Full text of DOI:10.3322/canjclin.52.3.130

Editorial
Health Literacy in the Information Age:
Communicating Cancer Information
to Patients and Families
Betty Merriman, MA;Terri Ades, MS, RN, CS,AOCN; John R. Seffrin, PhD
Ms. Merriman is Content Devel-
oper, Readability and Translations,
American Cancer Society, Atlanta,
GA.
INTRODUCTION
In this issue of CA:A Cancer Journal for Clinicians, authors Terry C. Davis et al.
address the crucial topic of health literacy with regard to cancer communication.
They describe the barriers that can keep people from understanding the
information they receive—barriers referred to collectively as a lack of health
literacy.The US Department of Health and Human Services defines health literacy
as “the degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate
Ms. Ades is Director, Quality of
Life/Health Promotion Strategy, Am-
erican Cancer Society, Atlanta, GA.
Dr. Seffrin is Chief Executive Officer,
American Cancer Society,Atlanta, GA.
This article is also available at
www.cancer.org.
1
health decisions.”
Nearly half of the adult population in the United States has low or limited
1
literacy skills. The authors indicate that people with low literacy skills come from
a variety of backgrounds: they may be native-born or immigrants and they come
from all races and classes. They tend to have more health problems, live in poverty, have fewer
years of education, and are older.
Low literacy adversely impacts cancer incidence, mortality, and quality of life:
• Cancer screening information may be ineffective; as a result, patients may be diagnosed at a
later stage.
• Treatment options may not be fully understood; therefore some patients may not receive
treatments that best meet their individual needs.
• Informed consent documents may be too complex for many patients and consequently,patients
may make suboptimal decisions about accepting or rejecting interventions.
The authors explore these and other implications of low health literacy and offer
recommendations for improving written and oral communication.They observe that it is easier to
change the communication skills of the health care provider than those of the patient. In other
words, it is incumbent upon the information provider to make the information as understandable
as possible.
DETERMINING READING GRADE LEVEL
Davis et al. refer to the reading grade level (RGL) of written materials as just one of the
components that contribute to a document’s overall comprehensibility. There are numerous
formulas used to determine a document’s RGL—both computer-based and hand-calculated.The
2
first formulas appeared in the 1920s and have proliferated in the decades since. Some of the most
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commonly used formulas include the FOG
Index, the SMOG, the Flesch-Kincaid, and the
Fry Formula.
sentences, thus artificially lowering the RGL.
Therefore, documents should first be edited to
remove these and other constructs that
compromise the accuracy of the results.
†
Nearly all of the formulas base their results
on two factors: sentence length and word
difficulty.The latter correlates to word length.
Words of more than two syllables are assumed
to be more difficult. The results are usually
expressed as a reading grade level, sometimes as
a decimal or fraction, e.g.,“8th RGL” or “12.5
RGL.” It must be noted, however, that there is
not a one-to-one correspondence between the
highest grade level completed and the literacy
skills of an individual.While most adults in this
country have completed high school, the
average reading grade level is eighth to ninth
Studies have shown that computer-based
analyses of documents can yield significantly
different reading grade level scores and that the
Microsoft Word program provides consistently
5
lower grade level scores. For example, an
analysis of this editorial by Microsoft Word
indicates a Flesch-Kincaid reading grade level
of 11.8, while hand calculation using SMOG
yields a score of 14.1. Calculating the RGL by
hand can be done almost as quickly as
formatting a document for computer assess-
ment, and in our opinion, the results are more
reliable. Instructions for using the SMOG
Readability Formula are provided below.
3
grade. Like many other skills, reading skills
atrophy if not used regularly, so people who
read very little after they finish school will have
4
correspondingly lower reading levels.
The SMOG Readability Formula6
Computer-based formulas may appear to
provide a quick and easy way to assess a
document’s reading grade level. Microsoft
Word, for example, provides the option of
displaying the results of several formulas that
determine RGL by selecting the spelling and
grammar check function in the drop-down
display menu underTools.When the readability
option is enabled, one first clicks through the
spelling and grammar check to reach a display
of statistics: word count, number of passive
sentences, and the document’s readability
results expressed as the Flesch Reading Ease
Score and the Flesch-Kincaid Grade Level.
But computer-based assessments have some
significant drawbacks. Because the software
programs recognize every occurrence of a
period as a sentence, abbreviations such as Dr.,
numerical expressions with decimals, and
bulleted lists will be counted as very short
Using material consisting of at least 30
sentences:
1. Select ten sentences at random from the
beginning, middle, and end of the text for
a total of 30 sentences. Exclude titles, lists,
or sentence fragments.
2. Find the total number of words with
three or more syllables in these 30
sentences.
3. Find the square root of that total number
and then add a constant of 3.This is the
RGL.
For text consisting of fewer than 30
sentences:
1. Count the number of polysyllabic words.
2. Calculate the average number of poly-
syllabic words per sentence.
3. Multiply that average number by the
number of sentences.
†
The origin of the acronyms FOG and SMOG is uncertain, however, they are most commonly referred to in the field by
these acronyms. FOG and SMOG have been said to stand for “Frequency of Gobbledegook” and “Simple Measure of
Gobbledegook” respectively.
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Editorial
4.Add that figure to the first total.
5. Find the square root of that number and
add the constant of 3.
resources to assist those preparing written
health information. The following resources
provide useful information:
• www.eastendliteracy.on.ca/clear
languageanddesign
EXAMPLES OF TEXT AT VARIOUS LEVELS
OF DIFFICULTY
• www.keenangroupinc.com
• www.med.utah.edu/pated/authors/
substitute2.html
The examples below provide a comparison
of health information written at various levels
of difficulty. As noted above, RGL cannot be
accurately calculated using only one sentence;
thus, the RGL listed in the following examples
is estimated:
With the onset of nausea, diarrhea, or other
gastrointestinal disturbances, consult your physician
immediately. (Approximately 13th RGL or
college reading level and above.)
If you experience nausea, diarrhea, or other
stomach or bowel problems, call your physician
immediately. (Approximately 12th RGL.)
If you start having nausea, loose bowel
movements, or other stomach or bowel problems, call
your doctor immediately. (Approximately 8th
RGL.)
If you start having an upset stomach, loose bowel
movements, or other problems, call your doctor right
away. (Approximately 4th RGL.)
WE ALL PREFER UNDERSTANDABLE
INFORMATION
Even those individuals with better literacy
skills face difficulties when confronted with
unfamiliar medical terms at a time when they
are under physical and emotional stress.At such
times, comprehension of both written and oral
information often diminishes.All people prefer
information that is as easy to understand as
possible.
Another approach to providing diverse
audiences with complex medical information
is to use a variety of formats.When it comes to
health information, there is no “one size fits
all.” Some people who are high-level in-
formation seekers want and can understand
comprehensive information.Others find a high
level of complexity overwhelming and want
simpler, more condensed information. In our
experience, however, people prefer infor-
mation that is written in plain language. Plain
language is not “dumbed down writing.” It is
clear, conversational language designed to
communicate effectively with a wide audience.
The issue of health literacy and effective
cancer communication is not a new one.
Research articles in the past have highlighted
the gap between the average reading grade
level of adults and the RGL of printed health
materials distributed by the American Cancer
It is important to keep in mind that the
RGL is, at best, a rough measure of a
document’s readability. The mathematical
process for calculating RGL may give the
impression of a greater degree of certainty than
is warranted. Developing an ear for plain
language is as important as testing printed
materials for reading grade level. Of equal
importance in assessing the readability of
printed materials are factors such as the tone of
the writing and design elements such as font
size and style, use of white space, and use of
appropriate graphics. Doak and Doak provide
an excellent guide for assessing written health
materials in Teaching Patients With Low Literacy
7
Society (ACS) and others. What is new,
however, is that there is an increased emphasis
on the development of easier-to-read
4
Skills. There are also very good online
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CA Cancer J Clin 2002;52:130-133
materials. The National Cancer Institute and
the Centers for Disease Control and
Prevention, as well as other organizations, are
setting examples for others to follow in the
development of printed materials at lower
reading grade levels.
solution, especially when products and
programs and the language used to promote
them are developed in cooperation with the
communities they are intended to reach. The
ACS Tell-A-Friend program for promoting
mammography, especially among medically
underserved women, and the Reach to
Recovery peer program in which breast cancer
survivors provide information and support to
newly diagnosed women are examples of
successful peer-counseling programs.
Disparities in health literacy are an
important factor contributing to inequalities in
cancer incidence, mortality, and quality of life
among medically underserved populations. It
will be necessary to appreciate the synergy of
appropriate information products and
community-based cancer control interventions
in reducing and, ultimately, eliminating such
disparities. Clear communication must
continue to be a high priority for health care
providers as well as public health and patient
advocacy organizations if we are to succeed in
reducing the cancer burden among diverse and
underserved populations. Good communi-
cation is not an option or a luxury; it is an
integral component of health care that has a
profound impact on individual health and
public health outcomes.
We, at the American Cancer Society, are
working with our writers and editors to
promote an understanding of health literacy
issues and to encourage the use of plain
language in written materials whenever
possible. Information about all of the major
cancer sites distributed by the ACS National
Cancer Information Center (800-ACS-2345)
is available in two formats: a comprehensive
version for people with very good literacy
skills, and an overview version with condensed
information written in plain language at an
eighth reading grade level. Both versions
can be accessed on the ACS Web site,
www.cancer.org.
Also projected for future development are
additional print pieces targeted for readers with
minimal reading skills—fourth or fifth RGL.
But Davis et al. caution that for some people,
materials at any reading level are not an
effective means of communicating health
information. Thus, videotapes and peer-
counseling programs often prove a better
5. Mailloux SL, Johnson ME, Fisher DG,
Pettibone TJ. How reliable is computerized
REFERENCES
assessment of readability? Comput Nurs
1995;13:221-225.
1. Davis TC, Williams MV, Marin MA, et al.
Health Literacy and Cancer Communication.CA
Cancer J Clin 2002;52:134-149.
6. US Department of Human Services. Clear and
Simple: Developing Effective Print Materials for
Low-Literate Readers. National Cancer Institute,
NIH Publication No. 95-3594, December 1994.
2. Klare, George R. Readability. In: Pearson P
David, Barr R, Kamil M, Mosenthal P, eds.
Handbook of Reading Research. NY, NY:
Longman; 1984:681-744.
7. Cooley, ME, Moriarty, H, Berger, MS, et al.
Patient literacy and the readability of cancer
educational materials. Oncol Nurs Forum
1995;22:1345-1351.
3. Doak LG, Doak CC, Meade CD. Strategies to
improve cancer education materials. Oncol Nurs
Forum 1996;23:1305-1312.
4. Doak CC, Doak LG, Root JH. Teaching
Patients With Low Literacy Skills. 2nd ed.
Philadelphia, PA: J.B. Lippincott Company; 1996.
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