Health Literacy: A Guide

To write in plain language means to use the simplest, most straightforward way of expressing an idea. Doing so will ensure your audience understands it the first time they read or hear it. Materials are in plain language if your audience can:

• Find what they are looking for
• Understand what they find the first time they read or hear it
• Use what they find to meet their needs

Healthcare providers have a legal and ethical responsibility to ensure that patients understand their health information.  Writing patient materials in plain language on a 3rd to 5th grade reading level improves understanding, ensures compliance, reduces anxiety, and improves patient-provider communication.

According to the National Literacy Institute, the average reading level of adults in America is estimated to be between the 7th and 8th grade levels. This means that most adults can comfortably understand written materials that are at or below this level. However, it's important to note that a significant portion of the population reads at a lower level, with about 1 in 5 adults reading at or below a 5th-grade level (National Literacy Institute, 2024).

Given this, it's generally recommended that public-facing materials, especially health information, be written at a 3rd to 5th grade reading level  to ensure that they are accessible to the widest audience possible. This approach helps accommodate varying literacy levels and ensures that important information can be understood by all.

National Literacy Institute. (2024, March 7). Literacy Statistics 2022-2023. National Literacy. https://www.thenationalliteracyinstitute.com/post/literacy-statistics-2022-2023 

General Guidelines

Plain Language Act of 2010:  Federal Guidelines  Trainings, webinars, publications all available.

Dictionaries and Glossaries (Searchable; Online)

• Plain Language Medical Dictionary is a project of the University of Michigan Taubman Health Sciences Library as part of the Michigan Health Literacy Awareness project.
• Everyday Words for Public Health Communication offers expert recommendations from CDC's Health Literacy Council and other agency communicators on how to reduce jargon and improve reader understanding. You can search for public health jargon or plain language words and find alternatives and example sentences.
• The Plain Language Action and Information Network (PLAIN) is a group of federal employees from different agencies and specialties who support the use of clear communication in government writing. Their guide, “Design for reading,” can help you use design elements to help users read and understand the information.
• The Clinical Research Glossary offers easy to understand clinical research definitions. All definitions are are developed by the Multi-regional Clinical Trials (MRCT) Center of Brigham and Women's Hospital, Harvard, and a team of patient advocates and other health professionals. This glossary is helpful to patients considering participating in clinical trials or those developing clinical trial participation materials.

Writing and Design Resources

• Program for Readability in Science and Medicine (PRISM):  Toolkit The Program for Readability In Science & Medicine (PRISM) was inspired by health literacy concerns in health care and health research. PRISM’s goal is to bring readability awareness and plain language training and tools to researchers nationwide. Using plain language is a proven way to help make scientific and medical information easier for study participants, patients, and the public to understand.  PRISM also offers a free, hour-long training course to help research teams improve the readability of consent forms and other participant materials.
• Making Data Talk:  A Workbook was created by the National Cancer Institute to help you select and communicate quantitative data in ways lay audiences can understand.
• Designing for Reading, from Plainlanguage.gov, contains tips for designing and developing effective communications. Writing that is legible and well-organized is far easier to understand than more traditional styles. Even with regulations and the limits of publishing in the Code of Federal Regulations, you can use design elements to help users read and understand the information.
• Clear & Simple from the National Institutes of Health  is designed to assist health communicators in developing audience-appropriate information and communicating effectively with people with low-literacy skills. It outlines a process—five standard steps—for developing health information materials. Planning questions are included for each step.
• The Toolkit for Making Written Material Clear and Effective is a health literacy resource from the Centers for Medicare and Medicaid Services (CMS). This 11-part Toolkit provides a detailed and comprehensive set of tools to help you make written material in printed formats easier for people to read, understand, and use.

Tools for Assessing Materials

• PEMAT:  The Patient Education Materials Assessment Tool (PEMAT) and User’s Guide from AHRQ is a systematic method to evaluate and compare the understandability and actionability of patient education materials. 
• Health Education Materials Assessment Tool  from Medline Plus and National Library of Medicine.
• The CDC Clear Communication Index (Index) is a research-based tool to help you develop and assess public communication materials.

Assessing Readability

• Assessing and Developing Health Materials (Harvard School of Public Health) brings together health literacy studies’ information including information on vocabulary and sentence structure, the reading process, as well as layout and design elements for health materials. Links on the page also include an overview, research findings, strategies and tools, and policies, reports, and initiatives.
• SAM Suitability Assessment of Materials instrument offers a systematic method to objectively assess the suitability of health information materials for a particular audience in a short time. It guides you to rate materials on factors that affect readability and comprehension. SAM rates materials in six areas: content, literacy demand, graphics, layout and type, learning stimulation & motivation, and cultural appropriateness.
• Assess, select, and Create Easy-to-Understand Materials from the AHRQ Health Literacy Universal Precautions Toolkit: Tool 11
• This tool from the Agency for Healthcare Research and Quality provides an overview and specific actions for practices to be able to assess, select, and create easy-to-understand materials including training staff, working with your patients to evaluate forms and other written materials, and tracking your progress in ensuring your practice is communicating clearly with patients and their families.

Older Adults

• Developing Materials for Older Adults:  From the CDC. This website offers ideas for how to tailor health information so that it fits the needs of your older readers. From the National Institute on Aging

• Reaching Adults Age 50+ More Effectively Through Print:  A tip sheet for writing materials for older adults.

Creating Culturally-Appropriate Materials

• The National CLAS Standards:  The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care aim to improve health care quality and advance health equity by establishing a framework for organizations to serve the nation's increasingly diverse communities.
• A Way with Words:  Guidelines for Writing Oral Health Materials for Audiences with Limited Literacy:  from the National Maternal and Child Oral Health Resource Center, Georgetown University

Lately I've been using the Automatic Readability Consensus Checker, which runs the text through 8 different readability scales and renders a judgement.

The Flesch Grade Level Readability Formula.  The formula is used in business, industry and government as well as education, to score materials from the upper elementary level through the secondary grades and beyond. The formula takes into consideration (1) the total number of words, and (2) the number syllables, and (3) the total number of sentences. It is one of the most popular and heavily tested formulas.

Fry Graph Reading Formula.  Calculates reading difficulty level by the average number of sentences and syllables per hundred words. These averages are plotted onto a specific graph; the intersection of the average number of sentences and the average number of syllables determines the reading level of the content.

SMOG – Simple Measure of Gobbledygook.  Measures readability that estimates the years of education needed to understand a piece of writing.