7.2 Plain Language and Health Literacy

Writing so people can use the message

Health literacy is more than reading skill. Healthy People 2030 splits it into two parts: personal health literacy (the degree to which a person can find, understand, and use information and services to make health decisions) and organizational health literacy (the degree to which organizations help people do so). A strong general reader can still struggle with a consent form, an insurance letter, a risk percentage, or a stressful diagnosis. For CHES purposes, assume responsibility is shared between the communicator and the system.

What plain language is and is not

Plain language means the audience understands and can use the information the first time. It is not childish language; it is organized communication. The writer uses familiar words, short sentences, logical headings, active voice, and explicit action steps. The goal is to remove avoidable confusion, not to delete necessary detail.

A strong message leads with the behavior or decision. Instead of opening with a paragraph on hypertension, a blood-pressure handout starts with: "Check your blood pressure twice this week and write down both numbers." The explanation follows. People need to know what to do, why it matters, when, and where to get help.

Use this plain-language checklist:

• Put the most important action first, in the active voice.
• Use everyday words; define any clinical term at first use.
• Keep sentences short and one idea per sentence.
• Use headings and bullets so readers can scan.
• Pretest with people from the intended audience.

Defining terms and handling numbers

Some terms must stay because they appear in care, consent, or instructions. When a term stays, define it in plain words at first use: "A1C is a blood test that shows your average blood sugar over about three months." Avoid stacking jargon such as morbidity, compliance, contraindication, asymptomatic unless the audience profile supports it.

Numeracy is a frequent barrier. Percentages, ratios, dose schedules, and risk comparisons confuse many readers. Use consistent denominators: present "3 out of 100" and "6 out of 100" rather than mixing a percentage with a fraction. The table below shows the difference:

For visuals, keep axes honest so charts do not exaggerate small differences, and pair numbers with a simple icon array when possible.

Layout and translation

Layout can defeat accurate content. Dense text blocks, all-caps paragraphs, low contrast, and tiny fonts all reduce usability, especially on phones. Use descriptive headings, lead with the action, bullet the steps, and protect white space.

Translation is not the same as health-literacy adaptation. A literal translation can keep the words but lose meaning, tone, or cultural fit. A sound process uses professional translation, review by native speakers familiar with the health context, and testing with the intended audience; images and examples may also need adaptation.

Test, do not assume

Pretest drafts with cognitive interviews, usability tasks, or teach-back. Ask participants what the message tells them to do, watch where they hesitate, and revise based on observed confusion. Readability scores (such as Flesch-Kincaid or SMOG) help estimate grade level but cannot prove a message is relevant, trustworthy, or actionable. The exam's best answers usually combine plain words, a clear action, audience testing, and dignity, and never frame low health literacy as a personal failing.

Reading-level targets and assessment tools

A frequent CHES benchmark is to write consumer materials at or below a sixth-to-eighth-grade reading level, because average U.S. reading skill sits near eighth grade and stress lowers comprehension further. Validated instruments measure literacy: the REALM (Rapid Estimate of Adult Literacy in Medicine) screens word recognition, the TOFHLA (Test of Functional Health Literacy in Adults) measures reading comprehension and numeracy, and the Newest Vital Sign uses a nutrition label to assess both in a few minutes. The PEMAT (Patient Education Materials Assessment Tool) scores understandability and actionability of a draft.

Knowing what each tool measures, not just its name, is exam-relevant.

The universal precautions approach

The health-literacy universal precautions principle says you should structure communication as if everyone may have limited health literacy, rather than trying to identify and single out low-literacy individuals. This protects dignity (no one is labeled) and improves comprehension for everyone, including high-literacy patients under stress. Practical universal-precautions tactics include limiting each visit to two or three key points, using teach-back routinely, providing a written summary at the recommended reading level, and following the Agency for Healthcare Research and Quality (AHRQ) toolkit guidance.

A revision walkthrough

Consider this clinic sentence: "Patients exhibiting symptomatic hyperglycemia should ambulate and maintain adequate hydration to mitigate complications." A CHES revision applies several principles at once:

The revised version reads: "If your blood sugar is high, drink water and take a short walk. Call the clinic at this number if you feel dizzy or confused." It leads with the action, defines the term, uses everyday verbs, and gives a clear next step with a safety net, which is what plain-language items on the exam reward.