Designing low literacy materials

If you use commercially produced materials, make sure you assess their reading level. Most companies indicate reading level on the materials. Whether you are using materials prepared by health care organizations or commercial companies or designing your own materials, here are some important guidelines to follow:

  • Try to use handouts written at a sixth-grade level. Approximately 75 percent of adult Americans will be able to read materials at this level.(Table 22 shows a example of material written at the sixth-grade level.)
  • Match the reading level of the handout to the reading level of the patient. Two useful computer programs-Rightwriter and Prose, the Readability Analyst-can help you determine reading level. Prose runs materials through several readability formulas to provide an average reading level. Microsoft Word also can check readability levels.
  • If you don’t have access to a computer program to test reading levels, use a readability formula. Popular and reliable formulas include the Fry Formula and the Simplified Measure of Gobbledygook (SMOG). These formulas assess the reading level of text by using word and sentence length. The greater the number of multi-syllable words, the greater the reading difficulty; the longer the sentences, the greater the reading difficulty. The Fry Formula assesses three samples of 100 words from different parts of a written text. The average number of syllables and the average number of sentences are plotted on a graph that shows grade level. The Fry Formula is not copyrighted, is easy to use, and is widely accepted by reading professionals. The SMOG formula also uses the number of syllables in a particular sample of texts; the test giver uses a conversion chart to translate this to a grade level.
  • Check the book Teaching Patients With Low Literacy Skill for more information about the Fry and SMOG formulas and on designing teaching materials.

When designing written patient teaching materials, you can use specific techniques to produce materials for patients with low literacy skills. First, choose short, common words rather than medical terms. For example, use pill instead of medication, eat instead of consume, and weigh instead of measure. Second, make sure sentences are short-about 10 words in length and written in the active voice. Instead of saying: „Most health care experts believe it is advisable for you to take this medication consistently,“ write: „You must take these pills every day.“ Third, paragraphs should be short and should present one important issue. Fourth, make the materials easy on the eyes. Type font size should be between 10 and 14 points. Avoid using capital letters, which are harder to read than lowercase letters. Larger fonts are helpful for elderly people and for others with impaired vision. Keep the right margin jagged and not justified (lined up evenly). Reading text is easier when the right margin is not justified because the jagged right edges help distinguish one line from another. Fifth, when describing a procedure, such as giving insulin or taking a pill, place illustrations next to the related ideas in the text.

If you have already purchased or designed materials that are not at the appropriate grade level, you can make them more readable by highlighting points that patients must know, such as how many pills to take, when and how to take them, what symptoms they should call about, and what phone number to call. Additional tips for teaching patients with low literacy skills include:

  • Set realistic objectives. Choose only one or two objectives per teaching session and make sure the objectives state exactly what behaviors are expected. Try to make the objective relevant for the patient, such as „to help you be able to go back to work by getting your blood sugar under control.“
  • Focus on behaviors and skills. Having the patient be able to show you how to position himself or herself to prevent a pressure sore is an example of a measurable skill.
  • Present the context first, then give new information. Provide the context of the instruction-the part the patient already knows-first. In Teaching Patients With Low Literacy Skills the authors suggest writing „Vegetables with many nutrients are carrots, broccoli, etc.,“ rather than writing „Broccoli, carrots, sweet potatoes, peas, spinach, cabbage, beets, and squash have many nutrients.“ In this last example, the reader must remember the entire list with no framework or context. By the end of the sentence, it is likely that a poor reader will have forgotten all or most of the items.
  • Break up complex instructions. Separate complex instructions into smaller parts. For most people, even those with high literacy skills, three to five items at a time is a reasonable limit.
  • Make educational sessions interactive. Make educational instructions interactive by having the patient do, write, say, or demonstrate something in response to your teaching. Interaction strategies greatly assist recall and the patient’s ability to carry out directions successfully.

Don’t be reluctant to use these techniques with patients who read well. Literacy experts have found that simplifying written materials seems to appeal to everyone-patients with low literacy skills as well as the highly literate.

Figures 1 and 2 are samples from a patient Tuberculosis Preventative Treatment Record used in Orange County, Calif. Figure 1 shows an illustration of a positive tuberculosis skin test and a bottle of isoniazid (INH). These simple diagrams help a patient with low literacy skills make the connection between skin test results and medicine that is used to treat TB.

Figure 2 helps patients know the dose they are taking, when they start taking INH, and how many pills to take each day. The nurse can help make the teaching session interactive by having the patient fill in information about the dose of INH, the start date, and how often to take tablets. Note that the sentences are short and use short, familiar words that will be understood by most people with low literacy skills. This brochure is available in both English and Spanish.

A long-term goal of the U.S. educational system is to improve the country’s literacy level. Until this goal is achieved, nurses and other health care professionals must make health care instructions easy to understand. Nurses provide a critical safety net for patients and families with low literacy skills. Nurses‘ teaching activities-done every day in all patient care settings-ensure that patients know about their disease condition, their treatment plans, how to prevent complications, how to take medications safely and effectively, and how to use medical equipment appropriately.

By being aware of the numbers of patients with low literacy skills and the techniques to help them, you help ensure that low literacy skills do prevent your patients from being able to manage their own health care needs.

Table 22

Example of Sixth-Grade Reading Level

Excerpt from „What Is the Treatment for Breast Cancer?“

  • Radiation may also be used. It is high energy X-rays that kill cancer cells. It usually takes 5-6 weeks to get radiation treatments. Radiation shrinks and kills cancer cells. It can also relieve pain. During radiation you may also have skin irritation. You will be taught how to care for your skin.
  • Chemotherapy can also be used. This is medicine used to treat cancer cells. Chemotherapy is usually put into the body by a vein. The drug goes through the body and kills cancer cells to keep the breast cancer from coming back elsewhere in the body. Chemotherapy is usually given over a period as short as three months or as long as nine months.
SOURCE: Medical University of South Carolina. (1999). „What is the treatment for breast cancer?“ In: Breast Cancer. [Online]. Available: