Article from the Boston Globe’s On Call Magazine, March 2003

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Patients are often asked to complete healthcare documents and forms. These materials may ask them to locate items on tables or graphs, look up information found in other documents, or rate satisfaction on a scale from 1–10. It takes advanced literacy skills to understand and complete such materials. But not all readers have these skills.

The 1992 National Adult Literacy Survey (NALS) found that about half the adults in the United States have problems understanding and using complicated forms, charts, maps, or schedules. NALS found that this is particularly the case for older adults, nearly 80 percent of whom have difficulty. This is not just an American problem. An International Adult Literacy Survey (IALS) reported similar findings in 14 industrialized countries around the world.

Michel Gauthier of Human Resources Development Canada in Ottawa knows this problem well. In his work as project manager in the Disability Benefits Division, he writes and reviews documents that Canadians must complete in order to get their benefits. Gauthier realizes that many people have trouble with these documents and has devoted much of his career to improving the situation. Building on research from colleagues across the US and Canada, Gauthier has analyzed the complexity of documents and identified ways to write them so readers can better understand.

It’s hard to write an easy healthcare form. As the writer, you not only have to consider content but also organization, design, and the types of tasks you are asking readers to do. Based on Gauthier’s work as well as my own experiences, here is a brief overview of what you need to consider in order to make the task of completing these forms easier for the most people.

Organization and Content

• Arrange information in an order that seems logical or natural for the readers. Begin with a brief statement introducing your document. Then present information in a logical sequence. In a hospital satisfaction survey, for example, you might ask first about the admission process and then continue with questions about treatment, discharge, and billing.
• Ask only for information you need now. If you need more information later, you can follow-up with another form or survey.
• Consider the environment in which people will complete your form. Think about how, when, and where readers will be given the document. Health histories, for example, are often given to patients in busy waiting rooms. Be sure there is adequate help for the patient to be able to complete the form quickly and accurately.

Language and Design

• Write your documents in plain language. This means use common words that readers already know, such as “heart” rather than “cardiac.” When you need to use a technical or an unfamiliar word such as “mastectomy,” explain it so readers can understand what the term means.
• Arrange content in categories. Categories help the person responding understand what is being asked for. Keep the number of items that readers must read and respond to in each category to the absolute minimum. Make sure that each category is clearly labeled with a header that indicates the content.
• Avoid including distracting information. Examples of distracting information include using words that are similar but not identical like “healthcare provider” and “primary care provider,” or mixing percentages, decimals, and fractions in a collection of numbers.
• Create documents that not only look inviting to a reader but also are easy to complete. Fonts should be no smaller than 12-point. The document should contain large spaces for people to write their answers in and sufficient white space so the print doesn’t look crowded. Don’t try to squeeze everything onto one piece of paper when two pages are needed.
• Show readers how to take the needed actions. For instance, show an example of an answer that is correctly circled rather than underlined, or a date written as mm/dd/yyyy.

Tasks

• Limit the total number of tasks you are asking readers to do. When possible, ask for information in just one way. For instance, ask only yes/no questions or fill-in-the-blanks or questions that ask for the patient to complete a rating scale. Don’t mix them if you don’t have to. If you truly need more than one format, use separate sections of the form for each type of question.
• Be specific in your directions. Let readers know whether to “check one box” or “check all that apply.” Tell them which sections they need to complete and which they can skip. For instance, you may be able to follow a yes/no response with an instruction like, “If no, go to Question #5.”
• Make it easy for readers to answer the questions. When possible, ask for concrete information (such as name, date, time, or place) rather than abstract information (such as how, why, or cause and effect). Avoid asking readers to look elsewhere for information they need to complete the form — such as in another paragraph or on another page. Try to structure questions so that they can be answered independently without relying on other answers.

Testing

• Assume the role of the reader and try using your own document or form. Make sure that you can complete the form in the given time, in the appropriate space, and with the information given. If you have difficulty, redo the form until you are satisfied that it is easy to understand and complete.
• After you have tried your own document, test it with intended readers. Notice where they have difficulty. Ask them what makes this document easy or hard to complete and get their suggestions about ways to improve it. Take the readers’ feedback seriously and use their suggestions in your next revision.

To Learn More

• Michel Gauthier is a project manager at Human Resources Development Canada. You can reach him by e-mail at michel.gauthier@hrdc-drhc.gc.ca.
• To download a copy of the guide, Assessing the Complexity of Literacy Tasks, visit the Web site at www.ibd.ab.ca/Literacy-task.html
• Helen Osborne helps healthcare organizations write forms and documents in ways people can understand. To learn more, please visit the Health Literacy Consulting Web site at www.healthliteracy.com

Print and Web Resources:

• Brown H, Prisuta R, Jacobs B, Campbell A (1996). Literacy of Older Adults in America. National Center for Education Statistics, US Department of Education.
• Creating Plain Language Forms for Seniors: A Guide for the Public, Private and Not-for-profit Sectors (1998). National Literacy and Health Program, Canadian Public Health Association.
• Doak, C, Doak, L, and Root, J (1996). Teaching Patients with Low Literacy Skills. J. B. Lippincott Company, Philadelphia.
• Kirsch I, Jungeblut A, Jenkins L, Kolstad A (1993). Adult Literacy in America. National Center for Education Statistics.
• Osborne, H (May, 1999). “In other words… creating medical forms people can understand,” p. 46-47. To read the full text of this article, go to www.healthlitreracy.com and click on “articles.”