Guidelines for preparing patient education handouts

Purpose
This information is designed to help health-care professionals develop and evaluate patient education handouts. If you are developing patient education handouts, please read this information first and obtain administrative support. If you are evaluating the appropriateness of pre-printed (commercial) materials, only certain sections may be applicable.

This information will help you:

• Develop and obtain approval of patient education handouts.
• Determine readability and appropriateness of patient education handouts.
• Use graphic and content standards for patient brochures, pamphlets, and handouts.
• Find and use additional resources for developing patient education handouts.

Developing and evaluating your content

Have a clear goal
The first step in developing patient education handouts is to have a clear idea of the goal for your project.

• Do you want the patient to simply understand his or her condition, or do you want him or her to comply with a complex treatment regimen?
• Do you want to change patient behaviors? If so, exactly what behavior–for example, increase the number of new mothers who breast feed their babies.
• Do you want the patient to refer to the handout daily and record notes there, or do you want him or her to read it once and file it away?
• Will all the information apply to most of the target patients or will you need flexibility to customize certain information for each patient?

Keep your goal clearly in mind during the entire process, because it will impact every choice you make. Your goal will determine whether you use illustrations and what specific information you include in the text.

Understand your reader
The second step is to have a clear understanding of your intended population. Is this handout for anyone and everyone using services provided at this institution? For pregnant teens only? For geriatric patients only?

• Who is the patient or family member who will be using this information? Age? Gender? Socioeconomic background? Ethnicity and cultural background? Educational background?
• What is the typical reader’s literacy level?
• What are the typical concerns or fears that these readers have about their medical conditions?
• Is the patient likely to have physical limitations, such as vision problems, that might influence his or her ability to use the publication?

Keep your purpose and reader in mind
Write, edit, and design the publication with the reader and your purpose clearly in mind.

• Address readers’ concerns and interests.
• Use appropriate language, style and tone for you reader and purpose.
• Explain all terms that might be beyond the reader’s understanding.
• Make clear what actions you want the reader to take. Clearly state the purpose of the publication.
• Develop illustrations as necessary for clarity and appeal.
• Always include phone numbers or other resources to which the reader can turn for more information or help with problems.

Content Standards
The information you present in your handout must be accurate, up to date, objective and organized. The content also must be consistent with physician information.

The content standards checklist should be used to determine content standards when developing a patient education handout. It is also recommended for evaluating content for pre-printed commercial patient education handouts.

Style Standards
The UC Davis Health System has established standardized style guidelines for all written materials. These guidelines are intended to provide clear, consistent communication and are specifically designed for general (lay as opposed to professional) audiences. These guidelines maybe be found on the Web at  http://ucomm.ucdavis.edu/downloads/styleguide.pdf or obtained at the Medical Sciences Public Affairs office. Some of the key points are addressed in the next section of this book under “Writing Style.”

Readability
To understand the information presented, the person must be able to read it. This may sound like a simple statement; however, there are several steps involved in determining readability.

Intended Population
Think about your reader and his or her information needs and literacy level. Look back at the questions in the previous section under “Content Standards.” Keep this information in mind when deciding what level of readability is appropriate for your piece.

Grade Level Determination
The next step is grade level determination. There are many acceptable formulas that can be used to determine grade level. G. H. McLaughlin’s SMOG Formula (one of the easiest methods to use) is based on 100 percent comprehension of the material and predicts the reading difficulty of written materials to within on and one-half grade levels (see below for condensed information; see reference to obtain complete text).

Depending on the intended population, the appropriate grade level may vary considerably. However, a general guideline for overall patient population is not to exceed the eighth grade level.

The following sentences give examples of how reading levels differ:

College Reading Level
With the onset of nausea, diarrhea or other gastrointestinal disturbances, consult your physician immediately.

12th Grade Reading Level
If you experience nausea, diarrhea or other stomach or bowel problems, call your physician immediately.

8th Grade Reading Level
If you start having nausea, loose bowel movements or other stomach problems, call your doctor immediately.

4th Grade Reading Level
If you start having an upset stomach, loose bowel movements, or other problems, call your doctor right away.

Calculating Grade Level with the SMOG Formula Developed by G.H. McLaughlin

1. Choose 30 random sentences by counting 10 consecutive sentences near the beginning, 10 in the middle, and 10 near the end of your material. Count as a sentence each independent unit that is grammatically independent; i.e., if it ends in a period, question mark, exclamation point, semicolon, or colon. Do not count headings in the 30 sentences.
2. Count the number of words with three or more syllables in the 30 sentences. This number is “A” (refer to the table below).
3. Again, refer to the table below to determine the grade level (“GL”) based on the value of A.
4. If A (the number of polysyllabic words in the 30 sentences) is greater than 31, then more editing is required as the information should be at 8th grade reading level or below.

A	GL	A	GL
1-2	4	13-20	7
3-6	5	21-31	8
7-12	6	>31	9

Writing Style
Another important aspect in determining readability is making sure the appropriate writing style is used. Some key points to consider:

• Avoid medical jargon. Define technical terms in lay language.
• Write in the active rather than passive voice.
• Keep the sentences short and to the point.
• Avoid complex grammatical structures.
• Use the second person “you” instead of the third person “the patient” or “persons.”
• Limit the number of words containing three or more syllables. Substitute one- or two-syllable words whenever possible.
• Check the readability or grade level of the material to be sure it is within the parameters determined previously.
• Check for spelling errors. Thorough proofreading is essential.

Examples of acceptable words, phrases and language:

• Depending on grade level, you may use:
  “doctor” instead of “physician”
  “shot” instead of “injection”
  “pill” instead of “medication”
  “high blood pressure” instead of “hypertension”
  “making” instead of “manufacturing”
  “cream” instead of “ointment”
  “use” instead of “utilize”
• Address one concept at a time and use uncomplicated sentences:Use “your doctor knows how to help you”, instead of  “naturally, your physician knows best what is likely to help your particular case.”

  Other factors, such as ink color, type style, layout and so on also affect readability. Many of these factors are also addressed in the next section.

NOTE: Many “grammar check” computer programs can evaluate materials for grade level. Check your computer software for an alternative to the manual described above.

Designing your handout
Now that the information is accurate and in the proper style, it is time to design the handout. Design assistance may be available from the Medical Sciences Public Affairs office. For information, call 734-9040.

Graphics Standards
The UC Davis Health System has detailed graphic standards which apply to all printed materials. For a copy of the graphics standards manual and answers to graphics standards questions, call the Department of Medical Sciences Public Affairs.

In planning the design and layout of your piece, your objective is to reinforce the overall message you want to convey to your readers. Every design choice you make should be in keeping with your overall goal for the handout. Some key points to consider when planning your design and layout:

• Present the most important information first.
• Use adequate spacing of copy blocks to provide rest for the eyes.
• Try to keep the eye span of copy blocks to no more than 60 to 70 characters.
• Do not use all italics or handwriting. It is harder to read.
• Do not use all capital letters. They are harder to read.
• In keeping with UC Davis graphic standards, use Berkeley Oldstyle body copy and Futura for headlines and secondary type applications. If you are using pre-printed materials, a serif type style such as Times may be used instead of Berkeley Oldstyle. Sans serif fonts such as Helvetica, Futura or Line Printer are more difficult to read and should be used sparingly. Proportional type spacing is easier to read than evenly spaced type (like Courier which resembles typewriter type).
• For most materials, use 11 point type on 13 point leading (line spacing). For readers who may have poor eyesight or marginal reading ability, 12 point type on 14 point leading may be best. Do not use print smaller than 10 point.
• Use headings and subheadings to organize information. List or itemize to clarify steps.
• Use no more than two type styles, because too many type styles are confusing and actually detract from your message.
• Print text in black (or a very dark color) ink on white or off-white paper. Use colored ink sparingly.
• When deciding whether to use numerals or spelled out numbers, consult the UC Davis style guide. In general, spell out numbers under 10 and use numerals for 10 and over. Always use numerals for ages, percentages and certain other uses.

Call the Multidisciplinary Patient Education Committee (MPEC) representative at 734-9797 for examples of appropriate patient education handouts.

Design Checklist
The Design Checklist will help you determine whether the design of your patient education handout is effective and appropriate to your reader. The list is also recommended for evaluating preprinted commercial patient education handouts.

Financing
The completed and approved patient education handout will never do anyone any good if it is not reproduced and distributed. The cost of the project must be estimated and arrangements made for financing.

Resources
Some possible sources for funding include:

• Departmental budget
• Medical Sciences Public Affairs Department
• Patient education department
• Combination of department budgets
• Commercial vendors
• Made available on the Patient Education Web site
• Other sources?

Approval process

• Content must agree with physician information.
• Content and design must agree with institution’s policies regarding publications. (See UC Davis Policy and Procedure Manual, section 1312; the UC Davis and UC Davis Health System Style Guide; and the UC Davis Health System Graphic Standards Manual.)
• Proofread carefully.
• Conduct interdepartmental review.
• Send to the multidisciplinary patient education and wellness committee with completed signature sheet.
• The Multidisciplinary Patient Education and Wellness Committee will contact you to schedule a periodic review.

Evaluation

Upon completion of the patient education handout and prior to printing, it is suggested that you pilot test the handout on an appropriate group of patients by asking them a few questions such as:

1. Is the information easy to understand?
2. Does this handout contain the information that you need to know?
3. Does this handout contain anything that you do not understand?

For examples of effective patient education materials, call the multidisciplinary patient education and wellness committee representative at 734-9797.

Project checklist

Yes	No	Content standards are met.
		Grade level determination is ________.
		Signature sheet completed and attached to patient education materials.
		Sent to the multidisciplinary patient education and wellness committee with completed signature sheet.

References

• Boyd, Marlyn (1987). A guide to writing effective patient education materials. Nursing Management, 18(7), 56-57.
• Mathis, Diana (1989). Writing patient education materials. Orthopaedic Nursing, 8(5), 39-42.
• McLaughlin, G. H. (1969). SMOG grading–a new readability formula. J. Reading, 12, 639-646.
• Development, Coordination and Review of Patient Education Programs. Hospital Policy and Procedure Manual, Section 2880. University of California, Davis, Medical Center.
• Hospital Publications. Hospital Policy and Procedure Manual, Section 1312. University of California, Davis, Medical Center.
• UC Davis Health System Graphic Standards Manual, 1994.
• UC Davis Style Guide, 2nd Edition, 1991.
• UC Davis Health System Style Guide, 2nd Edition, 1994.

These guidelines were developed to provide consistency in written patient education materials created by UC Davis staff members.