TABLE 4

Effective Use of Written Information in Primary Care

• Patient information should be written at the reading level of a 9–10 year old, fourth-grade level or lower. Even highly educated families prefer succinct and easy-to-read materials.84,87 Readability formulas are useful for testing and refining written information.89
• Adding graphics to text helps when parents are asked to choose among treatment options, rate quality of care, or complete developmental-behavioral screening tools (eg, pairing traffic light colors with bullet points, using the pictorial version of the Pediatric Symptom Checklist).88
• Offering a “face-saving” literacy probe before asking parents to complete questionnaires or screens with multiple-choice items to prevent random answers (eg, “Would you like to complete this on your own or have someone go through it with you?”).15,37,88
• Video presentations accompanying text are useful as is video instruction in child-rearing issues (described below).
• Use “teach-back,” that is, asking parents to restate in their own words the messages given. This method identifies whether information needs to be repeated and reexplained (in simpler language).40,52,5759
• Consider group counseling/well visits for same-language speakers to engender social support and “community helpers.”43,49,64,88
• Ask families if they can find someone to help them go through written information again once they have left the office.15,37,88
• Include on clinic Web sites or on printed lists of approved sites those offering parenting information in multiple languages.
• The brevity and clarity of text messages on developmental-behavioral promotion and anticipatory guidance sent by services such as the Maternal Child Health Bureau’s Text4Baby reach many families with literacy challenges and have established effectiveness (eg, increase uptake of vaccinations).78
• When new translations are needed, back-translation is insufficient (see Professional Resources in Table 5 below for links to the International Test Commission guidelines).Wording must be vetted by bilingual parents and providers because even plausible back-translations can be freighted with unexpected meaning (eg, the word “concerns” is prominent in Somali warlord slogans [making families reluctant to answer questions about their worries], but in Asian languages, “concerns” is a synonym for “care” as in “Do you care about your child’s health?” and thus renders needless worries).37,90
• Make sure that interpretation/translation services have links to Web sites with information in multiple languages and copies of vetted translations of questionnaires, screening tools, etc.
• Screen reading and other academic skills in school-age children and intervene when deficits are apparent or in the presence of psychosocial risk factors. There are a variety of ways to detect academic dysfunction such as reviewing school records or administering a brief literacy screener.91