Spoken vs Written Language

In response to Audrey’s important caution about printing out the NLM tutorials (or any other orally based language) as stand alone material - I’ll add the following points, using linguistic understanding of the important distinctions between how we comprehend written and spoken language. 


>From linguisitics and reading research we know that developmentally people are able to speak and understand oral language that is at least 2-4 grade levels above the level at which they read. 


You can see this most dramatically when you analyze the actual language structures spoken by “low literate” and low health literacy patients. We have found time and time again that their spoken language contains vocabulary and sentence structures they are unable to read. (We’ve analyzed the spoken language of the patients in the AMA Health Literacy video many of us are familiar with, discussed in our book, Advancing Health Literacy: A Framework for Understanding and Action, Jossey Bass, 2006 Chp 4). 

The most important implication for the discussion of how to present written versions of oral messages is that we read print and we read spoken language (dialogue) in quite different ways - using the different characteristics of the two types of language.

Here are some linguistic principles that I use in creating or critiquing written and spoken language health material for publics: 
 
•	Print is not simply speech written down, transcription.
•	Spoken language is dependent on context and written is more contextualized. 
•	Sentence structures often differ, especially in terms of reference, repetition and length of sentences.
•	Spoken language conveys meaning in tone and phrasing ( and other paralinguistic cues) These cues are not present in print. 

Unfortunately these well studied differences between written and spoken language structures and functions have been backgrounded in the field of health literacy.  There is an important opportunity to use spoken language and print supportively. This requires us to capitalize on the different characteristics of both types of texts, which in term present the reader/listener with real opportunities to make better meaning of it all. 


Best ( and seize these precious end of summer day!)

Chris


Christina Zarcadoolas, PhD
Health and Environmental Literacy Initiative 
Associate Clinical Professor 
Mount Sinai School of Medicine 
Dept. of Community and Preventive Medicine 
Box 1057
One Gustave L. Levy Place 
New York, NY 10029 
(212) 824-7061




-----Original Message-----
From: healthliteracy-bounces at nifl.gov on behalf of Seubert, Douglas
Sent: Mon 8/25/2008 10:37 AM
To: healthliteracy at nifl.gov
Subject: [HealthLiteracy 2261] Re: CAUTION in printing out Medline tutorials!
 
Kelli Ham brought up a good point. We've already had several discussions about using reading grade level as tool for evaluating and even developing written materials that are appropriate for our patients. But perhaps this point, along with a few suggestions, are worth repeating:

"Regarding reading level tests - medical terms in any text will likely
throw off the final readability score.  If the word 'laparoscopy'
appears several times in a text, it is a five-syllable word that will
skew the results.  The same is true for many other terms, even common
words such as diabetes.   It would be interesting to see how the scores
differ without the necessary medical terms."

I usually use the SMOG formula  because it tends to give a more accurate score than using the Flesh-Kincaid tool in Microsoft Word.

And I think we all agree that medical terms are necessary and also important to include in some written materials. 

When I am just checking to see if a printed document is in the ballpark, I'll use software to run a SMOG or FOG assessment (see links  below). If I want a more accurate assessment, I do it by hand (but that takes time).

Of course, it's always best to save a working copy of your document so you can go in and play with the text and punctuation while checking for a reading grade level and not have to worry about changing anything back in the original document.

In order to get a more accurate score using readability software, I have a few rules:

When I do a readability assessment of a printed handout, I read through it and note any medical terms. Yes, these words will jack up the readability score, and removing them from your document before you run a reading grade level assessment is a good idea. But my rule is that I do not remove a medical word unless it is clearly defined in the document. 

You should also check lists of bullets. There is no clear set of rules for how bulleted or numbered text should be punctuated. If they are complete sentences they typically get a period at the end of each bullet. More often than not, the bulleted or numbered list might be phrases, or even a list of single words (such as a list of symptoms or side effects). So another rule I have before running a readability assessment is to put periods after EVERY bulleted item, whether it's a complete sentence or not. In the mind of the reader, bulleted points should be a complete thought or statement. There is a natural pause when reading a list, and the bullets and extra white space help the information stand out from the rest of the document. In fact, the reader's eyes usually go directly to those sections in a document. Putting a period after each bulleted item can dramatically change the reading grade level assessment. Without the period, the readability software will treat it all as on
 e sentence. It's programmed to look for periods. Your bullet list usually has an introductory statement ending in a colon. If you don't have periods at the end of your bulleted text, the next period is most likely at the end of the first sentence that starts the paragraph following your list. That can result in one very long sentence with a lot of syllables and will make your readability assessment less accurate.

Another punctuation rule: put periods after the title, headings and subheadings throughout the document. Again these are independent and complete thoughts to the reader and should serve as signposts throughout the document. It breaks up the text into chunks and makes navigation easier. Putting the periods after headings and subheadings will separate them from the following sentence. Without them, the readability software will consider them as one sentence. If you have several in one document, it will affect the reading grade level score.

But the reading grade level should only be a tool to help you determine if a written document is following some basic readability guidelines. It is possible to get a document's reading grade level down to 4th or 5th grade and yet still be hard to read and understand. Just using plain language and short sentences isn't enough. As others have said, there are many things that add to the readability of a printed document including font style and size, white space, use of appropriate photos/diagrams and other visuals, and including options for audio, etc.

I apologize for "preaching to the choir." It just seems that sometimes we place too much emphasis on a document's reading grade level. Using Flesh-Kincaid, SMOG or another formula (even the fast and easy to use electronic versions) are a great tool, but only a starting point when assessing the readability of printed materials.

And here are a couple free assessment tools. You can cut and paste your text into the window and it will calculate a score for you. I found these to be fairly accurate and close to a score you'd get if you did the calculations by hand.

SMOG
http://www.harrymclaughlin.com/SMOG.htm

FOG
http://www.panix.com/~dhf/fog.html



Doug Seubert
Quality Improvement & Care Management
Family Health Center/Community Health Access

Marshfield Clinic
1000 N Oak Avenue
Marshfield, WI 54449
www.marshfieldclinic.org/quality

(715) 387-5096 (1-800-782-8581 ext. 75096)
seubert.douglas at marshfieldclinic.org


------Original Message------
From:	"Ham, Kelli" <kkham at library.ucla.edu>
Date:	Fri Aug 22, 2008 -- 04:24:23 PM
To:	ar at plainlanguageworks.com,healthliteracy at nifl.gov
Subject:	[HealthLiteracy 2259] Re: CAUTION in printing out Medline tutorials!

Hi Audrey,

 

Thanks for pointing out the "easy to read" issue with the tutorials.
The tutorials themselves are easier to understand, because of the
combined use of text, images and the voice.  The key here is the notion
of understanding, rather than reading level.   I have talked to folks
who are using these in literacy programs, with the learner listening as
they read the text, then going back without the sound to read the slide.
Still, I wonder if there is any publicly available results from
usability studies or focus groups with low-level readers on these
materials.  I agree that the reading level of the printed version isn't
at a true easy to read level, but it still is useful to know that it
exists and will work for some patients and consumers.   

 

Regarding reading level tests - medical terms in any text will likely
throw off the final readability score.  If the word 'laparoscopy'
appears several times in a text, it is a five-syllable word that will
skew the results.  The same is true for many other terms, even common
words such as diabetes.   It would be interesting to see how the scores
differ without the necessary medical terms.   At any rate, thanks for
the reminder to think critically about what is being labeled as
"easy-to-read".

 

Best regards,

 

Kelli

 

Kelli Ham

Consumer Health Coordinator

NN/LM Pacific Southwest Region

UCLA Louise M. Darling Biomedical Library

310-825-1984

 

From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Audrey Riffenburgh
Sent: Friday, August 22, 2008 10:28 AM
To: The Health and Literacy Discussion List
Subject: [HealthLiteracy 2258] CAUTION in printing out Medline
tutorials!

 

Hello, everyone, 

 

Please remember that the Medline Plus tutorials are not written in
easy-to-read language. I can't figure out how they can possibly be
listed that way on the site. They may be "easy" to listen to because a
voice reads the text for the viewer. However, the version that is
available for print is not in plain language. For example, I just did a
reading level analysis on the laparoscopy tutorial's text and it scored
grade level 14 (SMOG formula). That's college level, NOT easy! 

 

These tutorial modules are also organized according to the "medical
model" which means the disease description first, etiology of disease,
etc. and eventually--maybe--getting to useful action messages. Moreover,
the illustrations that are inserted in the print-outs are not labeled
and not placed near the text they supposedly support. 

 

So remember to look carefully at materials you offer to patients.  There
are more and more materials available that are called "easy" or "plain
language" but truly are neither. Since we don't yet have standard
definitions of terms and standard guidelines on what makes something
"easy" for the majority of the public, we should remember to think
before we use materials. 

 

Audrey Riffenburgh, M.A., President
Plain Language Works (formerly Riffenburgh & Associates)
Specialists in Health Literacy & Plain Language since 1994
Albuquerque, New Mexico

Founding Member, The Clear Language Group, www.clearlanguagegroup.com
Co-founder, Health Literacy Institute, www.healthliteracyinstitute.net

 

 

----- Original Message ----- 

	From: Ham, Kelli <mailto:kkham at library.ucla.edu>  

	To: The Health and Literacy Discussion List
<mailto:healthliteracy at nifl.gov>  

	Sent: Thursday, August 21, 2008 2:11 PM

	Subject: [HealthLiteracy 2252] Re: Easy to read Prostate Cancer
info

	 

	Hi Caroline,

	 

	The very last slide each of the Interactive Tutorials on
MedlinePlus will have a button that says "Print Module".  This will be a
pdf document that covers the material in the tutorial, although it won't
have as many images.

	 

	For the Prostate Cancer tutorial, I clicked on Summary and then
just clicked through the last few slides to find it.

	 

	Hope that helps,

	 

	Kelli

	 

	Kelli Ham

	Consumer Health Coordinator

	NN/LM Pacific Southwest Region

	UCLA Louise M. Darling Biomedical Library

	310-825-1984

	 

	From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Marshall, Caroline
	Sent: Thursday, August 21, 2008 10:11 AM
	To: healthliteracy at nifl.gov
	Subject: [HealthLiteracy 2244] Easy to read Prostate Cancer info

	 

	Hello all,

	 

	I am trying to find some easy to read handouts or brochures for
a series of town meetings.  The first meeting is on Prostate Cancer.  I
have found plenty of information  but I would like to include some  easy
to read handouts.  I have checked MedlinPlus but they offer a video
tutorial, this has to be in print. Do any of you know a resource I could
use.

	 

	 

	 

	Regards,

	
	Caroline

	 

	______________________________
	Caroline Marshall
	Health Sciences Librarian

	Horblit Health Sciences Library

	 

	 

	Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810
	V: (203) 739-7419 | F: (203) 739-7568 |
caroline.marshall at danhosp.org
	http://www.danburyhospital.org

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