Local context may be more important than technical elements of the text. A study of cancer patients in Australia (Butow), asked participants to examine five chemotherapy booklets and choose the most relevant and informative. Patients uniformly chose the booklet that reflected none of the principles of clear language. It had no illustrations or photographs and was written in a narrative format. The main difference between this booklet and the others was that it was produced by a local cancer society. Others were written by health care facilities or the national cancer association. Changes to print materials alone cannot address larger issues which more directly affected patients’ experiences. A Dutch study examined whether a clear pamphlet about mammography would encourage women to return for follow-up tests after their initial breast screening. Although women read the clear pamphlet more thoroughly than the more complex version, they did not return because the procedure was painful and their interactions with staff were not pleasant. Researchers concluded that the leaflet was “too weak an intervention” to influence women’s decision to return (Drossaert). The research showed that it does not matter how print materials are written if other factors are barriers to health care.

Looking ahead

Print materials alone do not help most people understand and remember the content. Some people do not and never will rely on print materials. In light of this, health professionals need to find other ways to provide patients with health information. Several researchers suggested that effective interventions would include more face-to-face interactions with patients, greater use of alternative media (including audio-visual materials) and opportunities for patients to discuss information with health care professionals and other patients. Future research could measure the effectiveness of:

• increasing the amount of time health professionals spend with patients (Tymchuk, Reid)
• supplementing print materials with presentations, instructions, group discussions and video materials (Davis 1996, Reid, Taub, Young);
• training members of specific communities to do outreach and patient education within their community, and to develop culturally-specific materials (Pardini).

Key Findings

• Medical research has not explicitly considered the impact of plain language materials on people with limited literacy.
• Many people cannot understand print materials alone. More interaction with patients is essential. Alternative media may help get the message across.
• Materials should address patients’ concerns and questions. Materials based on what health professionals believe patients “should” know are less likely to be understood than materials developed in the community or with patients.

When developing print materials…

• Readability formulas help, but are not enough. Good writing requires excellent organization, clear headings, and an engaging style.
• Rhetorical devices such as repetition, questions, and concrete examples can help people absorb and remember information.
• Materials should aim for a Grade 5 reading level on the Flesch-Kincaid scale. However, readability formulas cannot predict whether patients will understand the material.
• Illustrations and headings can help, but colours can distract or become an additional code that people need to learn to “read.”
• Materials should be developed in collaboration with target populations.