Creating better content for users with low health literacy
By Mark Robinson and Ana Savic. 13 February 2019
It’s been shown that as many as four in 10 adults in the UK struggle to understand and use typical medical information designed for the public.
This low ‘health literacy’ has been linked to a range of problems, including poor general health, inappropriate use of health services and reduced life expectancy.
We wanted to find out if this was a problem for the NHS website and what we could do to make things better.
We analysed our current content, spoke to health literacy experts and tested new content approaches with users. This is what we found.
A lot of older content on the NHS website is too complex
An initial audit of content on the NHS website found the average reading age for the content is almost 16. Almost eight in 10 UK adults are not at this level.
While we’ve been doing a lot of work to improve the website over the last few years, this has only touched a relatively small number of pages.
Our audit showed we still have a lot of content that’s not as simple as it could, and should, be.
We needed a new approach to content
Clearly, we needed to find a way to make sure content we produce works for users with low health literacy.
After speaking to health literacy experts and researching the issue, we found a lot of work has already been done on how to create better content (for example, the Health Education England health literacy toolkit). We didn’t want to duplicate this.
Instead, we decided to find out the best way to apply these lessons to the NHS website. Is there a quick and simple way to make our existing content better, or do we need to go back to the drawing board?
So, we came up with two approaches:
’Quick win’ – just simplifying the language of our existing content to reduce the length and reading age.
‘Start from scratch’ – rewriting and restructuring the content based on user needs, and applying a range of writing techniques to make it easier to understand and use (as outlined in the NHS digital service manual).
We applied these approaches to two pieces of content, on diabetic eye screening and on high cholesterol, and took them into user research labs to test them with users. See the diabetic eye screening content below.
Current diabetic eye screening content on the NHS website:
Diabetic eye screening content with reduced reading age:
Revamped diabetic eye screening content:
Testing with users with low health literacy is tricky, but essential
We felt the standard methods for recruiting users for testing would probably result in high health literacy users being over-represented.
To help avoid this, we added some extra questions to our usual recruitment criteria.
We asked users about their ability to use health information (such as: "How easy do you find it to understand information in the media on how to get healthier?") to give a health literacy score. Research has shown people with a low score are likely to have low health literacy, as they struggle to understand and use health information.
While this did help us recruit more users with low health literacy, some people with a low score didn’t seem to have low health literacy when interviewed. This might have been because they had low health literacy generally, but were ‘experts’ in their condition (such as diabetes).
Overall, we were able to recruit and test our new content with:
11 users with low health literacy
six users with medium to high health literacy
We asked them all to read the new pages and complete simple tasks like recalling information from what they’d read. We observed their behaviour as they used the pages and recorded their responses to the tasks.
It’s worth going the extra mile for your users
Overall, we found the more comprehensive ‘start from scratch’ approach was better than the ‘quick win’ approach.
Simply reducing the reading age of the content did make things a bit simpler for users, but starting from scratch had many additional benefits.
reduced reading time
easier to pick out and recall information
clearer calls to action
simpler to navigate
Users with high health literacy benefited as much as those with low health literacy. No users said the content was ‘too simple’ or ‘dumbed down’.
Starting from scratch took more time, roughly two days of writing time compared with one for the ‘quick win’ approach. But we felt the extra benefits for users were well worth the extra effort.
Use the NHS digital service manual
The key message to take away from our work is this: if you’re creating patient-facing content for digital NHS services, make sure you follow the guidance in the NHS digital service manual.
As tempting as it might sound, relying on simple measures like reading age alone to assess your content is not enough.
The range of guidance included in the service manual can help you produce simple, easy to use content that works for all your users.
Check the manual regularly. It’s updated all the time with advice and research insights.
We’ve recently updated it to include information about: