Health Literacy Studies

What is Plain Language?
Plain language is writing that effectively communicates with the specific audience being addressed (i.e., a plain language document geared to a scientific audience is different from a plain language document geared to the general public). Using plain language ensures that your audience can both find and understand the information you provide.

You should use plain language for all documents, presentations, and electronic communications. First, let's look at the characteristics of plain language.

Why Should You Use Plain Language?
A Government-wide directive requires Federal agencies to use plain language by January 1, 2002, in all documents written for the public.

More importantly, communicating clearly is its own reward-it saves time and money, and it improves reader response to your message. Using plain language avoids creating barriers that set us apart from the people with whom we are communicating.

NIH's mission is complex and involves at least three broadly defined groups with varying interests.

External Groups	Typical Interests
• General Public Citizens (including those with specialized literacy, cultural, and vision needs) Constituency Groups Vendors Members of the press Job seekers and students	seeking health information supporting or criticizing research priorities, budgets and methods seeking business opportunities through contracts researching a story or reading a press release seeking information about career opportunities
• Medical and Scientific Community Medical Practitioners Researchers Readers of scientific publications Students Advisory committee members	seeking research protocols for their patients seeking funding opportunities or regulatory guidance seeking research data seeking fellowship opportunities and student loans for advanced studies reading background briefings
• Governmental Community Members of Congress Investigators Staff of Federal and State agencies	seeking assistance for their constituents or stating a position seeking background information requesting information for appropriation hearings, briefings, and reports

Because part of the NIH mission is to reach all Americans with health information they can use, we must try to communicate in a way that helps people to easily understand our research results.

1. How Do You Engage Your Readers?
First, consider who your reader is. Often, there is more than one reader. For example,

Members of Congress often forward copies of letters from their constituents; both will read your response. Next, consider what the reader needs to know and organize your document to answer the reader's questions.

You should also write to the appropriate reading level. The NIH Plain Language Coordinating Committee recommends:

Note: You can use the Simple Measure of Gobbledygook (SMOG) Readability Index (see Evaluation section) to determine the grade level of your text. You can find tools in your word processing program to assist you in counting words and sentences and finding the average length of sentences and paragraphs.

a) Use common, everyday words whenever possible. Documents should be written clearly and simply. Government writing should be dignified, but not pompous.

c) Use "must" instead of "shall." The use of "shall" creates confusion. To impose a legal obligation, use "must." To predict future action, use "will."

e) Use positive rather than negative words, in most cases. Words can attract or repel readers, and a negative statement can be unclear. However, the negative is appropriate if you're cautioning the reader, as in "Don't smoke."

Avoid when possible using words that antagonize, such as allege, complaint, liable, and waste.

f) Avoid using gender-specific terminology. Try to avoid gender-specific nouns and pronouns unless referring specifically to either women or men.

g) Avoid long strings of nouns. Administrative writing often uses too many noun clusters-groups of nouns sandwiched together ("noun sandwiches").

h) Use active voice. Write sentences in the active voice when possible. The active voice eliminates confusion by naming the actor in the sentence. (However, passive voice is appropriate when the actor is unknown, unimportant, or obvious. For example, "Small items are often stolen.")

j) Use the present tense when possible. This makes your material more direct and forceful.

k) Use parallel construction. Arrange sentences so that parallel ideas look parallel. This is especially important when you use a list.

l) Be direct. Talk directly to your readers. Use imperatives when appropriate. This is especially true for lists of duties, how-to instructions, procedures, and regulations.

m) Avoid using exceptions. If possible, state a rule or category directly rather than describing that rule or category by stating its exceptions.

Appearance is an important aspect of clear communication. If your document is pleasing to the eye, it will be more likely to attract your reader's attention. Appearance can also be an aid to the reader, improving comprehension and retention. There are four main aspects of appearance:

People read documents to get answers. Organize your message to respond to their interests and concerns. Readers come to documents with several key questions:

Use introductions to help your reader understand how the document is organized. For a simple letter or memorandum, an introductory paragraph should suffice. For brochures and lengthy briefing documents or reports, use a table of contents or other list early in the document to guide the reader.

Sentence length should average 15-20 words. Sentences that are simple, active, affirmative, and declarative hold the reader's interest. Generally, each paragraph should contain only one topic. A series of paragraphs may be used to express complex or highly technical information. The more your writing deviates from this clear and to-the-point structure, the harder it is to understand.

Use adequate margins and provide white space between sections to break up your text. This makes it easier for the reader to understand.

Use headings to guide the reader; the question-and-answer format is especially helpful. Try to anticipate the reader's questions and pose them as the reader would.

If-then tables lay out the text visually, helping your reader see relationships more easily and usually requiring fewer words than straight text. For example, the paragraph below is written in the "dense text" method:

For good reasons, the Secretary may grant extensions of time in 30-day increments for filing of the appeal and all required documents, provided that additional extension requests are submitted and approved before the expiration of the original 30 days or the previously granted extension.

Use the tips and tools contained in this document but also use good judgment. For example, the question-and-answer format is an excellent way to present some material...but not necessarily all material. Decide which tools fit your situation and aid the reader.

You need to evaluate your document to ensure that you are communicating clearly. Always have another person read your document and offer suggestions for clarifying it. In addition, use at least one of the methods described below.

You can develop checklists to guide you through a thorough evaluation. At the simplest level, you need to look over the document for:

Another simple way to evaluate your document is to include a box at the bottom of the page that says:

We try to write clearly. If you have a suggestion on how to improve the clarity of this document, please send it to us at...

Evaluation of the process used to develop a product is called "process evaluation"; evaluation of the effectiveness of a document is called "outcome evaluation." Either method may be used to evaluate a particular document.

Easy process measures include counting the number of copies distributed, meetings attended, or articles printed. This information will tell you how a program is operating and whether the target audience receives your information.

Extending a step beyond process measures, outcome evaluation provides information about the quality rather than the quantity of response. The measures may be self-reported (e.g., interviews with members of the target audience) or be observed (e.g., changes in clinic visits or disease morbidity). Comparisons between a control group and the target audience are desirable.

Focus groups are especially helpful in evaluating frequently requested documents (e.g., health information brochures and forms). These groups are composed of individuals who share traits with the planned recipients of your document. Focus group members can give you excellent feedback about your document before it is finalized.

A simple but meaningful way to be certain readers will understand your document is to interview some of them. Such "protocol testing" requires one-on-one interviews with representative readers. This testing generally requires interviewing from three to nine people to find out what each sentence means to them.

According to Making Health Communication Programs Work: A Planner's Guide (NCI), true outcome evaluation requires a "before" and "after" version of the document. This type of evaluation is routinely used for health brochures and documents to be distributed to a broad audience. Outcome evaluation usually involves comparing the target audience's awareness, attitudes, and behavior before and after reading the document. These are quantitative measures that allow you to draw conclusions about the program's effect.

Many tools are available to measure the readability of your document. One is the SMOG Readability Index. It is a simple technique that can be used to assess the grade level of a document. First, count the number of words with three or more syllables in a chain of 30 sentences in your draft. Then look up the approximate grade level on the following chart.

* Developed by Harold C. McGraw, Office of Educational Research, Baltimore County Schools, Towson, Maryland.