Health Literacy Part 2

Abstract

Health literacy promotion techniques are important for the school nurse’s tool kit. Forty-three percent of the adult population have difficulty understanding basic health information, yet written materials sent home from schools are often at a level well above the average reader. Learning and applying techniques to improve the appearance and comprehension of your written materials will help to get the school nurse’s message home. This article is the second and final in a series of articles focusing on health literacy. The first article, focusing on verbal communication, was published in the September 2013 issue of NASN School Nurse.

Keywords

health literacy health teaching written communication plain language

Effective communication with parents is vital for improving health outcomes and maximizing learning for students. Part of the common core of school nurse responsibilities is sending home “progress notes” outlining the results of a visit to the health office during the day. Other written communication may include proper treatment of lice, notification of a whooping cough outbreak, an announcement of an upcoming parent CPR class, or a request for health history form completion. School nurses are frequently frustrated because such forms are not completed or necessary treatment is not executed correctly. Since research estimates that more than one-third of Americans struggle with the necessary skills to understand basic health information, what may be perceived by the school nurse as non-compliance may actually be not understanding (Weiss, 2007). Understanding the basic principles of health literacy and applying both verbal (part 1) and written communication techniques, as described in this article, will undoubtedly lead to an increase in “compliance.”

The Need for Readable Written Health Materials

Kumaresan (2013), in a recent Institutes of Medicine report, described health literacy as “the cognitive and social skills that determine the motivation and ability of individuals to gain access to, to understand, and to use information in ways that promote and maintain good health” (p. 9). Busy people, even the most highly educated, want and need easy-to-read materials; otherwise, they will put it aside for “when they have time.” In addition, for those with low literacy skills, easy to read is essential as the average reading level in the United States has been estimated at an 8th-grade level (National Patient Safety Foundation [NPSF], 2011a).

. . . the average reading level in the United States has been estimated at an 8th-grade level.

The world is a much different place from when Doak, Doak, and Root first wrote about creating more readable health education print materials in 1996. When evaluating the written word for as wide an audience as possible, one must now include Internet websites, e-mail, Twitter, Facebook, and other social media. The Internet is full of online health information. However, due to a lack of easy access to evidence-based information and no standard quality check, it is very difficult for the general public to find and evaluate quality health information, even if one has high health literacy skills. Additionally, Kumaresan (2013) noted that people with low levels of health literacy are less likely to have access to the Internet and online health information. It is encouraging that Baur (2013) noted that the U.S. government has been active in health literacy, most notable, in provisions in the recent Patient Protection and Affordable Care Act and in the Plain Writing Act of 2010, which requires federal agencies to use plain language in public communications. Moreover, excellent comprehensive online health literacy training programs have been developed by the Centers for Disease Control and Prevention (CDC, 2010), the National Institutes of Health (NIH, 2005, 2012), and the Agency for Healthcare Research and Quality (AHRQ, 2010).

Improving Written Communication

The seminal voice in describing how to create readable health education materials continues to be Doak and Doak. Their book, Teaching Patients with Low Literacy Skills (Doak, Doak, & Root, 1996), is out of print but is available on the Harvard University website as a scanned book. Their most recent work was as editors for Pfizer Principles for Clear Health Communication (Doak & Doak, 2004). While more current documents regarding health literacy exist, they all are mechanisms to clarify and expand on the principles first set forth by Doak et al. in 1996. The appendix describes extensive reference materials, all available online.

The first step in creating successful written materials is recognizing characteristics of poor readers. Typically, poor readers will take words literally, skip over hard words, read slowly, and tire easily (Doak & Doak, 2004). The AHRQ (2010) recommends using health literacy universal precautions. These precautions assume that everyone will have problems understanding health information. Doak and Doak’s five key principles in planning and evaluating effective health care materials have stood the test of time (see Table 1).

Table 1.

Planning Effective Health Care Materials

1	Explain the purpose and limit the content
2	Involve the reader
3	Make it easy to read
4	Make it look easy to read
5	Select visuals that clarify and motivate

Source: Doak and Doak (2004).

Limit the Content and Make it Relevant

All learners, adult or child, need to identify and find personal relevance with the topic. The learner should not have to search for the purpose. Put first things first. An essential question to ask is, “Is this nice to know or need to know?” Only need to know information should be included (CDC, 2010; Doak & Doak, 2004; NIH, 2012; Weiss, 2007). A method to sequence your topics that can help to ensure that you have met these objectives is to use Ask Me 3 (NPSF, n.d.). Be sure your document includes content that completes the following sentences: (1) “Your child has/is/the problem is . . .”; (2) “What you need to do is . . .”; and (3) “This is important because. . . .” See “Health Literacy Part 1” (Pontius, 2013b) for usage examples.

Is this nice to know or need to know? Only need to know information should be included.

Involve the Reader

Using Ask Me 3 (NPSF, n.d.), that is, putting the most important information first, telling them clearly what needs to be done, and explaining why it is important to them, quickly engages your audience. Other effective methods of reader engagement include the following:

creating a true-false quiz,

using question and answer (Q&A), structured as a first-person frequently asked questions (FAQ) table, or

including something the reader can cut out, such as a checklist or a poster.

Make the content relevant to the appropriate age, gender, and culture. Translate documents into the language of choice for the population whenever possible. Use cultural and ethnically relevant and sensitive terms and references. And be careful of colors and symbols, which can have unintended meaning.

For online and social media messages, consider sending out one message at a time. For example, on the topic of lice, send out one question and answer about the topic by e-mail, Twitter, or Facebook each day during the first week of school. On your school nurse website (which every school nurse should have), create FAQ pages or interactive quizzes that allow “clickable” questions. While designing interactive websites may be above the skill set of the school nurse, and beyond the scope of this article, the school nurse can create FAQs and simple messages that the district information technology (IT) specialist can then implement. The appendix includes several websites describing effective health website and social media design. The author’s website also has samples of FAQ formatted health information pages.

Make It Easy to Read

Although the audience for this article is the professional school nurse with a corresponding reading level and tone, both the author and the publisher have used the readability techniques described to invite the reader to take time to read and to make the reading experience comfortable and encouraging. Therefore, throughout this article, the article itself will be used to illustrate appropriate readability examples.

The most important recommendation is to “write the way you talk” (Doak et al., 1996, p. 78). This simple statement encompasses all the guidelines to follow. Write the message as if you were talking to the intended recipient in your living room. Using conversational language automatically drops the reading level by up to six grades, creating a document that is more interesting to read, thereby increasing the likelihood that it will actually be read and applied by the learner (CDC, 2010; Doak & Doak, 2004; Doak et al., 1996; U.S. Department of Health and Human Services, 2010).

Choose Your Words Carefully

The importance of using plain, non-ambiguous language in providing health information is well described (AHRQ, 2010; Baur, 2013; CDC, 2007; Doak & Doak, 2004; Doak et al., 1996; NIH, 2012; NPSF, 2011b; Weiss, 2007). The school nurse should use common, everyday language, avoiding jargon and choosing concrete terms as much as possible. Part 1 of this series describes words to avoid in both verbal and written interactions, as well as resources for plain language substitution for medical jargon and confusing words (Pontius, 2013b). However, in using plain language, it is imperative that it is not so plain that the audience feels talked down to or preached at (CDC, 2010). Respect your audience by speaking clearly but effectively. Table 2 provides more guidelines for effective word selection.

Table 2.

Choosing Clear Words

Say THIS:	Not THIS:
Use analogies familiar to your audience.
Look for a red spot about the size of a penny	Look for a red spot about 2 cm in diameter
Choose a piece of meat about the size of a deck of cards	Choose a piece of meat about 4 oz
Limit use of statistics. Use more general words. If using statistics, consider putting them in parentheses.
About a third of students need an inhaler	33% of students with asthma need an inhaler
Almost all children (95%) receive their immunizations	95% of all children receive their immunizations
Avoid jargon, technical, or scientific language.
Lice shampoo	Pediculicide
Birth control	Contraception
Limit the use of quotation marks. Choose other ways to tell who is speaking.
Bob: Where can I get my child his shots?	Bob asked, “Where can I get my child his shots.” The school nurse replied, “Your local health department.”
School Nurse: Your local health department.
Be consistent with word usage.
For example: Conjunctivitis and pink eye are often used interchangeably. Pick one and use it consistently throughout your document. If you want to use the less common but more accurate medical term, be sure to define it in the beginning and give the more common term for reference. e.g., “Conjunctivitis, also known as ‘pink eye’. . .”
Choose words with a single definition.
For example: “Keep your blood sugar in a normal range” may be confusing, both because your audience may know a range only as a place to cook and because normal for blood sugar has no concrete meaning.
Avoid unnecessary abbreviations and acronyms (unless they are the more common usage like CPR or HIV). Put the full word/words before the acronym when an abbreviation is used.
For example: State law now requires two measles, mumps, and rubella (MMR) shots.

Source: Adapted from Centers for Disease Control and Prevention (2009) and Doak and Doak (2004).

Use Active Voice

Active voice makes it clear what action should be taken. Start the sentence with a verb: “Take your child to the doctor for a different lice medicine if lice comes back.” “Tell the school if your child has ringworm.” Keep the tone conversational by including “you” or “your” close to the beginning of the sentence when possible: “Your child can get sick from whooping cough without a booster shot” rather than “Failure to obtain a booster shot can lead to whooping cough in children.” Also note the use primarily of active voice within this article. Active voice makes the tone conversational. Passive voice adds many more words and moves more slowly. The reader can more easily get lost in the words (CDC, 2010; Doak & Doak, 2004).

Use Headings, Subheadings, and Bulleted Lists

Breaking up complex topics into smaller portions allows the reader to deal with only one idea at a time. Giving each topic an advance organizer, or heading, helps the reader integrate the topic and concept into the working memory. The FAQ list is also a good method of organizing your information and providing useful headings. Always place the most important information at the beginning of the material. This is the most important piece of information they need to take away. Remember, readers may tire and stop reading before the end of the document. Experts also recommend that words-per-sentence be limited at 15 to 20 (Doak & Doak, 2004).

Make use of a bulleted or numbered list, including the most important information in the first part of each item in the list, with no more than seven items in a list (five is preferred). Using checkboxes instead of the traditional round, black bullets both organizes the information and engages the reader by providing something to check off. Also notice the comparison tables in this document. They all have the “good stuff” on the left side, and the poorer version on the right side. Providing consistency in layout when using a comparison table avoids confusion for the reader (CDC, 2010; Doak & Doak, 2004) (see Tables 2 and 3).

Table 3.

Active Voice, Shorter Words, and Listing

Active Voice—Better	Passive Voice—Poorer
Make clear rules.	Children need clear and consistent boundaries and immediate consequences to violating prescribed boundaries.
Tell your child what will happen if the rules are broken.
Do what you say you will do when your child breaks the rules— right away .
Tell the school nurse if you find lice or eggs on your child’s head.	The school nurse needs to be told of any lice or eggs found in the hair.
What to do if you think your child has lice: Look carefully for tiny insects the size of a sesame seed. Check all children in the family. Use a special lice shampoo.	Children with possible lice need to be treated with lice shampoo. All children in the family need to be checked for tiny insects that are about the size of a sesame seed.
All About Ringworm	Ringworm
Ringworm is contagious and spread by touching. You can get it from: Another person—it could be under fingernails A thing—like a shower floor An animal—like a cat Ringworm causes red, scaly patches of skin in a mostly circular shape. It begins as a solid patch and then clears in the center, making a “ring” shape. Ringworm is not a worm but a fungus infection. It can be on the head, body, genitals, or feet. Athlete’s foot is ringworm of the feet. Jock itch is ringworm of the genitals.	Ringworm is not a worm at all, but a fungus infection, which can be on the head, body, genitals, or feet. It is quite contagious and can be passed from person to person and animal to person easily. When the ringworm fungus is on the feet, it is called athlete’s foot, and when on the genitals, jock itch. Ringworm causes red, scaly patches of skin in a mostly circular shape. The ring shape forms after starting as a solid patch and then gradually clearing in the center. Direct contact, skin-to-skin, and contact with things like a shower floor or animals like cats can spread this fungus.

Consider bolding a few of the most important words to draw attention to them. Bolding can act like a simple subheading. When spacing your text, leave more space (3-6 points) above headings and subheadings than below them. This links the headings to the text immediately below and sets them off from each other (CDC, 2010). Table 3 describes examples of all these principles.

Strive for 6th- to 8th-Grade Reading Level

The reading level of a document is influenced by two factors: the number of hard words (multi-syllable or complex words), and the average length of the sentences in the document (Doak & Doak, 2004). We know the average reading level in the United States is 8th grade (AHRQ, 2010; NPSF, 2011a). Employing health literacy universal precautions, we should then strive to achieve a reading level from 6th to 8th grade. From the author’s personal experience, it is relatively straightforward to create or reduce a document to the 8th-grade level. It is much more difficult to achieve the 6th-grade goal.

There are over 40 different tools for evaluating readability. Experts such as Doak and Doak (2004) and the CDC (2010) recommend the Fry or SMOG methods—the latter an acronym for “simple measure of gobbledygook,” gobbledygook meaning nonsensical or jumbled up words. Manual methods take from 15 minutes to several hours to perform as they involve counting syllables or words in a sample of the document (at least 100 words) and then performing a calculation or plotting to a graph. SMOG is considered the easiest and quickest of the manual methods. To use SMOG, count the number of words with three or more syllables in three chains of 10 sentences and then determine the grade level from the SMOG table (see Table 4). Detailed instructions for use of these manual calculation methods can be found in Pfizer Principles for Clear Health Communication (Doak & Doak, 2004) or Simply Put (CDC, 2010).

Table 4.

SMOG Conversion Table

Total Polysyllabic Word Count	Approximate Grade Level (+ 1.5 Grades)
1-6	5
7-12	6
13-20	7
21-30	8
31-42	9
43-56	10
57-72	11
73-90	12
91-110	college level

Source: Developed by Harold C. McGraw. Online version available at http://www.harrymclaughlin.com/SMOG.htm.

Using computerized tools

Most of the readability tools have been computerized (except Fry). Multiple automated readability/grade level programs are available online for purchase or free (see appendix). You can input or copy and paste your text directly, or upload a text file. For the school nurse, the easiest and quickest method may be in using the readability statistics from within the Microsoft^® Word word-processing program. However, experts caution against computerized methods, especially Flesch-Kincaid Grade Level within Microsoft tools, which can underestimate reading level by two to three grades. The tools do not take into account if words are real or made-up, they are fooled by periods in abbreviations, the grade level in some versions is capped at 12, and of course, they do not measure all the other principles described in this article that are part of making a document more readable (Doak & Doak, 2004; NIH, 2003, 2012; Stockmeyer, 2009). But if the nurse recognizes these limitations, prepares her document before testing, and does not rely solely on these tools for clear writing, these tools can be a quick and easy helpmate.

Using Microsoft Word Readability Tools

In order to run the statistics from within Microsoft Word, you must enable them (see Figure 1).

The Flesch Reading Ease score is computed using the average number of syllables per word and words per sentence; therefore, it measures the complexity of the document. The higher the score, the easier the document is to read. A score of 40 is considered difficult to read. A score of 60 or higher is recommended. Flesch-Kincaid Grade Level calculates an estimate of the minimum education level required to read the document; you should strive for 6th to 8th. Sentence Length is helpful as experts recommend a maximum length of 15 to 20 words (Stockmeyer, 2009). The percentage of Passive Sentences is useful to confirm that you have created your document primarily in active voice. This statistic, however, is another area of concern because when the document is grammar checked, if you have chosen to “ignore” passive sentences in your document, they are also ignored in the calculation of passive voice statistics. There is a workaround supplied by Microsoft. Immediately after the readability statistics are displayed, press “F7” on a PC (or fn F7 on a Mac), and the calculation will include the passive sentences (Stockmeyer, 2009). Figure 1 shows the actual statistics for this article generated from Microsoft Word.

The use of this, or most any tool, is effective only on narrative prose. To correctly measure the readability, you should use it on the document BEFORE formatting into lists or short paragraphs, or remove such formatting from the test piece. Also, most tools require 100 or more words. Several other things can throw off computer analysis tools. First, it does not recognize real words from made-up words, so a paragraph full of gobbledygook, with appropriate punctuation, will have a grade level, regardless of the content. Second, each period is recognized as terminus of a sentence. Thus, words such as Mrs. or e.g. would count each period as the end of a sentence and could artificially lower the reading level of the document. Remove such words before testing a document. Include only bulleted lists for analysis if they are a complete sentence with a period. And grade level is only one small part of readability. Keep ALL the principles in mind when analyzing a document.

Make It LOOK Easy to Read

Making a document inviting is the first step in actually getting it read. Basic principles of graphic design, including use of space and font size, shape and style, as well as the judicious use of graphics, will dramatically help your document to get read.

Use a body font size of between 12 and 14 pts. Use a “serif” font for body text.

Font Size and Style

A font refers to the style of print as seen on the screen or page. For most audiences, use a font size of between 12 and 14 points (pt) whenever possible. For headings, use a font size at least two points larger than the main text. Bolding a word or heading will add an apparent or actual one-point increase in font size. Increasing the font size, and bolding, sets the heading off from the body of the text and helps the reader “chunk” and organize the content (CDC, 2010; Doak & Doak, 2004).

When it comes to type style, experts recommend using “serif” rather than “san-serif” for the body text for greatest readability in print, and the use of san-serif typestyles for headings, webpages, PowerPoint presentations, and when your type must be small (CDC, 2010; Doak & Doak, 2004). Serifs are the little “feet” or tails that are present on individual letters in typefaces such as Times New Roman (see Figure 2). The body text of this article is a 10 pt serif font called Garamond. The tables, headings, and title in this article are in san-serif fonts. The tables are in 11 pt Helvetica and the headings and subheadings are in 11 pt BlockBE. The article title is in 50 pt BlockBE. Arial is another example of a commonly used san-serif font. Serif fonts are preferred as the little tails make the individual letters more distinctive and therefore make the words easier to understand. Consider the capitalized word “Illustrate” versus “Illustrate.” In the first example, a san-serif typeface, the capital letter “L” and the lowercase “l” following it look exactly alike. But in the second example, a serif typeface, the little bars on the top of the “I” help to differentiate it from the lowercase “l.”

Italics, underlining, reverse type (white letters on dark background), and all-caps are all difficult to read, plus from the “texting” world, all-caps denotes “shouting” at your reader. Doak and Doak (2004) suggested limiting these types of text formats to no more than five words in a row, and only in headings, captions, pull quotes, or sidebars or for emphasis. Pull quotes are a line or two of highlighted or important areas “pulled out” of an article and placed in a box in enlarged text (see shaded pull quotes in this article). Sidebars are similar; they highlight components of the text, but they are placed in a column (or “bar”) on the side of the text. In this article, italics are limited to pull quotes, to the abstract, for occasional emphasis, and to the references. Titles and headings are bolded. Figure 3 summarizes these graphic design principles.

Layout

Good document design includes attention to white space, margins, and justification. White space refers to the openness around the words, sentences, and paragraphs. Use plenty of white space even if your page color is not white. It not only makes it look easier to read, but it helps the reader to keep his or her place. While it may seem judicious to attempt to limit a document to one page, so as to not overwhelm the reader, if you are sacrificing white space for a page filled with crowded text in order to keep to one page, open up the document, add space, and move to two pages. A reader will be more likely to read a two-page “open” document with plenty of white space than a one-page document crowded with words (CDC, 2010; Doak & Doak, 2004; NIH, 2012). By eliminating any unnecessary words, the text density will be reduced. However, creative use of white space is also helpful. Using items such as pull quotes or sidebars will not only draw attention to important concepts, but they also serve to break up the monotony of the text (see the shaded pull quotes in this article).

This is a pull quote. It usually repeats a line or two from the text, drawing attention to an important concept, but also breaks up the text, making it easier to read.

Margins should be no less than ½”, and 1” to 1½” is preferred. Using a two- or three-column format rather than a single column across the page adds space to the document by inserting a “gutter” between the columns. The preferred line length of a column is 40 to 50 characters. Use left line justification with right ragged (CDC, 2010). Center justification, except for an online title, is very hard for the reader to follow. Note that the layout of this article is three columns. Compare how much easier it seems to read than a term paper or typewritten letter that expands across the entire width of a page (see Table 5).

Table 5.

Line Length and Justification

Line Length
Paragraph 1
This is an example of a line of only 20 to 25 characters. It is more tiring as your eyes move back and forth often. It is possible to have too short of lines of text.
Paragraph 2
This is an example of the best line length. Your eye can move back and forth more slowly but not so slowly as to move across the entire page. This line length is 40 to 50 characters.
Paragraph 3
This one is too long for easy reading. The line length is 70 to 75 characters. Words that spread across the page look packed and don’t give much white space on the page. It may be too daunting for a reader to even try to tackle reading.
Justification
This is left justified with right ragged text. Notice the lines do not end all in the same place. Each line ends with the natural end of the words and sentences with uniform spacing between the words and letters.
This is left justified with full justification; each line ends in the same place with extra spaces added as needed. Words are spaced to make them end at the margin, except for the last sentence of the paragraph.
This is center justified. Each line ends in different places on both the right and left.
This is right justified. It is much harder to read than left justification.

Source: Adapted from Centers for Disease Control and Prevention (2009) and Doak and Doak (2004).

Graphics

A picture is worth a thousand words, or so it is said. Graphics can add important information to a document and dramatically increase retention. However, poor readers also have difficulty with visuals. Poor readers skip the principal features, lose the main features, get lost in the details, and interpret visuals literally. When looking at a document, readers cue into an image first, followed by the caption, and finally (hopefully) the text (Doak & Doak, 2004). Think about a new student visitor to your health office. Do you remember his face or hair, or do you remember his name? When first opening the NASN School Nurse to this article, what did you key in on first? The images and tables, or did you immediately read the text? A graphic should not be included just to have a graphic; it must contribute meaningfully to the message. A good graphic can reduce the amount of text needed for the message of the document. A graphic can be a table, figure, photographic image, line drawing, clip art, pull quotes, sidebars, speech bubbles, highlighting, or other emphasis symbols like arrows, a magnifying glass, or even a “Look Here!” Use graphics that

are literal and not abstract.

show simple steps in a procedure.

use color purposefully.

have captions to describe the action or purpose.

use adult rather than childish images.

avoid detailed or overly realistic anatomical illustrations.

avoid caricatures of a serious subject.

are culturally relevant. Use images that resemble your population.

have cues, such as a magnifying glass, a circle, color, or arrows to highlight important components of an image (see Figure 2).

show enlarged images with a sense of scale (CDC, 2010; Doak & Doak, 2004; NIH, 2003).

This document has a number of tables and several images. They give examples to help understand unfamiliar words or usage and provide actual images (such as the screen shot of the readability statistics from Microsoft Word) as well as pull quotes, which both break up the text and provide highlights and reinforcement of important concepts. Readers best identify with photographs when showing real-life events, whereas simple line drawings are more effective for situations that may be frightening (such as a medical procedure) or for showing sensitive issues (such as sexually transmitted diseases). Cartoons can also be useful to bring a sense of humor to a subject, and they are certainly appropriate for elementary-age students’ parents. However, be careful as they may be misunderstood or taken seriously (CDC, 2010). The CDC has a large inventory of royalty-free images in its Public Health Image Library (see appendix) for use in documents and webpages. Be careful of images from the Internet. Their use is subject to copyright permissions just as the use of print images.

Testing

The final step in the creation of your easy-to-read document is testing. I take my new documents to several staff members (both professional and support staff) as well as to my own family members and friends and ask for feedback. How long did it take you to complete? Did you read it all? What did you skip? Would you take the time to fill out this form? The answers to these questions can be essential to evaluating and improving your document. The Checklist for Easy-to-Understand Print Materials (CDC, 2010, Appendix A) is an excellent tool for reviewing your document.

Summary

Samples of two types of forms commonly used for parent communication, both built with strong use of all health literacy principles described in this article, are shown in Figures 4 and 5. Figure 4 (Pontius, 2013a) is a student health history adapted from a copyright-free pediatric office intake document from the AHRQ (2010) Health Literacy Universal Precautions Toolkit. Figure 5 (Pontius, 2013c) is a parent information form describing when a child should stay home from school. As the ethnic background of the author’s community is 40% Hispanic, these forms are available in both English and Spanish.

Research has shown repeatedly that poor health literacy is associated with poor follow-through, poor caregiving and self-care behaviors, and a lack of understanding of the importance of the health instruction (AHRQ, 2010). It is critical for school nurses to be cognizant of health literacy principles, using them in all written communication. Applying these principles in every parent encounter will significantly increase the success of your health teaching as well as the likelihood of successful completion of documents vital for the safe and effective care of your students at school. Improving written communication builds trust with families and will improve compliance and, most important, improve your students’ health outcomes. ■

Footnotes

Appendix

Appendix:

Resources

General/Miscellaneous
Author’s website: www.pershing.k12.nv.us. Choose “district” then “health services” from the top dropdown menu.
CDC Public Health Image Library: http://phil.cdc.gov/Phil/default.asp
Readability Test Tool: http://www.read-able.com
Multiple Readability Calculator: http://www.online-utility.org/english/readability_test_and_improve.jsp
ATOS for Text: http://www.renlearn.com/atos/analyze.aspx?type=3
Tools for Print Materials
CDC: Health Communication Basics: http://www.cdc.gov/healthcommunication/healthbasics/index.html
Health Literacy Universal Precautions Toolkit: http://www.ahrq.gov/qual/literacy/index.html
Toolkit for Making Written Material Clear and Effective: http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/index.html
Clear Communication: An NIH Health Literacy Initiative: http://www.nih.gov/clearcommunication/healthliteracy.htm
Pfizer Principles for Clear Health Communication: http://www.pfizerhealthliteracy.com/asset/pdf/pfizerprinciples.pdf
Simply Put: A Guide for Creating Easy-to-Understand Materials: http://www.cdc.gov/healthliteracy/pdf/simply_Put.pdf
Health Literacy and Patient Safety: Help Patients Understand: http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Tools for Electronic Media
Health Literacy Online: A Guide to Writing and Designing Easy-to-Use Health Web Sites: www.health.gov/healthliteracyonline
CDC’s Guide to Writing for Social Media: http://www.cdc.gov/socialmedia/Tools/guidelines/pdf/GuidetoWritingforSocialMedia.pdf
CDC’s Social Media Toolkit: http://www.cdc.gov/socialmedia/tools/guidelines/pdf/socialmediatoolkit_bm.pdf
Toolkit for Making Written Material Clear and Effective: Will Your Written Material Be on a Website? http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/Downloads/ToolkitPart08.pdf

Deborah has been the health services coordinator/chief school nurse at Pershing County School District, a tiny rural one-nurse district in Lovelock, Nevada, since 1999. She recently completed her term on the NASN Board of Directors and a term on the NASN Executive Committee.

References

Agency for Healthcare Research and Quality. (2010, April). Health literacy universal precautions toolkit (AHRQ Publication No. 10-0046-EF). Retrieved from http://www.ahrq.gov/qual/literacy/index.html

Baur

(2013). Health literacy work of the World Health Organization. In Hernandez

L. M.

(Ed.), Health literacy: Improving health, health systems, and health policy around the world: workshop summary (pp. 20-23). Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catelog.php?record_id=18325

Centers for Disease Control and Prevention. (2007). Plain language thesaurus for health communications. Retrieved from http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for_Health_Communications.pdf

Centers for Disease Control and Prevention. (2010). Simply put: A guide for creating easy-to-understand materials. Retrieved from http://www.cdc.gov/healthliteracy/pdf/simply_Put.pdf

Doak

(2004). Pfizer principles for clear health communication (2nd ed.). Retrieved from http://www.pfizerhealthliteracy.com/asset/pdf/pfizerprinciples.pdf

Doak

Root

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