Letter to the Editor: Developing an Online and Print Patient Education Tool for Pain Relief Options in Labor

February 2018 Issue

  1. Katherine Seligman Co-author
  2. Lauren Faber, BA University of New Mexico School of Medicine, Albuquerque Co-author
  3. Kylee Greider, BS University of New Mexico School of Medicine, Albuquerque Co-author
  4. Nicole Nesiba, BS University of New Mexico School of Medicine, Albuquerque Co-author

In today's technologic climate, patients and their families are routinely seeking out medical information on the internet. A study of 96 websites with anesthesia-related patient education materials (PEMs) showed they were all written above the recommended 6th-grade reading level.[1] Online PEMs for pain relief options in labor have also been shown to be above the recommended reading level and lack critical information on risks, benefits, and alternatives.[2] The Program for the International Assessment of Adult Competencies (PIACC) evaluates literacy in the adult population on a five-level scale, with literacy defined as “understanding, evaluating, using, and engaging with written texts to participate in society, to achieve one's goals, and to develop one's knowledge and potential.”[3]

In New Mexico, 46% of the population is considered functionally illiterate, which is designated as a level-two proficiency or lower on the PIACC scale.[4] Many of those individuals fail to identify a total on a sales receipt or identify information in a news article. This low literacy proficiency in the state makes providing accessible PEM while retaining scientific accuracy and integrity a challenge.

“Low literacy proficiency in the state makes providing accessible patient education material while retaining scientific accuracy and integrity a challenge.”

With this in mind, we aimed to develop a comprehensive patienteducation tool covering pain relief options for labor and delivery, including online, print, and audio information aimed at patients with all literacy levels. This culminated in the development of a free online resource (http://thepainlesspush.com), currently available in English and Spanish, with simplified print and audio material also available online for download. Appropriately designed PEMs should be available to all patients prior to hospitalization as well as during their time in labor and delivery to improve the informed component of the informed consent process.

Assessing a patient population's educational level is at best an indirect means to determine typical patient reading ability. No available correlation exists between PIACC literacy level and completed United States school grade level. Numerous preexisting validated analytic methods are available to check the readability of PEMs, and all reference a corresponding grade level for ease of interpretation. Three validated tools to assess readability and give an estimated score are the Flesch-Kincaid Grade Level (FKGL), the Simple Measure of Gobbledygook (SMOG), and the Gunning Frequency of Gobbledygook (Gunning FOG). The FKGL score focuses on word length (in syllables) and sentence length (in number of words used). Longer sentences and more syllables lead to higher scores. The SMOG focuses on polysyllabic words and sentence count. The Gunning FOG relates word count per sentence to the proportion of polysyllabic words. Thus, the main predictors for readability levels include polysyllabic words and sentence length and structure. The Readability Test Tool, available for free online (https://www.webpagefx.com/tools/readable), uses the FKGL, SMOG, Gunning FOG, and other indices to score websites and text items for readability.

The characteristics that increase texts' reading difficulty are particularly relevant for scientific literature and PEMs, where medication names, procedure names, and other medical terminology can dramatically inflate the readability level of the text. Although the scales are not intended to yield precise scores with isolated words, checking them can confirm suspected problematic terms and phrases. For example, “anesthesiologist” rates at a grade level of 49 when input into the Readability Test Tool online. “Doctor,” however, rates at a grade level of 7. “Epidural anesthesia” comes out at 28, but even the simplified phrase of “pain medicine” still rates at 13. By substituting words and phrases to reduce the reading level, authors risk sacrificing the scientific integrity of the education materials.

The Centers for Medicare and Medicaid Services (CMS) and the National Institutes of Health (NIH) provide recommendations for authors to assist in writing PEMs at a reasonable grade level. These include directions to limit paragraph size, use bullet points and lists, use underlining, include images, and use meaningful headings. Thepainlesspush.com website uses these design principles to make the scientifically accurate information more engaging and accessible.

Analyzing the text of thepainlesspush.com results in a SMOG score of 9, FKGL of 9.5, and Gunning FOG of 12. The simplified print resource and audio voice-over, by design, have lower reading levels: SMOG 6.2, FKGL 5, and Gunning FOG 7.6. The diversity in reading levels allows readers and patients with varying backgrounds to access information in a format that is right for them. Having it all available online for download or reference means that patients can choose the education material that they find most helpful.

By designing PEMs with limited-literacy and non-English-speaking patients in mind, as well as following the recommendations from CMS and NIH, we feel that we have created a unique combination of scientifically sound materials that are easily accessible to our patients. We believe that this tool can help patients be better informed of their options to moderate pain relief during labor and delivery, including the relevant risks and benefits of each.


  1. De Oliveira GS Jr, Jung M, McCaffery KJ, McCarthy RJ, Wolf MS. Readability evaluation of internet-based patient education materials related to the anesthesiology field. J Clin Anesth. 2015;27:401–405. doi: 10.1016/j.jclinane. 2015.02.005.
  2. Patel SK, Gordon EJ, Wong CA, Grobman WA, Goucher H, Toledo P. Readability, content, and quality assessment of web-based patient education materials addressing neuraxial labor analgesia. Anesth Analg. 2015;121:1295–1300. doi: 10.1213/ANE.0000000000000888.
  3. Goodman MF, Mohadjer L, Krenske T, Jacquie H. Literacy, Numeracy, and Problem Solving in Technology-Rich Environments: Framework for the OECD Survey of Adult Skills. Paris, France: OECD Publishing; 2012. doi: 10.1787/9789264128859-en.
  4. New Mexico Coalition for Literacy. NM literacy overview. Available at: https:// newmexicoliteracy.org/literacy-facts. Accessed August 21, 2017.