Part 1--Health Literacy and Clear Writing Go Hand in Hand: Make the Connection Between Literacy Level and Plain English

Contents

I Introduction
II Health literacy matters…
III Demystifying plain English—what exactly is it?
IV Be a Plain English Matchmaker…
V The nuts and bolts of plain English: Moving theory into practice
VI Words alone are not enough…
VII To enhance health literacy, be "plain"…

-- submitted by Carolyn Wilby, Clear Language @ Work Inc.

I Introduction

Literacy is defined in many ways. For instance, “literacy is the ability to use printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential." (Kirsch, et al., 1993). In turn, there are references to numerous types of literacy:

  • Prose literacy: The knowledge and skills needed to understand and use information from texts including editorials, news stories, brochures and instruction manuals.
  • Document literacy: The knowledge and skills required to locate and use information contained in various formats, including job applications, payroll forms, transportation schedules, maps, tables and charts.
  • Numeracy: The knowledge and skills required to effectively manage the mathematical demands of diverse situations. (International Adult Literacy and Skills Survey, Statistics Canada, Human Resources and Skills Development Canada, US National Center for Education Statistics, Organisation for Economic Co-operation and Development, 2005).

And, as if that weren’t enough to get us thinking and the neurons firing—definitions of literacy span across specific subject areas. For example, during these tough economic times there is a lot in the news about financial literacy, meaning our ability to understand financial concepts. For instance, we might describe a target group as "technologically literate"meaning they have a good grasp of what others might consider "techno-babble."

Of course, health literacy is another area that receives a lot of attention as we strive to make health issues understandable and, most importantly "actionable." We hope to provide people with written information they understand and are motivated to act on—to either stop existing behaviours or start new ones. Even within health literacy, there are numerous takes on its definition. For instance, 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." (Healthy People 2010, a U.S. public health initiative).

"…is a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment." (Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association).

"…has three levels: functional health literacy, which refers to communication of information; interactive health literacy, about the development of personal skills; and critical health literacy, needed for personal and community empowerment." (Nutbeam, 2000).

"is a shared responsibility in which patients and providers each must communicate in ways the other can understand." (Health Literacy from A to Z, Helen Osborne, 2005).

The Canadian Council on Learning reports that “the most commonly cited definition is one that emphasizes the skills of individuals: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” (Health Literacy in Canada, Canadian Council on Learning, 2007).

Regardless of definition, the key to enhancing all types of literacy is not only increasing the target group’s ability to read written information but also to understand it. “Approximately 800 studies published between 1970 and 2006 indicate that most health-related materials are written at reading levels that exceed the reading skill of an average high-school graduate.” (Health Literacy in Canada, Canadian Council on Learning, 2007).

This is disturbing when considered in combination with results from the 2003 International Adult Literacy and Skills Survey that found that “about 62% of employed Canadians between the ages of 16 and 65 had average scores in the document domain at Level 3 or above” and that “over one-half of unemployed Canadians of these ages had document literacy scores below Level 3.” (Building on our competencies: Canadian Results of the International Adult Literacy and Skills Survey, 2003). Level 3 is “The minimum skills level suitable for coping with the demands of everyday life and work in a complex, advanced society. It denotes roughly the skill level required for successful secondary school completion and college entry. Like higher levels, it requires the ability to integrate several sources of information and solve more complete problems.” (International Adult Literacy and Skills Survey, Statistics Canada, Human Resources and Skills Development Canada, US National Center for Education Statistics, Organisation of Economic Co-operation and Development, 2005).

Accordingly, if we continue developing health-related materials that exceed the reading skill of an average high-school graduate, we will continue to miss the healthy literacy mark for a huge segment of the population: our target groups will be no better off in terms of their ability to obtain, process and understand basic health information and services needed to make appropriate health decisions.

II Health literacy matters…

Where improving health is concerned, it is critical that we take measures to remedy this "mismatch" in terms of written information and our target reader’s ability to process and understand it: “Studies over the years have repeatedly demonstrated a strong link among literacy, level of education and level of health. Health and learning are closely intertwined and the interaction between them is evident at all ages, from early childhood through to the later stages in life. The equation is a simple one: the higher the person’s education status and ability to learn about health, the better that person’s health. Researchers and policy-makers in the health and education fields consider health literacy as a critical pathway linking education to health outcomes, as a casual factor in health disparities between different population groups and as a predictor of overall population health.” (Health Literacy in Canada, Canadian Council on Learning, 2007). Regardless of best intentions, the inability to process and understand the health information we produce renders it useless.

III Demystifying plain English—what exactly is it?

Although plain English is a concept focused on clarity, it has more than its share of confusion surrounding it. Similar to literacy definitions, plain English has a wide range of interpretations. In fact, googling plain English reveals it all—the good, the bad, and the ugly:

The ugly: plain English is "dumbing down" information; it’s condescending.

The bad: plain English is stripped of all emotion; it’s dull or "plain."

Finally, the good: plain English takes into consideration the target group’s literacy level, reading ability, and existing topic knowledge to match the word selection and writing style with the target group, making the information easy to find, read, understand, and act on after just one read.

To counter the "ugly" and the "bad" plain English advocates sometimes add phrases to the "good" definition like “Without sacrificing creativity…” and “Using language familiar to the reader…”. This is the case because although plain English focuses on ensuring the reader understands the information and is able to use the information, it is not mutually exclusive from adding a dash of the human element. Plain English can be creative, compassionate, and even humorous—it all depends on what is most appropriate for the specific target group.

IV Be a Plain English Matchmaker…

Make the connection between literacy level and written information

The key to effective Plain English writing is to be a Plain English Matchmaker—whether your target group is the public, a professional target group, specific industry "insiders," or your employees—low or high literacy—plain English matches your writing style to your target group.

For example, this article about plain English is written at a level of language and style appropriate for its high-level readership. The word selection and the way the words are used are higher literacy while still keeping the article clear, concise, and focused on taking action. The tone is informative but friendly; hopefully not "ugly" by being condescending or "bad" by being dull. As a starting point in striving to increase the readability, understanding, and usefulness of your written materials, try to be a plain English matchmaker:

Develop a solid understanding of your target group by gathering information from different perspectives. Ask yourself questions like:

  • What specifically do you want to write about?
  • Who do you want to write this communication piece for?
  • Who needs to know this information? Is there more than one intended type of reader?
  • What’s in it for them?
  • What is their demographic profile? (e.g., age, income, gender)
  • What is their psychographic profile? (e.g., needs, values, wants)
  • What is their current knowledge regarding the topic?
  • What is their current interest level in the topic? Are they motivated?
  • Where/how will they access the communication piece?
  • When do they need to know it? When is your completion date?
  • Why should they care? Why do they need to know it? Why will they consider it valuable?
  • Why are you bothering to write this communication piece?
  • How do you want them to use the information? What do you want them to do?
  • How will the information meet their needs?

Create a literacy profile of your target group: Often a "guesstimate" of your target reader’s literacy level is the best you can do because getting a precise determination can be time-consuming and require additional budget, yet even a guesstimate goes a long way in helping you create information that your target reader can read and understand. Ask yourself questions like:

  • Is English their first language?
  • What level of education do they have?
  • Do they have any other issues that may influence literacy? (e.g., physical, psychological, perceptual issues)
  • Overall, how would you describe their reading skills?
    • Poor
    • Basic or narrow
    • Read well depending on context?
    • High-level

Try to slot them into one of the four International Adult Literacy and Skills Survey literacy levels:

  • Level 1 Persons with very poor skills, where the individual may, for example, be unable to determine the correct amount of medicine to give a child from information printed on the package.
  • Level 2 People can only deal with material that is simple, clearly laid out, and in which the tasks involved are not too complex. It identifies people who can read but test poorly. They may have developed coping skills to manage everyday literacy demands but their low level of proficiency makes it difficult for them to face novel demands, such as learning new job skills.
  • Level 3 The minimum skills level suitable for coping with the demands of everyday life and work in a complex, advanced society. It denotes roughly the skill level required for successful secondary school completion and college entry. Like higher levels, it requires the ability to integrate several sources of information and solve more complete problems.
  • Level 4 People demonstrate a command of higher-order information processing skills.

V The nuts and bolts of plain English: Moving theory into practice

Theory is one thing. Putting theory into practice is another animal all together. It’s one thing to have a clear understanding of the concept of plain English and to have gained solid insight into your target group’s literacy level, reading ability, and existing topic knowledge, but now what?

The answer is, practice, practice, ...and, you guessed it, more practice. Yes, practice makes perfect, or at least plain English perfect—in terms of enhancing the readability and understanding of your written information. Just like any skill, plain English follows a range of guidelines that through experience, the writer learns to apply to best match each specific target group. For example, based on the target group’s reading ability, literacy level, and existing topic knowledge, ask yourself if your information follows these plain English guidelines:

  • Is the information organized logically?
  • Does it provide only relevant information? (i.e., information the reader needs to know, not information about the sponsoring organization)
  • Is the information concrete?
  • Is the tone and language appropriate?
  • Is it engaging and in the active voice as much as possible?
  • Is it concise with short sentences, short words, and no unnecessary words?
  • Is it direct only including redundant phrases and repetition if they add clarity?
  • Is it descriptive when needed to enhance clarity for the reader? (e.g., technical or complicated terms explained at the level appropriate for the reader)
  • Does it use idioms, abbreviations, and acronyms selectively based on appropriateness?
  • Is structure consistent throughout the headings and body text?
  • Is all of the information accurate? (e.g., information, grammar and spelling)
  • Overall, is the writing appropriate for the medium? (e.g., hard copy versus web)

VI Words alone are not enough…

Using plain English is just half the literacy battle. The way the information is presented can make all the difference in terms of promoting literacy or deterring it. For example, although something may have been written in plain English accurately matching the target group’s literacy level and knowledge, it may never be read if its layout scares the reader away.

Cramped layout, difficult to read font sizes, poor colour scheme, or inappropriate or confusing illustrations can turn the reader off. To help present your information in an inviting way that also enhances readability and understanding, ask yourself if your information follows these clear design guidelines:

  • Is the body text clear and comfortable to read?
  • Is the information easy to find through consistent font usage and styles?
  • Is the font choice appropriate for the audience?
  • Is the layout inviting with an appropriate amount of white space?
  • Are the images and graphics relevant to the content?
  • Overall, is the design appropriate for the medium? (e.g., hard copy versus web)

VII To enhance health literacy, be "plain"…

Plain English is the international language that everyone understands. In keeping with the literacy definitions at the beginning of this article, plain English enhances your target group’s ability “to use printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential.” Regardless of whether prose, document or quantitative literacy—and regardless of topic area, plain English enhances readability, understanding, and usefulness.

This is especially the case with health literacy where other variables like emotional state may influence your target group’s ability to clearly understand information. In addition, “the differences in health status associated with differences in health literacy are large enough to imply that significant improvements in overall levels of population health might be realized if a way could be found to raise adult health-literacy levels” (Health Literacy in Canada, Canadian Council on Learning, 2007). Plain English represents one of these ways; it is a "must have" for helping your target groups improve their health literacy by being able to find the information they need, understand it, and use it effectively.

Be sure to read part two in this three-part series in August where we continue to move theory into practice with Plain English Boot Camp—Tips for improving understanding of written materials. Please also feel free to share this article; health literacy works better when we all work together.

Copyright Clear Language @ Work Inc.