Even when the importance of developing health materials as part of a comprehensive discharge plan is acknowledged, correctional personnel must recognize that the majority of inmates have low literacy skills and that written materials must be designed with this in mind. To quote Smith and Smith (1994), who analyzed medical education publications, "information written above patients' reading level is useless and a waste of time and money" (p.1). The criteria for developing easy-to-read, high-quality discharge information vary, but the majority of experts agree that the following must be incorporated for the information to reach its reader: (1) clearly state purpose of the information, (2) write to a fifth or sixth grade literacy level, (3) use short sentences as much as possible, (4) personally address the reader, (5) use a respectful tone, (6) make the design and layout approachable, and (7) describe specific problem-solving strategies (Cotugna, Vickery, & Haefele, 2005; Doak, Doak, & Root, 1996; Fant, Clark, & Kemper , 2005; Irick & Fried, 2001; Moult et al., 2004).
The following recommendations can help correctional personnel develop written health information and discharge summaries for their prerelease population. Several of the following points were first discussed by Mellow and Dickinson (2006) when assessing prisoner reentry guidebooks, but can also be used for any written health information and discharge materials developed for the health needs of inmates being released. When appropriate, examples from health materials from across the country will be used to highlight the recommended style of writing.
The educational levels of inmates are below the national average (eighth and ninth grade level) with reading scores on average between the fifth and seventh grade level. A study in 1992 indicated that the majority of prisoners were functionally illiterate with 33% of prisoners performing at level 1 and 37% at level 2 on the National Adult Literacy Survey (Haigler, Harlow, O'Connor, & Campbell, 1994). Individuals with level 1 literacy can sign their name (low level 1 literacy), locate the expiration date on a driver's license, and locate the time of a meeting on a form (high level 1 literacy). They have difficulty, however, locating two features of information in an article, locating an intersection on a street map, and identifying and entering background information on an application for a social security card (Haigler et al., 1994) Those with level 2 literacy cannot use bus schedules to determine the appropriate bus to take, or read a news article and identify a sentence that provides interpretation of a situation (Haigler et al., 1994). Extreme care must be taken to ensure that the complexity and length of text is compatible with the limited literacy levels of many inmates.
Unpublished research by Mellow and Christian (2005) indicates that discharge materials produced for inmates are presently not tested to ensure the appropriate readability level. In a nationwide sample of reentry guides analyzed by Mellow and Christian, no reentry guides were written at the fourth or fifth grade level and the majority of the guides were written at the high school or college level. Information written above an inmate's level increases the frustration they already experience when returning to the community.
It is important, therefore, to evaluate all written materials before they are widely disseminated to the inmates. In essence, this is a "pretesting" of the material to determine if the inmates understand the content and what, if any, changes need to be made prior to a final printing. Converse and Presser (1986) note that the pretest sample should resemble the target population and be no fewer than 25 persons. Therefore, the sample selected should represent different inmate characteristics based on age, sex, race/ethnicity, and educational level.
Depending on the situation within the particular correctional facility, pretesting of inmates can be administered to them alone or in focus groups. Likewise, the pretest can be in an open or closed-ended format. The objective is to find out if the inmates have any problems comprehending the information. One should note, however, that individuals with low literacy levels may feel embarrassed and have a sense of shame about their poor reading skills and will verbally acknowledge they understood the material when asked, even if that is not the case (Safeer & Keenan, 2005). Others will come up with an excuse such as "I forgot my glasses," and ask to take the instructions back to their cell so as not to identify themselves as functionally illiterate. A simple way to evaluate their reading comprehension level of the material is to ask them some basic questions, in a one-on-one situation, about what they read. From this author's experience inmates may need some time to read the materials before responding. Allow them to read the materials for 20 - 30 minutes to reduce their anxiety and elicit a more valid response rate. At a minimum, the following questions should be incorporated into the interview:
• Was the handout/pamphlet/book easy to read?
• Can you show me what words or parts of the handout/pamphlet/book which were hard to read/understand?
• What parts of the handout/pamphlet/book helped you the most?
• What information was not listed that you think should be written down?
• The handout/pamphlet/book talked about_. Can you tell me in your own words what the handout/pamphlet/book said?
After the interviews, it is advisable to analyze if there was a difference in the comprehension rates of the materials depending on characteristics of the inmates (e.g., age, sex, race/ethnicity, education level).
Another way to measure the readability of written materials produced for inmates is to use readability software, such as the Flesch Reading Ease readability assessment tool available in Microsoft Word. The Flesch Reading Ease Scale is "the most widely used formula to assess such general reading materials as newspapers, magazines, business communications, and other non-technical materials" (Electronic Privacy Information Center, 2006). Many state and federal agencies, including the U.S. Department of Defense, require all training and informational documents to have a Flesch reading scale between a sixth grade and high school level. The following four points outline how to access these readability statistics when using Microsoft Word:
• On the Tools menu, click Options, and then click the Spelling & Grammar tab.
• Select the Check grammar with spelling check box.
• Select the Show readability statistics check box, and then click OK.
• On the Standard toolbar (toolbar: a bar with buttons and options that you use to carry out commands; to display a toolbar, press ALT and then SHIFT+F10), click Spelling and Grammar. When Microsoft Word finishes checking spelling and grammar, it displays information about the reading level of the document.
Like many readability tests, the Flesch Reading Ease score is based on the average number of syllables per word and words per sentence. It rates text on a 100-point scale; the higher the score, the easier it is to understand the document. Though not an exact science, Table 15.1. correlates the Flesch Reading Ease score with the level of reading difficulty and the corresponding grade level of the score (Smith & Smith, 1994, p. 114). Government agencies recommend that all documents be written at the standard difficult level (60-70). However, writing at the fairly easy or easy reading level is recommended for inmates.
A reentry handbook from Washington, DC is a good example of writing to the audience at the literacy level the majority can comprehend. The following are bullet points listed in their handbook on how to improve reading skills, but the format could just as well be used when addressing inmate-related health needs (Sullivan, 2002, p. 5). The Flesch Reading Ease Score of the text is 74 and is written at the sixth grade level.
Flesch reading ease score
Approx. grade level
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When parents help their children learn to read, they help open the door to a new world. As a parent, you can begin an endless learning chain: You read to your children, they develop a love of stories and poems, they want to read on their own, they practice reading, and finally they read for their own information or pleasure. They become readers, and their world is forever expanded and enriched.