Feedback from patients and family members was gathered in an informal manner. Patients and family members were approached in the waiting areas of the three units and asked for their general impressions of the print materials. Input was voluntary and anonymous. They were asked to comment only on the print material created for the unit they were in, not on the materials for other units. Only the English and French versions were shown. Feedback on the Spanish and Chinese translations, as well as the multi-lingual audio-recordings, should be carried through in the next phase of the project. The coordinator left notes on all interviews, but provided more detailed observation and feedback from the patients identified as "hard-to-reach."

She found that patients who did not speak either English or French paid little or no attention to visual materials on the walls, and suggests that this underlines the need for multi-lingual translations of key information. It also calls into question the role of visual cues and their ability to attract attention and convey information if there is a language barrier. She also found that some patients whose mother tongue is neither English nor French may have a functional knowledge in either of these two languages; this can deceive nurses who may over-estimate what the patient understands. For example, a dialysis patient, who spoke English as his second language, read the MRSA pamphlet, but did not know the word "pneumonia," one of the potential effects of an MRSA infection. He had never used this word in English. Once explained, he understood.

Sometimes the line between a linguistic barrier and another type of communication barrier was not clear. The husband of a chemotherapy patient identified as hard-to-reach for linguistic reasons looked at the storyboard, A Day in Chemotherapy. Like his wife, he spoke little English or French. He looked at each board carefully, but not in sequence. His only reaction was a nod of the head. It was not possible for the coordinator to know within the framework of the informal feedback process why he did not follow the sequence. She wondered: Was it because the words were not in his native language? Was it a sign of a sequencing problem - a learning problem? Did he lack basic reading skills - following text from left to right being an essential basis for reading the Roman alphabet? In further discussion, the Steering Committee wondered whether there might have been something in particular posters that attracted his attention. Whatever the reason, he was not receiving the message that was intended.

The feedback uncovered cognitive barriers in a patient who had had a stroke and visual impairment among some older patients who chose the simpler messages in larger typeface. The coordinator noted that new patients in Chemotherapy were so anxious that they never looked at the wall display until it was pointed out to them; returning patients, however, commented positively on the materials.

This raises the question of the role of mediation in conveying health messages. Simply relying on print or visual cues without showing or giving explanations may not be effective. Several feedback sessions seemed to indicate the importance of direct intervention.

Overall, the majority preferred the new materials, but it was not clear that plain language or visuals necessarily made information more accessible for the hard-to-reach. This will have to be investigated more thoroughly in the next phase.