Promoting Personal Health Literacy Through Readability, Understandability, and Actionability of Online Patient Education Materials

The culture of health care has its own shared norms, values, beliefs, customs, and language. Most patients enter the health care system with no formal training or understanding of the culture or language. To effectively communicate, providers must use common everyday vocabulary, speaking and writing in ways the patient understands. ¹ When my husband developed significant medical issues related to congenital heart disease, he commented, “I need an interpreter to understand the foreign language these doctors and nurses are speaking.” He did not speak or understand the shared language of health care, an essential tool providers use when communicating with members of the health care workforce and educating care recipients. When the cardiologist and cardiothoracic surgeon entered his hospital room, they shared the need for immediate repair of a bicuspid aortic valve and ascending aortic aneurysm. Using his study of Latin and Greek, which is the basis for medical terminology, my husband tried unsuccessfully to decipher what the physicians were telling him. His understanding increased when the cardiologist switched to common everyday language and illustrated the 3 aortic valve leaflets by drawing a Mercedes‐Benz symbol on the room's whiteboard. The physician's shift to common, everyday language conveyed the significance of the information, facilitated trust, encouraged communication, and promoted understanding.

Having earned 3 academic degrees, my husband has high literacy skills, but when he began his health care journey, his personal health literacy was low. The US Department of Health and Human Services Healthy People 2030 defined personal health literacy as “the degree to which individuals have the ability to find, understand, and use information and services to inform health‐related decisions and actions for themselves and others.” ² The National Library of Medicine writes with considerable authority that 9 of 10 adults struggle with health literacy, even individuals with high literacy skills. ³ The US Department of Education National Center for Education Statistics reported that 54% of Americans between the ages of 16 and 74 years read below the equivalent of a sixth‐grade level. ⁴ Statistics from the Conference Board of Canada show that 48% of Canadian adults have inadequate literacy skills. ⁵ With the aim of promoting personal health literacy, the Joint Commission standards for hospitals and health care organizations recommends that patient education materials (PEMs) be written at or below a fifth‐grade reading level. ⁶ According to the American Medical Association Foundation and the American Medical Association health literacy recommendations, all PEMs should be written at a sixth‐grade reading level or below with active voice, 1‐ or 2‐syllable words, short paragraphs, and simple tables and graphs. ⁷

The study conducted by Bhatt et al ⁸ in this issue of the Journal of the American Heart Association (JAHA) examined the readability, understandability, and actionability of online PEMs related to cholesterol management. After a medical database and website search, the authors analyzed 22 eligible online cholesterol educational materials from peer‐reviewed academic journals and websites of national health organizations. Readability was assessed using the Flesch–Kincaid Grade Level scores with a target score between fifth‐ and sixth‐grade reading level. The Patient Education Materials Assessment Tool was used to assess understandability and actionability. The results of the study indicated that the average readability of the selected PEMs was an 11th‐grade reading level, significantly above the fifth‐ to sixth‐grade reading level recommended by the Joint Commission, American Medical Association Foundation, and American Medical Association. Twenty‐one of the 22 selected PEMs failed to meet the fifth‐ to sixth‐grade reading level. ⁸ The authors discussed varied reasons for these findings. An extension of the authors’ discussion might include the potential differences in health literacy between the PEMs author and the patient. The author of the PEMs may be unfamiliar with writing PEMs consistent with the national reading‐level recommendations, thus introducing a potential unconscious bias related to the differences in health literacy between the author and the intended audience of the PEMs, leading to a possible lack of patient understanding of the educational materials. ⁹ , ¹⁰

Bhatt et al ⁸ reported that the average readability of PEMs for dyslipidemia has not advanced over the past 3 decades, remaining at an approximate reading level of 11th grade. This finding is illuminating given the countless PEMs provided to my family related to dyslipidemia and other cardiovascular health issues over the past 30 years. The authors shared practical strategies that can aid providers in the production of PEMs for individuals with low personal health literacy. ⁸ One of the strategies that resonated with me was to consider including patient advocates, plain language experts, or focus groups before PEMs publication. ⁸ If the patient cannot read or understand the PEMs, adherence to the instructions provided in the PEMs will fail to take place. Recruiting individuals to review the PEMs before publication will enhance readability and may improve future patient adherence to treatment plans.

One of the most important contributions of this study is the spotlight it has placed on the need for further endeavors to improve the readability of online PEMs. This study provides 2 important policy and practice implications that health organizations, providers, and educators may put into practice to promote personal health literacy. First, it is essential that national, regional, and local health care stakeholders develop PEMs that are easily readable, enhance understanding, promote action, and advance health literacy. ¹¹ Second, focusing on personal health literacy and readability of educational materials will assist patients in accessing, understanding, and acting on provided health information, potentially improving patient adherence to treatment plans and health outcomes. ¹¹

Disclosures

None.