Keep It Simple: Using Plain Language to Support Patient-Centered Care

Laura M. Cascella, MA, CPHRM

A significant hurdle in patient-centered care is effective communication throughout the care process. If patients do not understand their diagnoses, test results, recommended treatment plans, and follow-up instructions, they cannot fully participate in their care.

A common barrier to effective communication is poor health literacy. Research shows that only a small percentage of adults have proficient health literacy skills, and most adults have difficulty using the everyday health information that is routinely available in healthcare facilities.¹ These statistics are significant because people who have low health literacy are at increased risk for poor outcomes, higher rates of emergency department visits and hospitalization, and death.² Patients who have limited health literacy also might feel ashamed about their lack of knowledge, and they may "mask these difficulties in order to maintain dignity."³

Healthcare providers need various tools and techniques to improve communication with patients and develop "standards of practice that support and incorporate health literacy principles . . ."⁴ One important tool for tackling literacy barriers and improving patient comprehension is plain language. The principles of plain language focus on written information that is clear, concise, and logically organized. Readers should be able to find what they need, understand what they find, and use what they find to meet their needs.⁵

Because print and online written materials — such as patient education brochures, informational websites, provider instructions, and medical forms — play a vital role in the healthcare process, assessing the quality, readability, and usability of this information is crucial. The following strategies — compiled from various sources⁶ — offer guidance related to content, text, design and layout, and visuals. This information can help organizations and providers determine whether current or prospective materials align with plain language principles and support efforts to ensure patient comprehension and patient-centered care.

Content

Content refers to the focus, core message, and organization of written information. When assessing content, consider the following questions:

• Is the purpose and intention of the material clear based on the title and introductory information? Will the reader understand what the information is about and how he/she should use it from an initial glance?
• Is the content accurate and current? Misinformation about medical conditions and treatments is not uncommon, particularly with the explosion of online information. Healthcare organizations and providers should ensure their information reflects current knowledge and standards.
• Is the content appropriate for the age and culture of the target audience? Cultural competency goes beyond just language; healthcare providers should consider how cultural beliefs, knowledge, and values might affect patients' understanding of health information.
• Does the content focus on what the reader needs and wants to know? Does it avoid using extraneous details and distracting information (e.g., complex descriptions of disease processes)?
• Is the most important information presented prominently (e.g., at the beginning or using a visual cue that draws attention)? Readers might skim information, so the main messages should be obvious.
• Does the content contain one or more calls to action? For example, a call to action might prompt the reader to have a health screening or follow up with a healthcare provider.
• Are important concepts repeated within the material? Repetition can help the reader retain information.
• Is information presented in a logical order? For example, an informational flyer about a diagnostic test should explain how to prepare for the test before discussing what the results mean.
• Is similar information grouped together, and does material use descriptive headings and subheadings to help readers navigate the content?
• Does the material use short paragraphs and focus on one topic per paragraph to avoid overwhelming or distracting the reader? For example, a patient education brochure that discusses asthma treatment should separate information about long-term control medications and quick-relief medications.
• Does the material use examples and well-designed visuals that make complex material easier to understand? See below for more guidance on visuals.

Text

Text and content are related, but "text" refers to more granular elements such as word choice, sentence length, and tone rather than overall purpose and organization. When evaluating text, consider the following questions:

• Is the wording at an appropriate reading level for your target audience? Keep in mind that many Americans read at or below an eighth-grade reading level.⁷ Readability formulas — although not foolproof — can help determine how difficult text is to read. Examples of readability formulas include Fry, SMOG, and Flesch-Kincaid.
• Is the text conversational in tone and does it favor active voice over passive voice? A conversational tone uses contractions and pronouns and can help forge a connection with the reader. Using active rather than passive voice helps clarify actions and reduce ambiguity. For example, "Call your doctor right away if you have a fever" versus "If a fever develops, your doctor should be notified immediately."
• Does the material use words that are well known to individuals without medical training (e.g., "high blood pressure" instead of "hypertension" or "tooth decay" instead of "caries")? If no common term exists for a medical or technical term, is the term described the first time it is used?
• Does the text use short sentences? Short sentences help improve readability and avoid information overload; however, sentence length should vary slightly so the text doesn't sound choppy.
• Does the text use one- or two-syllable words when possible (e.g., "blood clot" instead of "embolism")?
• Are wordy phrases avoided? Although some wordy phrases are common in everyday language, they can still make text less precise and confusing. Examples of wordy phrases include "due to the fact that" (because), "in order to" (to), and "at the present time" (now).
• Does the text avoid overuse of abbreviations and acronyms, which can distract the reader? If the text includes abbreviations and acronyms, are they defined the first time they are used?
• Does the text use the same term consistently to identify a specific object or concept? Lack of consistency in terminology can confuse the reader and reinforce inaccurate perceptions.
• If the text contains numbers, are they presented in a clear, easy-to-understand way, and is their importance explained? Some people might have trouble making sense of ratios, percentages, and fractions. For them, "1 in 8 adults" might be easier to comprehend than 12.5%. Further, without a clear explanation, the reader might not understand if "1 in 8" represents a significant problem or risk.

Design and Layout

The elements of design and layout — such as font style, colors, and spacing — play an important role in the effectiveness of written materials. Even if the content is clear and the text is reader-friendly, poor design and layout can disorient and confuse the reader. When assessing these factors, consider the following questions:

• Does the material use at least a 12 point font or larger in an easy-to-read typeface? Recommendations generally suggest serif fonts for body text (e.g., Times New Roman) and sans serif fonts for headings (e.g., Arial).
• Does the material avoid using multiple font styles on the page and throughout the document? Using different fonts to differentiate headings and body text is acceptable, but using a mix of typefaces within the body of a document can create confusion.
• Does the material use dark font on a light background? Light fonts on dark backgrounds or fonts that do not contrast enough with their backgrounds are hard to see, particularly for people who have vision problems.
• Is bold or italic typeface used to show emphasis rather than underlining, which is difficult to read and might be confused with hyperlinking? Is the method chosen to show emphasis used sparingly but consistently within the material?
• Do headings use a mixture of uppercase and lowercase, and are they clearly differentiated from body text (e.g., set in bold)?
• Is the text aligned to the left margin (including the headings) rather than fully justified (flush with both margins) or centered? Left alignment and a ragged right margin help aid in readability.
• Does the material use short lists to focus on specific material, highlight information in a visually clear way, or clarify the chronological order of steps in a process? Lists can help break up dense information, making it easier to read and scan. However, long lists and lists with multiple levels (i.e., lists within lists) might be difficult to follow.
• Does the material use standard bullets (e.g., circles or squares), and is the bullet style consistent throughout the material? To avoid confusion, are numbered lists used to show only items in a sequence?
• Does the material use white space effectively and consistently, including heading spacing, line spacing, paragraph spacing, and margins? White space can prevent the content from looking too condensed and overwhelming. Plain language and health literacy recommendations suggest:
  • Having at least 1⁄2 inch to 1 inch of white space around the margins of the page and between columns for printed materials.
  • Using more space above headings than below them to help visually link each heading to its related content.
  • Setting line spacing between 1.2 and 1.5 lines.

Visuals

In patient materials, "visuals" can refer to photographs, illustrations, tables, graphs, pictographs, infographics, and more. Well-designed visuals can present or reinforce vital information. When evaluating the visuals in materials, consider the following questions:

• Do visuals help accurately show or clarify important information, and is their design simple and devoid of clutter and distractions?
• Do visuals have high-quality resolution and contrast? Although visuals should be simple, they should look professional to enforce the credibility of the material.
• Are elements such as sidebars, text boxes, and pull-quotes used to emphasize key messages?
• Does each visual relate to or present only one message? Visual elements that try to present multiple messages might confuse the reader.
• Are visuals logically located and do they include clear, concise titles and captions?
• Are visual elements age appropriate and culturally relevant and sensitive?
• Do visuals that show a process or series of steps have each element numbered to clearly indicate its place in the sequence?
• Do tables have clearly labeled rows and columns and consistent alignment? Do charts and graphs use descriptive, clear labels and legends?

In Summary

The premise of patient-centered care relies on effective communication that helps patients understand health information and participate in shared decision-making. Yet, inadequate health literacy has been — and continues to be — a persistent communication barrier, hindering patients' comprehension and marginalizing their role in care.

One important strategy for overcoming health literacy challenges is providing patients with written information in plain language. Materials should be clear, concise, purposeful, logically organized, and well-designed. Incorporating plain language principles as part of an overall strategy to address health literacy can support efforts to engage patients in their care and empower them with knowledge to make informed decisions.

Resources

For more resources about improving verbal and written communication with patients, see MedPro's Checklist: Strategies to Support Patient Comprehension and Risk Resources: Health Literacy and Cultural Competence.

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¹ U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy. Washington, DC: Author. Retrieved from https://health.gov/our-work/health-literacy/national-action-plan-improve-health-literacy; Centers for Disease Control and Prevention. (2013). The state of aging and health in America 2013. Atlanta, GA: Author. Retrieved from www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf

² National Institutes of Health, National Network of Libraries of Medicine. (n.d.). Health literacy. Retrieved from http://nnlm.gov/outreach/consumer/hlthlit.html; Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press. https://doi.org/10.17226/10883.

³ Institute of Medicine, Health literacy: A prescription to end confusion.

⁴ Centers for Disease Control and Prevention. (n.d.). Health literacy for public health professionals. CDC TRAIN. Retrieved from www.train.org/cdctrain/course/1078759/

⁵ Plainlanguage.gov. (n.d.). What is plain language? Retrieved from www.plainlanguage.gov/about/definitions/

⁶ Institute of Medicine, Health literacy: A prescription to end confusion; Plainlanguage.gov. (n.d.). Plain language guidelines. Retrieved from www.plainlanguage.gov/guidelines/; Centers for Disease Control and Prevention. (2019, August). CDC clear communication index: A tool for developing and assessing CDC public communication products. Retrieved from www.cdc.gov/ccindex/pdf/ClearCommUserGuide.pdf; Centers for Disease Control and Prevention. (2009, April). Simply put: A guide for creating easy-to-understand materials (Third Edition). Retrieved from www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf; Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., . . . West, D. R. (2015, January). AHRQ health literacy universal precautions toolkit (Second Edition; AHRQ Publication No. 15-0023-EF). Retrieved from www.ahrq.gov/sites/default/files/publications/files/healthlittoolkit2_4.pdf; National Institutes of Health. (2018, December). Clear communication: Clear & simple. Retrieved from www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/clear-simple; Centers for Medicare & Medicaid Services. (2010, September). Toolkit for making written material clear and effective (CMS Product No. 11476). Retrieved from www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit; Agency for Healthcare Research and Quality. (2014, August [updated]). The patient education materials assessment tool (PEMAT) and user's guide (Version 1; AHRQ Publication No. 14-0002-EF). Retrieved from www.ahrq.gov/ncepcr/tools/self-mgmt/pemat.html; U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2016, June). Health literacy online: A guide for simplifying the user experience. Retrieved from https://health.gov/healthliteracyonline/; Rudd, R. E. (2012). Guide for creating materials. Harvard T.H. Chan School of Public Health. Retrieved from https://cdn1.sph.harvard.edu/wp-content/uploads/sites/135/2012/09/resources_for_creating_materials.pdf; U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Quick guide to health literacy.

⁷ Stossel, L. M., Segar, N., Gliatto, P., Fallar, R., & Karani, R. (2012). Readability of patient education materials available at the point of care. Journal of General Internal Medicine, 27(9), 1165–1170. doi:10.1007/s11606-012-2046-0

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