Medical textbooks: can lay people read and understand them?

ABSTRACT

The proliferation of health information has created a rich field of resources that many lay people can use to make informed health care decisions. For a large segment of the population, these resources will go unseen and unused because they are written at a level that exceeds their reading recognition and comprehension skills. The study discussed in this article assessed the readability of information on six adult and two juvenile diseases in ten medical textbooks. Students in two library and information science (LIS) schools read the same information and indicated the words they did not understand. Results showed that the medical material is written well above the average person's reading ability. Words the students could not understand included anatomical and disease-related terms and drug names. More research needs to be done on lay people's comprehension of medical information.

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On their Web site the National Center for the Study of Adult Learning and Literacy (n.d.) states that "more than 40 percent of working-age adults in the United States lack the skills and education needed to succeed in family, work, and community life today." This figure indicates that almost half of the population may not be able to find, read, or understand health information and thus cannot make informed health care decisions.

A considerable amount of research exists on the need to improve access to health information by making it more readable for average readers. Lowering the readability level alone may not adequately address the issue of illiteracy because other factors may affect a person's ability to read and comprehend written material. For example, Parikh, Parker, Nurss, Baker, and Williams noted that "the shame and embarrassment felt by some low literate patients may pose an important psychological barrier to asking for help or requesting low literate materials, even when they are available" (1996, p. 34). They found that some patients "did not seek care because of embarrassment about their illiteracy" (p. 34). Estey, Musseau, and Keehan included "anxiety, physical discomfort, and unfamiliarity with the hospital environment" (1994, p. 74) as further impediments to understanding health instruction. Weaver (2003), one of the presenters in the Medical Library Association's teleconference, Reading Between the Lines, noted that unfamiliarity with an environment is often an overlooked factor in health literacy. Labeling this concept "contextual literacy," she explained that a person might be "health literate" in one's own country, but she/he may not be in another country (Weaver, 2003, p. 4). Furthermore, while some people may be "comfortable and know what to expect in ... hospitals and clinics," other people "don't and their anxiety at being in a totally alien setting impairs their coping abilities even more" (Weaver, 2003, p. 4). Thus, a variety of factors may affect people's ability to read and understand printed health information, written instructions, consent forms, or other healthrelated materials.

DEFINITIONS OF HEALTH LITERACY

What is health literacy? Several definitions were found in the literature. Healthy People 2010, the ongoing national promotion and prevention initiative aimed at improving the health status of individuals in the United States, defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Office of Disease Prevention and Health Promotion, 2001, p. 15). The Medical Library Association's (MLA Net, 2003) definition goes further and includes the following set of abilities:

* Recognize a health information need

* Identify likely information sources and use them to retrieve relevant information

* Assess the quality of the information and its applicability to a specific situation

* Analyze, understand, and use the information to make good health decisions.

This definition incorporates elements of evidence-based practice and puts the onus on lay people to find quality information, analyze it, and use the evidence as a basis for making their decision.

LITERATURE REVIEW

The key elements in making an informed health care decision are the person's ability to read and understand the information. According to Davis, Crouch, Wills, Miller, and Abdehou, "educators have measured the readability of written materials since the 1940s" but "medicine has only recently recognized problems in this area" (1990, p. 533). Health care professionals, they suggest, have taken "patients' educational and reading recognition levels to estimate literacy levels" (Davis et al, 1990, p. 533). While reading recognition (the ability to pronounce words) is important, "reading comprehension is the most important" of all the literacy skills needed in health care (p. 533).

In the literature on readability, there is conflicting evidence on whether an association exists between reading comprehension and educational levels. A few examples are provided to illustrate both sides of this conflict. Gibbs, Gibbs, and Henrich (1987) informally interviewed fifty people chosen at…