Medical concepts and language are very complex. People need easily understandable health information regardless of age, background or reading level. Here are guidelines to help you create easy-to-read health materials.
What are easy-to-read (ETR) materials?
ETR materials are written for audiences who have difficulty reading or understanding information.
How can you create easy-to-read materials?
Writing ETR materials for MedlinePlus is a process involving several important steps:
Step 1: Plan and Research
Determine and know your target audience. Consider reading level, cultural background and attitudes, age group and English Language Proficiency (ELP).
- Determine the target audience. Who will read your health materials? For example, the writing style and graphics will be very different for an HIV/AIDS brochure for Hispanic teens than California adults over age 50.
- Research your target audience. Use tools such as databases, demographic information, surveys and interviews to learn about the need of the target group. If extensive research is not feasible due to time or budget constraints, contact other organizations who communicate regularly with similar target audiences.
- Include your target audience. Bring members of the audience into early planning stages or to test a draft of your material, if at all possible. This can be time consuming, but is especially important in cross-cultural communication.
- Determine objectives and outcomes. What do you want your target audience to do as a result of reading your document? For example, if your objective is to show the proper use of asthma inhalers, emphasize the outcome of their proper use. A sample sentence might be: "Following the directions for your asthma inhaler may help you to breathe easier."
Step 2: Organize and Write
- Keep within a range of about a 6th to 7th grade reading level. See reading level calculator information below. This is especially important in the first few lines of text. If the reader has difficulty at the beginning, they may stop reading.
- Focus on a 2-3 key concepts.
- Use a clear topic sentence at the beginning of each paragraph. Follow the topic sentence with details and examples. For example, "Proper use of asthma inhalers helps you breathe better. Here are reasons why." Then give reasons.
- Examples and stories may help engage readers. Use words like "you" instead of "the patient."
- Structure the material logically, but include your most important points at the beginning of the document. You need to grab the reader's attention at the beginning. People often do not read all the text and may miss your key point if you save the best for last.
- Some users prefer step-by-step instructions. Others may find concepts arranged from the general to the specific easier to understand. The order may also depend on the type of task you are describing. Some tasks must be done in a step-wise way and others do not.
- Include specific actions the reader may or should take. Your document's purpose should not be solely to inform but also to get the reader to take an action.
- Avoid abstract words in instructions for actions. For example, instead of "Don't lift anything heavy," use "Don't lift anything heavier than a gallon of milk (over about 10 pounds)."
- Emphasize the benefits of the desired behavior. For example, "Do these steps to get enough medicine from the inhaler."
- Do not make assumptions about people who read at a low level. Don't talk down to the reader. Maintain an adult perspective.
- People for whom English is a foreign language may have not learned medical or health terms.
Language and writing style
- Find alternatives for complex words, medical jargon, abbreviations, and acronyms. At times there may not be an alternative or you may want to teach patients the terms because their providers will be using them. In that case, teach the terms by explaining the concept first in plain language. Then give the new term. Also provide a simple pronunciation guide. For example, " A normal heart beat starts in the upper right chamber of the heart, or atrium (ay-tree-yim)." Also, see thesaurus resources below.
- Keep most sentences 10-15 words long. Use varied sentence length to make them interesting, but keep sentences simple.
- Where appropriate, use bulleted lists instead of blocks of text to make information more readable.
- Use the active voice and vivid verbs. Here's an example:
Active: Amanda used her inhaler today.
Passive: The inhaler was used by Amanda today.
- Be consistent with terms. For example, don't use "drugs" and "medications" interchangeably in the same document.
- When possible, say things positively, not negatively. For example, use "Eat less red meat" instead of "Don't eat lots of red meat."
Visual Presentation and Representation
- Use colors that are appealing to your target audience. Be aware, however, that some people may be color blind and may have trouble distinguishing red from green.
- Use illustrations and photos with concise captions. Keep captions close to photos and illustrations.
- Avoid graphs and charts unless they actually help understanding. If you do use them, make sure they are simple and clear.
- Balance the use of text, graphics, and clear or "white space". Try for 40-50% white space.
- Avoid using all capital letters. Upper and lower case are easier to read. To show emphasis, use bold, larger type size or different fonts.
- Avoid italics of more than a few words at a time.
- Make print large enough for your target audience. For most readers text the equivalent of Times New Roman 12 point is adequate. For seniors, consider using 14 point.
- Use easy to read fonts such as Times Roman, Arial, Tahoma and Helvetica.
- Use bolded headings and subheadings to separate and highlight document sections.
- When possible, use graphics or spell out fractions and percentages.
- Only justify the left margin. This means the left margin should be straight and the right margin should be "ragged."
- Use column widths of about 30-50 characters long (including spaces) or 3 to 5 inches.
- Do not print text on top of shaded backgrounds, photos, or patterns.
Step 3: Evaluate and Improve
Always test your materials on a few individuals or a sample group from your target audience. Evaluate the feedback and revise your material if necessary. Testing during the writing process can help ensure your audience is getting the message. For more information, see the pretest and revision section from the National Cancer Institute's "Clear and Simple" publication or go Part 6 of the detailed guide, Centers for Medicare & Medicaid Services. Toolkit for Making Written Material Clear and Effective.
Following are samples of readability assessment tools:
- Fry Readability Graph. A commonly used readability assessment tool. See the Iowa Department of Public Health's Fry Readability Graph page. (PDF)
- SMOG. Less frequently used than the Fry Graph, but still widely used.
- Gunning FOG. One of the first readability tools. It is widely used. See the Iowa Department of Public Health's Gunning-FOG Readability page. (PDF)
- SAM (Suitability Assessment of Materials). A tool created by Cecilia and Leonard Doak. SAM assesses not only readability, but also usability and suitability elements.
- Flesch Reading Ease / Flesch-Kincaid Grade Level. Used in the Microsoft Word grammar checker. Use this method with caution. The Flesch-Kincaid score tends to be 2-3 grades lower than other trusted assessment tools. So if you get a score of 8, your text is probably actually more like 11 on the SMOG. For more information on readability, see Harvard School of Public Health's Assessing and Developing Health Materials page.
Readability software programs
These are examples of software programs. Other programs exist. Readability software may not be suitable for every ETR project. Note: NLM makes no endorsements in displaying these examples.
If you're going to use a website or software program, you'll need to prepare your text first. You will have problems with reliability and accuracy if you don'`t "clean up" your text first.Be sure to go through the document and delete:
- sentence fragments
- lists with bullets (if bullets are complete sentences, you can use them in your sample)
- periods that don't mark the end of a sentence, such as numerals in a numbered list (1. or 2.); abbreviations (Jill M. Sanchez, M..D. or Q. & A.); periods in e.g., or i.e.; decimals (98.6 degrees or 12.9%); or periods in times (9 a.m.)
If you don't remove extra periods, your software may "see" many more sentences than are really there. This will artificially lower your readability score.
- Health Literacy Advisor (Add-on to Microsoft Word)
- TextQuest (Windows and Mac)
- Readability Plus (Windows and Mac)
- Readability Studio (Windows)
- Stylewriter (Windows and Mac)
- UNIX commands to help identify readability and style issues
Step 4: Inform Us and Stay Informed
After you create ETR materials, we suggest you label them "easy-to-read." MedlinePlus will display materials as easy-to-read only if the sponsoring organization labels them. NLM does not evaluate materials for reading level. Make sure your materials are truly easy if you are going to submit them as "easy-to-read."
Here are some lists of other materials that may be helpful.
Sites with easy-to-read health materials
- National Institute of Diabetes & Digestive & Kidney Diseases. Easy-to-read publications page
- National Institute of Mental Health. Easy-to-read publications page
Guidelines and bibliographies for developing easy-to-read materials
- Centers for Disease Control and Prevention. Simply Put (PDF).
- Centers for Medicare & Medicaid Services. Toolkit for Making Written Material Clear and Effective
- Covering Kids & Families. Health Literacy Style Manual. October 2005.
- Group Health Research Institute. Program for Readability in Science & Medicine (PRISM)
- National Cancer Institute. Clear & Simple: Developing Effective Print Materials for Low-Literate Readers
- National Library of Medicine. Current Bibliographies in Medicine 2004-1. Understanding Health Literacy and its Barriers
- Society for Technical Communication, Usability Special Interest Group. Readability Research
- U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health Literacy Online: A Guide to Writing and Designing Easy-to-Use Health Web Sites.