Reaching beyond reading grade levels

A conversation with health literacy expert Helen Osborne about the role of reading grade levels in evaluating health information in the era of COVID-19

By , Barb Dube, PhD, and Laura Harter | 3 minute read | December 3, 2020

As healthcare providers continue to grapple with COVID-19, health literacy is more important than ever. Patients and the public are looking for consistent, reliable and actionable information in after-care instructions, consent forms, medication handouts and warning labels. Health information, such as written instructions for COVID-19 testing, prevention and treatment must be clear and understandable to be effective.

One way of measuring effectiveness is reading grade level. Reading grade helps define a person’s literacy level. Literacy is the ability to read and write; health literacy is the ability to read, understand and use health information. A person can have a high literacy level but a low health literacy level. The Joint Commission recommends that patient education materials be written at a fifth-grade reading level or lower1, and patient education companies are known to advertise a “third-to-fifth-grade reading level” for their materials. Lowering reading grade levels, however, is just one approach to making patient education materials more effective. It’s a tool, not a goal. One of the reasons for this, Osborne explains, is that reading levels “weren’t designed to assess health information written for adults. They were designed in the 1950s to help educators decide which textbooks to give to which school children.”

Commonly used reading level formulas include Flesch-Kincaid, Simple Measure of Gobbledegook (SMOG), Gunning-Fog Index and the Fry Formula. These formulas count the number of syllables per word; the more syllables a word has, the higher the reading level it’s assigned. Longer sentences (10 or more words) are also assigned higher reading levels than shorter sentences. It’s important to note that reading grades can be lowered artificially by replacing multi-syllable words with shorter or single-syllable words or adding shorter words. Replacing injection with shot, for example. This lowers the reading grade level but may not help with clarity and accuracy.

Patient education materials need to use health literacy best practices instead of relying on reading level assessments. Best practices include use of “white space” and lists; headings; subheadings; “chunking” information into like sections; providing definitions for medical terms; use of examples and illustrations; color; layout; design; and use of familiar words, even if they are long. Osborne offered compelling examples: “If you look at common words such as grandmother or hospital, people tend to recognize those words and know what they mean. But risk is a four-letter word that’s loaded with meaning and can be interpreted in many ways. It needs to be explained in ways readers can understand.”

By focusing on word and sentence length, reading grade formulas also ignore vital health literacy factors such as relevance to the reader and familiarity with the subject. For example, a document written for a person with newly diagnosed diabetes might need to explain more terms than a document written for a person who has had diabetes for years or decades. A person’s anxiety also matters; in a medical emergency, even a person with both high literacy and high health literacy skills might miss important information or have trouble figuring out what to do, where to go and whom to contact for help.

How well health messages are being delivered in the face of the current pandemic remains to be seen. COVID-19 is a new disease, requiring more explanation in patient education materials. Osborne observed some problems nationally. Admittedly, her background is in occupational therapy not public health. In her opinion, officials “seem to be missing the mark on at least three critical points: delivering a consistent message, making it actionable and acknowledging uncertainty. One example is mask recommendations. In the beginning officials said that masks needed to be reserved for front line workers. Soon after when conditions changed and the recommendation was for the public to wear masks, it was important to acknowledge that change and communicate it consistently. The role of managing uncertainty in health information is very important, and the response to COVID is making that clear.”

Helen Osborne, M. Ed, OTR/L, helps professionals communicate health information in ways that patients and the public can understand. She brings to this work her experience as an occupational therapist, training as an educator and her perspective as a patient and family caregiver. She is the author of the award-winning, best-selling Health Literacy from A to Z: Practical Ways to Communicate Your Health Message and the host of the podcast series Health Literacy Out Loud


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  1. Readability of Patient Education Materials Available at the Point of Care, Lauren M. Stossel, BA, Nora Segar, MD, MPH, Peter Gliatto, MD, Robert Fallar, MS, and Reena Karani, MD, US National Library of Medicine, National Institutes of Health, April 12, 2012