December 2016




Education materials often tough for patients to understand

by Vanessa Caceres EyeWorld Contributing Writer


Issues of comprehension and health literacy can affect quality of life and outcomes

Are patients really understanding their health education materials? If the results of a new study are any indication, the answer is no. Ophthalmic patient education materials are often written at a level that is too high for many to understand, according to the study, published in BMC Ophthalmology.1 The study authors completed a PubMed/MEDLINE database search for work that evaluated the readability level of ophthalmic patient education materials. They identified 13 studies that analyzed 950 educational materials. The materials included eye medication inserts, webpages, educational brochures, and informational leaflets. The median Flesch-Kincaid Grade Level readability score was 11, which referred to an 11th-grade reading level. The highest reading level, 12.9, came from glaucoma medication inserts. Other research has found that glaucoma medication inserts tend to have a higher reading level.

“The United States Department of Health and Human Services recommends that patient education materials should be written at a sixth- to seventh-grade reading level … to make them accessible for patients with low health literacy,” the authors wrote. In fact, a 2003 analysis from the National Assessment of Adult Literacy found that 36% of American adults have only basic or below basic levels of health literacy, according to the authors. “Low health literacy is associated with billions of dollars in additional healthcare costs and poor health outcomes,” they wrote. This can include negative effects on quality of life, poor medication adherence, worsened visual field loss, and a lower understanding of glaucoma.

The authors addressed brochures from the American Academy of Ophthalmology (AAO), which were revised in 2008 to make them easier to read. The Flesch-Kincaid Grade Level for those AAO materials was 8.3, or an eighth-grade reading level. However, the AAO once again revised its brochures in 2014 so that the materials are between a fifth- and eighth-grade reading level, and they also have an improved font and format for those with low vision, according to the study and an AAO press release.

Revising materials

As a second part of their study, the authors collected evidence-based guidelines on writing easy-to-read patient education materials and used the guidelines to evaluate and rewrite glaucoma patient education handouts at Duke University, Durham, North Carolina. Study authors had the revised handouts scored by two glaucoma specialists and reviewed during one-to-one interviews with glaucoma patients. After revision, the materials’ average reading level went from 10 to 6.4; they also improved for content, literacy demand, layout and type, learning stimulation and motivation, and cultural appropriateness. During the one-to-one interviews with five glaucoma patients, the revised materials received positive ratings. They also said that using concrete language, a positive tone, and information on what to expect about the clinical course of glaucoma are useful to include in patient education materials.

Although some of the feedback obtained from the patient interviews was expected—such as a request to keep information brief—other comments surprised researchers, said study author Jullia Rosdahl, MD, PhD, Department of Ophthalmology, Duke University. For example, the patients expressed an interest in learning more about vitamins and diet as they relate to glaucoma—two topics typically not addressed during glaucoma care visits, she said.

Making materials easier for patients

The challenge to making patient education materials easier to understand is not unique to ophthalmology, Dr. Rosdahl said. “I think most medical specialties struggle with this issue, not just ophthalmology. One of the added factors we face in ophthalmology is that our patients are typically older as well, and older age is a risk factor for worse health literacy,” she said. Although patient education has always been an important issue, it has become even more critical as the physician/patient relationship has evolved from a parental relationship to a more team-based approach of care, said Jeffrey Schultz, MD, vice chair of clinical affairs, director of the glaucoma service, and associate professor of ophthalmology and visual sciences, Montefiore Health System and Albert Einstein College of Medicine, New York. “Patient education is critical not only to permit the patient to be more involved in the decisions determining health management but also to better understand the disease process and yield more effective involvement in their own care,” he said.

Dr. Rosdahl recommends the use of the AAO handouts as well as those from the National Eye Health Education Program ( to provide information that is easier for patients to understand.

If a practice decides to create patient education materials on its own, it isn’t necessarily hard, but it can take time and effort, Dr. Rosdahl said. “Most of us find it harder to write at an eighth-grade reading level than at a 12th-grade reading level,” she said. An in-house marketing person with an interest in health literacy can be a potentially great candidate to write educational materials that are easier to follow, she said. Some resources that person can use include Microsoft Word’s feature to measure readability statistics and various resources available to address issues with health literacy, such as those summarized in the recent review.


1. Williams AM, et al. Readability of patient education materials in ophthalmology: a single-institution study and systematic review. BMC Ophthalmol. 2016;16:133.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information


Education materials often tough for patients to understand Education materials often tough for patients to understand
Ophthalmology News - EyeWorld Magazine
283 110
283 110
True, 12