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Literacy and Patient Information in the Amputee Population

Hrnack, Scott A. MD; Elmore, Shelbi P. BS; Brindley, George W. MD

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JPO Journal of Prosthetics and Orthotics: October 2009 - Volume 21 - Issue 4 - p 223-226
doi: 10.1097/JPO.0b013e3181bfa25a
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Approximately 185,000 people in the United States undergo amputation of either the upper or lower limb each year.1 In 2005, an estimated 1.6 million people were living with a lost limb.1 By the year 2050, this number will double.1 With the increasing number of patients undergoing limb loss, there will be need to have more effective programs to insure adequate health care for this population of patients.

Patient’s knowledge and understanding is a vital part of compliance when dealing with any patient particularly in the amputee population. By understanding the diagnosis, treatment plan, and other health information affecting care, patients will be more active, informed, and feel as if they are part of the decision-making process. Health care professionals use many pathways to pass along information to their patients.

One of the most common ways that prosthetic patients receive information from the health care team is through written materials, such as brochures and pamphlets. These can be particularly beneficial in teaching the patient about the expectations before surgery, the procedure itself, postsurgical treatment, and prosthetic fitting. The dilemma with a written form of communication is that the literacy level for some patients is not up to the same level as the reading level of the written information provided to them. Pediatric and oncology pamphlets have been documented in other studies to exceed patient’s reading levels.2–4

The 2003 National Assessment of Adult Literacy assessed the English literacy of adults in the United States.5 More than 19,000 adults were placed through tasks, which reflected a literacy level. A subset of questions pertained to health literacy and analyzed in a separate report (The Health Literacy of America’s Adults).6 Health literacy was defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”6 According to this report, 53% of Americans have intermediate health literacy (Table 1), whereas only 12% of the population qualified as proficient health literacy, 22% had basic health literacy, and 14% had below basic health literacy.6 In this study and others, average health literacy increased as higher education was achieved by the person.6–9 Forty-nine percent of the population who had little or no high school experience were below basic literacy.6 Williams et al.9 found that 21% of 2,659 public hospital patients could not read instructions on a fourth grade level.

Table 1
Table 1:
Definitions of health literacy levels

The goal of this article is to determine the reading level and therefore effectiveness of specific, written patient information regarding the amputee population. This information can then be used to decide if there is a need for revision of current publications or possibly new publications that will more efficiently state the intended information. Also, this can be extrapolated into other written documents that patients must review, such as consent forms.


Ten different publications on amputation were obtained either through the internet or local health facilities (see Table 2 for a complete list). Publications included information for the patient regarding preoperative care, surgical procedure, and postoperative prosthetic care. Although there are a vast number of publications on the internet, we limited the number due to ease of accessibility and free publications.

Table 2
Table 2:
List of prosthetic pamphlets

The publications were then scanned into a Microsoft Word 2003 document. All documents underwent spell check and review for correctness of transfer. All pictures and figure captions were deleted from the booklet. Next each document was entered into, a website that contains six readability calculators.

The six readability calculators on this website are the Flesch reading ease score, automated readability index, Flesch- Kincaid grade level, Coleman-Liau index, Gunning fog index, and simplified measure of gobbledygook index. Each of these calculators use mathematical regressional analysis to produce an equation that best estimates the relationship between difficulty of reading of a given text and linguistic characteristics of the text.10

The Flesch reading ease score is a numerical score from a range of 0 to 100. The higher the number the easier the passage is to read, whereas the lower the number is more complex. All of the other readability indexes noted in this article correlate to approximate reading grade level of the pamphlets. Grades that are 13 to 16 correlate to college level, whereas greater than 16 correspond to graduate level. All statistics were tabulated using Microsoft Excel 2003.


Literacy statistics of the pamphlets showed a range of 3,600 to 30,000 words (Table 3). Complex words were defined as a word consisting of two parts with one of those parts being a bound form. There were 500 to 5,800 complex words in the sampled readings. The articles combined had an average of 18.6 words per sentence.

Table 3
Table 3:
Literacy statistics

Combined data from the readability calculators can be seen in Table 4. The readability calculators that resulted (all but the Flesch reading ease score) in grade level results were averaged for each of the 10 pamphlets in the study and compared in Figure 1. The Flesch reading ease score ranged from 50.2 to 67.9 with an average of 59.9 ± 6.4. The average grade readability of all of the pamphlets, and all the readability indices was 11.7 ± 1.8.

Table 4
Table 4:
Readability calculators and data
Figure 1.
Figure 1.:
Total grade level averages for the pamphlets.


Depending on the interpretation of several articles published on the matter of health literacy, more than one-third to half of the general population would have difficulty understanding the written information in the any 1 of 10 pamphlets in noted in this article. Poor health literacy has been associated with failure to follow instructions, higher utilization of health care services, and limited preventive services.11,12 The aforementioned problems with low health literacy may be amplified in the elderly population.13,14 Other studies maintain that individuals with low literacy incur higher health care charges.15,16

This raises a question of the amount of competency patients have with other forms of written health communication. In an article by Hall and coworkers,17 the readability of current surgical consent forms was at almost a graduate level. Other studies have shown difficulties in readability concerning cancer information, research consent forms, and discharge instructions.3,8,18

Limitations of this study include the inability to grade or assess for picture, figures, or caricatures in the body of text. Pictures may provide a better instruction for the patients or have ability to better communicate the information. Also, several publications had a glossary to help define more difficult terms. Only free samples were analyzed in this article. These samples were picked specifically for the ease of patient attainment. The readability indexes were selected at random and chosen because each, with the exception of the Flesch reading ease score, correlated to an actual grade level of readability. The readability levels could then be compared easily. Note that the Flesch-Kincaid scoring method was consistently lower than the other indices, because it only evaluates up to a twelfth grade level, so more complex samples may be misrepresented. Finally, other factors, such as font, length of the sample, and general layout, can affect the readability of the information.18,19

The issue of health literacy seems to span through all aspects of medicine. Despite the readability of the written materials, there is still no substitute for direct patient interaction with the health care participant. There is a large amount of information a patient must retain to be functional with an amputation. Many of the decisions on treatment plan are multifarious and need to be tailored to the individual patient, so that modifications of some the written material may need to be made. The patient must have the interaction with the health care team to effectively communicate these differences.


Current patient information for literacy in the amputee population is much too advanced for the average person in the United States to comprehend. Although written materials will never substitute for direct patient interaction, it is clear that the current literature must be revised to a lower reading level to make pamphlets and handouts more effective in this population. There also may be need to readdress other written materials, such as consent forms, to evaluate the documents readability to a general population with a goal to increase patient’s compliance and care.


1.Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008;89:422–429.
2.Davis TC, Mayeaux EJ, Fredrickson D, et al. Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics 1994;93:460–468.
3.Glazer HR, Kirk LM, Bosler FE. Patient education pamphlets about prevention, detection, and treatment of breast cancer for low literacy women. Patient Educ Couns 1996;27:185–189.
4.Meade CD, Diekmann J, Thornhill DG. Readability of American Cancer Society patient education literature. Oncol Nurs Forum 1992;19:51–55.
5.Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. WA, DC: National Center for Education Statistics; 1993.
6.Kutner M, Greenberg E, Jin Y. The Health Literacy of America’s Adults: Results From 2003 National Assessment of Adult Literacy. WA, DC: National Center for Education Statistics; 2006:1–21.
7.Baker DW, Parker RM, Williams MV, et al. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health 1997;87:1027–1030.
8.Powers RD. Emergency department patient literacy and the readability of patient-directed materials. Ann Emerg Med 1988;17:124–126.
9.Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274:1677–1682.
10.McLaughlin GH. SMOG grading—a new readability formula. J Read 1969;69:639–646.
11.Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA 1999;281:552–557.
12.Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Int Med 2005;165:1946–1952.
13.Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281:545–551.
14.Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc 2006;54:770–776.
15.Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005;118:371–377.
16.Weiss BD, Palmer R. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. J Am Board Fam Pract 2004;17:44–47.
17.Hopper KD, TenHave TR, Tully DA, Hall TE. The readability of currently used surgical/procedure consent forms in the United States. Surgery 1998;123:496–503.
18.Paasche-Orlow MK, Taylor HA, Brancati FL. Readability standards for informed-consent forms as compared with actual readability. N Engl J Med 2003;348:721–726.
19.Paasche-Orlow MK, Parker RM, Gazmararian JA, et al. The prevalence of limited health literacy. J Gen Intern Med 2005;20:175–184.
© 2009 American Academy of Orthotists & Prosthetists