences with communication or developmental disorders. Approximately one in six Americans has a disorder or difference in communication resulting in unique challenges.1 There are also challenges for individuals suffering with mental health diseases and disorders that impair or obstruct clear communication, no matter how plain the language. These individuals will require strategies that are tailored to their needs and abilities. Developing improved ways to communicate health information to these audiences is a crucial component to addressing health literacy.
Demonstrating that plain language works
The best way to find out if plain-language documents will work for intended users is to test the documents with those users. This is called usability testing. Usability tests show that plain-language techniques help writers and document designers communicate clearly with the general public as well as people with limited health literacy skills (8). People who are given documents that are written with the audience in mind and that employ the elements of plain language and good document design find them easier to understand and use (18, 19).
Research supporting plain language principles can be found in the following:
Where plain language is an accepted practice
Plain language is not recommended just for health information. Its use is also being encouraged:
Conclusion: Plain language makes health information easier to understand
Our nation faces an enormous challenge to ensure that people with low health literacy skills have the opportunity to receive and understand the health information they need to make sound decisions. Limited health literacy is a complex communication and information problem that requires multiple approaches and methods to realize improvement. This brief examines plain language and its contribution to improving health literacy. Research and experience demonstrate that plain language is an essential element of clear communication. Although more research is needed to determine the most effective techniques to communicate clearly with all consumers and patients, existing research shows that plain language is a promising strategy to address the challenge.
1These include, but are not limited to: deafness, hearing loss, language delay, developmental delay, autism spectrum disorders, aphasia (the language disorder associated with stroke that can affect infants or adults), specific language impairment, stuttering, speech perception disorders, auditory processing disorder, spasmodic dysphonia, and traumatic brain injury.