Health Literacy Studies

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How to Create and Assess Print Materials
by Rima E. Rudd

Topics in this section include:

Reading Skills

Creating Materials

Assessing Materials

Teaching Patients with Low Literacy Skills by Doak, Doak, & Root (1996) *New posting

Resources on Creating and Assessing Web Sites

Citation: Rudd RE. How to create and assess print materials. Harvard School of Public Health: Health Literacy Website. 2005. Available at: http://www.hsph.harvard.edu/ healthliteracy/materials.html. Accessed [insert date].

Reading Skills
As we develop written materials for the general public, we need to think about vocabulary and sentence structure, organization of ideas, as well as layout and design elements so that we can eliminate as many unnecessary barriers as possible.

Reading is a complicated task. The components of reading include the following:

Alphabetics: the process of using letters in an alphabet to represent sounds in the spoken word. Needed skills include knowledge of basic sounds [phonemes] and an understanding of the relationship between these sounds and letters [phonics].

Fluency: ability to read with speed and ease.

Vocabulary: knowledge of the meaning of a word. Understanding less common words requires background knowledge.

Reading comprehension: a construction process. This process involves all the elements of a reading process to derive meaning from text.

Beginning readers are developing skills in sounding out words. They learn to link sound to meaning. Over time, they learn about linked words in short sentences. They often read one word at a time and may skip over unfamiliar words. New readers may tire easily. As a result, new readers often focus on individual words and have difficulty focusing on the meaning of a sentence.

Intermediate readers are building background knowledge and vocabulary. At the same time, they are improving word recognition and fluency. They are learning to derive meaning from text and to make inferences.

Advanced readers read with speed and ease. They understand the context and can make inferences. They are using the written word and applying literacy skills to a variety of academic and mundane tasks.

Creating Materials
Many guidelines are available to address key issues for the development of appropriate materials. In general, these guides suggest that it is important to address the following key components:

Language: vocabulary, sentence length, active voice

Organization: presentation of ideas, grouping of like ideas, highlights of key points, summaries, and, in general, attention to what people want to know as well as what professionals think they ought to know

Layout and design: white space, font style and size, bolded headings and sections, use of charts, graphs and illustrations

Below, we draw from various guides and offer key points about plain language, layout and design and formative evaluation to guide you in creating health education materials. We refer you to the resources linked at the end of this page for more detailed guidelines and illustrative examples.

PLAIN LANGUAGE
Plain language is defined as a clear, simple, conversational style and one that presents information in a logical order. Recommendations for plain language writing often include the following:

Organization

Provide needed background information or needed context

Group information into meaningful sections with clear headings

Emphasize and summarize main points

Style

Use everyday words

Explain technical terms and use examples

Avoid long, complex sentences

Write in the active voice

Engage the reader. Suggestions include: making reference to a shared context, using a question and answer format

Link information to trusted sources

Click here for:
Clear and to the Point: Guidelines for Using Plain Language at NIH

LAYOUT AND DESIGN
The design of material can make reading easier or more difficult. Recommendations often include the following:

Type and Spacing

Use a readable type style – generally a footed font [serif] in 12 point size

Use appropriate space between lines [generally 1.2 to 1.5 spacing]

Provide good contrast between the paper and the text

Do not print words on shaded or patterned background

Use upper and lower case

Avoid all cap text

Include ample white space

Lines

Use appropriate length lines [maximum of five inches]

Leave right margin jagged

Do not split words across two lines

Overall Design

Be consistent

Avoid clutter

Provide a guide for finding key information

Clearly label all illustrations and charts

Offer explanations

Make legends clear

Place charts as close as possible to explanatory text

Avoid wrapping text around illustrations

Use consistent and easily recognized headings

Signal main points with bold or highlights

PARTICIPATORY FORMATIVE EVALUATION
Recommendations for the development of appropriate materials include processes for review, piloting, and revisions.

Review all materials and use a consistent check list

Engage members of the intended audience in a critical review process

Re-work the materials based on reviews

Pilot materials with members of the intended audience

Re-work materials based on pilot test findings and solicited suggestions

Members of the intended audience can offer insight and guidance long before materials are piloted. Many programs use participatory processes for the development and design of materials.

RECOMMENDED RESOURCES for CREATING Print Materials

Simply Put. Developed by the Centers for Disease Control and Prevention (CDC).
This guide from the CDC helps you translate technical and scientific language used in many fields into information that captures and holds the interest of your intended audience. It provides tips for writing simply, using visuals, and organizing information for easy recall and understanding. Simply Put is available at http://www.cdc.gov/od/oc/simpput.pdf

Research-Based Web Design & Usability Guidelines. Developed by the U.S. Department of Health and Human Services (DHHS).
These updated Guidelines, released in August 2006, were developed to assist those involved in the creation of Web sites to base their decisions on the most current and best available evidence. The Guidelines are particularly relevant to the design of information-oriented sites, but can be applied across the wide spectrum of Web sites to improve the dissemination of health information in an effective and efficient manner. Research-Based Web Design & Usability Guidelines is available at http://www.usability.gov/pdfs/guidelines.html.

Clear and to the Point: Guidelines for Using Plain Language at NIH. Developed by the National Institutes for Health.
This 12-page summary provides guidelines and useful examples of how to write in plain language, engage readers, display information and evaluate materials. Clear and to the Point is available at http://execsec.od.nih.gov/plainlang/guidelines/index.html

Writing and Designing Print Materials for Beneficiaries: A Guide for State Medicaid Agencies (October, 1999). Author: Jeanne McGee. U.S. Department of Health and Human Services, Health Care Financing Administration. Center for Medicaid and State Operations. Publication Number 10145.
This guide, focused on the development of print materials for Medicaid beneficiaries, offers a thorough explanation of key issues for all health related materials assessment and development processes. The guide provides useful advice and excellent tips for writing, designing, and pre-testing written materials. The author offers clear examples throughout. The design and layout of the guide itself provides an excellent model for the presentation of information and concepts and adds to our understanding. We do encourage you to send for this book. We’ve added the very thorough Checklist to this web site. To view the ‘Guide Checklist for Assessing Print Materials,’ click here. You can order this text from the Centers for Medicare & Medicaid Services free of charge by clicking here.

Teaching Patients with Low Literacy Skills, Second Edition (1996). Authors: Doak, Doak and Root. Philadelphia, PA: J.B. Lippincott Company.
This 212-page ‘classic’ is for health educators and health care providers who wish improve communication with adults who have limited literacy skills. The book covers a wide range of topics, including: educational theories, how to test for literacy skills, how to assess the suitability of materials and how to create easily understandable visuals. The authors discuss how to test and revise health education materials. The book includes directions for using the Fry formula, a copy of the REALM and a copy of the Suitability Assessment of Materials (SAM). The SAM, an assessment tool, was created by Doak and Doak. This text is now available for free download on this web site. Click here.

The Right to Understand: Linking Literacy to Health and Safety Training, by Szudy and Arroyo (1994). Labor Occupational Health Program, University of California at Berkeley.
This 200-page manual is designed to help safety and health trainers meet the needs of workers with limited literacy skills. However, it offers clear and focused tips and processes for the development of any materials. Contents include sections on how to develop easy-to-read materials, how to evaluate materials, and how to conduct suitable trainings for a wide range of literacy skills. The ‘How To’ section includes writing, design and illustration tips. The ‘Evaluation’ section provides a quick checklist, instructions on using the Fry formula, a guide to field testing materials, sample questions for focus groups and many case studies on field testing. This manual is available from the Labor Occupational Health Program, Tel: (510) 642-5507. The cost is approximately $20.

Creating Plain Language Forms for Seniors: A Guide for the Public, Private and Not-for-Profit Sectors (1998). National Literacy and Health Program and the Canadian Public Health Association.
This 30-page guide, developed with attention to the needs of seniors, offers clear guidelines for creating forms in plain language. However, the many tips offered can be applied to all health related forms. The guide includes a section on how to use clear verbal communication with clients who need help filling in forms. The guide also includes sections on the benefits of plain language, forms as barriers, and a Plain Language Forms Tool Kit. Appendices include a glossary of plain words [Acrobat Reader required] and instructions on how to use the SMOG [Acrobat Reader required]. For more information, contact the Canadian Public Health Association, Tel: (613) 725-3769, Email: comm@cpha.com or see www.cpha.ca.

Clear & Simple: Developing Effective Print Materials for Low-Literate Readers (1994). National Institutes of Health, National Cancer Institute.
This guide outlines a process for developing materials with, and for, people with limited-literacy skills. The guide contains five sections. Each section highlights specific considerations for materials development: defining the target audience, conducting audience research, developing a concept for the product, developing content and visuals and pre-testing and revising materials. Clear & Simple is concise and easy-to-use, with key information presented in bulleted lists. It contains many illustrations and offers real world examples. The 61-page guide includes a list of low-literacy publications and software. A free copy of Clear & Simple is available from the National Cancer Institute: http://www.nci.nih.gov/cancerinformation/clearandsimple.

Beyond the Brochure: Alternative Approaches to Effective Health Communication (1994). AMC Cancer Research Center and Centers for Disease Control and Prevention.
Beyond the Brochure was developed by the AMC Cancer Institute in the mid 1990s. The goal of the writers is to help readers consider multi-media education materials. The 67-page guide presents innovative interventions and strategies to reach audience. The guidebook begins with a section on audience assessment and participatory processes. The section on pre-testing materials includes basic guidelines for discussion guide development. This publication is available at no cost at www.cdc.gov/cancer/nbccedp, click on ‘Publications’ or by calling CDC at: (770) 488-4751.

Making Health Communication Programs Work: A Planner’s Guide (1989). U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health and Office of Cancer Communications, National Cancer Institute.
This guide has become a standard reference and is often referred to as the ‘pink book’. It was developed by the Office of Cancer Communications and sets out key principles for each stage of a communication program development. The section on developing and pre-testing materials includes considerations for message construction, tips for developing PSAs, and methods for pre-testing. It offers practical steps for evaluation of communication programs. Appendices include the SMOG formula, a focus group moderator’s guide and helpful resources on designing a PSA. A free copy of Making Health Communication Programs Work is available from the National Cancer Institute: http://www.cancer.gov/pinkbook.

Assessing Materials
We have many tools at our disposal to help us assess the reading grade level of written materials. Most of these tools have been used extensively in the education field and have been well-tested. In addition, we have several guides available to help us make a broader assessment of written health materials.

Reading Grade Level Assessments:
Assessments of the reading grade level of text offer some insight into the level of difficulty of written material. Most reading grade level scores focus on the length of sentences and the vocabulary [generally assessed by number of syllables in words] in a text.

Long sentences often contain phrases set aside by commas, multiple ideas, and/or lists. Poor readers often read slowly. They have problems with long sentences because they can lose the main idea part way through the sentence [short term memory issue]. Very poor readers struggle with sounding out words and may not be able to derive meaning from simple sentences.

Multi-syllabic words are considered an indicator of vocabulary difficulty [e.g. utilize for use]. Poor readers often need to sound out words and longer words present a bigger challenge. Vocabulary development requires background knowledge and exposure.

SMOG:
There are a number of formulas to assess the readability of a text. The formulas fall into two major categories: those that are computer generated and those that are calculated by hand. The most frequently used computerized formulas include the Flesch Grade Level Formula and the Flesch-Kincaid Index. Newer word processing programs often have the Flesch formula built into the software for easy use. For those who do not have a computer, or conduct readability tests in the field, there are a number of formulas that can be calculated by hand. Hand-calculated formulas include the FOG method, Fry formula and the SMOG. The SMOG was created by McLaughlin in 1969 and predicts 100% comprehension. The Health Literacy Studies Group often uses the SMOG in its research, and finds the formula easy to compute and well designed for field work. Once you know the formula, you do not need any charts for reference.

Suitability of Materials:
Grade-level readability is one of many factors that contributes to the overall readability of materials. Even materials written on a low grade level may be difficult to comprehend if proper attention is not also paid to organization, layout, and design. To address the overall suitability of materials, including reading grade level, Doak and Doak developed the Suitability Assessment of Materials (SAM). Although the SAM was developed for use with print materials, it has also been used to assess video- and audio-taped instructions to patients.

The SAM scores materials in 6 categories: content, literacy demand, graphics, layout and typography, learning stimulation and cultural appropriateness. The SAM yields final percentage score. This score falls into one of three categories: superior, adequate or not suitable. The SAM can be used to identify specific shortcomings that reduce the suitability of materials- either in the development stages or with existing materials. A full description of the SAM and a scoring sheet is available in Doak, Doak & Root’s Teaching Patients with Low Literacy Skills, Second Edition, J.B. Lippincott Company, 1996.

Readability of Charts and Graphs:
The readability tools noted above are used for prose documents – information presented through sentences organized in paragraph. However, adults must grapple with documents. Document literacy was one of the measures on the NALS. Documents include forms, tables, graphs, charts, and lists. Until recently, we did not have a tool to measure the readability of information organized in rows and columns.

Researchers Mosenthal and Kirsch developed a measure for assessing document complexity, called the PMOSE/ IKIRSCH document readability formula (Journal of Adolescent & Adult Literacy, 41(8), May 1998). The formula uses the number of rows and columns, the structure, and the number of labels and items to assess the chart or table. Scores range from Level 1 to Level 5 Proficiency. The Proficiency Level can be translated into a grade-level equivalent.

The Health Literacy Studies Group uses the PMOSE/ IKIRSCH in research and finds it to be a useful tool. Attention to information presented in rows and columns is especially critical given the large number of forms and charts needed to navigate health care. It isimportant to note that the formula does not examine the type of language (such as long, technical words) used in charts and tables.

RECOMMENDED RESOURCES for ASSESSING Print Materials

The SMOG Readability Calculator by G. Harry McLaughlin. http://webpages.charter.net/ghal/SMOG.html
This Java application calculates a SMOG score for any length of text that can be typed or pasted into the calculator.

Resources for Creating and Assessing Web Sites

Bobby: www.cast.org/bobby
Bobby is a free web-based service to help identify and repair significant barriers to access. Bobby was created by the Center for Applied Special Technology (CAST). To use Bobby, you simply enter the URL of the web site you want tested and click Submit. Bobby limits the number of pages it will check, but you can test an entire set by downloading a version of Bobby.

The Children’s Partnership: www.childrenspartnership.org
The Children’s Partnership (TCP) is a national non-profit organization that informs leaders and the public about the needs of American’s children. TCP recently published a report, titled “Online Content for Low-Income and Underserved Americans: The Digital Divide’s New Frontier.” The report examines and makes recommendations about Internet content for underserved Americans, including those with limited literacy. The full report is available on TCP’s web site.

Jakob Neilsen’s site: www.useit.com
This site provides tips for the design of web pages, including information on writing for the web and guidelines for improving usability of the web for people with disabilities.

The Trace Center, a resource on web design: www.trace.wisc.edu/world/web
This site is focused on usability and access. It includes information on: web site guidelines, web access tools, resources on disability and web use, forums for discussing accessibility issues and organizations addressing web access issues.

Web Site Usability: A Designer’s Guide (1999). Authors: J. Spool. T. Scanlon, W. Schroeder, et al. San Francisco, CA: Morgan Kaufmann Publishers.
This 150-page guide offers practical advice for the design of web pages, and includes a chapter on readability and page layout. The authors discuss provide a guide for calculating the Fog Index and suggest ways to scan web pages. For more information, contact Morgan Kaufmann Publishers, www.mkp.com.

Article by Helen Osborne, “In Other Words … Communicating Across a Lifespan. Design in Print and Web-Based Communication.” On Call Magazine, January, 2001. Available at http://www.healthliteracy.com
This article defines universal design as ‘an approach to design that not only addresses specific physical disabilities, but also takes into account a wide array of physical, cognitive and linguistic abilities of people throughout the world over an entire lifespan.” The author offers practical advice on using universal design principles when designing web and print-based communications. She discusses font, line length, and graphics.

Readability check using existing software: Cut and paste web text into a blank Word document and test for readability (with Flesch Kincaid Grade Level Scale) using the “Tools” menu, under “Spelling and Grammar.” This does not consider .pdf files or graphics, but will give an indication of the reading level of written text. Hand-computed readability checks, such as the SMOG, can also be conducted on web site text.

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