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MHPrintGuidelines.pdf

G u i d e l i n e s f o r E f f e c t i v e P r i n t C o m m u n i c a t i o n

A Guide to Creating and Evaluating Patient Materials

Sincerely,

Deborah Deatrick, MPH Vice President of Community Health

Jeff Aalberg, MD Senior Medical Director, PHO

Jackie Cawley, DO Senior Medical Director, MaineHealth

Dear Colleagues:

MaineHealth’s aim to provide the best possible care for our patients and communities requires effective health communication. As our population ages and diversifies, and as medicine and self-care grow ever more complex, the ways in which we communicate become even more important. This guide is a tool for all MaineHealth member and affiliate organizations to communicate clearly and consistently with patients and families.

Supports our goals. Effective communication to our patients and community members supports MaineHealth goals to:

■ Promote patient understanding and ability to adhere to prevention, treatment and care plans

■ Provide safe, effective, quality care

■ Streamline care

■ Meet new Joint Commission accreditation guidelines

Reflects evidence and best practice. The Checklist to Develop and Evaluate Patient Education Materials and the guidelines that follow are evidence-based and reflect best practice. Many of our patients have limited literacy and health literacy skills. They require easy-to-understand information. All adults, when sick or stressed, need clear, accessible information. And almost all adults prefer it. No one wants to struggle to grasp instructions critical to his or her well-being.

Addresses national priorities. These guidelines also reflect recommendations of national medical, public health, research and policy groups including the Institute of Medicine, the American Medical Association, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and The Joint Commission.

Guidelines are only as effective as their implementation. We will help you learn how to use them. MaineHealth Learning Resource Center staff provide training and consulting in developing patient- friendly print materials. Contact them for help with your next patient materials project.

Thank you for your leadership and commitment to providing the best patient care possible and for helping to implement this guide in your organization.

G u i d e l i n e s f o r E f f e c t i v e P r i n t C o m m u n i c a t i o n Why is this important?

Table of Contents

Key Facts About Health Literacy 1

Developing Patient Education Materials: A Step-by-Step Approach 3

Checklist to Develop and Evaluate Patient Education Materials 4

■ Key Elements 1 and 2: Content and Structure/Organization 5

■ Key Element 3: Writing Style 7

■ Key Element 4: Appeal/Document Design 9

■ Key Element 5: Cultural Sensitivity and Appropriateness 11

Readability 12

■ What Is Readability? 12

■ Readability in Word Processing Programs 12

Checklist Worksheet 13

Additional Resources 16

Guidelines for Effective Print Communication

Key Facts About Health Literacy

Literacy and health literacy affects all Americans.

■ Literacy: The ability to read, write, compute, understand and use written information. Even adults with adequate literacy skill may struggle with health literacy.

■ Health literacy: The ability to use complex literacy skills in health-related circumstances and environments to help prevent, manage and treat health conditions.

■ Health literacy as a policy issue reflects the mismatch between the limited literacy skills and understanding of health context that adults “bring to the table” and the high levels at which health professionals usually communicate. Average reading level for working adults is about grade level 7/8. Elders and other vulnerable population groups demonstrate even more limited skills. “Yet, most health information is delivered at a high school level or above - far beyond adult abilities.” Well-educated adults prefer easy-to-read information. They don’t want to struggle to understand.

Results of the 2003 National Assessment of Adult Literacy showed that only 12 percent of American adults have proficient health literacy skills.

■ Nearly half of American adults lack adequate literacy skills. More than half lack adequate numeracy skills to function effectively in our information-dependent culture.

■ The most vulnerable populations have the most limited literacy skills: elders, Hispanics/ Latinos, immigrants, the poor and adults with chronic health conditions.

■ Groups with limited literacy skills have poor health. Research has shown lower adherence to medication and treatment plans, reduced levels of prevention, and increased hospitalizations and deaths.

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Key Facts About Health Literacy

Key Facts About Health Literacy Evidence supports 2 major solutions | Teach-back and plain language ■ Teach-back in verbal communication improves patient understanding and outcomes.

■ Plain language in all forms of communication - print, verbal, electronic, media - increases understanding and patient adherence to instructions.

■ Plain language is more than short words. It means using proven techniques to plan, structure, write and design clear, accessible information.

“Dumbing down” information is a myth - one of many.

■ Adults prefer easy-to-use information, especially when they are stressed or hurried.

■ Plain language is legal and is supported by the American Bar Association.

■ Plain language is savvy business. It protects organizations and satisfies customers.

As our patient population ages and diversifies, the need to understand health literacy and respond with effective communication strategies will increase.

■ Maine has one of the fastest-aging populations in the country and is growing more diverse.

■ Effective communication addresses patients’ needs, Joint Commission requirements, patient safety and patient-centered care goals, and business realities.

■ All departments can use the materials guidelines and supporting documentation to help achieve a common goal: communication excellence.

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P L A N N I N G

1 . Determine the purpose. List the behaviors or actions you expect your audience to take. Write down what they need to know to take those actions.

2 . Identify key players and those with a vested interest in the material. Consider who should contribute: content expert, legal adviser, clinician, health educator, care manager, marketing/ community relations, program managers and patient advisors.

3 . Identify the audience. Think carefully about whom you are tr ying to reach. Consider: W hat does the audience know? W hat skills do they need? W hat are their concerns? This is the time to talk with members of your target audience to learn more about them.

4 . Don’t reinvent the wheel. Check to see if the materials you need have already been developed within the MaineHealth system or beyond.

5 . Think about how your educational piece will be designed, printed and distributed.

6 . Develop a timeline for the project.

D E V E L O P M E N T / D E S I G N / T E S T I N G

7 . Develop and write the material, using these guidelines.

8 . Obtain feedback from clinicians and other members as appropriate to validate the accuracy of the clinical content.

9 . Consult with the marketing/community relations department about the material ’s design.

1 0 . Test your material ’s with consumers. Validate that it ’s meeting the goals you had in mind. Revise as needed. R E V I E W A N D A P P R O VA L

1 1 . Developer(s) will submit the material to the appropriate workgroup or committee for review and recommendations along with a brief statement of the piece’s purpose, the audience and the testing that has been done.

1 2 . Send material to your marketing/community relations department for review and proofreading. For larger booklets, you may want to consider contracting with an outside proofreader to review the full document. Contact the marketing/community relations department for more information.

Developing Patient Education Materials A Step-by-Step Approach

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A Step-by-Step Approach Checklist

Checklist to Develop and Evaluate Patient Education Materials Issue 1: Audience is clear. Audience is _________________________________________

Issue 2: Purpose is clear. Purpose is ___________________________________________

Issue 3: Patient/consumer testing planned ______________________________________

Key Element 1: Content

❏ Limited (three to five points) and action-focused (what to do/need to know) ❏ Accurate, evidence-based and up to date ❏ Framed to gain positive audience response ❏ Includes clear call to action as appropriate

Key Element 2: Structure/Organization

❏ Content broken into small chunks with important points first ❏ Subtitles/headings are statements, questions or action phrases that guide the reader ❏ Content sequenced according to reader need to know ❏ Key points are repeated as appropriate

Key Element 3: Writing Style

❏ Personal, conversational (use pronouns appropriately and consistently) ❏ Short words/short sentences/lay language; technical terms explained ❏ Mostly active voice; verbs carry the action ❏ Short paragraphs (about three to five sentences) that stick to one point ❏ Short lists (about three to five items) using bullets, not comma strings

Key Element 4: Appeal/Document Design

❏ Piece attracts attention/draws reader in ❏ Text design makes it easy to skim and scan content ❏ Overall design reflects plain language standards for font type and size, print/paper contrast, line length, white space, justification ❏ Images, lists, charts are clear/support message/reflect audience

Key Element 5: Cultural Sensitivity and Appropriateness

(As applicable, reflects needs and values of cultural groups defined by ability/disability, gender orientation, race/ethnicity, socio-economic status, etc.) ❏ Uses preferred and respectful terms to refer to the group or condition, and focuses on the person Example: “a person or patient with diabetes” instead of “the diabetic” ❏ Considers ease of potential translation/transadaptation if applicable ❏ Reflects group understanding of health/illness and role of medical care ❏ Considers use of complementary medicine or other practices ❏ Reflects expected roles of individual, family and clinician in medical decisions

Checklist Worksheet can be found on Page 13.

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Limit content. Organize and structure to guide readers.

Adults can read, remember and use only three to five key points at one time. If understanding a health condition or instruction requires more points, group or chunk them into sections that can be read over time. Double-check that information is accurate, evidence-based and up to date.

Plan with the end in mind - usually action. What behavior or action do you want the reader to carry out? Learn about your audience, and plan materials to address their needs, concerns, beliefs and skills.

■ Consider:

❏ What does the audience already know? What do they want to know more about?

❏ How does the audience feel, think and behave with regard to the actions we recommend? What skills do they have, and what skills might they need to learn?

❏ What kinds of messages and tone are likely to connect with the audience?

Example: A flu poster at the homeless shelter reads, “Stay home if you are sick.” This message is offensive, not supportive.

■ Create information structure and flow that reflect audience priorities and needs.

❏ Present the most important information first. Get to the point quickly.

❏ Stick to three to five major points. Most people can read and remember only this many at any given time. Many will read only the first few.

❏ Web users skim and scan for just the information they want. Make it easy to find!

❏ Avoid the medical model of information sharing, which starts by explaining the clinical diagnosis and/or human anatomy. Instead, use a patient-centered model that focuses first on the problem and the solution – what to do and how to do it. Details about the anatomy and pathophysiology of a condition may be of interest later, after readers understand the basics.

Key Elements 1 and 2 Content and Structure/Organization

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Key Elements 1 and 2 Content and Structure /Organization

Example of two different ways to introduce blood pressure control:

Less effective (medical model): “Blood pressure is the force of the blood against the walls of the arteries. The heart generates this pressure by contracting 60 to 90 times per minute, circulating blood to all parts of the body …”

More effective (patient-centered model): “High blood pressure: You can do something about it. If your blood pressure stays too high, you run the risk of having a stroke, heart attack or kidney problems …”

■ Present information in small chunks.

❏ Keep paragraphs short and limited to one idea.

❏ State the main message in the first sentence.

❏ On the Web, be especially brief. Bulleted lists work well.

■ Use subtitles to carry major messages or ask key questions.

❏ Use statements, action phrases or questions as subtitles. Subtitles tell the story.

Example: Less effective subtitle: “Hygiene”

More effective statement subtitle: “Keep your skin clean to prevent infection.”

❏ Questions can be effective subtitles but only if they are questions the audience is likely to ask and that are important to them.

Example:

Less effective question subtitle: “What does diabetes mean for cardiovascular health?”

More effective question subtitle: “Will diabetes affect my heart?”

■ Repeat key points as appropriate and in different ways.

❏ One way to repeat important information and create reader interaction, is by using creative techniques like testimonials, miniquizzes, check boxes to complete, rhetorical questions, etc. Powerful images with strong captions can also reinforce messages.

❏ When phone numbers or other contact information is important, consider putting it in more than one place, even on a single-page handout. When patients need to use contact information, they may be stressed and need to find it in a hurry.

Key Elements 1 and 2

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Write in plain language to make reading easier and more understandable.

■ Use short, everyday words and short sentences. Use as few medical and biological terms as possible. Keep your writing tight and specific, but not to the point of being choppy.

Instead of … Use …

Hypertension High blood pressure

Oncology Cancer

Hospitalization Stay in the hospital

Hypoglycemia Low blood sugar

❏ Average sentence length should be around 15 words for reading ease. Some sentences can be a little longer, some a little shorter. Cut out unnecessary words and phrases like “It is important to …” Keep your writing tight. In general, plain language writing style relies on strong nouns and verbs. Use modifiers such adjectives, adverbs and clauses with caution.

❏ State desired behaviors explicitly. General concepts don’t lead to action.

Example:

Original: “The Dietary Guidelines for Americans recommends a half hour or more of moderate physical activity on most days, preferably every day. The activity can include brisk walking, calisthenics, home care, gardening, moderate sports exercise and dancing.”

Rewrite: “Do at least 30 minutes of exercise, like brisk walking, most days of the week.”

Key Element 3 Writing Style

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Key Element 3 Writing Style

■ Use active voice. This means the subject of the sentence performs the action. Look for the passive voice when a form of the verb “to be” is used. Here’s the list: am, are, is, was, were, be, been, being. These words are usually followed by a helping word.

Example:

Passive: Patients are advised to bring their insurance cards to every visit.

Active: Bring your insurance card to every visit.

■ Be personal, conversational, human. Use pronouns when appropriate. Pretend you’re talking with a neighbor or family member. Write it as you’d say it. Use brief examples to model how to take the actions you recommend. Testimonials and vignettes also create connection.

Example of a patient testimonial:

“When my doctor first told me I had diabetes, I was shocked. After that, I didn’t remember anything she said. I was really glad the diabetes educator called the next day to see if I had questions.”

Example of personal vs. impersonal:

Impersonal: MaineHealth offers patients evidence-based care.

Personal: We offer you care based on the latest research.

■ Keep paragraphs and lists short.

❏ Keep each paragraph focused on one major point, using about three to five sentences. The first sentence (lead) gives the major point. Establish a “flow” within and between paragraphs.

❏ Ideal length for lists is about three to five points, sometimes up to seven. Do not embed lists in text using commas. Instead, itemize lists using bullets and be sure to title the list. Readers do not always read explanations before they read lists, so the title must tell them what it is.

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Design for reading ease and understanding “on the first read.”

Create clean, functional design in print and on the Web. Materials are not intended to be artwork, yet they should still engage and invite. Information that looks easy to read is most likely to get attention. This means designing text with a clear visual structure that makes it easy for a reader to skim, scan and get major points fast. Refer to your marketing/communications department for organizational brand standards.

■ Usually, simple is best. This doesn’t mean dull. It means clean and functional.

❏ Certain styles in text layout and graphics – such as titles and sentences all in lowercase and right-justified or title words “scrambled” in different fonts – do not support reading ease.

❏ Straightforward visual design helps the user see the information structure right away.

■ Use text features that increase reading speed and comprehension.

❏ Font size: Optimal font size for fast print reading is 11 - 14 points. Usually, older readers prefer larger print. Font size on the Web should be adjustable.

❏ Font style: Use all capital letters, stylized font or italics with caution. They slow down reading.

❏ White space: Adequate white (blank) space creates text structure and allows the eye to both see and “rest between” sections and pages. If space is limited, better to sacrifice text than white space.

❏ Justification: General rule for text margins is left justify, right ragged, with no text “wrapping” around pictures.

❏ Line length: Optimal is three to five inches. Shorter and longer lines slow reading speed and reduce comprehension.

Key Element 4 Appeal / Document Design

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Key Element 4 Appeal / Document Design

❏ Hyphenation: Do not split (hyphenate) words between lines.

❏ Ghosting: Do not superimpose print over pictures or other graphic elements.

❏ Creating emphasis: Use color, bolding, boxes, arrows and other visual devices with discretion, to call attention to key points.

■ Use images and other graphic elements to support the text, not decorate it.

❏ Print-paper contrast: Keep print dark and paper light, especially for older eyes. Reverse print (light print on dark background) can work in small quantities, such as for titles.

❏ Color: Save colored text mostly for titles or subtitles. Use color for images and design features with care – to enhance key points, information structure and appeal.

❏ Images: Images may support the text directly or indirectly. They work best when simple and uncluttered so readers understand them at a glance. Use captions to strengthen major points. When using images to teach, show the “right way.” If you must show a wrong action, put a big X through it (not a circle with a line).

❏ Cultural inclusiveness: Images should reflect cultural sensitivity and inclusion.

❏ Lists and charts: Keep lists short, preferably three to five items. Use subtitles to group the items and bullets for the list. Keep charts simple and designed for “reading across.” For a grid or matrix, limit items and give directions for use.

❏ Explaining risk: Use frequencies (numbers), not percentages.

Easiest to understand: x out of 10, or out of 100, or out of 1,000. In addition, for risks with a denominator of 100 or 1,000, best practice is to use pictograms along with numbers. Pictograms are organized groupings of small dots or squares that allow a reader to see an entire cohort (of 100 or 1,000). Dots or squares that represent the number of people at risk are colored to stand out.

■ Don’t miss the chance to include a key message on a cover or home page.

❏ Covers and home pages are prime “real estate.” Imagine your audience reading only the front and back covers of a print piece or only the home page. Did they get some key information? They might not read further.

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Plan, write and design materials to reflect the audience and be as inclusive as possible.

Culture is a broad concept that goes way beyond ethnicity or country of origin. It includes ability/disability, gender orientation, race/ethnicity, socio-economic status and other critical life-shaping forces.

Culture shapes understandings about the meaning of illness, appropriate care-seeking and care providers, prevention and treatment practices, health decision-making, and more. Understanding cultural diversity and the beliefs and practices of our patients helps inform how to communicate. Incorporating cultural understanding with plain language will also create translation ease.

■ Our patients are growing older and more diverse, reflecting national population trends.

❏ American populations growing most rapidly include seniors and Hispanic/Latino groups.

❏ These same populations carry a disproportionate burden of diseases and health conditions.

❏ Nearly two-thirds of the adults in these groups have basic or below-basic levels of literacy and health literacy skills. Many do not speak English as their primary language.

■ Plain language works across cultures to address cultural, linguistic and functional challenges.

❏ Plan message design and images that reflect the diversity of patients who will use your materials.

❏ Use respectful language. Speak about “patients with asthma” instead of “asthmatics.”

❏ Consider visual needs and possible functional impairments. At a minimum, use adequate font size, maintain contrast between text and background, and consider Web navigation challenges as appropriate.

Key Element 5 Cultural Sensitivity and Appropriateness

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Key Element 5 Cultural Sensitivity and Appropriateness Readability

What Is R e a d a b i l i t y ? Has anyone ever said to you, “All our materials have to be written at the sixth-grade level”? What does that really mean?

Grade levels are derived from readability formulas, which are mathematical formulas used to produce a numerical score. The score shows the relative difficulty of text on a continuum from easy (grade four to six) to very hard (grade 13 and above – college level). “The average reading ability of American adults is about seventh- to eighth-grade level.”

A readability score is given as a “grade level,” but a score doesn’t tell us whether an adult with a specific level of education will be able to read the text. There is no direct correspondence between an individual’s level of education and his or her ability to read a particular piece of text. For example, most high school graduates cannot read at the 12th-grade level. Readability scores are best used to assess whether your text is in the right “ball park” for your intended audience. In general, this means that material should be at an eighth-grade level or below for public audiences.

Readability in Word Processing Programs You may have discovered that popular word processing programs like Microsoft Word have readability functions such as the Flesch Reading Ease and the Flesch-Kincaid Grade Level. The results are not accurate.

Here’s the key point: If you follow these guidelines for writing in plain language, using shorter and nontechnical words and shorter sentences, you will likely write at a readability level appropriate for most patients.

The Learning Resource Center can provide a readability score for your material. If you would like to have your print material “scored” for readability level, contact the Learning Resource Center. We have a special software program that can provide results, or we can teach you how to calculate a readability score by hand.

H a v e q u e s t i o n s o r n e e d h e l p ? C a l l t h e L e a r n i n g R e s o u r c e C e n t e r a t 8 6 6 - 6 0 9 - 5 1 8 3 o r v i s i t w w w. m a i n e h e a l t h . o r g / h e a l t h l i t e r a c y

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Checklist to Develop and Evaluate Patient Education Materials Issue 1: Audience is clear. Audience is _________________________________________

Issue 2: Purpose is clear. Purpose is ___________________________________________

Issue 3: Patient/consumer testing planned ______________________________________

Key Element 1: Content

❏ Limited (three to five points) and action-focused (what to do/need to know) ❏ Accurate, evidence-based and up to date ❏ Framed to gain positive audience response ❏ Includes clear call to action as appropriate

Other Comments ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Key Element 2: Structure/Organization

❏ Content broken into small chunks with important points first ❏ Subtitles/headings are statements, questions or action phrases that guide the reader ❏ Content sequenced according to reader need to know ❏ Key points are repeated as appropriate

Other Comments ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Key Element 3: Writing Style

❏ Personal, conversational (use pronouns appropriately and consistently) ❏ Short words/short sentences/lay language; technical terms explained ❏ Mostly active voice; verbs carry the action ❏ Short paragraphs (about three to five sentences) that stick to one point ❏ Short lists (about three to five items) using bullets, not comma strings

Other Comments ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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Checklist Worksheet

Key Element 4: Appeal/Document Design

❏ Piece attracts attention/draws reader in ❏ Text design makes it easy to skim and scan content ❏ Overall design reflects plain language standards for font type and size, print/paper contrast, line length, white space, justification ❏ Images, lists, charts are clear/support message/reflect audience

Other Comments ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Key Element 5: Cultural Sensitivity and Appropriateness

(As applicable, reflects needs and values of cultural groups defined by ability/disability, gender orientation, race/ethnicity, socio-economic status, etc.) ❏ Uses preferred and respectful terms to refer to the group or condition, and focuses on the person Example: “a person or patient with diabetes” instead of “the diabetic” ❏ Considers ease of potential translation/transadaptation if …