Simply Put

A guide for creating easy-to-understand materials

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What’s in this guide?

Communication that is Clear and Understandable…………………………………………..3

Where this Guide Fits into an Overall Communication Plan………………………….4

Make Your Message Clear ……………………………………. ……………………………………….5

Text Appearance Matters ………………….. ………………………………………………………..9

Visuals Help Tell Your Story …………………………………………………………………………10

Layout and Design…………………………………………………………………………….17

Consider Culture……………………………………………………………….…….23

Translations Take Your Message Further …………………………………………………………25

Testing for Readability …………………………………………………………………………………..27

Appendix A – Checklist for Easy-to-Understand Print Materials………………………….29

Appendix B – Resources for Communication Planning ………………………………………30

Appendix C – Formulas for Calculating Readability ………………………………………….31

Appendix D – Resources ………………………………………………………………………………..38

Acknowledgements………………………………………………………………….43

Strategic and Proactive Communication Branch Division of Communication Services

Office of the Associate Director for Communication Centers for Disease Control and Prevention

Atlanta, Georgia

April 2009 Third Edition

Communication that is Clear and Understandable Communicating a broad range of health messages to a wide variety of audiences can be challenging. Differences among audiences make it necessary to avoid the one-size fits-all mindset when developing effective health communication materials. Culture and literacy skills are two important factors, among others, to consider when designing health communication materials that will capture the intended audience’s attention. According to the National Assessment of Adult Literacy (NAAL), released in 2006 by the U.S. Department of Education, 30 million adults struggle with basic reading tasks. The NAAL also found that only 12 percent of consumers have proficient health literacy skills1— suggesting that nearly nine out of ten adults may lack many of the skills necessary to sufficiently manage their health. Low health literacy can affect a person’s ability to locate health care providers and services, fill out health forms, share personal health information with providers, manage chronic diseases and engage in self-care.

One-third of U.S. adults have trouble reading and acting on health related information

Source: National Center for Education Statistics, 2003 National Assessment of Adult Literacy

It is important to remember; however, that even those with higher health literacy skills want health information that is understandable, meaningful to them, and easy to use. In This Guide: The guidance in Simply Put helps you transform complicated scientific and technical information into communication materials your audiences can relate to and understand. The guide provides practical ways to organize information and use language and visuals. This guide will be useful for creating fact sheets, FAQ’s, brochures, booklets, pamphlets, and other materials, including web content.

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Where this Guide Fits into an Overall Communication Plan Developing a communication plan involves many steps. This guide will help you accomplish just one of them – designing your health communication materials.

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There are several things to do before you start:

• Identify the intended audience and define the key health problem/s or interest/s.

• Get to know the intended audience to help determine their key characteristics, including gender, race/ethnicity, location, beliefs, behaviors, culture, literacy skills, and current knowledge about the identified topic.

• Determine key messages. Be sure to test them with the intended audience to ensure they will be received appropriately.

• Determine the best way to communicate messages to the audience (i.e., print, audio, video).

• Decide how to distribute the materials to the audience (i.e., mail, brochure display, web page).

An early step in the development process is determining whether the intended audience needs or wants the information your material will provide. This ensures that funds and staff time will be used wisely. Learning about the interests, needs, and values of the intended audience allows for more targeted materials. Knowing the best ways to reach your audience will help to decide on the most effective format and design for your materials.

Steps for Developing Health Communication Materials That Are Evidence-Based and User Friendly 1. Identify intended audience and

define/research the key health problems or interests

2. Engage the intended audience- determine what their needs, beliefs/values, and interests are, and their level of knowledge of the identified health topic

3. Determine key concepts and messages based on knowledge of the audience

4. Design a draft of the material 5. Pretest materials with intended

audience 6. Tweak draft according to feedback

from the audience 7. Publish and distribute materials 8. Evaluate the audiences’ satisfaction

and understanding

Once you have developed a draft of your material, be sure to pretest it with the intended audience. Pretesting helps ensure that the message you send is the message your intended audience receives, rather than some other interpretation. Make appropriate revisions to your materials according to the findings of the pretest. The final steps in developing health communication materials are to market it and distribute it, and re- evaluate its effectiveness in communicating key messages to your intended audience. This guide does not discuss all of these steps, but Appendix B contains a list of resources to help you through many aspects of communication planning.

Make your Message Clear Creating materials that lead to increased knowledge or a change in beliefs, attitudes, or behaviors requires messages that are clear, relevant, and appropriate for the intended audience. This section gives tips for deciding what to say and how to say it so the audience will understand, remember, and act on your message.

1. Give the most important information first To quickly engage the audience:

• Give the most important information first • Tell them what actions to take • Explain why it is important to them

For example: Always wash hands with soap and warm water for 20 seconds before and after handling food. Food and water can carry germs that may make you and your family sick.

2. Limit the number of messages

Give your audience no more than three or four main ideas per document or section of your document.

Stick to one idea at a

time

Focus on what your audience needs to know and do. Skip details that are only nice to know. If you are writing a brochure on how to prevent Lyme disease, you don’t need to tell the audience how and when Lyme disease was discovered. Tell them what to do to prevent it instead.

Stick to one idea at a time. Develop one idea fully before moving to the next idea. People are confused when materials skip back and forth between topics.

Avoid lengthy lists. Create short lists (3-7 items) with bullets, not commas. People with limited reading skills tend to forget items in longer lists. If you have a long list, break it into subheads.

3. Tell audiences what they need to do.

Clearly state the actions you want your audience to take. Use concrete nouns and an active voice. Active voice is where the subject does the action.

Say: Follow these rules to avoid getting sick from food:

• Cook meat until it is not pink in the middle.

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• Wash your hands after touching raw meat.

• Wash fresh fruits and vegetables before eating them. • Keep hot food hot and cold food cold.

Not: Following safety precautions can reduce food-borne disease transmission.

Highlight the positive. Tell your audience what they should do rather than what they should not do.

Use: Wear your helmet every time you ride your bicycle. Instead of: Do not ride your bicycle without wearing a helmet.

4. Tell your audience what they will gain from understanding and using the material . Tell your audience how your materials will benefit them. Answer the question, “What’s in it for me?”

For example: You will learn what to do to have a healthy pregnancy and ways to prevent possible complications.

5. Choose your words carefully.

Keep it short. Use words with one or two syllables when you can. Keep most sentences, if possible, between eight to ten words and limit paragraphs to three to five sentences.

Communicate as if you were talking to a friend. A conversational style has a more natural tone and is easy to understand.

Write as if you were talking to a

friend Say: You could get sick if you are near the chemical.

Not: Exposure to the chemical could cause adverse health effects.

Respect and value your audience. Don’t talk down or preach. People are less likely to act on information if they are made to feel bad about their current behavior or health situation.

Use a tone that encourages the audience. Emphasize small, practical steps. Offer concrete examples of successful action steps.

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Limit use of jargon, technical, or scientific language. Define necessary jargon or technical terms first. Then explain them in language your audience will understand.

Say: high blood pressure Not: hypertension Say: birth control Not: contraception

Choose words with a single definition or connotation. People with limited literacy skills may not be able to figure out the meaning from the context.

For example: “Poor workers” could mean workers with poor performance or workers with limited income. Be consistent

with word use

Be consistent with word use. Pick the most familiar words and use them throughout your text.

For example: Mad cow disease and bovine spongiform encephalitis may be the same thing, but your audience may think they are two different diseases.

Use analogies familiar to your audience. When making comparisons, use references that your audience will recognize.

Say: Feel for lumps about the size of a pea. Not: Feel for lumps about 5 to 6 millimeters in diameter.

Avoid unnecessary abbreviations and acronyms. Provide the acronym first and then spell the word (s) out in parentheses when using a familiar abbreviation or acronym. Apply this rule also when creating content that will be spoken in video or audio materials.

For example: In the early stages of infection, HIV (human immunodeficiency virus) often causes no symptoms.

Provide the term before the acronym when using unfamiliar abbreviations.

For example: Breathing secondhand smoke is a known cause of sudden infant death syndrome (SIDS).

Limit use of statistics and use general words like most, many, half. If you must use statistics, try putting them in parentheses.

Say: Researchers found that almost all Americans (90%) believe the possible harm from vaccines is very small.

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Not: Researchers found that 90% of Americans believe the risk from vaccines is very small.

Mathematical concepts, such as risk, normal, and range, may not have meaning to your audience. If possible, use words such as “chance” or “possibility” instead.

Use: Most Americans believe the chances that something bad can happen to them after getting a vaccine is small. Instead of: Most Americans believe there are very few risks associated with vaccines.

Limit the use of symbols. What is meaningful and natural for one audience may be confusing or misleading to others. Pretest any use of symbols.

Use symbols sparingly

For example: The following symbols may not be familiar to or have the same meaning for everyone:

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Limit use of quotation marks. Choose other formats to show who is speaking when writing dialogue.

For example: Jane: How hard can it be to stop smoking? Ann: Most people have a very hard time quitting. I had to try three times

before I quit for good.

Text Appearance Matters The way your text looks greatly affects readability. Choosing the appropriate font style and size is important in creating health communication materials that are easy to read.

1. Use font sizes between 12 and 14 points. Anything less than 12 points can be too small to read for many audiences. Older people and people who have trouble reading or seeing may need larger print.

2. For headings, use a font size at least 2 points larger than the main text size.

Examples of font sizes: This is 8 point. This is 10 point. This is 12 point. This is 14 point. This is 16 point. This is 18 point.

3. Font Style

For the body of the text, use fonts with serifs, like the one used in this line. Serif fonts are usually easier to read than sans-serif fonts. This is because the serif makes the individual letters more distinctive and easier for our brains to recognize quickly. Serifs are the little “feet” on letters.

S S Use sans serif fonts in headings and subheadings. Sans serif is more readable when your type must be small or when used on a web site.

Serif Sans Serif

Do not use ALL

CAPS Keep the following style tips in mind:

• Do not use FANCY or script lettering. • Use both upper and lower case letters. Do not use ALL CAPS. ALL CAPS ARE

HARD TO READ. • Use grammatically correct punctuation.

Limit use of light text on a dark background.

• Use bold type to emphasize words or phrases. • Limit the use of italics or underlining. They are hard to read. • Use dark letters on a light background. Light text on a dark background is

harder to read.

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Visuals Help Tell Your Story

Visuals can improve your communication materials when used correctly. This section provides tips to help you choose effective, appealing visuals. Pictures help grab an audience’s attention and help tell a story. Be sure to test visuals to ensure there are acceptable with the intended audience.

1. Choose the best type of visual for your materials

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Photographs work best for showing “real life” events, people, and emotions. Photographs tend to be more compelling to audiences. When choosing a photo, be sure any background images will not distract your audience from the image you wish to highlight.

Simple illustrations or line drawings may work best in some instances. An illustration or drawing can simplify complexities and highlight key components of an idea. Drawings work best for:

Photos are best for illustrating life events • showing a procedure (drawing blood)

• depicting socially sensitive issues (drug addiction)

• explaining an invisible or hard-to-see event (airborne transmission of tuberculosis). Use simple drawings and avoid unnecessary details. Steer clear of abstract illustrations that could be misinterpreted. Simple drawings are useful for showing desired actions or to address abstract subjects. They can be useful among disparate audiences, especially mixed cultural groups.

Cartoons may be good to convey humor or set a more casual tone. Use cartoons with caution; not all audiences understand them or take them seriously.

2. Use visuals to help communicate your messages

Present one message per visual. When you show several messages in one visual, audiences may miss some or all of the messages.

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Label visual with captions. Be sure visuals and captions are placed near related text.

Use visuals that help emphasize or explain the text. Consider the space available and potential use of the visual. Steer clear of visuals that merely decorate or are too abstract.

Present one message per

visual

For example: Images A and B are both meaningful. Image A would work better with public health professionals. Image B works better as an illustration for the general public. Both documents use visuals that are audience appropriate.

Image B Image A Show the actions you want your audience to take. Avoid choosing images that show what the audience should not do.

For example: If you are telling people to choose healthy snacks, such as fruit,

Image A is effective because it shows them what to eat. It reinforces your message. Image B shows them what they should not eat, but on its own it gives them no visual link to what they should eat. Also, “X” is not universally known to mean “no”.

Image A Image B

3. Make visuals culturally relevant and sensitive Use images and

symbols familiar to your audience

Use images and symbols familiar to your audience.

Not all cultures understand that this image means “no smoking”

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Include illustrations that are inclusive and appealing to people who may have physical challenges or constraints.

If you show people in your visuals, try to make them of the same racial or ethnic group as your intended audience. Select images that are familiar and that the audience will be able to relate to. For materials designed for diverse audiences, show people from a variety of ethnic, racial, and age groups. Photographs may help certain audiences identify with your message.

4. Make visuals easy for your audience to follow and understand.

Place visuals near the text to which they refer. Audiences may not be able to connect a drawing placed in the top, right-hand corner of a document to text found in the lower, left-hand corner. Be sure all visuals connect directly to written messages.

Place visuals

near the text to which they

refer.

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Use brief captions that include your key message. Some people may read only your captions. Make them count by including your key message. Use brief, complete sentences with correct punctuation. A caption can tell exactly what the visual is trying to convey. The caption also repeats a sentence found in the body of the document to reinforce the message.

Wear gloves to keep from spreading germs.

Some captions are successful because they use a narrative to involve the audience.

When showing a sequence, number the images.

Captain Santos helps a child put on his bicycle helmet correctly.

Use cues like arrows and circles to point out key information in your visuals.

For example: The image below is from a brochure on how to avoid injuries at a construction site. The arrow highlights the hard hat, the most important item in the image.

Always wear a hard hat at the job site.

5. Sometimes drawings alone can help your audience understand.

Pictographs are pictures that represent words or ideas. Pictographs can convey information quickly and help a person understand and remember the intended message(s). They are most effective when focusing on a specific action and require thorough pre- testing to ensure effectiveness.

Pictographs can

convey a lot of information

quickly

This pictograph communicates, without text, how the medication should be taken.

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Photos can also work as pictographs

For example: The most effective pictographs involve a person performing an action. This helps people understand what actions need to be taken.

.

6. Use realistic images to illustrate internal body parts or small objects

Use realistic images for context. To highlight internal body features, show the entire body for context. Audiences may not understand the intended meaning of the visual if taken out of context.

For example: Image B provides context to more effectively show plaque build-up

within the heart blood vessel. This may not be as clear with Image A.

Image B Image A

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For a sense of scale, draw small objects larger to show detail. Also show something familiar to give your audience a sense of scale.

For example: The mosquito depicted below is drawn several times larger than actual size to show what it looks like. Then it is shown next to a penny to demonstrate how big it really is.

Enlarged to show detail Shown to scale

7. Use high quality visuals

Visuals should have a sharp resolution, true color and contrast, and good composition. High-quality visuals make your messages more credible. Furthermore, adults may not even pick up your materials if they contain childish or “cutesy” visuals. Seek professional design help in creating materials that attract and inform your audience.

Need help creating effective visuals? The Centers for Disease Control’s Public Health Image library has a variety of images relating to public health. http://phil.cdc.gov/Phil/default.asp Other visual resources are listed in Appendix D.

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Layout and Design Present your information and visuals in ways that make your materials easier to understand and more appealing to your audience.

1. Design an effective cover

Make the cover attractive to your intended audience. If the cover does not include images and colors your intended audience likes, they may not pay attention to it.

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Show the main message and audience. Health communication materials, such as brochures, web pages, flyers, posters, should be designed so that people are able to grasp your main idea and know who the material is speaking to just by looking at it.

Make the cover attractive to your intended audience

For example: Cover A is much more effective than Cover B in getting the

attention of your audience and in telling them what they can expect to find inside.

Bone Health and

Osteoporosis

Cover A Cover B

2. Organize your messages so they are easy to act on and recall

Present one complete idea on one page or two facing pages. If people have to turn the page in the middle of your message, they may forget the first part of the message.

Place the most important information at the beginning and restate it at the end of the document. It is best to state your main message first, expand on your message with straight-forward language and then repeat the main message at the end, usually with a call for change or action.

3. Organize ideas in the order that your audience will use them

For example: What to do if you find a chemical spill:

1. Leave the area right away. 2. Remember where the spill is so you can avoid it. 3. Report the spill to the police or fire department. 4. Warn others to stay away from the area.

Use headings and sub-headings to “chunk” text. Headings are a cue to upcoming message content. Use headings that express a complete idea, rather than just a word or two.

For example: Heading A communicates much more information than Heading B. Use headings and

sub-headings to “chunk” text

Heading A: Wear your seatbelt — it could save your life. Heading B: Seat Belts

Questions can be successfully used as subheadings. People can skim the questions to see what applies to them or are of greatest interest. Also, questions can make your materials more interactive. People tend to think about answers.

Make sure that you ask questions that lead your audience in the right direction. If they are not interested in the question at the beginning of a section, they may not read the information that follows.

Leave more space above headings and subheadings than below them. This gives a stronger visual link between the heading and the text that follows.

Leave lots of white space White space is the absence of text or visuals on a page. It keeps a page from being cramped, overwhelming, or amateurish. Many professional graphic designers recommend 10 to 35 percent white space per page for print materials.

Leave at least 1⁄2 inch to 1 inch of white space around the margins of the page and between columns. Limit the amount of text and visuals on the page.

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For example: Document A is easier to read than Document B because it has more white space.

White space takes on an added importance on the web because more of a strain is placed on the eyes than with print material. Information on web design principles can be found at http://www.usability.gov/pdfs/chapter6.pdf.

4. Make the text easy for the eye to follow

Break up text with bullets

Break up text with bullets

For example: The bullets used in Example A make the items in the list easier to read than in Example B. People are encouraged to participate when the bullets are boxes that can be checked off.

Example A Example B

Children should get six shots by age 2: measles, mumps, rubella Haemophilus influenzae type b polio diphtheria, tetanus, pertussis hepatitis B varicella

By age 2, children should get shots against measles/mumps/rubella; Haemophilus influenzae type b; polio; diphtheria, tetanus, pertussis; hepatitis B; and varicella.

Use right edge “ragged” or unjustified for the best readability.

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Use columns. Columns with line lengths of 40 to 50 characters are easiest to read. Compare Paragraphs A, B, and C below.

Paragraph A This column is only 20 to 25 characters long and is hard to read. Your eyes jump back and forth too much and quickly get tired. Paragraph B This column is the best length. It is 40 to 50 characters long. Your eye can return to the beginning of the next line easily, and it doesn’t jump back and forth very much. Try to design your materials like this one Paragraph C This paragraph is hard to read because the lines are too long. After reading one line, your eyes have to move back across the entire page to find the start of the next line. Paragraphs that run across the whole page also look very dense and don’t allow for much white space on the page.

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Place key information in a text box. Text boxes make it easier to find the most important information on the page.

For example: The eye is drawn to the shaded box on this sample page.

When your audience interacts with the

information, they are more likely to remember and act

upon the information.

5. Invite your audience into the text. Interaction is an effective way to increase the success of your teaching materials. When the audience interacts with the information provided, they are more likely to remember and act upon the information. Below are a few ideas on ways to engage your audience.

Ask questions. Write a short question and leave a blank line to write in the answer.

For example:

What is your best weight? Write it here. My best weight is _______ pounds.

Ask your audience to problem solve. Pose a problem and ask your audience to write or say how the problem can be resolved.

For example:

What are you going to do when you are craving a

cigarette? Write down some ideas here. 1. _________________________________ 2. _________________________________ 3.

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Include word/picture association opportunities. Ask the audience to circle one among several pictures to associate an abstract concept such as “physical activity” with a concrete action.

For example: Circle what you will do to get aerobic exercise

.

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Consider Culture Culture affects how people understand and respond to health messages. The best way to ensure that your materials are culturally appropriate is to engage members of the target audience early on in the communication planning phase. They can assist in identifying messages and images that are likely to work best within their culture.

1. Use terms that your audience uses and/or is comfortable with.

For example: If your audience of elderly people with diabetes usually goes to the health department to see a doctor, ask them if they say “clinic,” “doctor’s office,” or something else to ensure that the words being used in your materials will be familiar to the intended audience.

If you need to identify a group of people by race or ethnicity, use a term preferred by that group. Preferred terms may vary even within an ethnic or racial group. Ask a sample audience.

The best way to make sure your materials are culturally

appropriate is to talk with members of the audience you

are trying to reach

For example: One group may want to be identified as “African American,” while another group may prefer to be identified as “Black.”

OR

One group may want to be identified as “Native American,” while another prefers “American Indian.”

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2. Target messages to each cultural or ethnic group or subgroup. Groups may have different needs, values, and beliefs that will affect how they interpret your message. Minority groups often have subgroups that differ greatly from one another. What is effective for one minority group or subgroup may not work at all for another.

Using culturally appropriate images, concepts, and language is not enough. Messages should always be tested with the intended audience.

Sabemos (Spanish for “we know” is a bilingual, culturally appropriate toolkit developed by HHS/CDC to support the efforts of Hispanic parents and community leaders in protecting children from secondhand smoke. The kit was developed based on research acquired during focus groups with parents and leaders from the Hispanic community and key informant interviews. The findings from were used to develop key messages and tools for community leaders working with Hispanic/Latino populations.

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Translations Take your Message Further It is best to develop your materials in the language of your intended audience. However, translating them from English (or another language) is often necessary due to time limitations and/or available resources. This section will provide tips to help ensure that translations of your materials are both culturally and linguistically appropriate.

1. Messages that work well with an English-speaking audience may not work for audiences who speak another language. Find out about your audience’s values, health beliefs, and cultural perspectives. You can do this by conducting individual interviews, focus groups, or other kinds of audience research, including secondary research (i.e., literature reviews).

2. Design material for minority populations based on

subgroups and geographic locations. All members of a minority population are not alike. Mexican Americans, for example, may respond differently than Cuban Americans to certain words, colors, and symbols. Likewise, Korean women living in New York City may view a health issue very differently from Korean women living in Los Angeles.

Messages that work well with an English speaking audience may not work for audiences who speak another language

3. Get advice from community organizations in the areas you wish to reach. Local groups that

work regularly with your audience can give you valuable insight about your audience. They can also recruit participants for surveys or focus group testing and help you gain the trust of your audience.

4. Carefully select your translator. Choose a qualified translator who is familiar with your

intended audience. A qualified translator is typically a native speaker of the target language, has ten or more years experience in translation, and is preferably certified by a recognized institution. A qualified translator will produce documents that reflect the message and content of the source document. It is important to keep in mind that if the source document is not written clearly or in plain language the translated document will maintain this same attribute. When materials are used for intended audiences with more than one linguistic variation (for example, Mexican-American and Cuban-American) have multiple translators check the translation.

5. Avoid literal translations. Allow your translator to select from a wide range of expressions,

phrases, and terms used by the audience. This flexibility will result in more culturally appropriate material.

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6. Use the back-translation method. Once the material has been translated to the intended language, translate it back to English. (This step should be done by someone other than the original translator.) Check to see if the meaning and tone of the message have stayed the same.

7. Field test draft materials with members of your intended audience. Field testing will allow

you to get feedback from your members of your intended audience and to make changes based on their comments and suggestions.

Beware of these common pitfalls:

• Do not translate English slang phrases or idioms literally. • Do not translate into a dialect unless it is used by your audience. • Do not omit foreign language characters or accent marks when publications are written in

languages that use those elements. Missing characters or punctuation marks can change the meaning of a word or sentence. Make sure your word processing software and desktop publishing software have all the punctuation used in the intended audience’s language.

• If you list a phone number to call for more information, make sure staff fluent in the intended language is available. Or add a qualifier; such as, “Spanish speakers are available between 1:00 to 5:00 pm EST.”

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Testing for Readability Readability formulas are useful tools. They provide a general idea of how hard a document will be to read based on the average syllables per word and average words per sentence. However, they do not measure a persons’ level of comprehension. Comprehension levels are often two or more grades below reading or education level. Comprehension drops even more when a person is under stress. Readability formulas do not take into consideration the effects of layout or design elements. They cannot predict how well your audience will accept or act upon your message. The use of readability formulas alone does not guarantee well-written, understandable text. They should be used only in conjunction with other means of assessing effectiveness.

1. Reduce reading level before using formulas. There are several basic techniques to lower the reading level of your document. Begin by reducing the number of words per sentence and by using one and two syllable words when possible. Reducing these numbers can improve reading ease.

Also look for the number of times passive voice is used in your document. Change to active voice when possible. Active voice improves readability.

For example: This sentence is written in passive voice: “Heart disease and lung cancer are caused by smoking.” Using active voice is better: “Smoking causes heart disease and lung cancer.”

If you think the reading level of your document is too high because of long names of organizations, diseases, or other proper nouns, use a readability formula without those words. It may be that the readability is at the right level, except for the long words. If this is the case, revise your text to remove longer words

If you find that the reading level is still too high even when you don’t count the long words, write in “plain language” or use “everyday” language that people are most likely to understand. For ideas on substituting easier words and phrases, take a look at the reference library found at www.plainlanguage.gov/howto/wordsuggestions/index.cfm

One of the best ways to see how a “plain language” approach can improve a document is to look at examples of documents before and after they were edited into plain language. For before and after examples go to: www.plainlanguage.gov/examples/before_after/index.cfm

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2. Testing a document’s readability level.

There are several ways to determine reading level. You can test a document’s reading level by hand or by using computer software. Also, you can achieve consistency in your evaluations by using the same readability formulas through every draft stage. The Flesch-Kincaid Readability Test, the Fry Readability Graph, the Gunning ‘FOG’ Readability Test (FOG), and the Simple Measure of Gobbledygook Readability Formula (SMOG) are several good tools. See Appendix C for help in using them.

The best way to judge if your material will be

understood is to pre-test it with a sample group from

your audience

Several word processing software programs, including Microsoft Word® and Corel WordPerfect®*, include reading level assessment capabilities. Plain language experts, however, do not consider these computer tests reliable or valid for readability analysis and recommend:

• free-standing software, including Readability Calculations* or Readability Plus* from Micro Power & Light (www.micropowerandlight.com)

• a website using SMOG formula: www.harrymclaughlin.com/SMOG.htm* • additional tools are listed in Appendix C.

Readability tests are

only one useful tool for assessing readability of

written materials.

However, remember that readability tests are only one useful tool in assessing readability. The best way to judge if your material will be an effective communication tool is to pre-test it with a sample group from your intended audience.

Material testing and analysis are important considerations. For health communication efforts to succeed, learn what your audience knows or thinks about a subject, and anticipate how they may interpret new ideas. For example, by conducting usability testing focus groups or individual interviews with people from your intended audience before your first draft, you can gauge what they already understand about the topic. And you can test several possible approaches to presenting information. This testing should begin before you write the first word and continue until the final draft.

Find more information on how to conduct usability testing. Most programs need more than one research method, including pre- and post-testing methods. Many of these methods are thoroughly described in Making Health Communication Programs Work, U.S. Department of Health and Human Services, and in Methodological Review: A Handbook for Excellence in Focus Group Research, M. Debus. Usability testing is also defined by the Plain Language Association INternational at www.plainlanguagenetwork.org/plaintrain/Testing.html * Note: Mention of the software products does not constitute an endorsement by the CDC

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Appendix A: Checklist for Easy-to-Understand Print Materials

Message Content If you read only the captions, would you learn the main points?

Have you limited your messages to three to four messages per document (or section)?

Have you post-tested your materials? Layout and Design Have you taken out information that is “nice to

know” but not necessary? Is the most important information at the

beginning of the document? Is information presented in an order that is

logical to your audience? Is it repeated at the end? Is information chunked, using headings and

subheadings? Do lists include bullets? Have you identified action steps or desired behaviors for your audience? Have you eliminated as much jargon and

technical language as possible? Have you post-tested your materials? Is technical or scientific language explained? Have you used concrete nouns, an active voice,

and short words and sentences? Text Appearance Is the style conversational?

Does your document have lots of white space? Are margins at least 1⁄2 inch?

Have you post-tested your materials?

Translation Is the print large enough (at least 12 points)? Does it have serifs?

Have you used bold, italics, and text boxes to highlight information?

Are the language and content culturally appropriate?

Have you avoided using all capital letters? Are the visuals culturally appropriate? Is text justified on the left only? Have you had the piece back translated? Did you use columns with a line length of 40

to 50 characters of space? Is the translator fluent in the same linguistic

variation as the intended audience? Have you post-tested your materials? Have you post-tested your materials?

Visuals Understandability

Is the cover attractive to your intended audience? Does it include your main message and show who the audience is?

Have you tested the complexity of the language used in your material for comprehension? Are your visuals simple and instructive rather

than decorative? Have you pre-tested your materials with members of your intended audience? Do visuals help explain the messages found in

the text? Have you post-tested your materials with members of your intended audience Are your visuals placed near related text? Do

they include captions?

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Appendix B: Resources for Communication Planning Here are some additional resources for doing effective communication planning. 1. CDC’s National Center for Health Marketing offers clear and audience-centered products and services at www.cdc.gov/healthmarketing/ 2. CDCynergy― This is an interactive CD-ROM health communication planning tool, developed by CDC. It includes the following:

• an on-line workbook for developing a communication plan • information and examples to guide you in making choices about audiences, messages, channels, implementation, and evaluation • a glossary of health communication terms • a quick training guide to using the software

For more information about CDCynergy, visit our website at www.cdc.gov/healthmarketing/cdcynergy/ 3. Making Health Communication Programs Work― “Pink Book”- The “Pink Book” provides comprehensive instruction on communication planning, from formative research to communication principles to product evaluation. It is available at http://www.cancer.gov/pinkbook.

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Appendix C: Formulas for Calculating Readability Using SMOG Perhaps the quickest way to check a reading level manually is to use the SMOG estimating formula. G. Harry McLaughlin created SMOG (Simply Measure of Gobbledygook) in 1969 to estimate they years of education needed to understand a piece of writing. Here’s a quick way to estimate reading level. • Simply count the number of words with three or more syllables in three chains of 10 sentences in difference parts of your draft. • Then look up the approximate grade level in this chart. • The SMOG formula can predict the grade level difficulty within 1.5 grades in 68 percent of passages.

McLaughlin worked with programming expert Alain Trottier to produce a free SMOG calculator. The online calculator can service 30 to 2000 words at this link: www.harrymclaughlin.com/SMOG.htm.

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Appendix C: Formulas for Calculating Readability (continued) Using Fry Formula In 1977, Dr. Edward Fry created one of the most widely used readability formulas. Fry calculates the grade reading level by averaging the number of sentences and syllables per hundred words. Steps for you to follow: • Randomly choose three samples from your document with 100 words each. • Count the number of sentences in the hundred words, estimating length of the fraction of the last sentence to the nearest 1/10th. • Count the total number of syllables in the 100-word passage. Do not count numbers. Do count proper nouns. If you don’t have a hand counter available, an easy way is to simply put a mark above every syllable after the first syllable in each word. Then, when you get to the end of the passage, count the number of marks and add 100 to include the first syllable in each word that you did not mark. • Find the average number of sentences and the average number of syllables for the three samples by dividing the total of all three samples by three. • Use the graph on the next page to plot the average sentence length and number of syllables. The two lines will intersect at the approximate grade level. If a great deal of variability is found, try putting more sample counts into the average

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Appendix C: Formulas for Calculating Readability (continued)

Fry Graph* for Estimating Grade Levels

A ve

ra ge

N um

be r

of S

en te

nc es

(P

er 1

00 w

or ds

)

Average Number of Syllables

(Per 100 words) * From: Fry, Edward. Elementary Reading Instruction. 1977, McGraw-Hill

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Appendix C: Formulas for Calculating Readability (continued) Using Fry on Short Documents When your document has fewer than 300 words, you can use an adaptation of the Fry method. 1. Count total words, total sentences, and total syllables for the entire text. (Note: hyphenated words count as one word.) 2. Do these calculations: – Multiply the number of sentences by 100 and divide by the total number of words. This will give you the average number of sentences per 100 words. – Multiply the number of syllables by 100 and divide by the number of total words. This will give you the average number of syllables per 100 words. 3. Plot the averages on the Fry graph to find the readability score. Here is an example with fewer than 100 words.

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Appendix C: Formulas for Calculating Readability (continued) Here are two examples testing 100 words:

Example 1:

Example 2:

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Appendix C: Formulas for Calculating Readability (continued) Using Lexile Readability Analyzer Lexile Analyzer®, produced by MetaMetrics®, allows you to test the readability of your text by generating a Lexile® measure. (A free, limited version is available at www.Lexile.com.) The Analyzer measures sentence length and the familiarity of words used. Your word choice will be compared to word frequencies within a large database of literature. The Lexile® measure is a text difficulty score followed by an “L”. The scale ranges from below 200L for beginning-reader material to above 1700L for advanced text.

Lexile® Value Grade Level

300L 2nd grade 400L 3rd grade 1300L 12th grade

Using PMOSE/IKIRSCH Document Readability Formula Researchers Mosenthal and Kirsch developed a measure for assessing document complexity, called the PMOSE/ IKIRSCH document readability formula. The PMOSE/IKIRSCH formula measures complexity based on three factors:

• The structure of the document, • The density of the information, • The relative dependence on information from other documents.

This tool is particularly useful for documents that include forms, tables, graphs, charts, and lists. PMOSE/IKIRSCH measures the readability of information organized in rows and columns. 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.

Proficiency Grade Level Equivalent Level 1 Grade 4 >8 years of schooling Level 2 Grade 8 to high school diploma Level 3 Grade 12 some education after high school Level 4 15 years of schooling college degree equivalent Level 5 16 years of schooling or

more advanced post college degree

The next page is the Mosenthal and Kirsch’s worksheet that you can apply to your text. Please note that the complexity of word choice is not a consideration in this tool.

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Appendix C: Formulas for Calculating Readability (continued)

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Appendix D: Resources Books Bigwood S, Spore M. Presenting Numbers, Tables, and Charts. New York: Oxford University Press; 2003. Debus, M. Methodological Review: A Handbook for Excellence in Focus Group Research, Academy for Education Development; 1988. Doak C, Doak L, eds. Pfizer Principles for Clear Health Communication: A Handbook for Creating Patient Education Materials that Enhance Understanding and Promote Health Outcomes, Pfizer; 2nd Edition, 2004. (www.pfizerhealthliteracy.com/pdf/PfizerPrinciples.pdf) Doak C, Doak L, Root J. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia, PA: J.B. Lippincott Company; 1996. (www.hsph.harvard.edu/healthliteracy/doak.html) Graham L. Basics of Design: Layout and Typography for Beginners. Albany, NY: Delmar; 2001. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A first look at the findings of the National Adult Literacy Survey. 3rd edition. Vol. 201. Washington, DC: National Center for Education, U.S. Department of Education; 2002. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of American’s Adults: Results from the 2003 National Assessment of Adult Literacy (NCES2006-483). Washington, DC: U.S. Department of Education; 2006. Lohr, Linda. Creating Graphics for Learning and Performance: Lessons in Visual Literacy. NJ: Merrill Prentice Hall; 2003. Lynch P, Horton S. Web Style Guide, 2nd edition; 2005. National Cancer Institute. Clear & Simple: Developing Effective Print Materials for Low-literate Readers. Pub. No. NIH 95-3594. Washington, DC: DHHS; 1995. National Cancer Institute. Making Health Communication Programs Work.(aka “Pink Book”) U.S. Department of Health and Human Services; National Institutes of Health; 2004. Nelson R. Consumer Informatics: Applications and Strategies in Cyber Health Care (Health Informatics). Springer; 2004. Nielsen-Bohlman L, Panzer A, Kindig D, eds. Health Literacy: A Prescription to End Confusion. Committee on Health Literacy, Board on Neuroscience and Behavioral Health, Institute of Medicine of the National Academies. Washington, DC: The National Academies Press; 2004. Osborne H. Overcoming Communication Barriers in Patient Education. NAL Call No.: R118 O83 2001 ISBN: 083422030X. Gaithersburg, MD: Aspen Publishers, Inc; 2001. Rudd RE, Anderson JE, Oppenheimer S, Nath C. Health Literacy: An Update of Public Health and Medical Literature. Chapter 6 in Comings JP, Garner B, Smith C. (eds.) Review of Adult Learning and Literacy, Vol. 7. Mahway, NJ: Lawrence Erlbuam Assoc., pp. 175-204, 2007. Southern Institute on Children and Families. The Health Literacy Style Manual. Covering Kids and Families National Program Office. Columbia, SC: Maximus (Reston, VA); 2005. Strunk W. Jr., White E. The Elements of Style. New York, NY: MacMillan; 1979. Thompson T, Dorsey A, Miller K, Parrott R, eds. Handbook of Health Communication. Mahwah, NJ: Lawrence Erlbaum Associates; 2003.

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Appendix D: Resources (continued) Journal Articles, Reports, Brochures, Pamphlets, and Miscellaneous Publications Albright J, de Guzman C, Acebo P, Paiva D, Faulkner M, Swanson J. Readability of patient education materials: Implications for clinical practice. Applied Nursing Research 1996; 9(3):139-43. Baker G. Writing easily read patient education handouts: A computerized approach. Seminars in Dermatology 1991; 10(2):102-6. Baker L, Wilson F. Consumer health materials recommended for public libraries: Too tough to read? Public Libraries 1996; 35(2):124-30. Baker L, Wilson F, Kars M. The readability of medical information on InfoTrac: Does it meet the needs of people with low literacy skills? Ref User Serv Q 1997; 37(2):155-60. Baker S. Who can read consumer product information? American Journal of Health-System Pharmacy 1997; 27(2):126-31. Baker D, Parker R, Williams M, Clark W, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health 1997; 87:1027-30. Basara L, Juergens J. Patient package insert readability and design. American Pharmacy 1994; NS34(8):48-53. Brownson K. Education handouts. Are we wasting our time? Journal for Nurses in Staff Development 1998; 14(4):176-82. Carmona R. Improving Americans’ health literacy. Journal of the American Dietetic Association 2005; 105:1345. Cardinal B, Seidler T. Readability and Comprehensibility of the Exercise Life (brochure). Perceptual and Motor Skills 1995; 80:399- 402. Coey L. Readability of printed educational materials used to inform potential and actual ostomates. Journal of Clinical Nursing 1996; 5:359-366. Davis R, Jackson R, Bocchini J, Arnold C, Mayeaux E, Murphy P. Comprehension is Greater Using a Short Vaccine. Information Pamphlet with Graphics and Simple Language. Journal of General Internal Medicine 1994; 9(Supp. 2):103.

Davis, T, Bocchini J, Jr, Fredrickson D, Arnold C, Mayeaux E, Murphy P, Jackson, RH, Hanna, N, Paterson, M. Parent Comprehension of Polio Vaccine Information Pamphlets. Pediatrics 1996; 97(6):804-10. Davis T, et al. Improving Vaccine Risk/Benefit Communications with an Immunization Education Package: A Pilot Study. Ambulatory Pediatrics 2002; 2(3):193-200. Feldman S, Quinlivan A, Williford P, Bahnson J, Fleischer A, Jr. Illiteracy and the readability of patient education materials. A look at Health Watch. North Carolina Medical Journal 1994; 55(7):290-2. Gabriel V, Stephenson T. Readability of patient information leaflets. Journal of Pediatric Pharmacy Practice 1998; 3(1):29-32. Grotsy R. Plain Language: It’s effect on organizational performance. Clarity. May 2004; 51:17-19. Hobbie C. Maximizing healthy communication: Readability of parent educational materials. Journal of Pediatric Health Care 1995; 9(2):92-3.

Hospital Case Management, It’s on paper but do they understand it? Simple testing gets written handouts on target. Hospital Case Management 1999; 7(4):75-6, 80.

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Appendix D: Resources (continued) Houts p, Doak C, Doak L, Loscalo,M. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Education and Counseling 2006; 61:173-190. Johnson H. Readability study of client health education materials: A resource for assuring the effectiveness of written materials. Raleigh (NC): North Carolina State Dept. of Environment, Health, and Natural Resources. May, 128 p. Available from: ERIC Document Reproduction Service, Springfield, VA 1994; No. ED382934. Katz M, Kripalani S, Weiss B. Use of pictorial aids in medication instructions: A review of the literature. American Journal of Health- System Pharmacists. December 1, 2006; 63:2391-2397. Kleimann S, Enlow B. Is plain language appropriate for well-educated and politically important people? Results of research with congressional correspondence. Clarity. November 2003; 50:4-11. Koba H. Putting it plainly becomes communications. Mission of Ontario, Ministry of Health. Journal of the Canadian Medical Association 1993; 148(7):1202-03. Kreuter M, Strecher V, Glassman B. One size does not f t all: The case for tailoring print materials. Society of Behavioral Medicine 1999; 21:276-83. Kripalani S, Weiss B. Teaching about health literacy and clear communication. Journal of General Internal Medicine 2006, 21(8):888- 90. Massett, H. Evaluation of CDC Print Materials. Presentation to the Office of Communication, CDC. December; 1996. Meade C, Howser D. Consent forms: How to determine and improve their readability. Oncology Nursing Forum 1992; 19(10):1523- 28. Meade C, McKinney W, Barnas G. Educating patients with limited literacy skills: The effectiveness of printed and videotaped materials about colon cancer. American Journal of Public Health 1994; 84(1):119-21. Michielutte R, Bahnson B, Beal P. Readability of the public education literature on cancer prevention and detection. Journal of Cancer Education 1990; 5(1):55-61. Michielutte R, Bahnson J, Dignan M, Schroeder E. The use of illustrations and narrative text style to improve readability of a health education brochure. Journal of Cancer Education 1992; 7(3):251-60. Montori V, Rothman R. Weakness in numbers: the challenge of numeracy in health care. Journal of General Internal Medicine 2005; 20:1071-1072. Neuhauser, L. & Kreps, G. Online cancer communication interventions: Meeting the literacy, linguistic and cultural needs of diverse audiences. Patient Education and Counseling. Available online: doi:10.1016/j.pec.2008.02.015 Parker R, Gazmararian J. Health literacy: essential for health communication. Journal of Health Communication 2003; 8:S116-8. Plimpton S, Root J. Materials and strategies that work in low literacy health communication. Public Health Reports 1994; 109(1):86- 92. Rice M, Valdivia L. A simple guide for design, use, and evaluation of educational materials. Health Education Quarterly 1991; 18(1):79-85. Riche J. Text and reader characteristics affecting the readability of patient literature. Reading Improvement 1991; 28(4):287-92. 40

Appendix D: Resources (continued) Root J. Effective materials for the low-literacy population. California AIDS Clearinghouse Reviewer 1990; 2(3):1&3. Rudd RE, Kaphingst KA, Colton T, Gregoire J, Hyde J. Rewriting Public Health Information in Plain Language. Journal of Health Communications, 9: 195-206. 2004. Sentell T, Halpin H. Importance of adult literacy in understanding health disparities. Journal of General Internal Medicine 2006; 21(8):862-6. Shield J, Mullen M. Developing client education materials. In: Communicating as Professionals. Chernoff R, ed. Chicago, IL: American Dietetic Association; 1994. Siminerio L, Frith M. Need to assess readability of written materials for diabetes education curricula. Diabetes Care 1993; 16(1):391- 93. Spyridakis J, Wegner M. Writing for Human Performance. Relating Reading Research to Document Design. Technical Communications, 2nd quarter 1992; 202-15. Stephens S. Patient education materials: Are they readable? Oncology Nursing Forum 1992; 19(1):83-5. Substance Abuse and Mental Health Services Administration, DHHS. You Can Prepare Easy-to-Read Materials, “The Fact Is….” Communication Series; 1992. Tips for improving patient education materials: The right readability level is one key to success. Health Care Food and Nutrition Focus 1997; 14(2):1, 3. Zimmerman M, Newton N, Frumin L, Wittet S. Program for Appropriate Technology in Health (PATH). Developing Health and Family Planning Materials for Low-Literate Audiences: A Guide. Oxford University Press 1996. Web Sites AMA Foundation Health Literacy Initiative http://www.ama-assn.org/ama/pub/category/8115.html The AMA Foundation is working to raise awareness among health care providers about the link between health and literacy. Their web site includes a toolkit, a train-the-trainers seminar, and a grants program. Current Bibliographies in Medicine/Health Literacy http://www.nlm.nih.gov/pubs/cbm/hliteracy.html This site is part of the National Library of Medicine Database and has a large amount of background information about health literacy. Health Literacy Studies/Harvard School of Public Health http://www.hsph.harvard.edu/healthliteracy This site has information for researchers and practitioners in the public health, medical, and adult education fields. You can find the following health literacy materials: PowerPoint overview, preview of a new video, curricula, literature review, annotated bibliography, and links to related sites. Of special interest to literacy teachers and learners is a listing of links to easy-to-read health information sites, grouped by health topic. Medical Library Association Health Information Literacy http://www.mlanet.org/resources/healthlit/tfhil_info.html This site includes resources for health information professionals and consumers.

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Appendix D: Resources (continued) National Institute for Literacy http://novel.nifl.gov The National Institute for Literacy (NIFL) is a government-administered group that supports and encourages efforts to provide a high- quality system for adult literacy. The site includes information about NIFL programs and services, as well as provides information about policy, legislation, and programs related to literacy. Plain Language Association International http://www.plainlanguagenetwork.org/ Plain Language Association International is a volunteer professional association that advocates clear writing and provides free online resources to help you use language that is easily understood. Writing Reader-Friendly Documents http://www.plainlanguage.gov/index.cfm The Plain Language Action and Information Network promotes the use of plain language for all government communications. They offer to all federal agencies limited editing and review services, sponsor occasional seminars about plain language, and offer a half- day introduction to plain language free-of-charge. Clip-Art Resources Centers for Disease Control and Prevention The Centers for Disease Control’s public health image library has a variety of images relating to public health. http://phil.cdc.gov/Phil/default.asp Johns Hopkins University This database of clip-art is from Johns Hopkins Center for Communication Programs’ Health Communications Network. http://www.hcmn.org/clipart. Multimedia and Web Services Anatomy Clip-Art This web site features an electronic gallery of high-quality images from various medical fields. http://www.uthscsa.edu/mw/illustration-about.aspx Visuals Online (National Cancer Institute) The NCI Visuals Online database contains images of food and people that can be used free of charge. Website: http://visualsonline.cancer.gov/

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Acknowledgements CDC wishes to thank the following external reviewers for the 2009 edition of Simply Put: Terry Davis, Louisiana State University Health Sciences Center Linda Neuhauser, UC Berkeley School of Public Health Audrey Riffenburgh, Plain Language Works Rima Rudd, Harvard School of Medicine

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.

Simply Put A guide for creating easy-to-understand materials

Strategic and Proactive Communication Branch Division of Communication Services

Office of the Associate Director for Communication Centers for Disease Control and Prevention

Atlanta, Georgia

July 2010 Third Edition

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