Why plain language is not enough on its own
Readers with limited health literacy need health information they can understand, yet understanding a message does not by itself change what a reader does. Improving health literacy also asks for interventions beyond the text, for change in health professionals and the health care system, and for a share of the work from everyone with a stake in it, the medical writer included.
Why clear wording is needed
A health communication specialist observed in 2013 that in Spain a good deal of health information for patients was usually too complicated, explained in terms that were meaningless to them and blind to their communicative needs and background knowledge, which deterred people from reading it, mostly those with low literacy skills. For that reason, in her view, designing clear, visually appealing and easy-to-read patient education materials is of immense importance.
Study after study has concluded that the literacy demand of health information materials outstrips the literacy levels of their readers.
What plain language does not change
Closing that gap, one plain language consultant argued in 2010, requires more than simplifying health messages with plain language and pictures and making sure that health information materials are culturally relevant and appropriate for their intended audiences, essential as these approaches are. In her account, plain language is one powerful tool in the health literacy toolkit, but in 2010 there was little evidence that this widespread practice improved health outcomes or changed health behaviours. Understanding is insufficient to change health behaviours. Cultural competency may improve health communications by building trust, but it too, on its own, does not ensure behavioural change. Some evidence suggests that community-based and participatory approaches may be effective.
To change health behaviours, one group of health literacy researchers suggests, the field of health literacy must broaden its scope to include active engagement and self-empowerment. The consultant adds that the field must shift its discourse from "a primary focus on fundamental literacy in health" to "a complex, social determinant of health and empowerment model", and deal not only with the symptoms of the problem but also with its root causes.
Barriers to health literacy
Many factors compromised the health and quality of life of those whose health literacy was less than proficient, 88% of adult Americans in 2010, such as exposure to complex health systems, a plethora of confusing or conflicting information from diverse media including the internet, the use of jargon and technical language, and health professionals' lack of awareness and knowledge about health literacy.
Besides weak reading skills, especially among the undereducated, the elderly and some ethnic minorities, other well-recognised barriers to health literacy, one group of health literacy researchers notes, are the complexity of print and web health information materials, their lack of cultural appropriateness, inaccurate and incomplete health communications in mass media, and the lack of materials with content that empowers health behavioural change.
Interventions that improve health literacy
Strategies to improve health literacy range from large-scale policy actions to optimise schooling to interventions targeted at small communities or patient groups.
A systematic review analysed the interventions for improving health literacy in Europe between 1995 and 2018. The low quality of the included studies kept it from drawing firm conclusions about the effectiveness of the interventions, but the type of intervention, whether group, individual or community-based, appeared to matter little. The review suggested that interventions to improve health literacy, and thereby motivation, empowerment and self-confidence, should be tailored to the needs of participants, presenting information and critical skills in an appropriate format with correct and engaging language.
Improving the comprehension, acknowledgment and application of health literacy can support policy action intended to address major public health challenges. Training and educating healthcare professionals, teachers, social workers and community volunteers about the importance of health literacy and effective health communication is vital.
Who shares the responsibility
Proficient health literacy involves more than the fundamental literacy skills of individual adults. One group of researchers, citing the Institute of Medicine Committee on Health Literacy and the Healthy People 2010 Action Plan, holds that change in the health literacy behaviours of health professionals and of the health care system is integral to improving health literacy.
The responsibility for ensuring that individuals obtain health literacy skills, two academics in health education hold, does not rest on one person's shoulders but is shared by all invested partners: patients, health care professionals, insurance companies and government entities.
In Spain in 2013, the health communication specialist observed, various health actors, such as non-profit and educational organisations, patient organisations, health centres and hospitals, were becoming more concerned about the importance of health literacy, both for patient safety and for the sustainability of the health care system. Although that importance was increasingly recognised and interest in health literacy had become more international over the previous decade, there was still plenty of room for improvement in accessing, understanding, appraising and applying health-related information in health care, disease prevention and health promotion.
In 2010 there was a growing recognition, within both medicine and journalism, that to inform the public about complex medical choices and treatments, communicators must be prepared to educate an audience that has a low level of health literacy.
The medical writer's part
Medical writers cannot formulate health literacy policies, pursue public policy changes, or implement initiatives and programmes that enhance patient empowerment and health literacy, in the health communication specialist's view, but they can improve patients' health literacy by fostering effective communication, a cornerstone of patient safety. They can do so by creating information appropriate to the health literacy needs of a specific population and by providing audiences with information in ways they can understand.
Medical writers should not be indifferent to health literacy, since they are responsible for writing verbal and written communication. They can play a proactive role in improving health literacy by conveying truthful, flawless and correct health information in clear documents that the targeted reader can understand. Conveying information the targeted reader can understand means adapting the language and the scientific content to the audience. A writer creating documents that patients can use and understand, such as informed consent forms or lay summaries, must consider the reader's health literacy. Medical writers also have an opportunity to improve health literacy by communicating science responsibly.
Medical communicators, in the plain language consultant's account, need to participate in and facilitate the change in the health literacy behaviours of health professionals and the health care system that the report of the Institute of Medicine Committee on Health Literacy and the US government's Healthy People 2010 advocated. They need to educate themselves about the scope of the health literacy problem, to equip themselves with the necessary tools, especially the techniques of plain language and cultural competency, to make their health communications effective and actionable, and, most importantly, to engage directly with their intended audiences. By educating themselves and other health professionals about the enormity of the health literacy problem and the tools for communicating health information effectively, they can become advocates and facilitators of proficient health literacy for everyone.
Three author teams writing on health literacy follow the golden rule that effective health information materials are all about audience. The consultant draws from it that communicators must know the intended audience, write specifically for that audience and, above all, involve that audience in developing the material at every stage of the process.