h e a lt h l i t e r a c y : c o m p r e h e n s i o n c o r r e l at e s t o g o o d h e a lt h

a v i a l a n g u ag e w h i t e pa p e r

Health Literacy: Comprehension Correlates to Good Health
Imagine yourself and your family in the middle of another country. Your child is ill and you need to find your way to the hospital as quickly as possible. You studied the language in college and recognize many of the words, but it has been years since you’ve used it and your comprehension is poor and your speaking ability worse still. Suddenly, you find yourself in situation in which you are unable to satisfactorily convey your meaning. Details like symptoms, health history, and medicine types, so easy to articulate at home, are greeted with blank looks and confusion. What do you do?

Who Are the Health Illiterate?
Although many Americans find it difficult to understand and use information written at a competency level higher than the eighth grade, materials provided by health care providers are, on average, written at grade levels 10 to 12. A National Adult Literacy Survey in 1993 revealed that “of the 90 million Americans who have difficulty comprehending medical information, 47 percent have low or limited literacy skills.” Of these, 25 percent are immigrants from non-English-language backgrounds who often have to rely on interpreters to communicate. Research also shows that limited-Englishproficient (LEP) and minority populations are more likely than their white counterparts to have chronic disease, lack health insurance, and have difficulties communicating with their health care providers1.

Q: what is health literacy? A: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. — U.S. Department of Health & Human Services

Even for those who speak English as a second language, comprehension of new vocabulary or subject matter can be quite low. This is especially true when faced with difficult medical terminology. Add to this complicated grammar and syntax, compound/complex sentences, use of idiomatic expressions and confusing or unfamiliar cultural references, and real understanding can prove elusive indeed. As a result, comprehension suffers and the opportunities for misinterpretation are greatly increased: a potentially dangerous scenario in many health care settings. The table below, provided by the Center for Health Care Strategies (CHCS), compares the relative difficulty experienced in 2005 by four ethnic groups when communicating with their health care providers.


Center for Health Care Strategies, August 2005

Copyright 2010 viaLanguage. All Rights Reserved
Copyright 2009© viaLanguage. All Rights Reserved.

The Importance of Health Literacy
The effects of health illiteracy are varied and potentially far reaching. The following can typically be said of individuals with low health literacy. They are: • At greater risk of hospitalization errors • More likely to have longer hospital stays • Less likely to comply with treatment • More likely to make errors with medication2 In addition to an overall lower health status, those with low health literacy are less likely to take preventative health measures, which can have disastrous consequences, especially during pandemics such as the current H1N1 outbreak. According to the Journal of General Internal Medicine, patients with inadequate health literacy are twice as likely to be hospitalized as those with adequate literacy (32% vs. 15%). Moreover, it is estimated that low health literacy results in 3 percent to 6 percent higher health care expenses, with federal and state health plans such as Medicare and Medicaid financing the majority of this expense3.

Health Literacy and LEP Audiences
Ensuring health literacy is crucial when dealing with an LEP audience. A contributing factor to the disproportionately low health literacy rates among LEP audiences is the commonly low literacy rates among these groups in their own native language. For example, Somali has existed as a written language for a mere 20 to 30 years. Among the Burmese refugee population, the literacy rate ranges from only 40 percent to 70 percent4. To effectively communicate with a multicultural audience, one must also consider cultural factors such as race, ethnicity, religion, age, and gender. For example, many ethnicities don’t share the same high value that many place on Western medical practices. Concepts such as a separation of mind and body, and the scientific method, may be unfamiliar.
It is estimated that low health literacy results in 3-6% higher health care expenses, with Medicare and Medicaid financing the majority.
—Center for Health Care Strategies, August 2005

Some Asian immigrant cultures, for example, are influenced less by science and more by traditional or Eastern views of medicine. By contrast to Western models, these approaches tend to be more holistic and ritualistic, often incorporating religious or animistic practices. Consider how one might view the cause(s) of an illness. Western medicine, informed as it is by science, views illness as undesirable and demanding treatment. But among the Hmong culture the same condition might be thought the result of evil spirits or the departing of one’s own spirit from the body5. Simply gathering information from a Hmong patient can be complicated by cultural differences. Among the Hmong, saying “no” can actually be considered disrespectful, requiring health care communicators to avoid or rephrase yesor-no questions when creating medical forms or questionnaires targeted at this community. When distinctions of this kind are added to the complex nature of most U.S. health care materials, complicated medical terms, and a dizzying insurance system, it is little wonder that confusion and miscommunication are so common among LEP audiences.

Ensuring Literacy with Your Health Care Communications
Health care marketers play a significant role in promoting health literacy by ensuring that their communications respect and incorporate cultural differences. Experienced marketers understand that marketing campaigns are only as effective as their ability to convince the target audience that their needs are clearly understood. This is nowhere more critical than when communicating to LEP audiences, and a firm grasp of health literacy trends is a key piece of the process. The consequences of failing to meet these demands go far beyond a simple breakdown in communication; the health and very life of the LEP patient can be put in jeopardy.

Agency for Health Care Research and Quality, 2008 Center for Health Care Strategies, August 2005 4 USDOS, Bureau of Population, Refugees, and Migration, September 2006 5 Hmonghealthcare.org
2 3

Copyright 2010 viaLanguage. All Rights Reserved
Copyright 2009© viaLanguage. All Rights Reserved.

Identifying the Literacy Level
Employing readability tools can be an effective way to help establish the literacy level of a given document or communication. One of the most recognized readability tools in the healthcare community is the Fry Readability Formula, which is one of the more accurate formulas for identifying low grade levels in English documents. It works by calculating the average number of sentences and syllables per 100-word passage and plotting them on the Fry Graph to determine the grade level Each text assessment results in a score based on the U.S. high school grade-level system (i.e., a data point on “8” means an eighth-grade student should be able to comprehend the material).

Similar to Fry, Flesch-Kincaid Grade Level is another tool to measure readability and can be found in your Microsoft Word toolbar. It measures number of syllables per word and words per sentence. Here’s an example of how it scores:

text example
1. Your health matters. 2. Some people cannot speak English. 3. They often need help when they go to the doctor. 4. Consider the cultural nuances of your target population.

Flesch-Kincaid grade score
1.3 5.3 6.9 12

Copyright 2010 viaLanguage. All Rights Reserved
Copyright 2009© viaLanguage. All Rights Reserved.

Tips for Creating Readable Health Materials in any Langauge
1. health materials should focus on key messages and what patients need to know. Best practices include: • Write clearly and in an active voice. TIP: Tools to check literacy levels: • Use familiar vocabulary and simple terminology. english: Use Fry or Flesch-Kincaid • Use short sentences. • Use graphics, videos or pictures that “show” rather than “tell.” spanish: Use the (HRE) Huerta • Keep materials at a fourth- to sixth-grade level. Readability formula 2. employ readability tools to analyze and ensure the proper literacy levels. • In addition to using the Fry Graph above, for English texts, word processing applications , such as Microsoft® Word, can automatically determine the Flesch-Kincaid Grade Level and readability ranking. • Because readability formulas used in English can’t be applied to foreign language documents, professional translators should utilize various other language-specific assessments. • For Spanish, consider the Huerta Readability formula (HRE), an assessment similar to the Flesch-Kincaid Grade Level test designed for analyzing texts in Spanish. 3. health materials should be culturally relevant. • Use images and examples that reflect the target audience. Pictures should display people of their own demographic rather than a generic stock photo of an “ethnic” person or family. • If menu/food recommendations are included, they should reflect items that are relevant to the audience’s diet • Do not use slang or cultural references that may be unfamiliar to an immigrant or LEP population. • Initiate a community review to test materials for comprehension and effectiveness. 4. use professional linguists instead of machine translation. • Materials should be translated by professional linguists and reviewed for grammatical inconsistencies and readability, important details that are beyond the capabilities of machine or computer-based translations. (see table below). • Professional translators can reducethe literacy level of source material by two grades. Note that a further reduction requires that considerable creative license be granted to the translator • Have your translation team utilize a glossary, style guide and translation memory to ensure consistency in word choice and readability levels across all documents. This will also help save money!
Original Sentence
¿Cómo se llama? (What is your name?) Есть ли у вас проблемы с физическим или умственным здоровьем? (Do you have any physical or mental health problems?)

How it is called? Are you in there problems with physical or mental health?

How is called? Are there you in problems with the physical or health mental?

How does it call? Whether there are at you problems with physical or intellectual health?

Getting It Right — Every Time
Creating low-literacy level texts sounds as simple as rewording complex medical terminology, right? Wrong. As a matter of fact, this very brief that you are reading rates at a 12th grade literacy level, and we haven’t even included any medical jargon! In conclusion, when developing health care outreach materials for LEP populations, it is crucial to keep health literacy levels in mind. Developing a solid understanding of an audience’s reading ability helps equip you to maximize the effectiveness of your communications, fostering greater cultural understanding, increased patient involvement and, ultimately, improved health.

About viaLanguage
To learn more about health literacy and how viaLanguage can help your organization reach your multilingual members and communities, contact us at 1-800-737-8481 or visit us online at www.viaLanguage.com.

Copyright 2010 viaLanguage. All Rights Reserved
Copyright 2009© viaLanguage. All Rights Reserved.

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