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Overview

Practices often ask patients to fill out forms or provide them with written materials to read. Almost a quarter of U.S. adults have low literacy and a third have low numeracy. The average reading level for U.S. adults is 8th or 9th grade. Materials written for the "average" adult—and health education materials are frequently written way above the average reading level—means that half of adults will have difficulty understanding them. Assessing, selecting, and creating simple forms and easy-to-use educational materials can help your patient be successful with tasks that involve written information.

Action

Train a staff member to evaluate the quality of the materials you give to patients.

Have at least one person in your practice learn how to assess the materials you distribute. Focus first on important and frequently used materials, such as your lab results letter, after-visit-summary, appointment reminder, or fact sheets about managing chronic conditions. Be sure to review materials developed by your practice as well as those produced by outside sources to ensure they are appropriate for your patients.

Assess whether materials are easy to read, understand, and act on.

There are many ways to assess patient materials. Combine approaches that examine a broad array of features that can make materials easy to understand and act on with those that measure how readable materials are.

• Assess understandability and actionability. AHRQ's Patient Education Materials Assessment Tool (PEMAT) provides separate measures of how easy materials are to understand and how easy they are to act on. You can also try the shorter , which has been adapted . Both are validated ways to assess written and audiovisual education materials.
• Get patient feedback. Ask a diverse group of patients to evaluate your forms and other written materials that you hand out or are available on your patient portal. Go to Tool 17: Get Patient Feedback for guidance.
• Use readability formulas. Readability formulas focus on the length of the words and sentences, not on meaning. A high score signals that materials are difficult to read, but a low score does not necessarily mean they are easy to understand. Be aware of the limitations of readability formulas. Search the internet for "free readability formulas" to find online resources for commonly used formulas, such as the Fry, SMOG, and Flesch Reading Ease.

Choose materials that are easy to read, understand, and act on.

• Identify poor-quality materials. Identify materials that performed poorly on any of your assessments. Consider whether these materials can be improved or whether they will need to be replaced.
• Select better materials. When you identify unsatisfactory materials that cannot be revised, search for new ones. Make sure you assess the new materials using the tools mentioned above to see if they are really better.
• Use the internet. There are many free health education resources available on the web, such as the collection, which contains interactive tutorials. Check out whether sites have simple navigation and are easy to read and understand. Before directing patients to a website, .
• Consider alternatives to written materials. Even if your materials are written at the 4th or 6th grade level , some adults will not be able to read them. Ask your patients how they like to get health information. For example, patients with sight loss may prefer large print or braille materials. Patients may prefer audio and video resources. Deaf and hard-of-hearing patients may prefer videos with closed captions or sign language. Videos are also useful for demonstrating self-care activities, such as injecting insulin, using an inhaler, or exercising. Make sure that a patient has the equipment, bandwidth, and know-how needed to view audiovisual materials before distributing them.
• Do not eliminate paper-based materials. Print and send information by regular mail if patients prefer it.

Create new materials to fill gaps and revise homegrown materials that need improvement.

Sometimes you just cannot find easy-to-understand instructions or other health information. Or you realize that the materials your office has created are not as easy to understand as you need.

• Use guides. The Department of Health and Human Services has several guides to help you design or revise materials and websites so they are easy to understand. Check out:
  • (PDF, 1.9 MB)
  • Plain Language Words

• Involve patients. Invite patients to contribute to the development of new materials. They're the experts on what information is important to them and what makes sense.
• Design for readability. Check that your materials to make materials easy to read, such as left justifying text, leaving white space, and avoiding all caps and italics. 
• Streamline forms. Review all forms patients fill out. 
  • Do they use common, everyday words and avoid ?
  • Is there adequate room to fill in the requested information?
  • Do they ask only for the “need to know” information, and ask for it only once? Share information collected from patients with everyone who needs to know so patients are not repeatedly asked for the same information.
  • Use the appendix Inclusive Language on Intake Form and visit Tool 13: Welcome Patients for additional guidance on revising forms.
• Watch out for numbers. Ensure that your materials follow recommendations for improving communication of health-related numbers:
  • Provide only the information patients must have to make informed decisions or take care of their health.
  • Provide numbers along with verbal descriptors (e.g., "low risk").
  • Use simple graphics to express numbers and provide a context for interpreting them. 
  • Express risk/benefit in whole numbers, not fractions, decimals or percentages (e.g., "1 in 10,000" rather than ".01 %").
  • Provide absolute risk (e.g., a decrease from 6 out of 100 people to 3 out of 100 people) rather than relative risk (e.g., a reduction of 50%), especially when the numbers are small.
  • Provide both the positive and the negative (e.g., "5 in 100 people will get the side effect, and 95 out of 100 will not get the side effect").
  • Do the math for patients, rather than expecting them to perform calculations.
  • Stay consistent. Use the same denominator when making comparisons (e.g., "1 in 1,000 versus 20 in 1,000" instead of "1 in 1,000 versus 1 in 50").
  • Present risk in terms of a time span that is meaningful for patients, such as a 10-year period rather than lifetime.
• Assess the new materials during the development process. Do not wait until the product is finished before you assess it. Assessment tools can remind you to follow health literacy principles.
• Consult on legal issues. When using a form for a legally binding purpose, consult a lawyer for legal advice. Remember—having patients sign something they do not understand is not legally binding, so be sure to advocate for plain language.
• Get approvals. Some practices may need administrative approval to revise or replace written materials. Changes to materials accessed through the electronic health record or patient portal may also require support of information technology staff. Consult with your administration for guidance on how to get approval and support for revised materials.  

Develop a schedule for regularly assessing and updating written materials.

Some organizations assess each written material every 2 or 3 years.

Track Your Progress

Every 4 months, tally the number of materials that have been assessed and the percentage of those that were rated as poor quality that have been replaced or revised. 

Before you start using this tool, tally the percentage of questions that were not answered on forms filled out by patients in a given week. In 2, 6, and 12 months, do it again and see if the percentage of unanswered questions has gone down.

Before implementing this tool and 2, 6, and 12 months later, collect patient feedback on a selection of questions about this tool from the Health Literacy Patient Feedback Questions. 

Refer to Tool 2: Assess Organizational Health Literacy and Create an Improvement Plan to learn how to use data in the improvement process.

Additional Resources

The following are examples of easy-to-understand patient forms and letters. You can edit and share with legal advisors, as needed.

• Permission to Bill Insurance
• Release of Medical Information
• Lab Results Letter
• Appointment Reminder
• Inclusive Language for Intake Forms