meeting patient needs in the hospital setting— are written nutrition education resources too hard...

ORIGINAL RESEARCH

Meeting patient needs in the hospital setting—are written nutrition education resources too hardto understand?

Louise PERKINS and Jennifer COHENRoyal Prince Alfred Hospital, Camperdown, New South Wales, Australia

AbstractAims: To determine the readability of written nutrition education resources currently used in the Nutrition andDietetics Department in a large teaching hospital and assess whether these resources are of an appropriatereadability level for the target population.Methods: Dietitians in the department (n = 17) were interviewed to identify resources in use. Readability analysisof current resources (n = 235) followed, using the Simplified Measure of Gobbledegook (SMOG). The SMOG scoreswere compared with census data for the average reading ability of the target population based on the number ofschool years completed.Results: The readability level for the resources ranged from 6 to 15. The mean was 10.4 � 1.89 (n = 235). Thiscompared with a reading ability in the target population of between years 6 and 8. This discrepancy suggests thatthe resources may be too complex and are unlikely to be well understood by the target population.Conclusions: In the time-poor clinical environment where there is reliance on written nutrition resources to supportand reinforce education messages, it is pertinent to pay more attention to readability level. Written resources areunlikely to be effective if they are too complex. It is therefore suggested that dietitians consider the readability whendeveloping and reviewing written nutrition education resources to ensure best-quality patient care. The results ofthis project suggest that the SMOG index is a useful method to use for this purpose as it is widely available, easyto use and expedient in implementation.

Key words: education, nutrition, readability, written resource.

INTRODUCTION

The Australian healthcare system is facing a challenge withlonger hospital stays and frequent readmissions for patients,1

increasing the financial burden on healthcare facilities dra-matically. In order to address this problem in Australia, thegoals of the current healthcare management system are beingchanged. Patient education and the shortening of hospitalstays are two strategies commonly used to achieve this.2 Thisis particularly the case for chronic diseases where the self-care management system is considered to be the optimalmeans of enhancing the well-being of patients.2

Internationally, dietitians and other healthcare profes-sionals are now facing a challenge. The shorter hospital

stays of patients are impacting on the time available forstaff to provide education.2–6 Studies have shown that manypatients have a poor recall and understanding of oral infor-mation given in hospital7 because of poor short-termmemory, anxiety, depression and stress during theirhospital stay.1,6,7 Written education materials are thereforeextremely important to supplement, reinforce and clarifymessages which are poorly understood during consulta-tion, facilitate patients’ learning and aid recall.7–12 They alsoprovide the patients with consistent messages and allowflexibility of timing and delivery of information. Patientscan refer to the written information whenever necessaryand use them to learn at their own pace.2,12 It is thereforeessential that health professionals provide written educa-tion material that patients can understand to facilitate bestpossible intervention outcomes.

According to 2001 census data for the area health servicestudied, 61.3% of the population (1.93 million people) didnot have further education beyond year 12 (Higher SchoolCertificate) and 33.5% of the population spoke languagesother than English at home.13 These factors impact on a

L. Perkins, MNutr.Diet, SRD, Formerly Dietetic Clinical EducatorJ. Cohen, MNutr.Diet, Formerly DietitianCorrespondence: L. Perkins, 1st Floor, East 250 Euston Road,London, NW1 2PG. Email: [email protected];[email protected]

Accepted January 2008

Nutrition & Dietetics 2008; 65: 216–221 DOI: 10.1111/j.1747-0080.2008.00273.x

© 2008 The AuthorsJournal compilation © 2008 Dietitians Association of Australia

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mailto:[email protected]

mailto:[email protected]

person’s reading ability where written nutrition educationresources are predominantly available in English.

It has been reported that the highest education level com-pleted by an individual is not a good indicator of readingability.14–17 Current reading ability could be up to 4–5 gradeslower than the highest level of education completed.12 Theaverage reading level of the Australian population, excludingmigrants educated in non-English-speaking countries, hasbeen estimated to be year 8 level (or 13 years of age).18 In thehealthcare context, this is significant as recent literature hasalso demonstrated that the majority of the written educationmaterial used in the health care setting is written at 10thgrade or above.19

A reading level of year 10 (school certificate) comprehen-sion level (aged 15–16 years) is likely to be higher than thereading ability of many of the potential patients in thispopulation,5,12,17,20,21 as demonstrated by the figures above.The literature recommends that printed patient educationalmaterials need to be written at levels between the range ofyears 6–8, in order to match the literacy levels of a widerange of the Australian population.18,22,23 Health profession-als writing resources for a patient population derived fromthis area health service may need to consider the readabilityof written materials more closely based on this information.

There are a number of measures that allow health profes-sionals to establish whether an educational resource that hasbeen developed might be effective in achieving outcomes.One of these is the ‘readability’ of the material. Readability isthe ease of comprehension as a result of writing style.2,12 Thelower the readability score, the easier the item is to read andcomprehend. The question that remains unanswered inmany hospital dietetics departments is whether the readabil-ity of the written education material provided is at a levelthat most of the target population will understand.

The aim of the present study was to determine the read-ability of the written nutrition education materials in use inAugust 2004 in the Department of Nutrition and Dietetics ina large teaching hospital in Australia.

METHODS

The protocol was approved by the Hospital Ethics ReviewCommittee. All dietitians in the department (n = 17) wereinterviewed regarding the 322 written education resourcesavailable in the department across all clinical specialties.Although specialist dietitians develop their own resources inmost cases, outliers and ward cover necessitate all other staffbeing aware of what is available for their use in each spe-cialty. Each dietitian was asked to identify the resources theyused. This usage data were then used to determine whichresources would be analysed for the study. Any resourcesthat were no longer used in the department were discardedor archived. These were not included in the analysis. Thewritten education materials were divided into eight differentclinical streams.

Readability level of items of written education material inuse in the department was assessed using the McLaughlin’sSMOG formula (Simplified Measure of Gobbledegook). The

SMOG method (Appendix I) uses a formula based on thenumber of polysyllabic words found in 30 sentences (10consecutive sentences near the beginning, in the middle andnear the end of the text) throughout the document.This method is considered to be one of the simplest touse5,9,15–17,19,20,24 and the most accurate formula.9,15 It hasbeen used extensively in assessing patient educationmaterials,5,15–17 with good validity19,24 and it is highly corre-lated with other readability formulae.15 The analysis is basedon 100% comprehension.9,21,24,25

RESULTS

Two hundred and thirty-five (n = 235) items of writtennutrition education material were in use in the department.All of these were analysed for readability level, excludingrecipes, shopping lists and food lists. It was found that theresources in use had a mean readability level of 10.4 � 1.89with a range of 6–15.

The written education materials were divided into eightdifferent clinical streams: nutrition support (n = 38), gastro-enterology (n = 31), liver disease (n = 5), general dietaryinformation (n = 45), heart disease (n = 57), diabetes(n = 14), renal (n = 15) and eating disorders (n = 19). Themean readability levels of the written education materialused in each of these clinical specialties are presented inTable 1.

When comparing the readability levels by source, includ-ing those developed by the dietitians in the hospital depart-ment, commercial and industry, professional healthorganisations and government agencies, it was found thatthe publications with the highest readability levels werethose published by commercial organisations and those withthe lowest levels were published by the Department ofNutrition and Dietetics (see Table 2). This means that theresources developed in the department are the easiest to readand comprehend.

DISCUSSION

Dietitians working in healthcare settings in Australia areincreasingly relying on written nutrition education resourcesin their consultations with patients. In the current healthcareclimate where a shorter length of hospital stay and manage-ment of medical conditions in the home are encouraged,written education material is important in the effectivedietetic education of patients.

It has been suggested that there is a discrepancy betweenthe reading ability of patients and the readability level ofresources used by health professionals in their educationsession.12 If patients do not easily understand resources, theeffectiveness of the education and the long-term compliancewith advice provided are not likely to be optimal. As a resultof the time constraints placed on the clinician, resources arerarely assessed to see if they are meeting client’s needs. In thetime-poor clinical setting, readability formulae provide anobjective, rapid and simple measure that is useful in thewriting and revising of resources.5,9,15–17,19,20,24

Meeting patient education needs in the hospital setting


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The analysis of all departmental resources demonstrateda mean readability of 10.4 � 1.82. This means that onaverage, resources are written at a comprehension level of astudent who is midway through completing the school cer-tificate. This is significant as analysis of the statistical data onthe area health service population showed an averagereading ability of between years 6 and 8, with a high pro-portion (33.5%) of the population coming from culturallyand linguistically diverse backgrounds,13 which is likely tohave a further impact on their capacity to comprehendresources that are predominantly available in English. Themean readability of the resources was also above the level ofyear 8 reading level suggested in the literature.18,22,23 Thisindicates that the majority of written nutrition educationresources used by dietitians in this department may not bemeeting patient needs effectively if the population accessinghospital services is representative of the population of thearea health service.

For ease of analysis, the resources were broken into clini-cal streams. The resources that could be most easily readand understood (lowest readability level) were found inresources in the clinical areas of renal and nutrition support(texture modification), both 9.1. Although the renal dietitianhad considered readability principles when recently devel-oping the renal resources, readability analyses indicated thatfurther simplification was needed. This may not be possibleas resources used for renal patients need to include termslike ‘potassium’ (four syllables) and ‘sodium’ (three syllables)as well as polysyllabic food names such as ‘potato’ (threesyllables) and ‘vegetable’ (three or four syllables dependingon pronunciation).

The SMOG index uses sentence length and the number ofsyllables in a word to determine the complexity of the text.Use of the SMOG index in the assessment of nutritionresources may be flawed as the number of polysyllabic wordsin a resource influences the SMOG analysis. If words such as

Table 1 Readability of written education materials used in different dietetic clinical specialties based on the SMOG indexresults

Total number ofresources

SMOG index(mean � SD)

Readability range(school year)

Nutrition supportGeneral 8 10.6 � 1.19 9–12HIV/oncology 18 9.8 � 1.10 9–13Texture modification 7 9.1 � 1.70 8–12

Gastroenterology 31 11.7 � 1.46 8–14Liver 5 11.4 � 1.82 9–14General dietary information 45 11.4 � 1.37 9–15Heart disease 57 10.3 � 3.03 7–15Diabetes 14 9.3 � 2.03 6–13Renal 15 9.1 � 1.68 5–12Eating disorders 19 10.2 � 2.48 6–15All resources 235 10.4 � 1.89 6–15

SD = standard deviation; SMOG = the Simplified Measure of Gobbledegook.

Table 2 Difference in readability levels between commercially produced and hospital-produced written education materials ineach clinical speciality

Total numberof resources

SMOG index(mean � SD)

Readability range(school year)

Commercial Hospital Commercial Hospital Hospital Commercial

General nutrition support 3 8 11.6 � 0.58 10.0 � 1.00 11–12 9–11HIV/oncology 17 1 9.8 � 1.13 10.0* 9–13 10Texture modification 0 7 – 9.7 � 1.70 – 8–12Gastroenterology 7 23 12.5 � 1.51 10.7 � 1.15 9–14 8–12Liver 3 2 12.0 � 1.73 10.5 � 2.12 11–14 9–12General dietary information 32 12 11.5 � 1.46 11.0 � 1.13 9–15 9–13Heart disease 31 26 11.0 � 1.58 9.6 � 1.58 9–14 6–11Diabetes 14 19 11.1 � 1.27 8.1 � 1.43 9–13 7–11Renal 1 14 11.0* 9.0 � 1.66 11 5–12Eating disorders 3 12 12.3 � 1.15 9.7 � 2.46 11–13 6–15

*Value only, not mean � SD.SD = standard deviation; SMOG = the Simplified Measure of Gobbledegook.

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‘potato’ and ‘vegetable’ are used repeatedly in the resource,the text is deemed to be complex even though these wordsare in common use. Potato cannot be abbreviated. Thishighlights one of the limitations of using readability formulain isolation and applying a tool that has been developed forgeneral reading material to a more specific kind of educa-tional resource. This method provides an effective tool forassessing resources although other factors can enhance read-ability, such as use of pictures and certain text fonts (seeTable 3). This assessment was beyond the scope of thisresearch. Perhaps a new validated method specific to nutri-tion related resources could be considered that accommo-dates for complex, polysyllabic food-related words that arecommonly in use.

It is also interesting to note that the highest readabilitylevel (most difficult for people to read and understand) wasfound for resources in gastroenterology. Gastroenterologyhas many terms that are polysyllabic, such as ‘diverticulitis’(six syllables) and ‘ulcerative colitis’ (four and three syl-lables). In comparison, short terms, such as stent andpolyp, have fewer syllables but may not be recognised.This again highlights a limitation of using the SMOG indexin isolation when developing nutrition and medicalresources.

In the present study, resources developed by non-hospitalsources, such as food companies and professional associa-tions, tended to be of a higher readability level than thosedeveloped within the department. As stated previously, thereare significant time constraints placed on clinicians in thehospital setting and high-quality, commercially producedpublications are often used. The findings of the presentstudy indicate that these resources may not be ideal for thepatient as they tend to be written at levels much higher thanthe reading ability of the population.

Simple, clear messages are most effective for all groups.There could be a concern among health professionals thatsimple resources may patronise more highly educatedpatients. The evidence suggests that highly educated patientsprefer resources that are shorter and easy to comprehendwhen receiving them in a hospital setting. This is due to thestress associated with their hospital stay.26 It is thereforereasonable to aim for resources equal to or below the sug-gested level of year 8 and this is likely to suit the majority ofpatients.5,12,17,20,21

A limitation with the present study was that the research-ers were unable to assess the actual reading ability of thehospital patients; therefore, area demographic data wereused as a basis for comparison. Although this may over- orunder-estimate the reading ability of the target population,the results show that the resources were above the readabil-ity level recommended in the literature for the generalAustralian population of year 8.

These results may not only apply to dietitians and otherhealthcare professionals in the hospital setting, but also todietitians and other healthcare staff in private industry whoprovide patient education materials. This fact was high-lighted by the higher readability and complexity levels of thecommercially produced resources. Health professionalscould consider establishing guidelines for the developmentof accessible written educational resources for use in theeducation of patients. They may also consider using read-ability tools, such as the SMOG formula. Although thismethod may be limited when used in isolation, it provides atool for health professionals in the development of writteneducation resources, facilitating comprehension of the mate-rial by the patients and in this way supporting more effectivepatient education. It is important to remember that manyfactors influence readability (see Table 3).

Table 3 Characteristics of the ideal educational resource based on a compilation of recommendations from theliterature.2,16,19,27–33

Content • Present ideas logically, with one idea or issue in each paragraph• Messages should be simple, relevant, concise and easy to follow• Information should be accurate and up to date. Include publication date so that the resource

can remain currentReadability level • Aim for the resource to be between years 6 and 8 in reading level

• Use the SMOG index to assess the resource• Peer review should be sought following development for further improvement

Words and phrases • Use simple words and short sentences• Use everyday English and avoid medical jargon• Define medical terms• Avoid simplifying the text using expressions that may be simpler to read but are not common

phrases• Use active voice and conversational tone

Fonts • Font size—14–16 for texts and 16–18 for headings• Font type—Arial, Tahoma, Century Gothic or Bookman Old Style

Layout • Match content with headings• Allow ample space within texts and between paragraphs• Use suitable pictures or tables that enhance understanding, support the educational message

and make it more visually pleasingPaper • Use dark print on a light background



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Written education resources are an essential part of theeducation of patients in the hospital setting. The healthcareenvironment in Australia is changing to accommodateshorter length of stay in hospital, reliance on self-care andpatient management at home. Most of the resources in use inthis dietetics department are written at a readability level thatis higher than that recommended for the population fromwhich the hospital patients are derived. Written educationmaterials in use may need further evaluation and modifica-tion to meet the needs of the patients accessing the servicesof the dietetics department in this hospital.

Future directions and recommendations

• Assess written education resources for readability using atool such as SMOG;

• Establish policies and procedures that provide guidancefor development of resources;

• Regularly analyse and update resources as the needs of thepopulation change and new research influences patientmanagement;

• Use professional development opportunities—trainingin effective resource development should be provided bynutrition and dietetics departments in hospitals inAustralia;

• Evaluate resources developed outside the department andintended for use in the department for readability;

• Assess patient compliance and outcomes on the basis ofthe improved resources;

• Ensure that resources are reviewed by patients;• Translate resources once readability has been assessed;• Create culturally and linguistically sensitive resources

through consultation with the target population.

ACKNOWLEDGEMENTS

We would like to acknowledge P. Chiu, M. Tsang and theNutrition and Dietetics Department at the Royal AlfredHospital.

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APPENDIX I

The SMOG readability formula

To calculate readability level using the SMOG formula:The number of polysyllabic words (words with three or

more syllables) in three sets of 10 consecutive sentencesselected from the beginning, middle and end of the passagewas counted. The square root of the total number of poly-syllabic words, estimated to the nearest perfect squares,added to 3, and then converted to corresponding levelsusing the conversion table A. Passages of less than 30 sen-tences could also be assessed by multiplying the totalnumber of polysyllabic words by a conversion factorobtained from conversion table B, and then converted tothe corresponding levels as described.34



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meeting patient needs in the hospital setting— are written nutrition education resources too hard...

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