How do patients receive and understand information?

Given the choice, patients prefer clear materials with some illustrations (Bernardini, Bjorn, Cardinal, Davis 1996). Improving the layout and look of materials can have an impact on how participants react to them. In one study, patients trusted therapists who used clear consent forms more than therapists with unclear forms; they believed that the clear forms were more relevant, even though the two forms included essentially the same information (Wagner). In several studies, texts with illustrations emphasizing key points were better received than solid text (Michielutta, Moll). One study, which has yet to report its findings, posited that culturally-specific material was essential (Pardini) while another showed that patients preferred materials with culturallysensitive illustrations (Davis 1998a). Some studies acknowledged that many patients simply do not use print as their preferred method to access information (Davis 1998a, Husted).

How can information and forms be made more readable?

Many researchers understood the principles of clear language that should have made health education materials easier to understand. They revised materials by breaking up longer sentences, substituting lay language for professional jargon, using point form, illustrations and white space, and lowering reading levels.

Most studies found that the ideal reading level for print materials was Grade 5 on the Flesch-Kincaid scale (Meade). However, even if a document was technically more readable, people did not necessarily understand more. Several studies found that the print material alone was not enough to ensure that patients were able to read, understand and remember information (Butow, Cardinal, Davis 1998a, Drossaert, Estey 1994, Tymchuk).

Why are “readable” materials not understood? Several studies noted that people with higher levels of education were more likely to understand print materials than people with less education. However, lowering the reading level of a text from, for example, grade 11 to grade 5 did not guarantee that people with grade 12 or even a year of university would understand the information (Cardinal). Several studies sought to understand why materials were so difficult to understand.

They concluded that:

• research is an artificial environment, which could affect how much attention patients give to the task of reading (Bjorn);
• materials which are more readable according to technical measures, such as readability formulas, may still use unfamiliar syntax, vocabulary or points of reference (Estey 1994, Reid);
• patients who need information may be affected by physical factors such as pain or discomfort, or stress caused by illness (Estey 1993); and
• there are significant differences between what patients want to know and what health professionals think they should know (Reid, Davis 1998a).

What factors affect patients’ use or disregard of print materials?

A few studies noted that people understand and remember what is important to them, yet the kinds of information that health professionals believe is important is not the same as the knowledge sought by patients (Reid). Most health education materials are developed with little regard for issues patients feel are important. An American study noted that patient education materials designed for low income, low literate minority women did not include information about cost, while cost was their most pressing question (Davis 1998a). In another study, physicians and patients were asked to underline the twenty most important points in the same leaflet. Physicians chose passages which described physiopathology, while patients indicated treatments and prognosis. From this, the study concluded that the most useful materials begin with what patients know and have questions about, rather than with what health professionals feel people should know (Reid).