Writing to Grade Level

I’ve been asked how to write patient education or information sheets for the general public, ensuring that it is at the appropriate grade level. Some people feel that it is very easy to “write down” to a lower reading level, while others are very intimidated about the very idea.

In my opinion, writing to a lower grade reading level, most often Grade 8, is not writing down. Nor is it when I’m asked to write to a Grade 6 reading level. Writing down or, as some say, dumbing down, insinuates that the people who are reading the copy are not as smart as we are. I had a rather lively debate with a fellow writer once about this. This writer said that the best way to see if your text was good for a Grade 6 reading level was to find some children in that grade and have them read it.

Although I understand the reasoning, I disagreed with that approach. An adult with a 6th grade reading level has way more than 12 years of life experience. So, their ability to understand certain concepts could greatly outstrip those of a 12-year-old. Just because one’s reading is at a certain level, doesn’t mean that the comprehension or the experience is at that level.

There is a movement called the plain language movement. It came to be because so much documentation is written in such complicated language that it is getting ridiculously difficult to understand. In fact, according to the Plain Language website, in June 1998, US President Bill Clinton issued a memo requiring government agencies to write in plain language.

That all being said, plain language varies between reading levels. So, how do we tell what reading level we have?

The easiest and most commonly used judge of reading level comes with the Microsoft Word program, the Flesch-Kincaid Readability Test . It’s not extremely accurate because it uses the number of words per sentence, the number of syllables per word, and so on. This is a big drawback when you are writing patient education sheets because there are times when you need to use bigger technical terms and they automatically shoot up your reading level. In cases like this, if I’m using the FK test to check my reading level, I will take out the complicated medical terms for the assessment and then get a more accurate reading level that way.

There are companies and experts who can tell you reading levels, but I prefer to use the common sense approach. This means things like:
No long sentences
Limited or no use of semi-colons
Bullet lists whenever possible
Short paragraphs
Simpler words over the multi-syllable words.

Just those five points make a big difference in reading level.

If you want to write simple, concise, and easy-to-understand material, think short and sweet. Read your text out loud to yourself. Use active voice, avoid passive. The sentence “The patient took the medication and felt much better,” sounds a lot easier to understand than, “The medication given to the patient provided significant improvement.” Are there any sentences that leave you gasping for breath because they’re so long? Do you have any lists that could be bulleted? Think about simplicity. Explain all your long or complicated terms the first time they’re used and then abbreviate or use the everyday term when possible.

Just out of curiosity, I checked the Flesch-Kincaid reading level of this piece to the above paragraph: it clocked in at grade 9.9. When I removed the bullet list above, it jumped to 10.4.

I truly enjoy the challenge of meeting different grade levels. One client sometimes asks me to write the same patient education information in both grades 6 and 8 levels. Grade 8 is a piece of cake most times, I think. Grade 6 can be enormously challenging, but it’s a challenge I like.

We want to encourage people to read our work, we don’t want them to get frustrated, and we don’t want them to feel as if we’re talking down to them. That’s important to remember.

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Exercising - we're supposed to but.....

Exercising – we all should do it. We’re told we should do it, we know we should do it but….what, where, when, and how. Well, at least I don’t have to ask why.

I’ve tried joining gyms. Friends would tell me, “you’ll love it after the first few weeks,” and “it’s addicting, you get a high.” Um. No. I didn’t. I didn’t love it, I didn’t get addicted, and I certainly didn’t get high. I hated it, didn’t want to do it, and dropped of exhaustion every time I got home.

To tell you the truth, when this happened, I felt like a failure – after all, everyone else loves it, right? It took me a while to realize it but exercising doesn’t have to be an organized gym attendance type of thing. My husband likes to do that – I don’t. Like many things, I do things one way, he does things another.

As a Mayo clinic researcher recently reported, walking is just fine as exercise. It not only helps keep the body in shape, it seems to help keep blood pressure under control as well. Walking is easy to do unless you have a disability, it’s free, and it has an added benefit that a gym doesn’t have. You can walk your dog, you can walk with your friends, you can walk to do your errands, and you can walk to amuse yourself. You can people watch when you walk into the city, you can enjoy the fresh air of a park walk, you can go with the flow with other walkers in a walking club, or you can just walk around your neighbourhood and enjoy the view. And for those cold wintery days, many large malls have walking clubs where you can walk and talk with other walking club members.

Add to this that walking is a weight-bearing activity, something that is important for fighting osteoporosis. Of course, the more vigorous your walk, the more exercise-like it is, but there’s a lot to be said for a nice stroll too. We rush so much through life these days that a nice comfortable walk is as much for the mind as it is for the body.

So, if you’re like me and really aren’t in to exercising, no matter how many good intentions we had along the way, walking is really something that even we can do. I admit it. I should get out and walk some more. Ok, time to challenge myself and off for a walk!

News for today:

When it comes to walking, it's all good, says Mayo Clinic researcher
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Suicide, not a disease, so no walkathons, ribbons, or research race

There was more news about suicide yesterday in the papers. This time it’s about whether some antidepressants really do raise or lower the risk of suicide. I don’t know – I’m not an expert in that department. I think suicide is way more complicated than if a drug helps or prevents it. What I do know is that suicide hurts like hell. My baby brother took his life in February 2005. He was 35 years old.

Quebec has one of the highest young male suicide rates in the country. Young men are one of the highest risk groups for suicide. In a youth suicide report published by the Canadian Task Force on Preventative Health Care, it says: “Suicide has accounted for about 2% of annual deaths in Canada since the late 1970s. Eighty percent of all suicides in 1991 involved men. The male:female ratio for suicide risk was 3.8 to 1. In both males and females, the greatest increase between 1960 and 1991 occurred in the 15- to 19-year age group, with a four-and-a-half-fold increase for males, and a three-fold increase for females.”

Statistics aren’t that much better in the United States. Published in Explaining the Rise in Youth Suicide, by David M. Cutler, Edward L. Glaeser, and Karen E. Norberg, March 2001, are these findings: “Suicide rates among youths aged 15-24 have tripled in the past half-century, even as rates for adults and the elderly have declined. For every youth suicide completion, there are nearly 400 suicide attempts.”

According to an article by Stewart Tendler that appeared in the London Times, UK, in November 2004, suicides made up 13% of the inquest deaths in England and Wales in 2003. Compared with 744 women who committed suicide, 2,511 men did. Although the numbers in the UK seem to have stabilized, it is still the younger men, between 15 and 24 years, who have the highest suicide rate.

Excuse me? Did I read that correctly? Eighty percent of the suicides in Canada in 1991 involved men?? Suicide rates have tripled in the US among older teens and there were 1,767 more men in the UK who committed suicide than women? Between 1960 and 1991, there was a 4.5-fold increase for males and a 3-fold increase for females in Canada? Where is the outcry? Where is the demand for something to be done about this? Oh, right, I forgot, we don’t talk about suicide. It makes people uncomfortable. Talking about suicide means that we have to talk about mental illness, depression, pain, and despair. Not exactly cocktail chatter.

I’ve read, although I can’t pull the sources right now, that the rate among young men may actually be higher because of accidents that are really disguised suicides without actual intent, meaning that some of the young men who crash their cars or do dumb stunts that result in death may actually be playing with suicidal behaviour. I can’t back that up, but I do recall reading it. I wonder if there is some merit to that though.

Action has to be taken to help those young people who feel that there is no other outlet, no other way to solve their problems than to end their lives. I’m not a psychologist or a social worker. I don’t have the answers to any of the questions of how to stop this, but if people were dying at these rates of a disease, or some sort of fatal accident, I’m sure that people would be taking action. The only way action is going to happen is if we start to talk about the people who we lose through suicide. We need to bring it out to the forefront of people’s thoughts. We need to do something because our young people, our young men, are so desperate that they see no other way out.

Do I sound angry? I am. I’m angry, upset, saddened, and frustrated. JP was 35 years old. He had a rough life and was never able to get the help he really needed. He hung himself on a Friday night in February. He was alone.

I would do anything to get my brother back. The help I gave him wasn’t enough. The help his friends gave him wasn’t enough. His two young sons weren’t enough. We all tried in our own way, stumbling through the mental health minefield. The help I did give wasn’t enough, he couldn’t take it. I don’t know why, but it didn’t work. I miss him and my mind often goes to where he must have been before he died. My heart still cries for him and probably always will.

We have to stop this. We have to.

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Why don’t older people and some sleeping pills mix?

There’s a new study out that says more than half of elderly patients in hospitals who are prescribed sleeping pills (sedatives) are still using them 6 months later. This is disturbing and I would add the issue of all the other medications with sedative effects that this population tends to take and there’s a huge concern, in my opinion.

While it may not seem such a big deal, people taking sleeping pills to get a good night’s sleep, it’s not the sleeping part that is the problem. When we look at the older population, we see a larger number of people with problems that can affect their mobility, their cognition (thought process), and safety. Since sleeping pills are supposed to make you drowsy, if an older person has to go to the bathroom in the middle of the night, this drowsiness could easily make them lose their balance and fall (and breaking a bone or striking their head, for example), they could become disoriented as sedatives can do, or they can not wake up and be incontinent in bed – something that might not have happened otherwise.

There is also the issue of about daytime sleepiness. Many people, young or old, who take sleeping pills experience a daytime effect of lingering sleepiness. This could end up messing up the person’s body clock because of the temptation and need to sleep during the day, starting a vicious cycle of making it hard for them to sleep at night and requiring yet another sleeping pill. The daytime drowsiness could affect their safety and increase falls or, if the person is still driving, could even cause an accident. Someone who is sleepy from a sleeping pill could have cognitive problems, seeming confused and lost when normally he or she wouldn’t be. This could start a whole round of medical concerns from family and friends that aren’t necessary. Someone who is sleepy from sedatives could end up being housebound, increasing social isolation, and they can become less able to care for themselves, starting a downward spiral in self care.

While some of this may seem way off, sadly, it’s not. Medications often work differently in older people than they do in the younger population. Drug testing isn’t usually done in the older age group so it’s not always understood how drugs can affect them.

In this particular study, the sedatives are benzodiazepines. Benzodiazepines are also given for anxiety. According to the study findings, of almost 12,500 patients who had been prescribed a benzodiazepine while in the hospital, more than 6,100 were still taking them over the next 6 months.

So, how does this affect us? If you’re in the population mentioned in this study, be aware of what you are taking. Ask your pharmacist about the drug’s side effects; ask your doctor if there isn’t another type of medication that might be safer for you. If you are the child of someone who may be in this situation, keep in mind that excessive sleepiness, memory issues, falls, things like that, could be the result of your parent taking sleeping pills. If you’re a nurse or a healthcare worker, keep in mind that this can happen to your patients as they are discharged home, so maybe you can keep this in mind when discussing discharge planning.

Sleeping pills have their place – not much replaces a good night’s sleep. But we need to be careful how we go about getting it.

Letting our children grow up and away

As a parent, you do your best to protect your children. Of course, you don’t want anything to ever happen to them, but from time to time, accidents do happen.

I know that when my kids were small, as much as it pained me to see them scrape their knees or hurt themselves, I knew that it was all part of growing up and exploring. I see some parents telling their children not to run because they may fall, not to climb because they may slip. Yes, they may, but they have to run and climb too. Scrapes heal, bruises go away – but being constantly told you shouldn’t or can’t do something because you might get hurt, takes away from the ability to make your own choices about what you should and shouldn’t do. It’s not as if my children were accident-free. From broken bones to stitches to emergency surgery for appendicitis, we had our share of hospital visits, that I can say.

Of course, I’m not talking about letting your child pull over a pan of boiling water or sticking a fork into an electrical socket, but allowing your child to climb on a jungle gym, playing superman with a towel clothespinned to a t-shirt, or having a pillow fight with a friend are activities that can end up with an injury, or with lots of giggles.

We weren’t the type of parents who sent our children to camp. For one thing, they were way too expensive for us and another – important – thing was that our kids weren’t the type to want to go away to camp. Until 3 years ago, when my youngest son came home with a pamphlet for a camp two hours north of us; it was a sports/wilderness camp for boys 12 years old and up. It has been around for many years. I knew someone whose son had gone for a few years and had begun to work there as a leader-in-training. At first, my heart sank when my son came home all enthusiastic about going, because I thought, there is no way on earth that we can afford to send him to a sleep-away camp for two weeks. Tht is, until I found out that it only cost 375.00. That’s right. For the full two weeks. It’s a camp that gets funding from many different sources to make it and keep it affordable. It’s been around for so long that many of the campers are sons of men who went to there.

When my son came home after his first summer there (two weeks), he said to me in the car, “Mom, I did things that I never imagined myself ever doing.” I thought I was going to cry. He climbed rocks faces, jumped into rivers, kayaked, camped, and just had a wonderful, wonderful time. And it was the beginning of something wonderful for him.

After two summers of being a camper, last summer, he was invited to participate in a special week at the beginning of the session, reserved for boys who the leaders saw as being potential leaders. My son was ecstatic because becoming a leader had now become a serious goal. While he was there that week, he did even more things that he never imagined, including kayaking on rapids. What I found out later is that something went wrong on one of those trips and he could have been severely hurt, even killed, at one point. There was a miscommunication somewhere and my son went down some rapids and headed straight for a log that was across the river. Quick thinking had him flip upside down, but then the fast current made it almost impossible to tear off his kayak skirt so that he could right himself. He told me after that this was “the most scared” he had ever been.

Part of me was severely ticked that this could happen, but a bigger part of me knows that accidents happen and that we can’t wrap our kids in cotton batting and still expect them to be able to go out and challenge life head on. I am so forever grateful that he escaped unscathed and I know what could have happened. However, he could have stayed home and almost been hit by a car crossing the street too. Life is full of challenges and dangers. So, what did my husband and I do Sunday evening? We dropped off our son for yet another week of this leadership training. We know that what happened last year was an accident and that the leaders are now aware of the breakdown in communication. We know that we have to let our kids do things, to try things. And we have to hope and pray that they come out ahead at the end.

Just like when my daughter broke her arm, or my oldest son broke his elbow, my heart sank when my youngest told me of his kayaking adventure. But, as with all the other accidents the kids have had, I know that holding them back won’t keep them safe. Holding them back would only encourage, in a sneaky way, other types of risk taking. So, I let them go. I hold my breath and I wait for them to come back. And then I listen to all that they learned. And I never forget those words from my son, “Mom, I did things that I never imagined myself ever doing.” That makes it all worth it to me.

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