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When it comes to patient education, are some things better left unsaid? A look at writing for readability

"In Canada, 60% of adults, and 88% of seniors have low health literacy."

Nova Scotia Health aims to provide patients and families with appropriate, comprehensive, and helpful patient education pamphlets to support them in managing their health. To develop these pamphlets, the Patient Education Team supports staff and physicians throughout the creation process. A key part of this process is editing content for readability, with the goal of a 6th grade reading level. When our team reviews pamphlet drafts, we try to remove medical jargon and replace it with more familiar plain language. We do this so patients and families can better understand their diagnosis, treatment, and instructions from their health care teams (Weiss, 2014).

Approximately half of all Canadians experience some challenges understanding the health information and teaching provided to them (Guo, 2012). This is true of many Nova Scotian families, especially those whose first language is not English (NS Department of Health, 2010). This can make reading and understanding our pamphlets challenging at the best of times, on top of the added stress of being ill or having an ill family member.

Low health literacy has been linked to increased emergency department visits, as well as increased hospital admissions, poorer health outcomes, faster disease progression, and increased co-morbidities (Imoisili et al., 2017; Jager et al., 2019). Writing in plain language is one way to better accommodate our patients and families, and help them navigate the health care system, but it isn’t without its own challenges.

During our review process, we add explanations for certain terms that others would prefer to leave out. For example, ‘nausea’ is followed by ‘(feeling sick to your stomach)’, ‘urine’ is followed by ‘(pee)’, and ‘stool’ or ‘bowel movement’ is followed by ‘(poop)’.

For some health care teams, this can be off-putting. We receive many requests from staff and physicians to remove terms or change them to less unsavoury ones. Although using everyday words may seem unprofessional, we choose to include them because we know they help more people understand the information being shared (Hadden et al., 2017; Wittenberg et al., 2015; Kaphingst, 2012). In this context, it is helpful for health care teams to remember the end users—our patients and families.

To ensure we are on the right track, we actively follow plain language trends and rely on validated measures of health literacy. We have found that we’re not alone in this practice. Other health organizations also use common words to describe taboo terms, including:

• The UK’s National Health Service (NHS); read their 2019 post: Pee and Poo and the Language of Health
• City of Hope^® National Medical Center, which uses a tool called the Plain Language Planner for Palliative Care: Plain Language Essentials, supported by the Comfort Communication Project (Wittenberg et al., 2015)

The urge to polish your pamphlet, or make it as professional as possible, can be hard to resist, but when it comes to patient education, it may mean the difference between knowing when to call 8-1-1 and when to call 9-1-1. 

Imagine you have been instructed to look for signs of ‘constipation’ post-surgery, but you don’t know that ‘constipation’ means ‘not being able to poop’. Or imagine you have been instructed to look for blood in your ‘stool’, but the only ‘stool’ you are familiar with is in your kitchen, and now that you have been discharged, you are unsure who to call and ask.

"Even individuals with adequate literacy skills can have difficulty understanding patient education materials due to unfamiliar vocabulary and concepts involved in the comprehension of health information."

As requests to remove or change terms to less 'unpleasant' ones are likely to continue, we aim to work collaboratively with Nova Scotia Health staff, physicians, and stakeholders to make sure our pamphlets are readily grasped by the patients and families reading them. We are always looking at ways to improve our materials and are actively examining our use of appropriate terminology.

Our Patient Education Team has training and experience making information resources on health care topics concise and clear. For more information, check out our new Content Creator Toolkit or the Patient and Family Education Material Guidelines. Questions? We're here to help. Email the Patient Education Team anytime at pamphlets@nshealth.ca.

Kallen Rutledge

Librarian Educator
Nova Scotia Hospital, Central Zone