Words and jargon a lay reader misunderstands
A lay reader can misread a word they know, take a word in its everyday sense where the writer meant a technical one, fail to see what a familiar term means for them, and be confused by the jargon of research and by the euphemisms and high-register words used for bodily functions.
Familiar words that are misunderstood
Words regarded as common may sometimes be misunderstood. A study of 700 people attending an accident and emergency department with a head injury asked what unconscious meant: 16% thought they could still talk while unconscious, 16% said they could stand up, and 41% believed their eyes could not remain open after losing consciousness. The study has implications for the design of public health information, including the scripts emergency services use when responding to phone calls. A leaflet would have to state the signs of unconsciousness, and a call script would have to include questions designed to test for it.
A term can be familiar to someone without their understanding what it means or, more importantly, what it means for them. Most people are likely to know that a biopsy means taking a sample from the body and sending it away for tests, but may not realise that the procedure might involve having a large needle inserted, possibly into a sensitive part of the body, which might be very painful, and could be embarrassing and distressing.
More common words may also confuse. Avoid is frequently used in health instruction, especially in nutrition. When the sentence "Avoid the following foods…" was tested with eleven patients selected at random in a metropolitan hospital, ten had no idea what it meant, and some said they just skipped over it.
When the medical subject is unfamiliar, readers tend to take the words literally. Doctors and nurses know the circumstances and time limitations of their recommendations, but the lay audience may not. For example, a nurse advised a patient taking stool samples over several days to check for blood not to eat beets, because they turn stools black, and the patient, an intelligent woman, took the words literally and never ate beets again for the remaining fifteen years of her life.
Words with an everyday and a technical meaning
Words that have a specific meaning in science do not mean the same for the lay public. In medical usage, for example, significant is a very specific statistical term that means a test result may not show a chance difference, while for the lay public it means important.
These scientific terms have different meanings for lay audiences, and each has a suggested lay equivalent:
| Scientific term | Meaning for lay audiences | Suggested equivalent for lay audiences |
|---|---|---|
| Significant | Important | Did not happen by chance |
| Fraction | Small part | A part |
| Trauma | Psychological event | Physical damage |
| Enhance | Improve | Intensify, increase |
| Positive trend | Good trend | Upward trend |
| Positive feedback | Good response, praise | Vicious cycle, self-reinforcing |
| Theory | Hunch, speculation | Scientific understanding |
| Uncertainty | Ignorance | Range |
| Error | Mistake, wrong, incorrect | Difference from exact true value |
| Bias | Distortion, political motive | Offset from an observation |
| Values | Ethics, monetary value | Numbers, quantity |
| Scheme | Devious plot | Systematic plan |
| Anomaly | Abnormal occurrence | Change from long-term average |
Words such as acute, chronic and significant can be considered jargon because not everyone truly understands what they mean. Some expressions can be misinterpreted by lay audiences, such as positive correlation, which may be taken to mean something good.
At a Liverpool children's hospital in the 1980s and 1990s, parents signed consent forms agreeing to a post-mortem examination and to the removal of tissue, unaware that this allowed doctors to harvest and store body parts and whole organ systems. Various hospitals are thought to have stored 150,000 organs using similar consents. The word tissue, taken directly from the Human Tissue Act, was not apparently difficult, but its legal meaning differed from its everyday meaning and should have been explained. The grief of the parents whose children's organs had been stored without their knowledge led to a government inquiry and fierce legal disputes.
Concept, category and value-judgment words
A common source of the comprehension gap between patients and their instructions often rests with three kinds of words: concept, category and value-judgment words. This was shown by assessments over thirty years of the suitability of more than 2,000 health care instructions in nearly all media, many submitted with health care professionals' comments on the words and topics their patients had difficulty understanding. An effective strategy to overcome this gap is to use examples that illustrate the meanings of these words.
The sentence "We want to get your glucose in the normal range" uses concept words, and the reader may think, "Well I know what normal is, and I have a range in my kitchen." Adding "that means a glucose between 70 and 130" can provide an explanation. Even seemingly common words such as diet, and simple pictures such as the food pyramid, need an example to explain what is meant. To many, diet means a commercial weight-loss product, and a phrase after it such as "all the foods you usually eat and drink" helps to clarify. The food pyramid could be described as "a picture idea of which foods to eat more of and which to eat less of".
Category words can also mislead. In a test of a nutrition pamphlet at a dialysis clinic that advised patients to eat red meat but not shellfish and poultry, one patient seemed to understand the advice, but on further questioning he said he ate lots of fried chicken. Asked about poultry, he replied, "Oh, I never eat poultry; we're not supposed to have that." A clearer statement might be "Don't eat chicken, turkey, or duck."
Value-judgment words, as in excessive bleeding, adequate rest and regular exercise, can be unclear and confusing, leaving the reader to ask how much bleeding is excessive, how much rest is adequate and how often is regular. Specific examples answer those questions: instead of "If there is excessive bleeding", write "If there is bleeding through your bandage".
Unfamiliar medical words
For patients at all literacy levels, unfamiliar vocabulary may not be understood, and this often arises in descriptions of medical tests, treatment options and care management. Medical words with Latin or Greek prefixes or suffixes, such as prenatal, postpartum and atypical, are hard for people with limited reading skills, who may grasp only part of the word and assume a reverse meaning.
A 2013 leaflet for an absorbent silicone wound dressing used many unusual terms, such as minimizing maceration, peel forces, moist wound environment, compromised skin, exudate, skin stripping and excoriation. Context may often help proficient readers with unusual vocabulary, but weaker readers tend to have poor guessing skills. One plain-language writer holds that the context around two of the leaflet's most difficult words, conformable and debridement, helps too little, and that readers are more likely to skip what they do not understand or cast the leaflet aside than to consult a dictionary. He estimates that perhaps only one in 500 readers without a medical background will understand the two words. Conformable means similar in form or nature, and debridement means the removal of damaged tissue or foreign objects from a wound.
A UK Department of Health sentence on the diets of children under five, reproduced in a leaflet for parents, uses terms such as principal determinant and dietary energy, which will puzzle a mass audience. According to the Department of Health, dietary energy just means calories, a technical term whose ubiquity will probably make it well understood.
Where an uncommon medical word must be used, readers' understanding can be helped by following it with more common words, by using an example that explains it, or by referring to a visual that illustrates its meaning. Determinologisation is a cognitive and communicative phenomenon covering a set of strategies for treating specialised lexical units, aimed at making texts understandable to lay readers. The strategies include explanation, definition, exemplification, analogy, and comparison and substitution by a more popular term. One specialist in health literacy holds that knowing how determinologisation functions is a must for medical writers preparing written materials for patients.
Some words, such as nitrogen fixation and oxidation, are not easily expressed in simple terms.
Some words are unlikely to be understood by the public but might still be good words to use. Receptor is often used in patient information, not because a lay audience can be expected to grasp receptor-mediated ion exchange channels, but because the word is descriptive: it is similar to receptacle and evokes a drug being received by something that then triggers an effect. In most cases the precise mechanism of action is not important, and receptor can be used without worrying too much about precisely how it will be understood.
Research and side-effect jargon
A common challenge in describing the side effects of drug therapy is decoding coded adverse event terms. A writer presented with terms such as abdominal discomfort, chest discomfort, mood altered and neurological symptoms has to find a way of explaining them to a lay audience, which is more or less impossible without additional information.
Some terms seem easy to understand for anyone with a scientific background or working in healthcare but are not common in everyday language. One plain-language specialist suggests these translations for ten of them:
| Medical or scientific jargon | Plain-language translation |
|---|---|
| Adverse event | Medical problem |
| Biopsy | Sample; small sample for testing |
| Blood sugar | Level of sugar in your blood (not "blood glucose", because glucose is a scientific term) |
| Chronic | Long-lasting; keeps coming back; lasts more than 3 months |
| Diagnosis, diagnosed | Your condition (for "your diagnosis"); learn if you have (for "to diagnose"); you have (for "to be diagnosed with") |
| Exam | Examination |
| Outcome | Result |
| Randomised | A computer assigns you to a group; put in a group by a computer |
| Screening, screening test | Check-up; to look for (for "screening"); test to learn if you have (for "screening test") |
| Therapy | Treatment |
Using not only difficult terms but also different terms to mean the same thing can be very confusing for patients. Without a common source of clinical research terminology for a non-scientific audience, the public, including current and prospective research participants, may grapple with similar terms that different research stakeholder groups use differently in different contexts, and be confused by the lack of consistency and clarity. For example, the terms side effect, adverse event and serious adverse event all have very specific regulatory definitions and significance, but to a research participant they all fall under the category of risks, or "bad things that could happen to me" when taking part in a study. The team piloting a shared plain-language glossary for clinical research held in 2020 that the clinical research enterprise should strive to decrease or eliminate the need for patients and participants to parse the nuances of terminology and regulatory guidance in order to determine the personal significance of the information presented.
Euphemisms and high-register words for bodily functions
Both taboo and high-register language can cause confusion. On a hospital ward a nurse asked a newly admitted young woman, "Have you opened your bowels today, dear?", and she replied apologetically, "I'm sorry, nurse, I haven't brought them with me."
One plain-language writer has never understood why some medics talk to patients about stools and back passages, as if they were in a hardware store. He has occasionally persuaded health trusts to use words like poo and pee in their leaflets, and he reports that these words are becoming more widespread. He accepts that there is a difficult line between being clear and causing offence, but feels it is better to err on the side of clarity. In his view, "What colour is your poo?" is likely to be well understood by most people without embarrassment, while few people understand faeces and even fewer can pronounce it.
In 2006 a physiotherapy leaflet titled "Good Defaecation Dynamics" drew ridicule. The same writer holds that explaining better bowel habits was both brave and worthwhile and that only the title was absurd: called "How to crap well", the leaflet would doubtless have offended a few but struck a blow for clear, basic English.
A faecal occult blood test kit came with 600 words of medicalised instructions that culminated in "Flush tissue with stool", which meant flush the used tissue and the rest of your poo down the toilet. The blogger who received the kit remarked that the episode had convinced him that the literate need to learn how to write as badly as the illiterate need to learn how to read. By 2015 the UK's National Health Service was sending everyone who reached 60 a poo-sample collection kit to test for bowel cancer, and the plain-language writer found its instructions pretty good.