Literacy, ESL, and Health Care - Candace Myers, MSc, SLP(C)

Low literacy levels among ESL speakers are a significant concern in health care.  Much of the information health care professionals provide is in written form.  The following article reviews the effects of low literacy skills, and provides resources for health care professionals in producing clear "plain language" materials for patients.  This information was obtained from Literacy Partners of Manitoba http://www.mb.literacy.ca and other websites as indicated.

Burt Perrin summarises the direct and indirect impact of literacy on health in How Does Literacy Affect the Health of Canadians, 1998, found at http://www.phac-aspc.gc.ca/ph-sp/phdd/literacy/literacy.html. Some of these effects are listed below.

Direct Effects

• Persons with low literacy skills cannot read medication labels and sometimes take medication incorrectly. This applies to both prescription and over-the-counter medications.
• Persons with low literacy skills have problems complying with medical directions (e.g., a diabetic following a prescribed treatment). 
• Persons with low literacy skills cannot read written instructions for preventative care, self-care and follow-up care after an illness or injury.
• Persons with low literacy skills have problems understanding appointment slips, informed consent forms, discharge information and oral instructions.

Indirect Effects

• Persons with low literacy skills are less likely to request care early in the course of their illness.

How Can Health Care Workers Overcome Literacy Barriers?

• Health care workers can help patients overcome literacy barriers by creating an environment accessible to low literacy people
• Following effective teaching principles to make sure that their patients understand vital information
• Using principles of plain language and clear design when preparing written information for patients

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Health Literacy Project, Phase 1: Needs Assessment of the Health Education and Information Needs of Hard-to-Reach Patients. (2001). Montreal: The Centre for Literacy of Quebec. Part 1: Background Document on Literacy and Health. [46 pages. ISBN 0-9681034-9-9 Printed copies of these documents may be purchased at $ 10.00 for single copies or $ 15.00 for the pair (Parts 1 and 2), including shipping & handling from the Centre for Literacy of Quebec, 3040 Sherbrooke St. West, Montreal, QC, H3Z 1A4. Phone (514) 931-8731 ext. 1415, Email: literacycntr@dawsoncollege.qc.ca. This is also available on the web at http://www.nald.ca/PROVINCE/QUE/litcent/health/ 
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Section 1 gives an overview of health literacy. It gives the IALS statistics, and mentions the concern raised by Thomas Sticht that the arbitrary criterion used for separating individuals into different levels may have led to an overestimation of the percentages of adults at levels one and two. It discusses the links between literacy and health, focusing on the work of Burt Perrin. It then records the progress made in recognizing the need to produce health documents in plain language. It summarizes the currently recommended techniques to improve oral communication. "These techniques typically include:

• Limiting teaching objectives
• Giving many examples that have meaning to the patient
• Demonstrating procedures such as measuring dosages and counting pills
• Making learning participatory. Ask patients to restate instructions in their own words
• Repeating the information several times
• Organizing your instruction so the most important messages are presented first and last
• Including family members or other caregivers in the education process (p.10)."

Plimpton, S. & Root, J. (1994). Materials and Strategies that Work in Low Literacy Health Communication. Public Health Reports, 109(1), 86-92. 

The authors describe their response to the problem of the gap between the high reading level of health pamphlets and the low literacy skills of the target audience: a series of training sessions on how to produce low-cost, easy-to-read, easy-to-reproduce documents.  In 1994, the authors found a virtual absence of, but universal need for, easy-to-read materials. Certainly much progress has been made since then, but the article is still interesting for its list of things to avoid, such as

• information overload
• unclear message
• long words, complex sentences
• technical language
• uninviting tone
• disregard for culture or literacy level of target audience
• solid print without graphics
• cluttered page with graphics overload
• small font
• irrelevant illustrations (p.88).

Literacy and Health Resources on the Web

(This is only a sampling of the many resources available on the web. Please send any interesting resources that you find to health@mb.literacy.ca)

Health Sites

The American Medical Association.
Enter "literacy" in their search engine to find articles on literacy and health. http://www.ama-assn.org/

Harvard School of Public Health, Health Literacy Studies.
This site offers powerpoint and video presentations and research reports on literacy and health. http://www.hsph.harvard.edu/healthliteracy/

Health Canada.
This site contains a wealth of reports and resources. http://www.hc-sc.gc.ca

Health Literacy Consulting.
This private site contains articles on "helping health organizations communicate in ways people can understand". Health Literacy Tips is a useful section. http://www.healthliteracy.com

The National Literacy and Health Program.
The Canadian Public Health Association's (CPHA) National Literacy and Health Program (NLHP) promotes awareness among health professionals of the links between literacy and health and contains some excellent resources. http://www.nlhp.cpha.ca/

Literacy Sites

International Adult Literacy Survey (IALS)
http://www.nald.ca/nls/ials/introduc.htm

National Adult Literacy Database (NALD).
NALD is the host of hundreds of Canadian literacy websites, the source of up-to-date news, and the repository of important Canadian literacy reports and papers. http://www.nald.ca

Full Text Documents
Beyond the Brochure: Alternative Approaches to Effective Health Communication.
A guidebook published by Cancer Prevention and Control to adapting existing materials for hard to reach audiences, and developing new materials such as posters, display boards, fotonovellas, role-play, songs, storytelling, games, etc. http://www.cdc.gov/cancer/nbccedp/bccpdfs/amcbeyon.pdf

Clear and Simple: Developing Effective Print Materials for Low Literate Readers.
A publication of the National Cancer Institute, this guide presents a process for developing publications for people with limited-literacy skills. With helpful examples, it outlines the following steps: 1, Define the target audience; 2, Conduct target audience research; 3, Develop a concept for the product; 4, Develop content and visuals; 5. Pretest and revise draft materials. http://oc.nci.nih.gov/services/Clear_and_Simple/HOME.HTM

The Directory of Plain Language Health Information.
This document, available in HTML and PDF, tells health educators how to find excellent examples of plain language health information on a variety of subjects. It also contains plain language and clear design tips and the SMOG readability formula. http://www.pls.cpha.ca/english/directry.htm

Perrin, Burt. How Does Literacy Affect the Health of Canadians  
http://www.phac-aspc.gc.ca/ph-sp/phdd/literacy/literacy.html