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defined as the ability of a person toobtain, process, and understand healthinformation, as one of the 20 key pri-ority areas to transform the U.S. healthcare system (IOM, 2003). Like theother priority areas (such as diabetes,hypertension, and nosocomial infec-tions), health literacy was selected dueto the prevalence of illiteracy, as wellas the potential positive effectsimprovement would have throughoutthe health care industry. In addition,the IOM released a specific reportabout health literacy in 2004. Thereport states that 90 million Americanshave difficulty understanding and act-ing upon health information andincludes specific recommendationsthat health care systems and providerscan take to promote a health-literatesociety (IOM, 2004). Clearly, creatingreadable patient education materials isan important step in improving healthliteracy.

Determining ReadabilityBased on the high incidence of

functional illiteracy in the U.S., it islikely that dialysis clinics have a signif-icant number of patients who are func-tionally illiterate. It is also likely thatthe average dialysis clinic’s patienteducation materials are written on alevel that is not readable by many of itspatients. Brownson (1998) argues thatit is a waste of valuable nursing time todevelop patient education materialsthat cannot be used by all patients.Thus, it is critical to determine the

ally illiterate (Winslow, 2001). Rather,they make attempts to hide their read-ing problems. They might have afriend or family member read docu-ments for them, state that they forgottheir glasses, or tell you they will readthe document when they get home(Smith, 2003). However, these cues areoften missed by health care providers,and these patients are usually skillful athiding their deficiencies.

To acknowledge this nationwideproblem of functional illiteracy,numerous authors have recommend-ed that patient education materials bewritten on a fifth to sixth-grade readinglevel (Doak et al., 1996; Monsivais &Reynolds, 2003; Winslow, 2001).However, the majority of patient edu-cation materials are written on high-school or college reading levels(Brownson, 1998; Winslow, 2001).Doak et al. (1996) note that under-standing the instructions that comewith over- the-counter medicationsrequires a tenth-grade reading level,and reading the instructions on afrozen TV dinner requires an eighth-grade reading level. A recent analysisof 31 HIPAA privacy notices foundthat they were written on a second orthird-year college reading level(Hochhauser, 2003). There is clearly agap between the average person’sreading ability and the reading level ofmany instructions and documents inour society.

The Institute of Medicine (IOM)has included health literacy, which is

Writing and Designing Readable PatientEducation Materials

Michael D. Aldridge

Michael D. Aldridge, MSN, RN, CCRN, isa Nurse Educator in the pediatric intensive careunit at the Children’s Hospital of Austin in Austin,Texas. He also serves as the Home DialysisCoordinator for the Children’s Dialysis Clinic ofCentral Texas in Austin, TX.

Much of the communicationbetween dialysis patients andtheir health care providersoccurs verbally, but we often

rely on written materials to augment orreinforce our verbal instructions.Dialysis patients may refer to writtenmaterials that provide instructionsabout medication dosages, dietary reg-imens, fluid management, and treat-ment schedules. Patients must be ableto both read and understand thesewritten materials if there is any hope ofthem adhering to treatment plans.

The average adult in the UnitedStates is unable to read above theeighth-grade level (Doak, Doak, &Root, 1996). A large percentage ofdialysis patients are older than 65years of age and are particularly at risk,as 40% of people over 65 read belowthe fifth-grade level (Doak et al., 1996).People reading below the fifth-gradeare considered functionally illiterate.

While the literacy levels of dialysispatients have not been described inexisting literature, there are trends inthe overall population that provide uswith the larger picture. People withlow socioeconomic status, immigrants,high school dropouts, and the unem-ployed have higher rates of functionalilliteracy than the average adult(Quirk, 2000). According to a 1993government report, the states ofLouisiana, Mississippi, and Texas havethe highest rates of functional illiteracyin the entire country (U.S. Congress,Office of Technology Assessment,1993).

Due to shame and embarrassment,patients rarely admit they are function-

Functional illiteracy is a problem often overlooked by nurses. Although the average adult in theUnited States cannot read above the eighth-grade level, most patient education materials arewritten on a high-school or college reading level. If patients cannot read educational materials,then there is little hope of them using or understanding the information. Strategies for improv-ing the readability of education materials specific to the needs of nephrology patients are dis-cussed in this article.

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readability of patient education materi-als. Ideally, this analysis will occur dur-ing the development of new educationmaterials; however, it can also be doneretrospectively for existing materials. Ifthe grade level is found to be too high,then steps can be taken to simplify thematerial.

The concept of readability is notnew, and can be described as the“characteristics of written material thatmake that material ‘easy’ or ‘difficult’to read” (Kahn & Pannbacker, 2000, p.3). Readability can be determined by anumber of different formulas, most ofwhich use sentence length and wordlength as primary factors.

Readability should not be confusedwith comprehension or understand-ing. The latter terms imply that thereader has internalized the material,and are measured by testing or appli-cation exercises (Kahn & Pannbacker,2000).

There are over 40 different formu-las used to determine readability(Winslow, 2001). One of the mostcommon and easiest to use is theSMOG formula. This formula wasdeveloped by McLaughlin (1969), andhas been used for more than 30 years.

The process for using the SMOG for-mula is described in Table 1.

Determining the readability of adocument that is stored electronicallyis even simpler. Most word processingprograms have a built-in feature thatwill automatically calculate the read-ability for you (see Table 2).

Strategies for SimplifyingReading Levels

The goal is to have patient educa-tion materials on a fifth or sixth-gradereading level. Patients with good read-ing skills are unlikely to be insultedwhen presented with a brochure that iseasy to read. In fact, adults generallyprefer material that is easy to read overmaterial that is challenging to read(Doak et al., 1996).

There are two aspects to considerwhen simplifying any document:design and writing. Design refers to thevisual elements of the brochure. Thegoal is to create something that is visu-ally appealing, uncluttered, and easy tofollow. Well-designed documentshave:• Important elements and key

points highlighted with visual cuessuch as italics, bold face, andboxes;

• A limited number of fonts;• All type in at least 14-point font

size; • Lists that are bulleted so they are

easy to follow; • Critical information placed

prominently and repeated morethan once;

• Graphics and pictures to augmentthe text and help to explain diffi-cult concepts; and

• A lot of white space on the page. Table 3 highlights strategies to use

in the design of patient educationmaterials.

Writing refers to the words thatmake up the text, as well as the sen-tence structure and the style in whichthe text is written. Generally, wordsthat are more than three syllables longincrease the difficulty of the word to beread and understood. Many medical,nursing, and dialysis-specific wordscontain more than three syllables,which contributes to these materialsbeing difficult to read. Table 4 presentswords that are commonly used in dial-ysis patient education materials andoffers simpler words that can be sub-stituted instead.

In addition to decreasing the num-ber of words that contain more than

Writing and Designing Readable Patient Education Materials

1. Pick 10 sentences in a row at the beginning, middle,and end of the document (a total of 30 sentences).

2. Count every word in the sentences that has three ormore syllables. Read words aloud to determine thenumber of syllables. Words that repeat count eachtime they appear. Proper nouns and hyphenatedwords of more than three syllables count also.Abbreviations are counted as the whole word theyrepresent.

3. Figure the square root of the total number of wordswith three or more syllables.

4. Add three to the square root. This is the grade-levelof the document.Example: Your 30 sentences have 55 words with

three or more syllables.The square root of 55 is 7.4.Add 3 to 7.4 to get 10.4, which is thegrade-level of the document.

Table 1Using the SMOG Formula

Note: Adapted from McLaughlin, G.H. (1969). SMOG grading –A new readability formula. Journal of Reading, 12, 639-646.

If your document is in Microsoft Word (MicrosoftCorporation, 2002), do the following:

1. Click on “tools” “options” “spelling and grammar”2. Select the “show readability statistics” box3. Click “ok”4. When you are finished with your document,

select “spelling and grammar.” Word will com-plete its spelling and grammar checks, and thenpresent the readability statistics for your docu-ment.

Nearly all word-processing programs will produce read-ability statistics. If you use another word processing pro-gram, instructions can usually be found by searching for“readability” in the Help menu.

Table 2Using Computers to Determine Readability

Note: Instructions adapted from Microsoft Word for Windows2002 [Computer software]. (2002). Redmond, WA: MicrosoftCorporation.

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individual dialysis clinics or transplantunits. For example, if a certain medica-tion used in treating hyperphos-phatemia is not routinely prescribed ina clinic, then it should not be includedin that clinic’s brochure. A guiding ruleis to try to tell patients what they needto know, not what is nice to know(Brownson, 1998).

Patient education materials –unlike verbal instructions – serve as apermanent record of the instructionsgiven to a patient. Therefore, theyshould be accurate and include onlytreatments that are accepted in com-mon practice. For example, suppose adialysis clinic surveyed its home peri-toneal dialysis patients and found thatnone of its patients actually washedtheir hands or wore masks when per-forming exchanges. Because they havenot experienced unusually high ratesof peritonitis, the clinic concludes thathandwashing and wearing masks isoptional and then states this in theirnew home training manual. Later, apatient who follows these writteninstructions gets peritonitis, transitionsto hemodialysis, and dies of complica-tions. It would be difficult to legally jus-tify telling home patients they did notneed to wash their hands or wearmasks during exchanges, and the writ-ten training manual would serve asstrong evidence in court. Although thisscenario is fictional, it serves as areminder about the potential liabilityof written materials. To address this,some clinics require a disclaimer to beadded to all educational materialsgiven to patients. You can consult therisk management department if youare unaware of your clinic’s policy.

When designing patient educationmaterials, it is advisable to leave blankspaces for patients to personalize thematerial with information like theirindividual lab values, medicationdosages, blood pressure readings, dryweights, etc. In the hyperphos-phatemia brochure example, a spacecould be added to write in the patient’scurrent dose of phosphate-bindingmedications. A chart could also beconstructed with the dates and phos-phorus levels to help patients tracktheir progress. Personalizing the infor-

• Use bold or italics to emphasize key points• Use black letters on white paper for clarity• Use at least 12-point font size.

❏ One study found that patients prefer 14-point Arial type• Avoid using many fonts, as it is distracting to the reader.• Use picture or drawings to illustrate concepts or procedures

❏ Keep them simple. Pictures from textbooks or journals are too complex.❏ Do not use pictures that demonstrate the wrong behavior.

• Do not use all caps – IT IS DIFFICULT TO READ.• Justify the text to the left margin and leave the right side ragged.• Use headings and subheadings to divide the text.• Leave a lot of white space on the page.

❏ The goal is for the handout to look uncluttered.• Use interactive elements to encourage patients to use the material.

❏ Examples include charts for lab values, blood pressure monitoring, dryweights, medication dosages, and so on.

❏ Have patients fill in the blanks as you discuss the material with them.Example: An alternative to eating ice cream is to eat ____________.

• Bullets (like in this table) help the reader follow the information.

Table 3Improving Readability: Design Strategies

Note: This table is summarized from the following references: Brownson (1998);D’Alessandro et al. (2001); Eyles, Skelly, & Schmuck (2003); Horner et al. (2000);Winslow (2001).

three syllables, the length of sentencesshould be no more than 10 to 15 wordslong. The longer a sentence is, themore difficult it is to comprehend.Commas and semicolons can easily bereplaced with periods to divide onelong sentence into several short sen-tences. Finally, writing in the activevoice is easier to read and mimics con-versational English. Table 5 summa-rizes strategies to improve readabilityby altering writing.

Using the strategies. Severalstrategies have been reviewed forimproving the readability of patienteducation materials. The followingexample will demonstrate how thesestrategies can be applied to improvethe readability. Table 6 shows a para-graph with an example of two com-plex sentences from a brochure onhyperphosphatemia. By applying thestrategies discussed, the paragraph issimplified into four sentences that areeasier to read.

The difficult paragraph is writtenon a 12th-grade reading level. Toimprove readability, several wordsthat had more than three syllableswere replaced with shorter words. The

long sentences were divided into sev-eral shorter sentences, and everythingwas written in the active voice.Phosphorus was consistently referredto as “phosphate” throughout the para-graph. These simple maneuvers pro-duced a paragraph written on the fifth-grade reading level.

Although this reading level isappropriate for most patients, it isimportant to remember that even ifpatients can read the material theymay not be able to understand theconcept. In this example, a pictureillustrating the action of phosphate-binders would help patients under-stand this concept more than wordsalone.

Writing and Designing NewMaterials

The same strategies that can beused to simplify existing documentscan also be used when creating newpatient education materials fromscratch. Designing new patient educa-tion materials provides the opportuni-ty to create something truly meaning-ful for patients. In addition, the educa-tion can be tailored to the specifics of

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mation might encourage patients toactively use the brochure.

Finally, remember to do a pilot teston patient education material beforeprinting hundreds of copies. Ask othernurses and physicians to read it forcontent and accuracy. Most important-ly, ask for feedback from patients whowill be using the material (Brownson,1998). Find out whether they under-stand what you are trying to commu-nicate, and ask them if they would usethe brochure. Patients often have goodinsight into the very problems we aretrying to address, and the changes youmake from a pilot test can make yourfuture educational efforts much moreeffective.

Limitations of PrintedMaterials

The strategies described will helpimprove the readability of writtenpatient education materials. However,we should not be under the illusionthat making materials more readablewill address all of the patient educationchallenges. As mentioned before,readability does not equal comprehen-sion, and we cannot rely on writtenmaterials alone to educate patients.

Brownson (1998) argues that manypatients simply disregard educationalhandouts. This is probably more com-mon in patients who are functionallyilliterate, as the utility of the handout isless in this group. In fact, many ofthese patients rely on television, familymembers, and friends as a resource forhealth information (Brownson, 1998).Educational efforts could be enhancedby targeting these sources of informa-tion as well.

Educational materials should alsobe mindful of the cultural needs of par-ticular groups. Clinics with large popu-lations of Hispanic or Asian patients,for example, should examine theireducational handouts. Do the materi-als need to be translated into anotherlanguage? Are there cultural refer-ences that should be included orexcluded?

Horner, Surratt, and Juliusson(2000) describe the process of revisingteaching materials for children withasthma. The patients and families

Writing and Designing Readable Patient Education Materials

Table 5Improving Readability: Writing Clearly

• Be consistent in the words you choose❏ Example: Don’t refer to “medicines,” then “medications,” then “pills.” Pick a

word and use it throughout the material.• Replace words with more than three syllables with shorter words (see Table 4).• Sentences should be 10 to 15 words longs.

❏ Divide long sentences at commas and semicolons• Turn the passive voice into the active voice:

❏ Passive voice: Your exchanges should be done every night.❏ Active voice: Do your treatment every night.

• Define words that your patients might not understand.❏ A glossary might be helpful at the end of your document.

• Do not include technical words, statistics, or abbreviations.• Use the second-person (“you”) instead of the first-person (“I”) or the third-

person (“the patient”). It is more personal.• Use numerals (1, 2) instead of numbers spelled out (one, two).

Note: This table is summarized from the following references: Brownson (1998);D’Alessandro et al. (2001); Horner et al. (2000); Winslow (2001).

Table 4Improving Readability: Simplifying Complex Words

Note: Table is summarized from the following references: D’Alessandro et al.(2001); Horner et al. (2000); Winslow (2001).

Replace this word

AdministerAnemiaBlood transfusionCatheterContaminatedDetermineDiabetesDialyze, dialysisDiscontinue, terminateDifficultiesDocumentEdemaEffluentErythropoietinExperienceHypertensionIndicateInjectionIntravenousNotifyObtainOintmentPhosphorusPhysicianProcedureSodiumSubcutaneousTroubleshootingUltrafiltrateUtilizeVenipuncture

With this word or phrase

GiveLow blood countReceive bloodTubeDirtyFind outHigh blood sugarRemove fluid and wasteStopProblemsRecord, write downSwellingDrain fluidEpoHaveHigh blood pressureShowShotIn a veinCallCollectCreamPhosphateDoctorTask, skillSaltUnder your skinProblem solvingRemove fluidUseDraw blood

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spoke both Spanish and English, so thenew teaching materials were translatedinto Spanish and lined up side by sidewith the English version. This allowedreaders, many of whom spoke Englishas a second language, to move backand forth between the English andSpanish text. This maneuver improvesreadability in this population, becausemedical words used in the patient’sdisease process may be more readilyunderstood in their English formrather than their Spanish form.

The continuing emergence of theWorld Wide Web has had vast effectson patient education. It is now com-mon practice for patients to search theInternet for medical information.However, this practice may presentchallenges as well. Hochhauser (2002)states that consumers tend to scan doc-uments on the web, rather than readthem word-by-word. This could leadto patients misunderstanding theintended information. In addition,there is evidence that web-basedpatient education materials are writtenon higher-than-average reading levels.One study (Graber, Roller, & Kaeble,1999) found a sampling of patient edu-cation material from the Internet to bewritten on a 10th-grade reading level.Another study (D’Alessandro,Kingsley, & Johnson-West, 2001)looked specifically at pediatric patienteducation materials on the Internet,and found those materials to be writtenon a 12th-grade reading level.Therefore, similar challenges exist indesigning and writing patient educa-tion materials that will be Web-based.

Finally, we must remember thatchanging any behavior, such asincreasing adherence to taking phos-phate-binding medications, is multi-factorial. Patients may simply lack themotivation or support to change theirbehavior, and a handout alone isunlikely to change that fact.

ConclusionWell-designed and appropriately

written patient education materials canaugment other educational efforts andultimately improve patient care.Improving readability does not guar-antee that patients will understand oruse education materials; however,these simple strategies increase thelikelihood that the materials will beuseable. It is important for nephrologynurses to understand how to createsuch materials in order to providepatients with chronic kidney diseaseincreased opportunities for under-standing their disease process and howthey can best adapt to it.

ReferencesBrownson, K. (1998). Educational hand-

outs: Are we wasting our time?Journal for Nurses in Staff Development,14, 176-182.

D’Alessandro, D.M., Kingsly, P., &Johnson-West, J. (2001). The read-ability of pediatric patient educationmaterials on the World Wide Web.Archives of Pediatric Adolescent Medicine,155, 807-812.

Doak, C.C., Doak, L.G., & Root, J.H.(1996). Teaching patients with low litera-cy skills. Philadelphia: LippincottPublishers.

Eyles, P., Skelly, J., & Schmuck, M.L.(2003). Evaluating patient choice of

typeface style and font size for writtenhealth information in an outpatient set-ting. Clinical Effectiveness in Nursing, 7,94-98.

Graber, M.A., Roller, C.M., & Kaeble, B.(1999). Readability levels of patienteducation materials on the WorldWide Web. Journal of Family Practice,48, 58-61.

Hochhauser, M. (2003). Readability ofHIPAA privacy notices. Retrieved March6, 2004, from http://www. benefit-slink.com/articles/hipaareadability.pdf

Hochhauser, M. (2002). Patient educationand the Web: What you see on thecomputer screen isn’t always what youget in print. Patient Care Management,17(11), 10-12.

Horner, S.D., Surratt, D., & Juliusson, S.(2000). Improving readability ofpatient education materials. Journal ofCommunity Health Nursing, 17, 15-23.

Institute of Medicine. (2004). IOM reportcalls for national effort to improve healthliteracy. Retrieved April 16, 2004 fromhttp://www4.nationalacademies.org/news

Institute of Medicine. (2003). Officials shouldtarget 20 key areas to transform health caresystem. Retrieved March 18, 2004 fromhttp://www4.nationalacademies.org

Kahn, A., & Pannbacker, M. (2000).Readability of educational materialsfor clients with cleft lip/palate andtheir families. American Journal ofSpeech-Language Pathology, 9, 3-9.

McLaughlin, G.H. (1969). SMOG grading– a new readability formula. Journal ofReading, 12, 639-646.

Microsoft Word for Windows 2002 [Computersoftware]. (2002). Redmond, WA:Microsoft Corporation.

Monsivais, D., & Reynolds, A. (2003).Developing and evaluating patienteducation materials. The Journal ofContinuing Education in Nursing, 34, 172-176.

Quirk, P.A. (2000). Screening for literacyand readability: Implications for theadvanced practice nurse. Clinical NurseSpecialist, 14, 26-32.

Smith, L.S. (2003). Help! My patient’s illit-erate. Nursing 2003, 33(11), 32hn6-32hn8.

U.S. Congress, Office of TechnologyAssessment. (1993). Adult literacy andnew technologies: Tools for a lifetime(OTA-SET-550). Washington, DC:U.S. Government Printing Office.

Winslow, E.H. (2001). Patient educationmaterials. American Journal of Nursing,101(10), 33-37.

Difficult (12th-grade reading level):The patient should be taking phospho-rus-binding medications with everymeal or snack, as these drugs preventabsorption of phosphorus from thegastrointestinal tract into the blood-stream. The excess phosphate eventu-ally leaches calcium from the bones,resulting in weakening of the bonestructure.

Easier (Fifth-grade reading level):You should take some medicines everytime you eat a meal or snack. We callthese medicines phosphate binders.The medicines keep the phosphate inyour intestine. This helps calcium stayin your bones and keeps your bonesstrong and healthy.

Table 6Example of Patient Education Materials for Hyperphosphatemia