discussion

Description

Referencing at least 3 of the course readings, describe some of the different types of medical writing for lay audiences. What are the purposes of these types of medical writing? How do these differ from the types of medical writing for professional and medical audiences? Do you know of any other types of medical writing for lay audiences that the readings did not discuss?Social media: A tool that can benefit
public health?
Sara Ferrão
Freelance Medical Writer, Lisboa, Portugal
Correspondence to:
Sara Ferrão
+ 351 964541832
saraferrao.mw@gmail.com
Abstract
Te global use of social media has changed
access to health information, and the internet
has become its primary source for the general
public. However, judging health information
on social networks remains difficult for nonmedical readers since most available information is unregulated and of questionable
quality, possibly leading to poor health
behaviours and decisions. COVID-19 is the
greatest public health emergency of this
generation that led to a widespread increase
of misinformation. Health communicators
can play a role in fghting this infodemic by
writing about complex issues in accessible
language and providing reliable sources.
Filtering and translating the information
published online is an essential process that
will positively infuence public health.
Te internet has drastically changed the way
people access information about almost
anything. Health is no exception to this trend and
the internet has become the main source of
information for many patients wanting to know
more about specifc health issues.1
Te internet gave rise to social media,
enabling individuals or communities to share
information and ideas in real-time using internetbased tools: e.g., Facebook, Twiter, Instagram,
and blogs. Social media quickly spread from a
purely social function for young people to having
a wider use across all ages and professions,
enhancing education or professional networking
and community interaction.2
In recent years, the importance social media
has had in infuencing societal trends has been
amazing. Although infuencer marketing is an
established marketing strategy, social media has
www.emwa.org
made it extremely powerful. Infuential people
went through the enormous COVID-19
become well-known online, they build a
challenge that created both a huge demand for
reputation within their area of expertise and
information as well as a breeding ground for fake
gather a large number of followers, who pay close
news and ludicrous myths. Tis health crisis was
atention to their views and are
associated with a new conguided by their choices and
cept: an infodemic, which
The internet has
lifestyle.
refers to the large volume of
drastically changed
misinformation generated
the way people access
Social media and the
about the disease, its spread,
COVID 19 infodemic
and its treatments. Te WHO
information about
Social media also became an
defned an infodemic as an
almost anything.
essential part of public health
excessive amount of misinHealth is no exception
communication and infuence,
formation that creates conto this trend and the
enabling patients to become
fusion and distrust among
more active consumers of
people, hampering an effective
internet has become
health information. However,
public health response.3
the main source of
unlike sponsored medical comOne of the challenges was
information for many
munication and health journadealing with the increasing
patients wanting to
lism, blog posts and personal
amount of false health content
commentary channels have
circulating on social media
know more about
been completely unregulated.
platforms.4 Most social media
specific health issues.
With increased social media
companies (e.g., Facebook and
and internet participation, it has become obvious
Twiter) worked alongside the WHO to flter out
that there is a need for quality assurance of such
unfounded medical advice to counter the spread
of non-founded ideas that could risk public
information and its sources.1 Tis need was
brought into sharp focus this year as the world
health.3 Examples of this are taking drugs
Volume 29 Number 4 | Medical Writing December 2020 | 47
Social media: A tool that can benefit public health? – Ferrão
without a prescription or a bath in bovine faecal
mater, drinking toxic detergents, or otherwise
partaking in risky behaviours that could have a
social negative impact, such as panic shopping or
spreading “conspiracy theories”.5 Nevertheless,
social media was responsible for much unfltered
information online, due to its accessibility and
the infnite possibility to spread data throughout
the general public.
With the obvious growth of social networking
and the public s hunger for accurate COVID-19
related information, science organisations, policymakers, healthcare professionals, and organisations also began to communicate via social media.
Tis was helpful in mitigating the infodemic
phenomenon and was effective in raising
awareness about misinformation and how it can
be minimised.
Ways to improve health communication on
social media
Judging health information on social networks
remains difficult for nonmedical readers as much
of this freely available information is unregulated
and of questionable quality. Accurate methodology and reporting is important as it adds to the
belief construct and reassures the scientifc
community that the data the authors set out to
obtain is correct and accurate. For example,
scientifc communication is usually regulated by
the peer-review and publishing process, which
ensures that each published study is appropriately designed, performed, and reported.6
However, for the general public, this peer-review
process is non-existent. Sometimes a press
release, blog, or a simple statement citing data can
be confusing and raise unfulfllable expectations.
To avoid this, health writers should highlight
whether or not a given study was peer-reviewed
and explain that this means the validity and
quality of reporting has been checked by other
experts in the feld. Also, it is important to place
the study data in the long evidence-building
process, e.g., “this is the frst study in humans and
the results will now need to be confrmed in
larger, controlled studies”, so the public knows
what to expect and how to act accordingly.
When writing for patients and lay audiences,
word choice is imperative. Each word must
accurately refect the data in a language the reader
understands. One single word can alter the
meaning of a simple sentence, for example: “Tis
study shows treatment X is effective” vs. “Tis
study suggests treatment X is effective”. Te
Figure 1. WHO’s infographics available on Facebook, designed to educate
about ways to reduce the risk of becoming infected with COVID 19
(htps://www.facebook.com/WHO/photos/a.167668209945237/3538127066232651
general public may perceive the word “shows” as
the same as “suggests”, thus raising false
certainties about a subject that can be wrongly
relayed across social media platforms. Another
example is the word “signifcantly” that is ofen
used when reporting quantitative data but has a
specifc meaning in science. Undoubtedly, the
word “signifcantly” should only be used if there
is a p-value associated with the datapoint.
However, if a study result has a non-signifcant
result, it does not mean there is no clinical
difference. Other factors such as the sample size
must be taken into account for the practical
signifcance to be determined, so it is also
important that the medical writer places the
study results in context when communicating to
the lay audience.
48 | December 2020 Medical Writing | Volume 29 Number 4
Furthermore, the language and vocabulary
used should be appropriate for the lay audience,
and it has to be engaging and appealing on social
media. Using short sentences with a straightforward message in a relaxed tone with everyday
language is preferable, and bullet points make
complicated concepts easier for the reader to
capture, understand, and remember.
Lastly, reconceptualising the data by using
imagery, visualisation, or numeracy are useful
ways of explaining health data. For example, in
the context of the COVID-19 pandemic, several
health organisations like WHO adopted this
strategy and used engaging imagery on social
media to make the public aware of important
health issues to be taken into account during the
pandemic (Figure 1).
Ferrão – Social media: A tool that can benefit public health?
Tus, fltering information published online
and, sometimes, translating it so that it targets a
specifc audience is a necessary process that can
have positive implications on public health. It is
clear that governments and institutions must
create guidelines and mechanisms to control the
information fow on the internet.7 Health writers
should also be encouraged to critically analyse
information before communicating it on social
media and be a part of the fltering and “translating” process, as this is their feld of expertise.
Te COVID-19 infodemic brought to light
the urgent need to teach the public about the
clinical trial process and the role that scientists,
regulators, and manufacturers have in creating
and developing a drug and, to what lengths they
go to ensure that medicines are safe and effective.
Tis information, brought by the science communicators, must be reliable and accessible, as
the general public should be able to understand
the basics of science in order to make correct and
informed decisions. Since patients increasingly
use social media to educate themselves about
their health problems, used responsibly, it could
be a useful tool to educate patients and promote
public health messages.8,9
Acknowledgements
Te author would like to thank Lisa Chamberlain
James for her encouragement, and Amy Whereat
for providing helpful comments and valuable
writing and editing assistance.
Conflicts of interest
Te author declares no conficts of interest.
References
1. De Martino I, D Apolito R, MacLawhorn
AS, Fehring K, Skulko PK, Gasparini G.
Social media for patients: Benefts and
drawbacks. Curr Rev Musculoskelet Med.
2017;10:141–5.
2. Ventola CL. Social media and health care
professionals: Benefts, risks, and best
practices. P T. 2014;39(7):491–9.
3. Te Department of Global
Communications: UN tackles ‘infodemic of
misinformation and cybercrime in COVID19 crisis. 2020 [cited 2020 March 31].
Available from: htps://www.un.org/en/
uncoronavirus communicationsteam/
untackling%E2%80%98infodemic%E2%80
%99-misinformation-and-cybercrimecovid-19.
4. Ratzan SC, Sommariva S, Rahu L.
Enhancing global health communication
during a crisis: Lessons from the COVID-19
pandemic. Public Health Res Pract.
2020;30(2):e3022010.
5. Cuan-Baltazar JY, Muñoz-Perez MJ,
Robledo-Veja C, Pérez-Zepeda MF, SotoVeja E. Misinformation of COVID-19 on
the internet: Infodemiology study. JMIR
Public Health Surveill. 2020;6(2):e18444.
6. Eysenbach G. How to fght an infodemic:
Te four pillars of infodemic management.
J Med Internet Res. 2020;22(6):e21820.
7. Abroms LC. Public health in the era of
social media. Am J Public Health.
2019:109(S2):S130–1.
8. Giustini D, Ali SM, Fraser M, Boulos MK.
Effective uses of social media in public
health and medicine: A systematic review of
systematic reviews. Online J Public Health
Inform. 2018:10(2):e215
9. Charalambous A. Social media and health
policy. Asia Pac J Oncol Nurs.
2019:6(1):24–7.
Author information
Sara Ferrão, MSc, is a pharmacist and a
freelance medical writer with more than 7
years experience. She s passionate about communicating health and medicine and has been
focusing her work on developing accessible
and engaging content for the lay audience.
She also provides writing and translating
services for pharmaceutical companies.
Since patients
increasingly use social
media to educate
themselves about their
health problems, used
responsibly, it could be a
useful tool to educate
patients and promote
public health messages.
www.emwa.org
Volume 29 Number 4 | Medical Writing December 2020 | 49
A stroll through the medical
blogosphere
Correspondence to:
Stevan Mijomanovic
The School Medicine
University of Belgrade
Dr Subotića 8, Belgrade
Serbia
stevan.mijomanovic@
gmail.com
Stevan Mijomanović, Sofija Mićić Kandijaš
The School of Medicine, University of Belgrade,
Belgrade, Serbia
Abstract
Medical blogs are a very popular way of communicating health-related information. They can be
written by medical professionals or laypeople, and
topics include diseases, procedures, health policies,
and personal topics such as everyday experiences.
In this article, we provide examples of medical
blogs that illustrate the language used, which can
be technical, semi-technical, or informal. Medical
blogs need to be accurate and well written
because they provide precious information about
health-related issues.
Keywords: Medical blogs, Language, Form, Style,
Lay audience
If you have a rash or fever, more often than not, you
will consult the Internet before you visit your
general practitioner. Once you open your browser
and start searching for a medical topic, you will be
flooded with links to many kinds of websites.
Some will take you to online scientific journals,
while others will take you to different wikis, question and answer portals (Q&A), or blogs. In this
paper, we focus on medical blogs.
‘Blog’ is blend of the term ‘Web log’, a specific form
of online diary. Blogs serve as platforms for voicing
personal or professional views on a certain topic.
Topics are listed in chronological order and may
have photos and videos as well as hyperlinks to
other web pages or blogs. Blogs are easily accessible,
and anyone with a computer and access to the
Internet can author one. Usually, users can subscribe
to a blog, leave comments, and find references to
other blogs and relevant pages. This interconnectivity and ability to provide feedback facilitates ‘knowledge sharing, reflection, and debate, [and] they often
attract a large and dedicated readership’.1 Usually
blogs appear as diaries expressing the author’s feelings, opinions, and ideas. Some blogs, however, are
educational tools used by students and education
© The European Medical Writers Association 2015
DOI: 10.1179/2047480615Z.000000000330
professionals, while others aim to serve as a forum
for people who share similar opinions or professions.
Medical blogs
Medical blogs do not differ much from other blogs,
although they focus, broadly speaking, on health
and health-related issues. Their content varies from
diseases, medication, health policies, health
research, and nutrition to personal experiences.2
Typically, medical blogs focus on one topic, but it
is not uncommon for them to cover two or more.3
Medical blog authors vary from physicians,
nurses, medical students, patients, patients’ family
members, lawyers to journalists. The content can
be considered as either informative or affective;
informative content uses medical terminology
extensively, while affective content uses an abundance of adjectives.2 Three groups of bloggers are
identified: physicians, patients, and nurses. It has
been noticed that physicians tend to focus on illnesses, patients mainly focus on medication, and
nurses focus on their everyday life and experiences.2
Blogs written by physicians can be on a specific
illness, procedure, or health policy, or they can
deal with their everyday experiences or professional
communication. Some bloggers are anonymous or
write under pseudonyms, and for those who
appear to be more transparent, it is usually impossible to check their credentials and identity with
certainty.
This fact and the easy accessibility of blogs lead us
to the question of the validity and relevance of the
information disseminated on medical blogs. Not
all of the authors reference the information on
their blogs to a medical journal or traditional
medical literature. Blog authors who publish scientific papers or books tend to mirror the conventions of
scientific writing.4 Some blogs (e.g. Intensive 5) have
more contributors who range in function from
editors and section editors to consultants. These
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Mijomanović and Kandijaš – A stroll through the medical blogosphere
are often associated with official institutions, so they
tend to be more credible.
The personal diary nature of blogs tends to make
their writing a stream of consciousness. As Scott
Plutchak6 noticed while experimenting with blog
writing, it takes less time to write a blog post than
other types of documents; he observed that even
with the time spent on revisions, blog writing is
far less time-consuming than writing editorials.
Writing editorials or scientific papers, in his
opinion, is not the mere reporting of one’s thoughts
and ideas, but an exploration, a finding out of what
one thinks about a certain topic. However, one of the
advantages of this type of online publishing is the
direct dissemination of information, knowledge,
opinions, and ideas on a peer-to-peer level; blogs,
Twitter, and e-mail discussions are far superior for
this kind of exchange than online journals and traditional publishing.7 A likely reason for this is the
informality of blogs, which can also be a
disadvantage.
Form and style
Patient-written posts tend to be longer than those of
nurses and physicians. Nurses tend to use more
adjectives and everyday language. Patients tend to
avoid names of their diseases ‘(e.g. the beast
instead of ‘migraine’) or use only abbreviations
(e.g. Type 2 instead of diabetes type 2)’.2
‘Abbreviations (e.g. CLL for chronic lymphocytic
leukemia), enumerations, and citations of conversations as well as common speech, medical terms, and
opinion-related words are used frequently in
medical blog posts’.2 The format of medical blogs
seems to encourage a more conversational style
and can sometimes even lead to online discussion
boards. Sentences tend to be syntactically simple
and correct. The language and the scope of
medical terminology used, however, differ significantly according to the aimed or expected audience.
The following randomly selected examples illustrate
some of linguistic and content variants of medical
blogs.
Example 1
Sinus bradycardia HR ∼60 bpm with intermittent sinus
arrest / sinus exit block, shown by 2 missing p waves followed by 2 ventricular escape beats at a rate just under
40 bpm. 8
This particular example is an answer to a question
in an educational post where readers (students or
younger practitioners of medicine) are supposed to
interpret a photo that contains rhythm strips of a fictional case-scenario. The answer is revealed after
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one click on the question of the post. This example
is obviously aimed at professionals, not laypersons.
The language is highly technical, abundant in noun
phrases and abbreviations. An average person with
no medical education would probably have difficulties understanding this.
Example 2
My dear readers, if you even exist anymore :-), I have neglected you. For that I am sorry. My last post was more
than a year ago.[…]So, insert drum roll here, here it
is! My first video lecture demonstrating how to use
ultrasound to gain peripheral venous access. Hope
you’ll like it, because there are others following
soon, and I intend to bore you with them as well;).9
This example is of a personal blog written by a
doctor. The content is as diverse as the heading of
the blog itself says: ‘about medicine, science, internet,
soap bubbles, design, imaginary friends, books, music
for robots, uncreative taglines … ’9 The language
varies from very informal (use of emoticons, and
idioms) to more specific or technical. The audience
here is not specified, but there is a specific conversational or familiar tone as if talking to friends or
peers. The posts vary from medical applications
(Apps) to medical emergencies during football
matches. The language is informal where possible
and reverts to being technical where needed.
Example 3
In theory, all doctors should treat all patients equally. In
practice, nice, friendly patients get better, quicker treatment. Queue shock, horror, outrage.10
This example is from the British Medical Journal 11
which has various direct links that can take you to
diverse blogs dealing with myriad of topics. This
one comes from a doctor’s blog. The main audience
is patients as indicated by the title, Inside secrets to
getting the best hospital care. 10 Thus, the language
used is far from technical. It is conversational, yet
borderline formal, with frequent informal intrusions
(e.g. rubbish care, stroppy, demanding, impatient arse 10).
The style of the post is very humorous, one might
even say satirical, if, say, the reader is a doctor. If
you are a patient, you might find it a bit offensive,
yet practical.
Example 4
This year, there has been a major resurgence of
measles, a dangerous disease that for decades had
been virtually unknown in the United States. And
it’s become clear that measles has re-emerged as a
public health issue in this country because large
numbers of individuals remain unvaccinated.12
Mijomanović and Kandijaš – A stroll through the medical blogosphere
Figure 1: A well-organized medical blog.
As a part of the blog Well 12 of the The NewYork
Times, this post is written in journalistic/column
style. The post itself begins with a more personal
touch with the author introducing the story from
her private life but then it goes on to be more
factual and narrative. The terminology is in the
sphere of plain language (Confronted with a patient
suffering from a fever, red eyes, runny nose, cough and
blotchy rash, we don’t even think of measles[…] 12).
The language is adapted for the broadest audience
possible.
Writing a medical blog
People who decide to write a medical blog should
pay attention to the type of information they
provide, accessibility and readability of the blog,
and the language used.
Since blogs are a personal view on any issue close
to authors’ heart, they undoubtedly portray their
views, opinions and attitudes. Medical blogs,
however, usually provide the readers with facts
about health-related topics and should, therefore,
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be more objective. The credibility of the information
is achieved through mentioning the sources either
by referencing them or by inserting a hyperlink to
a research/article. Another way to achieve credibility is for the authors to clearly display their credentials, to respect patient’s confidentiality and
disclose any potential conflicts of interest (e.g.
KevinMD 13).
Blog posts, as was mentioned before, appear in
chronological order, thus writers should strive to
make blogs more organized in order to make the
navigation through the site easier. This could be
achieved either by organizing the blog topically
(by adding different sections: physician, patient,
health policy, health tips, audio, video etc) or by
adding ‘tags’ that serve as keywords for the post
(e.g. Better Health 14, see Figure 1).
The language of the posts depends on the readership, but more often than not, the audience are laypersons. With this in mind, authors should try to
avoid technical language and rely on plain language
(where possible). Instead of saying that herpes
zoster is caused by varicella-zoster, it would be
227
Mijomanović and Kandijaš – A stroll through the medical blogosphere
Table 1: Useful links for future medical bloggers
Topic
Links
Plain language
Plain Language Medical Dictionary.
http://www.lib.umich.edu/plain-language-dictionary
How to write medical information in plain English
https://www.plainenglish.co.uk/files/medicalguide.pdf
Medical Translator
http://www.iodine.com/translate
How to Start a Blog
http://www.wikihow.com/Start-a-Blog
How To Start a Blog – Beginner’s Guide for 2015

How To Start a Blog – Beginner’s Guide for 2023

Blogger
https://www.blogger.com/
WordPress
https://wordpress.com/
MedWorm
http://www.medworm.com/
iMedisearch
http://www.imedisearch.com/
WebMd
http://www.webmd.com/
How-to guide
Blogging platforms
Medical search engines
better to say that shingles are caused by the chicken
pox virus. If the author wishes to retain the technical
terms, one can do so by adding them in parenthesis.
This makes the posts more readable and also provides the audience with information for further
research. Sentences should be clear and syntactically
simple. Authors should avoid clusters of noun
phrases, abbreviations, impersonal sentences, and
reduce the use of passive. The language should be
accessible to everyone, but not colloquial (avoid
jargon).
For some useful links that could help you start a
medical blog, see Table 1.
Conclusion
There is an abundance of medical information on
the Internet. The most common are medical blogs,
which come in diverse forms. The general idea
behind these blogs is to familiarize different types
of audiences about various medical topics (both professional and personal). The main challenge in
writing a medical blog is to adapt the technical
language in an understandable way for lay audiences. People who decide to use the Internet in
order to find health-related information expect to
find medical information in plain language. Since
this type of information is of great importance to
readers it is paramount to make those sources trustworthy and authentic, both in the form and content.
References
1.
228
No author listed. 7 things you should know about …
Blogs. [cited 2015 Aug 28]. Available from: http://
www.educause.edu/ir/library/pdf/ELI7006.pdf.
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2.
Denecke K, Nejdl W. How valuable is medical social
media data? Content analysis of the medical web.
Information Sciences. 2009;179(12):1870–80.
3. Miller EA, Pole A. Diagnosis blog: checking up on
health blogs in the blogosphere. American Journal
of Public Health. 2010;100(8):1514–19.
4. Kovic I, Lulic I, Brumini G. Examining the medical
blogosphere: an online survey of medical bloggers.
Med Internet Res. 2008;10(3):e28. doi: 10.2196/
jmir.1118.
5. Intensive. An online education and knowledge translation resource provided by The Alfred ICU. Available
from: http://intensiveblog.com.
6. Plutchak TS. I see blog people. J Med Libr Assoc. 2005;
93(3):305–7.
7. Chatterjee P, Biswas T. Blogs and Twitter in medical
publications: too unreliable to quote, or a change
waiting to happen?. Afr Med J. 2011;101(10):712, 714.
8. Yong S. Alarming Alarms, 2015 May 25 [cited 2015
Aug 31]. In: Intensive blog. Available from: http://
intensiveblog.com/alarming-alarms/.
9. Kovic I. Ultrasound guided peripheral venous access
video lecture, 2015 Feb 18 [cited 2015 Aug 31]. In:
Igor Kovic, M.D. blog. Available from: http://ivorkovic.com/blog/#ixzz3kManyTpP.
10. Dr Teddy. Inside secrets to getting the best hospital
care, 2015 Apr 29 [cited 2015 Aug 31]. In: Doc2Doc.
Available from: http://goo.gl/yjnhYl.
11. BMJ blogs. Available from: http://blogs.bmj.com/.
12. Chen PW. Putting us all at risk for measles, Doctor
and Patient, 2014 Jun 26, [cited 2015 Aug 31]. In:
Well, Health blog on The New York Times.
Available
from:
http://well.blogs.nytimes.com/
2014/06/26/putting-us-all-at-risk-for-measles/.
13. Kevin MD. Social media’s leading physician voice.
Available from: http://www.kevinmd.com/blog/.
14. Better Health. Smart health commentary. Available
from: http://getbetterhealth.com/.
Mijomanović and Kandijaš – A stroll through the medical blogosphere
Author information
Stevan Mijomanović is a Teaching Assistant of English at
the Faculty of Medicine, University of Belgrade. He is currently in his third year of doctoral studies at the Faculty of
Philology, University of Belgrade. His main interests
include Cognitive Linguistics, Applied Linguistics, and
the language of medicine.
Dr Sofija Mićić Kandijaš is an Associate Professor of
English at the Faculty of Medicine, University of
Belgrade. She has published several books and numerous
papers in national and international journals. She was a
member of the EMWA EPDC as well as a workshop
leader.
Medical Writing
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VOL. 24
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229
Patient education accessibility
Stella Hart
Patient Education Institute, Coralville, IA,
USA
Correspondence to:
Stella Hart
Patient Education Institute, 2000
James Street, Suite #219,
Coralville, IA 52241, USA
stella-hart@patient-education.com
Abstract
Patient education that overcomes literacy barriers
supports quality care. This article provides an overview of health literacy, describes the concepts of
readability and accessibility, and discusses how to
empathise with the patient’s experience and ask
interactive questions. The tips in this article are
based on a learner-centred approach and 20 years
of publishing X-Plain® patient education tutorials.
This information should help health content
writers facilitate patient comprehension, improve
health outcomes, and achieve care goals set by
healthcare providers.
Keywords: Patient education, Patient engagement,
Accessibility, Health literacy, Readability
Patient education accessibility involves creating
health materials that are designed and presented
so that they can be understood by audiences of
diverse literacy levels. Certain instructional design
principles, along with strategies to enhance readability, help facilitate patient understanding, bridge
gaps in health literacy, improve health outcomes,
and reduce readmission rates. Successful patient
education enables patients and their families to
become active members of their healthcare team,
empowers them to ask questions, supports communication with healthcare providers, and results
in shared decision making.
Health literacy
Health literacy is the ability to understand and
process health information in order to make competent choices related to prevention and treatment of
health problems. Health literacy is a stronger predictor of health outcomes than age, income, employment status, education level, or race.1 Low health
literacy is associated with poorer health outcomes,
including increased rates of hospitalization and
mortality. Low health literacy is related to general
illiteracy. According to the National Assessment of
Adult Literacy, 14% of the United States population
190
© The European Medical Writers Association 2015
DOI: 10.1179/2047480615Z.000000000321
struggles to write, read, listen, or speak effectively.2
The cost of low health literacy for the United States
economy is estimated at up to $238 billion U.S.
dollars each year.3 In fact, the mortality rate attributable to low education is comparable to the mortality rate for smoking tobacco, and educational
disparities widen with each successive generation.4
Medical writers are tasked with simplifying
content so that it reaches all patient populations,
especially those most at risk for not understanding
critical health information. Various educational
models and adult learning theories can help
medical writers achieve desired behavioural outcomes and support long-term recall of information
for health consumers. Common behavioural goals
in patient education include making informed
decisions, developing skills for self-care at home,
committing to medication compliance, and modifying habits for a healthier lifestyle.
Readability and accessible language
Reading level can be calculated with automated formulas that are based on word length, punctuation
use, and number of syllables.5 However, automated
readability calculations can be misleading. For
instance, you might write ‘See a healthcare provider
for treatment without ado.’ According to an online
readability calculator, this sentence is written at a
fifth grade reading level, even though the word
‘ado’ is not widely used. Saying ‘See a healthcare
provider for treatment without delay’ is easier to
understand, but the formula generated by a computer gives this sentence a higher readability level
because the word ‘delay’ is longer than ‘ado.’ This
sentence could still be made clearer: ‘See a healthcare provider for treatment right away.’ The
reading level for this sentence is second grade.
Writers should therefore use tools that calculate
readability in conjunction with their own judgment.
Using such formulas is not the only way to
improve readability. Content should be simplified,
presented impartially, and organized in a logical
order. Content structured so that it gradually
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Hart – Patient education accessibility
builds understanding from the simple to the
complex helps consumers understand the main
points and supporting details. The structure and
organization of the lesson should be apparent to
the patient in advance so that he or she knows
what to expect from the program. An ‘advance organizer’ provides clear orientation for users to process
the information they are about to take in. Such a
map is critical for individuals with learning disabilities or low literacy levels.6
Writers should break down complex medical concepts into short words and sentences.7 Speaking
directly to the patient, using active voice, and avoiding clichés and idioms increases accessibility and
reduces confusion.7
Punctuation and numerical values should be
chosen based on what is most understandable to
the audience. Symbols should be used cautiously.8
For example, not all patients may recognize the
ampersand symbol (&).9 Conversely, the per cent
symbol (%) is more understandable and recognizable than the word ‘per cent.’
Writers should explain technical or uncommon
words with definitions and examples.7 Information
that may be new or unfamiliar to a reader can be
phrased strategically so the reader can gather clues
from the context to increase comprehension. Using
the same word consistently instead of synonyms
can also help prevent confusion.
Using concrete or practical examples to illustrate a point can help further a patient’s understanding and influence their behaviour. For
example, ‘Your healthcare provider may recommend that you increase the amount of
vitamin A in your diet. Foods that are high in
vitamin A are dark green, leafy vegetables and
deep orange vegetables. Examples include
spinach, carrots and squash.’
team. It also facilitates communication between
healthcare providers and patients, which saves providers time, enhances the quality of care, and
improves health outcomes.11
The tone of patient education should be factual
and empathetic. A judgmental or patronizing
tone can impede the learning process and negatively affect the patient. Unless writers are aware
that their audience has a background in healthcare, it is better to assume they do not have
medical field experience or an understanding of
biological concepts. Evaluation studies on XPlain® (the patient education materials published
by the Patient Education Institute) show that
users who have more experience or who are
highly health literate are not offended by simplified content.12,13
Viewing the patient as a person, rather than a condition, and writing with person-first language are of
primary importance.14 ‘Disabilities are not persons
and they do not define persons,’ so medical professionals should refer to affected patients as
people with a medical condition or disability,
rather than as disabled people.15 For example,
writing ‘people with diabetes’ is more sensitive
than ‘diabetics.’ Similarly, ‘to have’ may imply possession and ‘to be’ may imply identity; using ‘have’
rather than ‘be’ is considered less stigmatizing. For
example, it is better to say ‘a person with hearing
loss’ rather than ‘a person who is hearing
impaired.’13 Table 1 lists further examples.
Table 1: Examples of terms that could be offensive to lay
readers and empathetic alternatives
Term that could be
offensive
Amputee
Bipolar man
Cancer patient
Autistic child
Empathetic alternative
A person with an amputated limb
A man with bipolar disorder
A patient with cancer
A child with autism or a child who is on
the autism spectrum
A woman who uses a wheelchair
Keeping the patient’s experience in
mind
Wheelchair-bound
woman
Learning that you have a disease or disorder or that
you need a procedure can be frightening and can
impact your identity. Stress, such as that caused by
an illness or injury, can detrimentally affect a
person’s health literacy abilities.10 Medical writers
should be conscious of the patient’s potential experience, while being careful not to sacrifice educational
effectiveness. Keeping the patient and their potential
sensitivities in mind while developing content can
help increase the patient’s satisfaction with the
care they have received. Increased understanding
and satisfaction empowers patients to ask questions
and become active members of their healthcare
Sensitivity to norms within a community makes
patient education empathetic and increases the
writer’s credibility. For example, many individuals
with hearing loss prefer to use the term ‘Deaf’ to
describe their community and culture.16
To ensure that educational programs are accepted
and understood by the target audience, involve
patients in reviewing the materials during the development process.7 Patient involvement and review
increases accessibility and the likelihood of success
as the solution is implemented. Direct online feedback from real patients in clinical settings simplifies
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Hart – Patient education accessibility
Figure 1: An online feedback form for the Arabic-language version of X-Plain®.
the collection and analysis of patient feedback. An
example of an online feedback form is shown in
Figure 1.
Visual instructional design
Research shows that text paired with simple line
drawings engages readers more than text or
graphics alone. Line drawings also prevent overstimulation that could impede cognitive processing.17
Line drawings that clearly represent a concept are
more accessible than complex or highly realistic
images, such as photographs.18
In a study published in Patient Education and
Counselling, researchers analysed peer-reviewed
studies in health education, psychology, education,
and marketing journals. They found that:
‘pictures closely linked to written or spoken text
can, when compared to text alone, markedly
increase attention to and recall of health education information. Pictures can also improve
comprehension when they show relationships
among ideas or when they show spatial
relationships. Pictures can change adherence
to health instructions. All patients can benefit,
but patients with low literacy skills are
especially likely to benefit. Patients with very
low literacy skills can be helped by spoken
directions plus pictures to take home as reminders or by pictures plus very simply worded
captions.’19
The design and layout of text and graphics can be
used to increase understanding. Text should be presented in a large, simple font.17 Plenty of blank
space should be used to balance the graphics and
text on the page. Whenever necessary, bullet point
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Figure 2: An example of patient information in which
graphics, blank space, and bullet lists are used to improve
readability.
lists can be used to break down or organize information. An example is shown in Figure 2.
Asking questions
Interactive questions can be used to facilitate learning while providing corrective and reinforcing feedback. An example of an interactive question and
answer set with feedback is shown in Figure 3.
The following guidelines for developing questions and answers are based on 20 years of publishing X-Plain® tutorials and enhancing them based on
user feedback:
 Questions should be written so that they apply
to a wide variety of patients in different healthcare settings.
 Questions should be written about the most
important point of the preceding section of
the lesson. The most important point could be
a concept that will be expanded on in later sections; understanding the concept could be
Hart – Patient education accessibility
Figure 3: An X-Plain® question and answer set with feedback.
necessary for the patient to understand what
comes later. The most important point could
be related to how the patient can practice selfcare at home, prevent medication errors, identify a complication, or know when to contact
their healthcare provider.
 Ask questions about how the patient can help
themselves and improve their health or
quality of life. Testing viewers on terminology
is not always critical to understanding main
concepts. Common misconceptions should be
targeted as question topics whenever possible.
For instance, during the informed consent
process, patients may conclude that the risk of
complications for a procedure is high after
reading about the many potential complications. It is necessary to emphasize the rarity
of complications after listing risks – when the
clinical evidence applies – by asking a question
confirming the rarity of complications.
Confirming that the risk is a possibility,
however, helps mitigate liability. An example
is shown in Figure 4.
 Clear and simple questions increase the likelihood that the patient will retain correct information later on. Questions should not test the
patient on concepts not explained in the
lesson. ‘Trick questions’ can undermine
patient confidence. Being able to answer a question correctly increases patient satisfaction.
 When a patient answers a question incorrectly,
the feedback should explain the correct answer
and give the patient a hint.
Conclusion
Medical leaders have identified patient engagement
as one of the most critical concerns of health systems
during the digital transformation of the healthcare
industry.20 To truly engage patients, health education materials should be designed so that they
are accessible to audiences of diverse literacy levels
and learning styles. Medical writers should make
creative and thoughtful instructional design
decisions, and the final product should respect the
humanity of patients.
Acknowledgements
I would like to thank Moe Ajam, Roland Hart,
Danae Livingston, Christian Craig, and Lynne
Postudensek for reviewing this article.
References
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2.
Figure 4: A sample question that confirms the rarity of
complications.
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2015
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Low Literacy Skills. 2nd ed. Philadelphia:
J. B. Lippincott; 1996.
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Materials, 3rd ed. Atlanta, GA: Centers for Disease
Control and Prevention; 2009. Available from: http
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Author information
Stella Hart joined the Patient Education Institute as a
medical editor in January 2013. She received a bachelor’s
degree in English and music from Drake University in
Des Moines, IA, USA in 2011.
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