Article from the Boston Globe’s On Call Magazine, November 2001

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

As health professionals, we have increasingly become aware of the need to present patient education materials in ways patients and families can understand. We may think we are ensuring this when we make the effort to assess the readability of a document or to assess a patient’s literacy or language skills. But these steps alone cannot tell us for certain whether patients and families – our intended readers – can truly understand.

Patient education materials can be difficult to understand because they often use language (such as medical words and healthcare jargon) and reasoning that are familiar to health professionals but not to patients. Written materials may also be difficult to understand because the writer may make wrong assumptions about a patient’s level of familiarity or experience in a healthcare setting. So the only way to tell whether the written material you are giving out can be understood by the people who need to understand it is to test it with its intended readers.

There needs to be a match between the provider’s instructions and the patient’s comprehension, say Leonard and Cecelia Doak, authors of Teaching Patients with Low Literacy Skills and president and director of education at Patient Learning Associates, Inc. Testing materials with intended readers, they say, is the most effective way to find areas of mismatch and misunderstanding.

At a dialysis clinic in the southern United States, the Doaks tested a nutrition brochure that outlined which foods patients can and cannot eat. The brochure specified that patients must avoid eating poultry and shellfish. The Doaks asked a man who was undergoing dialysis to read this brochure. They then asked him what foods he can eat for dinner. “I can have fried chicken,” the man proudly responded, “but never poultry.”

“Poultry,” say the Doaks, is a category word. Category words describe a group of items. When you use a category word, make sure to give examples that readers are familiar with and can understand. Although poultry is a fairly common two-syllable word, it was not a part of this man’s everyday vocabulary. He is much more familiar with “chicken” and “turkey,” words he sees in the supermarket. In an instance such as this when a patient misunderstands a category word, there can be serious health consequences.

Hints for Successful Testing

Testing is the step that health providers need to take to assure that patient education materials are truly understandable. The Doaks offer the following suggestions to help you find out if your readers can understand what you are writing.

Test early in the process. As early in the writing process as you can, find out how well intended readers understand your information. Ask for feedback even on your rough draft. While you are writing is a time when it is fairly easy and inexpensive to fix any parts of the document that need changed.

Ask 10 to 20 people for their opinion. You do not need to test your materials with a large number of people. A representative sample of 10 to 20 intended readers is usually enough. If anything is seriously wrong with the material, it is likely at least one of the first ten people who read it will notice it. You don’t need to spend big money or big time when you test materials, say the Doaks. All it takes is your interest in wanting to find out if this is a suitable instruction.

Decide how you are going to test your material. The decision may depend on who the intended audience is. You can test written materials by giving it to one person at a time or by giving it to a group. This group is sometimes referred to as a “focus group.” The Doaks prefer speaking with people individually. They say they get the “straight story” this way. They have found that many people, especially those with limited literacy or language skills, are reluctant to speak up in a group. This may be because people fear embarrassment, are unaccustomed to giving an opinion in front of others, or lack the fluency needed to speak up. Teenagers and college students, on the other hand, may be more comfortable in a group since they are used to giving their opinion in a classroom setting.

Always start with “will you help me?” When you ask intended readers to review your materials, you are asking for a gift of their opinion. Make it clear that you are testing your materials, not their reading or comprehension skills. You can set this tone by introducing yourself and asking, “Will you help me?”

Regardless of how you pretest your materials, make sure to get individual feedback when giving patients new information or instructions. Do not do this, however, by asking, “Do you understand?” People who do not understand are most likely to say “yes” in order to avoid embarrassment or additional questions. Instead, find out if information is clear by asking open-ended questions such as, “How will you take this medication? Where will you keep it? What will you do when you need more?”

What to Look for When You Test

When you are testing your materials, focus on these key elements:

• Actions. Patient education materials often include both need-to-know actions (skills and behaviors) and nice-to-know facts (background information). You need to be sure readers can pick out the actions they need to take. So when you test materials, focus on those actions. For example, when testing an asthma brochure, ask patients how they will use an inhaler rather than how air circulates in the lungs.
• Visuals. Visuals, such as photographs, drawings, and designs can enhance or get in the way of understanding. Bright colors, fancy borders, and overlays, in which printed words are superimposed on a picture, can all distract from the central message. Test visuals to see how readers perceive them. In a medication brochure, for example, there was a picture of a small glass beside a bottle of medicine. While the intent was to convey the message that the medication should be taken with water, some intended readers assumed the medicine was to be taken with a shot of whiskey.
• Ease of use. Find out how easy the material is to use. For instance, see if intended readers can accurately follow instructions needed to complete a questionnaire or survey. (For ways to test questionnaires, see Chapter 10 in the Doak’s book, Teaching Patients with Low Literacy Skills.) When you ask a person to read a tri-fold brochure (one piece of paper folded into thirds), notice which section they read first and where their eyes go next.

Testing for these points will help you learn whether intended readers will be able to use, understand, and act on the written healthcare information you give them.

How to Find Out More:

Leonard Doak is president of Patient Learning Associates, Inc., and Cecilia Doak is director of education at the same organization. You can contact the Doaks by e-mail at: lendoak@aol.com

Printed Resources

• Doak C, Doak L, Root J (1996). Teaching Patients with Low Literacy Skills. 2^nd ed. Philadelphia, PA: J.B. Lippincott.
• Osborne, H (2000). Overcoming Communication Barriers in Patient Education. Gaithersburg, MD: Aspen Publishers.