Clear & Simple

A target audience is the group of people you want to reach with your message. People with limited health literacy skills cross all ethnic and class boundaries. There are some common characteristics among people with limited health literacy skills, for example how they may interpret and process information.

The target audience may be defined by age, sex, marital status, educational level, occupation, income, religion, race, ethnicity, language, geographic location, lifestyle, health-related attitudes and behaviors, and many other characteristics. These characteristics influence each step in the process of developing materials, so understanding them is important.

Key considerations:

• Some individuals think in concrete/immediate rather than abstract/futuristic terms.
• Some people lean toward literal interpretation of information.
• Some people lack basic language fluency to correctly comprehend and apply information from written materials.
• Some people may have difficulty processing information like following medical instructions, or reading a prescription label.

By designing materials for those with limited health literacy you help to ensure everyone in your target audience can understand your message. People with average or good reading skills appreciate messages that are conveyed simply and clearly. Additionally, health literacy can vary for the same person depending on the situation. A person who typically has high health literacy may experience challenging comprehension moments if they are upset or distracted, for example. On the other hand, readers who want more detail can be directed to sources of in-depth information. Testing your product with the audience is the only way to evaluate the effectiveness and appropriateness of materials and is discussed in greater detail later in the guide.

The National Institute of Health’s Making Health Communication Programs Work: A Planner's Guide (1989) provides further details on how to define target audiences.

It is important to understand relevant physical, behavioral, demographic, and psychographic characteristics of your audience. This information plays a key role in the development of culturally relevant materials. It is also critical to the goal of reaching audiences at all literacy levels. Research can tell you:

• what the target audience may already know about your topic.
• what rumors, myths, and misinformation may exist about the topic.
• how audience members may feel about the topic.
• what questions and information gaps you will need to address.

The first task is to explore existing sources of information. These may include library databases, health statistics gathered by government agencies, information offered by nonprofit organizations, among others.

If critical information about your audience is not available in existing data, you may have to conduct new research to fill in information gaps. National statistics may not capture unique characteristics of your target audience, so whenever possible, supplement national data with local population data.

Information You Need About Your Audience

• Age, sex, income, educational level, career path, residence, and community or cultural identification;
• Health behaviors (e.g., exercise, alcohol consumption, vaccine adherence)
• Past health experiences
• Cultural habits, preferences, and sensitivities related to your topic
• Barriers to behavior change (e.g., access to public transportation, quality of care, discrimination)
• Effective motivators (e.g., benefits of change, fear of consequences, incentives, or social support)

Research Methods:

1. Surveys that measure the respondent's knowledge, attitudes, and practices on a specific topic are conducted by telephone, mail, online, or through face-to-face interviews with members of the target audience.
   • Advantages: Surveys provide highly targeted, directly relevant information and can provide estimates representative of the total population.
   • Disadvantages: Surveys require time, statistical expertise, and ample resources to accomplish. They also require a mechanism for locating and reaching large numbers of your target audience. Mail surveys may be inappropriate for readers with limited health literacy skills.
2. Focus Groups are small group discussions of 6 to 10 representatives of the target audience and usually take place in 1- to 2-hour sessions. A facilitator, preferably an individual sharing characteristics common characteristics of the target population (e.g., gender, race, ethnicity, shared experiences) is best-suited to conduct the meetings.
   • Advantages: Focus groups require fewer audience representatives and are faster than other research methods. They help explain why members of an audience believe or act as they do and allow for in-depth discussion of issues. Sometimes, they can be less expensive than other approaches.
   • Disadvantages: Focus group findings are qualitative, not quantitative, meaning they require expertise in conducting, reporting, and applying results appropriately. They also require you to locate and motivate members of your target audience to participate. Some findings may not extend to the total population.
3. Audience Interviews involve individual interviews with members of the target audience. An interviewer conducts each interview. Interviews often occur in locations frequented by members of the target audience, such as religious facilities, clinics, community centers, senior centers, and school. They may be arranged by appointment or conducted with people who agree on-the-spot to participate.
   • Advantages: Interviews may yield more in-depth information than focus groups.
   • Disadvantages: Individual interviews are both more time- and labor-intensive than focus groups.

Planning Questions

Q: I don’t have the time or budget to do new audience research. Do I have to apply these methods in order to develop an effective limited health literacy product?

A: The best approach is to make audience research a part of your product-development process for audiences of all literacy levels. Then the time and budget for research will be built-in automatically. What are the alternatives to formal research? You may be able to seek input from target audience members who serve on an advisory board or from individuals who have close working contacts with the target audience. If you rely on indirect information sources, remember to pretest the product with members of the audience themselves. It is important to get direct audience involvement at some point to test the comprehensibility and appropriateness your materials. Pretesting should supplement earlier findings and confirm that the product is on target.

Q: When should I do audience research?

A: You can test key ideas you may have in mind at the beginning of the planning process. Audience research can also help you decide if a key message that you have always used in your products is still effective or if it will work with a new audience. You may wish to see if a simply crafted message conveys a complex concept clearly. Audiences can play a key role during early planning in determining whether spokespersons are credible.

For more information about research approaches, see Making Health Communication Programs Work: A Planner's Guide (1989) and Family Planning Print Materials for Low-Literate Audiences: A Guide.

You are now ready to use information from your audience research to outline the objectives, style, format, and approach of the product that will carry your message. Many writers prepare a formal concept statement at this stage for those involved in the product’s development. Discussing the concept with individuals or groups who understand the needs of your target audience is an easy, inexpensive way to double-check the appropriateness of your intended approach. It is, however, no substitute for pretesting materials later with your target audience. Researchers Leonard and Cecilia Doak pioneered the field of health and limited health literacy. In their ground-breaking work, Teaching Patients with Low Literacy Skills, (J.B. Lippincott, Philadelphia, Pa., 1985), they suggest five principles to use in developing the concept for a low-literacy publication.

The 21st century offers a wide range of outlets through which health professionals can convey important messages. New and emerging formats include social media tools, mobile applications, streaming media, videoconferencing, and many other internet-based options. These supplement traditional approaches, such as brochures, posters, and toolkits. It is not uncommon for a single well-written and well-produced printed item to serve the needs of the target audience — provided it is culturally appropriate. At the most basic level, it is important to determine early on the appropriate medium for conveying a message to a target audience.

If you choose print, you must still decide between a 1-page factsheet, a 10-page booklet, or a series of short factsheets delivered at different points in the learning process. Budget and target audience information help shape decisions about the length and scope of the product. Design questions include photo and graphics selection, layout and color, packaging and paper stock.

You will also have to look at the setting in which you want audience members to receive their information. Offices and waiting rooms can provide communicators with an opportunity to develop a slightly more robust product than if the audience will access information on a mobile device. It may not be possible to meet information goals if you focus solely on a bus advertisement or in pharmacies, when readers’ time is limited. If your target audience is at-risk teens, then careful planning is required. Addressing their unique communication needs will have important implications for the tone, structure, and design of products.

1. Define the behavioral objective(s) of the material.

Some products are purely informational, while others are designed to help target audience members adapt new behaviors or engage in new ways of thinking to improve their understanding and awareness on a topic. Concrete action objectives help guide planning decisions and avoid unnecessary details in content. For example, a new diagnostic factsheet designed for women with limited health literacy skills might tell readers that getting a test is important for good health. Another product may focus more on behavioral objectives like improving diet, losing weight, reducing stress, and increasing exercise. Another factsheet would provide readers with a toll-free telephone number to call or contact information for a new clinic in their neighborhood.

1. Determine the key information points the reader needs to achieve the behavioral objective(s).

What will move the reader to take the desired action?

Information from audience research can help inform planning and may answer some important questions, such as how and when a product will be used. Will the product be used by the reader alone? By a professional trainer? Or during an appointment with a health or social services professional?

The context of the learning process when the reader receives information is also important. Is the product designed to address an illness, diagnosis, treatment intervention? Or will it be used during recovery and rehabilitation? Will the reader likely have already received related information?

The process of concept development is also affected by whether a product or products stand alone or whether they are part of a series of materials. It is also important whether materials are component products within a broader communications plan, such as an awareness campaign or recruitment effort.

Another consideration is the careful selection of resources that might be useful and relevant for the reader. It may be appropriate to include a resource list of key organizations and Web sites where the reader can obtain additional information.

1. Select the most appropriate presentation method(s).
   • How will the product be distributed: in person, on a rack in a retail or office environment, in the mail, in a clinical setting, or through another method, such as on a mobile device or tablet?
   • Is the material intended for one-time or long-term use?
2. Decide on the reading level for the material if you select a print presentation.

How do you estimate reading level? A number of readability formulas are often used to assess the reading level of materials. Reading levels and readability formulas are useful aids in targeting publications to an audience. Using one or more of them is a simple process that can be accomplished manually or with a computer software program. Each method takes only a few minutes. Among the better known formulas is the SMOG Readability Calculator.

Readability formulas only measure the difficulty of the vocabulary used and average sentence length, not the reader's level of comprehension. Computer-based programs analyze a document's grammar, style, word usage, and punctuation and then they assign a reading level. Using such formulas in product development is not a guarantee of well-written, understandable content. Creators acknowledge that using the formulas as writing guides can have negative consequences. If sentences and words are too short, the result may be a choppy product that leaves out familiar terms solely because they are polysyllabic. In addition, some formulas may not be applicable to readers with limited health literacy skills. Some other means of assessing the effectiveness of the material is almost always required. Most importantly, make sure you write for your audience.

1. Organize topics in the way the person will use them.

Provide readers with the most important points first and last. Studies show that limited health literacy audiences remember these best.

Literacy experts also suggest presenting information in chunks of text with a clear, ordered format, one idea at a time. You can outline these as steps (Step 1, Step 2, Step 3) or chronologically (first, second, next, last). Another approach is to use a main heading and subheadings, depending on how you want the person to access and comprehend the information.

The goal is to give the reader action steps to improve information retention and immediately move the individual into desired behaviors. Examples might include having them call a clinic or send off a request to receive more information.

SMOG Readability Calculator

Count the number of words with three or more syllables in a 30-sentence section of your draft. Using this chart, look up the approximate grade level. The SMOG formula can predict the grade level difficulty of a passage within 1.5 grades in 68 percent of passages.

SMOG Conversion Table
Total Polysyllabic Word Count	Approximate Grade Level (+1.5 Grades)
1 - 6	5
7 - 12	6
13 - 20	7
21 - 30	8
31 - 42	9
43 - 56	10
57 - 72	11
73 - 90	12
91 - 110	13
111 - 132	14
133 - 156	15
157 - 182	16
183 - 210	17
211 - 240	18

Planning Questions

Q: I have to limit my publication to a few key points. How do I decide what the reader needs and what I can leave out?

A: Focus on your behavioral goals. Is each information point fundamental to the reader understanding, accepting, and taking the desired action? Does each information point help to motivate a desired action? One approach is to separate need-to-know from want-to-know and want-to-tell. Some, if not all, of the information in the second two categories can probably be safely eliminated. Tough decisions always remain. Pretesting can help determine what information the audience really needs.

Q: Writing at the correct reading level for the audience is important. What should I use to help me write at an appropriate level?

A: Good writers may not trust their usual instincts to tell them what will work for people with limited reading skills. Look at the checklist in the next section. It outlines the fundamental principles of writing and designing a limited health literacy publication. The checklist can help you address your readers' needs and provides a basic framework for writers. Readability formulas have both value and limitations. A writer may set out to write simply, using an action-oriented approach. It is a good idea to then put down the draft for a while and return to it with a critical eye. Rewriting to achieve appropriate flow and comprehensibility and applying readability formulas can help. Readability formulas and software can be useful in approximating a reading level or, in the case of some software products, identifying specific problems that inhibit readability.

You may test your product at one level and find you must simplify some of the text, taking care not to detract from the message and goals of the product. Pretesting may also show that one or two concepts are still not well understood.

For more information, see Teaching Patients with Low Literacy Skills, Cecilia Conrath Doak, M.P.H. and Leonard G. Doak, BSEE, PE(J.B. Lippincott, Philadelphia, Pa., 1985) and Making Health Communication Programs Work: A Planner's Guide (1989).

Now that you have a product concept, you can begin outlining and writing the first draft. What you include will draw heavily from your important early — and continuing — research. In developing a limited health literacy product, you will need to tailor content, layout, and visuals (i.e., photographs, illustrations, and diagrams or charts) to the needs of a reader with restricted reading and communication skills. What does this mean in concrete terms? There are several key principles to use in creating effective materials for this audience. You can refer to the list as you draft and review your work.

Content/Style

• The material is interactive and allows for audience involvement.
• The material presents "how-to" information.
• Writing reflects peer language whenever appropriate to increase personal identification and improve readability.
• Words are familiar to the reader. New words are defined clearly.
• Sentences are simple, specific, direct, and written in the active voice.
• Each idea is clear and logically sequenced (from the reader’s perspective).
• There are a limited number of concepts in each piece.
• The writer uses concrete examples rather than abstract concepts.
• Text highlights and summarizes important points.

Layout

• The material uses headings and labels sections.
• Headings are simple and are close to text.
• Layout balances white space with words and illustrations.
• Text features both upper- and lower-case letters.
• Underlining or bold formatting — not caps — provides emphasis.
• The font selection (design, size) are easy-to-read. Aim for a 12 point or larger size.

Visuals

• Visuals are relevant to text, meaningful to the audience, and logically located.
• Illustrations and photographs are simple and free from clutter and distraction.
• Visuals use age-appropriate images selected with the age of the target audience in mind.
• Illustrations show familiar images that reflect cultural context.
• Visuals (graphics, photos) have captions written with appropriate, helpful descriptions. Each visual is illustrative and is directly related to one message.
• Visuals are shown in pretesting with the audience to verify preference and help with information retention.
• Cues (e.g., circles or arrows) point out key information.
• The color palette is appealing to audience members during pretesting.

Readability

• Readability analysis has been carried out to determine reading level.

Planning Questions

Q: Are pictorial signs, symbols, and charts more effective than words for readers with limited literacy skills?

A: Not necessarily. Some experts suggest that "universal" symbols, such as a stop sign, an arrow, or a big black "X," usually test well with this audience. If a pictorial representation is open to interpretation, however, it can fail to communicate with any audience. Likewise, while a simple chart may work well, a large matrix or visually busy schema are likely to confuse.

Q: How do I handle a complex topic with 8 or 10 important messages when I can only afford to do one publication?

A. A strong grouping of main and sub-points is a workable solution to this problem. When individual sections are organized effectively and when each can stand alone, readers can approach the text at their own pace.

Q: My budget doesn’t allow for illustrations and I cannot use color because my products will need to be photocopied. Can I still design an effective low-literacy product?

A: Although color is a powerful communication tool, strong format, good use of white space, and alternative highlighting devices can help a black-and-white product convey your message. In addition, products do not always need illustrations to break up text. Boxes, lines, and white space can keep a design from being too dense. Pictures are valuable if they illustrate an action or a key point. They do not have to be expensive to produce. In fact, simple line drawings may be preferable to detailed pictures for limited health literacy audiences.

Communicators may find that audiences don’t understand a product perfectly. The decision to include a passage or illustration is subjective, no matter which principles are being used in the development of a product. That is why testing a material with the intended audience is important. Audience understanding and acceptance is critical to ensure that materials are culturally relevant and responsive to the needs and concerns of the target audience.

Pretesting is a qualitative measure of audience response to a product and is essential for measuring comprehension. It is also important to measure audience attraction to the product, and the audience’s personal feeling about the material. Although funds may not be available for extensive pretesting, some pretesting is essential. The focus of this section is pretesting limited health literacy materials.

What To Test For

1. Comprehension
   Pretesting products can help communicators learn whether test respondents understand any behaviors the material recommends for readers. To some audience members, writing can be unclear, confusing, or hard to believe. Test questions can also address the suitability of words and the meaning or relationship of visuals to text. It is also instructive to learn about the meaning each respondent attaches to key words, symbols, abbreviations, and visuals.
2. Attractiveness
   Pretesting can yield important information about the kind of feelings draft materials generate and whether audience members are enthusiastic or turned off by text. Communicators can ask audience members if the individuals depicted in the materials are appropriate representations for their community or group and if they connect with them.
3. Acceptability
   There are many well-intentioned health communicators who attempt to launch products but end up offending their intended audience. Material may not be compatible with local culture or may not be realistic. The choice of a celebrity spokesperson can be risky; not all readers may recognize an actor, sports personality, or singer. Text may not be suitable for the sex, age, or ethnic group for whom a product is being developed, especially if the audience includes seniors or teens.

Organizing a Pretest

Pretesting with audiences that include people with limited health literacy skills can present communicators with unique logistical challenges. First, there is the issue of what to test and at which stage of product development. Experts recommend testing a rough draft of copy with graphic concepts explained and a few potential illustrations included. Another option is to pretest an early layout of the product with rough graphics in place. You can also pretest at both of stages of product development.

Some researchers believe it is best to test a product in the same type of environment where the reader will use the material. For example, if a patient will read the factsheet in a noisy, busy clinic, take care to expose test readers to the same distractions by pretesting in a similar setting.

You can organize a pretest in several potential environments and settings:

• Clinic or hospital waiting rooms
• Physicians’ offices
• Residential settings (homes, age-restricted communities, extended care centers, independent living facilities)
• Community facilities (churches, recreation centers, senior centers)
• Adult basic education and English language classrooms
• Government facilities (Social Security offices, WIC centers)
• Nonprofit offices (job training centers, wellness and day program sites)

Engaging fewer participants may work if the material is very simple, short, or requires little in the way of attention for comprehension. A smaller group of participants may also work if the product is directed at a single, homogeneous target group. Conversely, your efforts may require more participants if the material is complex, lengthy, demanding, or culturally diverse.

Determining Reading Levels for Pretesting

Are you pretesting materials with the right readers?

Engaging participants who have the same characteristics as the audience you are trying to reach is critical for achieving valid results. Recruiting participants through groups or settings that include people with limited health literacy skills is a logical starting point. But the only way to make sure your pretest volunteers read at the same level as your intended audience is to test their reading skills.

A number of tests are used to measure reading levels and comprehension. One or more can be integrated into the pretest interview to avoid offending or causing discomfort to potential participants and respondents.

The Wide Range Achievement Test

The Wide Range Achievement Test (WRAT) is an efficient way to determine reading levels and takes only a short time to administer. The WRAT focuses on word recognition because at the most basic level, if a person does not recognize a word, comprehension is impossible. The WRAT test involves listening to the participant read from a prepared list of words, arranged in increasing order of difficulty. The reader looks at each written word and says it out loud. Pronouncing a word correctly shows that the reader recognizes the word. The test is over after the reader mispronounces ten words. The test administrator notes the level at which the last mispronunciation occurred, and the "stop" level equates to a grade level of reading skills. Planners can compare this level with the reading level of their intended audience to see if pretest readers are a good representative match.

The Cloze Technique

The Cloze technique is used to measure the reader's ability to comprehend a written passage. Because it requires readers to process information, it may take up to 30 minutes to administer. In a Cloze test, text appears with every fifth word omitted. The reader tries to fill in the blanks. This task demonstrates how well the respondents understand the text. Their ability to identify the correct word also reflects familiarity with sentence structure.

You can integrate either a WRAT or a Cloze test into the pretesting process by purchasing off-the-shelf tests or developing and scoring a test yourself based on the materials you are pretesting. The resources section at the end of this guide provides contact information for obtaining testing instruments.

Conducting the Interview: Special Considerations

Effective products are designed to meet audience needs. Effective pretesting must therefore be tailored to participants with limited health reading skills.

Here are a few suggestions for pretesting:

• Give only one product to each individual or group to focus respondents’ attention on your materials — even if you are testing a series of publications.
• Distance yourself from the product and assure participants that you want their honest assessment. Otherwise, audiences may steer away from critical discussion. Some respondents may not be comfortable explaining negative responses or may not understand the material or pretesting process.
• Make sure participants understand that it is the materials that are being tested, not them. Explain this clearly when you introduce the materials and the process. Respondents need reassurance.
• Pay attention to audience interests. If necessary, change the pace to keep reader attention levels up. You may need to split up a group to allow for more one-to-one interaction and switch the focus of discussion.
• Select people to recruit and interview pretest participants who are culturally sensitive and who have good social skills. Unless potential participants feel at ease with the interviewing staff, they may not agree to take part.

Avoiding Waste: Using Results to Revise

Pretest results raise issues and point out problems, but the next steps are up to you. Simple or comprehensive revisions can address any number of problems that pretesting uncovers. It may not be necessary to scrap the product and begin all over again. If one or only a few respondents raise a concern, revisions may not be necessary — depending on the nature of comments. Any remark that shows lack of understanding of a key concept should receive careful attention. If one person fails to grasp a point, others may have the same problem but may not air it. Personal comments about a product's appeal or personal relevance are less of a concern. Percentages are more complicated. If you test the material with 10 people, each response needs to be considered seriously. With 50 participants, a percentage can be relied on more comfortably.

You should start all over when most responses indicate fundamental problems and whenever results show that:

• readers cannot identify key behavioral actions the material is designed to convey.
• readers find the format unappealing or off target.
• readers believe the medium interferes with the message.
• readers say the format is altogether unappealing or off target.
• readers report that the product is culturally inappropriate and lacks relevance.

The results of pretesting, however, are not a blueprint for revisions.

Planning Questions

Q: How can I get access to people from the target audience for pretesting?

A: Many agencies coordinate efforts with literacy organizations, directors of adult basic education and English as a second language programs, local nonprofits, community groups, and medical facilities. You also can cooperate with groups that represent your target audience. If your budget allows, offering incentives, such as small cash payments, can help motivate individual participation and garner support. Overworked and underfunded literacy programs also are more able to provide timely assistance if your agency can compensate them for their participation.

Q: Professional intermediaries distribute our pamphlets to their clients. Should they be part of pretesting?

A: Professional intermediaries and advisory groups can be an important source of insight for your product’s success. You should weigh the responses of test audience members against professional views in cases where opinions vary or conflict. It is important to not rely on professional review alone, no matter how close professionals are to clients.

For more information, see Making Health Communication Programs Work: A Planner's Guide (1989).

For More Information

• 2003 National Assessment of Adult Literacy, U.S. Department of Education, National Center for Education Statistics(link is external).
• Making Health Communication Programs Work: A Planner's Guide, U.S. Department of Health and Human Services, National Cancer Institute, Bethesda, Maryland, 1989.
• Zimmerman M, Newton N, Frumin L, Wittet, S. Developing Health and Family Planning Print Materials for Low-Literate Audiences: A Guide, Program for Appropriate Technology in Health, Washington, D.C., 1989.
• Leonard and Cecilia Doak. Teaching Patients with Low Literacy Skills, J.B. Lippincott, Philadelphia, Pa., 1985.
• Vernon, John A., PhD, et al., Health Literacy: Implications for National Health Policy (Report), October 2007.

• King Jr., Talmadge E., M.D., et al., Medical Management of Vulnerable & Underserved Patients: Policy, Principles, and Practice, McGraw-Hill Medical Publishing, New York, New York, 2006.