Planning and wording a plain-language text
A plain-language document for patients or the public is planned before it is worded. The team, the audience and the goals decide what goes in, and the content is then held to a few essential messages, ordered from the reader's side, put in words the reader already uses and in short active sentences, addressed to the reader directly, and, where it began as a technical text, adapted in steps.
Readers of every skill level
Medical writers often get requests to "translate" complex health information into patient-friendly documents, a translation sometimes referred to as converting to plain language: using words, terms and concepts that most readers in the intended audience can relate to, understand and use. Writing in plain language is both an art, requiring common sense, and a science, with rules, and it is much more than simply using common words and short sentences.
Two patient-education specialists suggest that if medical communicators want their messages understood by a large majority of American adults, they must write for readers with a wide range of reading skills. Surveys have shown that adults at all reading levels prefer text that is simply stated, and writing simple text means using common vocabulary and simple, predictable structures for sentences and paragraphs, and avoiding jargon, complex statistics and extraneous content the reader is unlikely ever to need or use. It may seem that adjustments to written text are needed only for less-skilled readers, but research shows that these adjustments and strategies also make documents more rapidly understandable by those with highly developed reading skills.
Writing for a public audience is more difficult than it might at first appear, but some common rules make a start: sentences should be short and clear, everyday words should replace complex ones, and specialist language must be either avoided or explained. However hard writers try, they can never know how anyone who reads what they have written will interpret it, and they can only do their best to convey the correct message by keeping the language clear and direct.
Research-based strategies are available to accommodate nearly all readers, and these have the greatest impact:
- Make the text easy to read and look easy to read.
- Present the context first, and make the text interactive with the readers.
- Use simple visuals with captions and refer to them in the text.
Individuals will better understand, recall and comply with health-related instructions developed with these strategies.
The team
In the view of one health-literacy consultant, a plain-language project is best done by a team whose members include:
- a writer who is skilled in plain language and is an advocate for the learning needs of the intended readers
- one or more content experts who have subject-matter mastery and can also help tell "need to know" information, the essential behaviours and actions, from "nice to know" background facts and figures
- readers representing the intended audience in their literacy, language, and interest in or familiarity with the subject, who can offer invaluable insight about whether documents are understandable, engaging and helpful
The usual advice for writing for a mass audience also has typical readers involved as much as possible in the writing and testing process.
The audience and the goals
The first step is to determine as much as possible about the reading audience: their education, literacy, language, culture, age, disability, and interest in or familiarity with the subject. If the document is intended primarily for readers with low literacy skills, plain language alone may not be sufficient, and nonprint alternatives such as pictures, audio or video can enhance comprehension of the text.
The next step is to determine the goals of the project, by asking: "As a result of readers reading this document, what do you hope or expect they will know, do, and feel?" Project managers, such as an employer or an outside client, can usually easily describe what they want readers to know, but often have more difficulty describing what readers should do and feel after reading. All three elements are essential in determining the document's content, tone and format. After that initial conversation about the goals, it is fairly easy to tell the need-to-know from the nice-to-know.
A project manager may stipulate that the document be written at a specific reading grade level, and that request should be a cue to explain the limitations of such an approach.
Key messages
The writer should try to limit the content to three to five "need-to-know" skills or behaviours rather than large amounts of "nice-to-know" supporting facts. Plain-language tips from one health-information company call for reducing background information and presenting the content succinctly.
Patients often feel overwhelmed by the amount of information they receive from their health care provider, and as a result can have difficulty understanding and following instructions. Medical writers can help minimise that confusion by bringing attention to the most important elements of the material through key messages: the four or five critical pieces of information a patient absolutely needs to know, which answer the question, "If your patient only has 5 minutes to read your material, what do you absolutely need that patient to understand?" Key messages come in a summary style and an action style, and some topics benefit most from one and others from the other.
Order and lists
The content should be organised from the reader's perspective, and the best order might be from first to last for self-care instructions, from most common to least likely perhaps for side effects, and from safest to most risky for decision-making. The usual advice for a mass audience is to organise the material in a reader-centred, easy-to-use way, asking what most people will want to know first, second and third. The health-information company's tips call for making the content easy to read quickly for people who are skimming or scanning the text. In sentences and paragraphs, the context should come first, before the new information is stated.
Complex information can also be broken up into lists. In one example, a passage about antiretroviral therapy explained why osteonecrosis might occur in a complicated sentence whose main verb was long delayed by a sequence of risk factors: the length of combination therapy, corticosteroid use, alcohol consumption, severe immunosuppression and higher body mass index. In a small-scale test, most of the ten respondents had some difficulty clearly identifying the risk factors from the original, none had any difficulty using the rewrite, and all preferred it. The European Medicines Agency accepted the revised text.
Interaction, further help and pictures
A document can be made to look and feel inviting by including patient interaction with it through questions and answers, blanks to write in and brief reviews. Effective documents invite readers to interact with the text, for example through checklists or spaces for readers to write questions. The end of the document should give ways for readers to learn more, including at least one or two nonprint options, such as a phone number to call or a place to go. The usual advice for a mass audience is to use well-labelled pictures and diagrams.
Words and numbers
Common one- or two-syllable words should be used whenever possible, such as heart attack rather than myocardial infarction. The usual advice for a mass audience is to use words the writer's parents or grandparents are likely to understand and to avoid footnotes and acronyms whenever possible. One plain-language campaigner adds that it helps a lot to prefer concrete to abstract language. The health-information company's tips call for familiar words and concepts in place of difficult words and jargon.
When technical or complex terms are needed, their meaning should be clearly explained, as in defining chemotherapy as "treatment with drugs that kill cancer cells", and terms should be used consistently, so that once surgery is written it stays surgery rather than surgeries, surgical procedure, operation or procedure. The company's tips also call for teaching whenever needed.
Some readers find quantitative information more difficult to understand than well-written prose, and comprehension may be especially poor when readers are presented with numbers greater than 100 and numbers less than 1. If quantitative information is needed, other ways of expressing it can be considered, such as images, stories or metaphors.
Sentence length, voice and verbs
The health-information company's tips call for short, direct sentences and for focusing on one idea at a time. One health-literacy consultant advised in 2010 simple, short sentences of no more than about fifteen words that express a single idea. A guide of the same year to writing for readers with a wide range of reading skills advised writing at a sixth- to seventh-grade level by using common words and an average sentence length of fifteen words or less. Writers of military manuals are required to keep the average sentence length to fifteen words or less. The usual advice for a mass audience, as given in 2015, is fifteen to twenty words on average. Choppy sentences should be avoided, because even struggling readers appreciate text that is both interesting and engaging.
The active voice lets the writer write more concisely and engage the reader with direct statements: "Change your bandage in the morning and in the evening" rather than "The bandage should be changed in the morning and in the evening". The usual advice for a mass audience favours the active voice unless the doer is unknown or obvious or the writer wants to focus on the person or thing being acted upon. The health-information company's tips also call for the active voice. It is well known that active voice and conversational style make for easier reading, as does keeping the verb and subject close together in a sentence. In the experience of two patient-education specialists, testimonials and narrative are almost always the easiest parts of patient instructions to read.
Inside the sentence, the plain-language campaigner holds, "The dog ate the biscuit" word order helps a lot, and writing with verbs rather than nouns is good too. In one example, a UK Department of Health sentence, reproduced verbatim in a health authority's leaflet for parents, had as its main nouns provision, energy, growth, development, determinant and diets, and its important message for parents of under-fives was to give their children plenty of calories. A verb-led rewrite says that to ensure children under five grow and develop normally, one of the main things they need is calorie-rich food. A further version goes on to say what else the child needs, as if speaking to a parent face to face about a named child.
Even though health information is often qualified and may change, conditional "if… then" sentences should be avoided as much as possible, because they are much more difficult for most readers to comprehend.
Tone and address
The text should address readers directly, using you and your rather than the patient. The usual advice for a mass audience is to personalise the writing with you and we where that suits. The health-information company's tips likewise call for the second person, addressing the patient directly as "you".
Information should be framed in positive yet honest ways, so that a medical preparation that really tastes like chalk is not called "a pleasantly flavored drink". New concepts should be given context, and information framed within the intended reader's culture, logic and experience.
Plain, personal, possible
Health education content can inform patients accurately about existing health care practices, goals and knowledge, which helps them distil the plethora of available information, form an educated opinion of relevant health choices and become more engaged in their health. Among the difficulties of health education and health literacy, health is personal and therefore subjective, and the language of medicine can seem foreign and be difficult to comprehend. Two writers from the health-information company hold that these hurdles can be bypassed by adopting the three p's of "plain, personal, possible" when creating health education materials. Keeping content plain can help people overcome limitations in their health literacy.
As diseases and health care become more globalised, patients from diverse backgrounds need to be educated, and people have different needs, goals, learning styles, levels of support and perspectives on health. To connect with readers across these differences, one of the two suggests making the writing personal: writers should consider addressing readers directly as "you" and using the active voice, be clear who their audience is and compose the text accordingly, and connect choices to what is likely to matter to individual patients.
Adopting new health goals and maintaining them is challenging, and people may struggle for years. They should be gently reminded that it is possible to make small changes along the path to becoming healthy. To make change seem realistic and possible, the same writer suggests that the writing should seek to build readers' confidence and so make them more powerful in charting their own health care, focus on what people can do rather than on unsuccessful examples, and provide multiple paths or choices so that people can choose by their goals, habits and personalities. She holds that good research, judicious use of web-based materials and printed literature, and conversations with people are important for creating powerful content, and that the three p's should be practised while planning, writing, designing, publishing and revising educational content.
The RAISE dimensions
Writing for lay audiences requires language that readers without expertise in the subject can understand, which means carefully selecting, organising, wording and supporting content to convey the relevant points in a straightforward and engaging manner, and applying the principles of plain language can help writers achieve this. Plain language requires interventions in wording, structure and design that respond to the needs of the readers and the goals of the communication.
Romina Marazzato Sparano's RAISE rubric organises those interventions under five dimensions: relevance, accessibility, intelligibility, suitability and efficacy. Two of them, intelligibility and suitability, unpack the principle called "understandable" in the ISO plain-language standard, and they cover two related but distinct linguistic aspects known technically as textuality and adequacy. Creating and maintaining the logical flow of a text poses different challenges from choosing terms and wording that fit an audience's stylistic preferences.
Relevance covers the selection of topics and objectives, their explicitness in the text, and the perspective and depth of their treatment. To decide these, the writer can rely on the judgement of experts, including their own, review the literature on the readers' characteristics, and invite readers into the process through interviews, surveys and sampling. That collaborative development is called co-design, and it requires negotiation and compromise that often leads to innovative solutions. For example, under its Rapid Acceleration of Diagnostics initiative in response to the COVID-19 pandemic, the US National Institutes of Health fostered the accessibility of COVID-19 home tests through a collaborative project that included input from advocacy groups such as the Alliance on Ageing and Vision Loss, the American Council of the Blind and the World Institute on Disability, usability and accessibility consulting by subject-matter experts, insight from government agencies and user testing by Georgia Tech HomeLab. Its learnings are captured in a 2023 best-practice document from the US Access Board.
Accessibility covers where the content is published, the rhetorical structure of the message and the physical design of the document, including images, graphics and videos that help capture and maintain the reader's attention and process the text. It intersects with but goes beyond digital accessibility, which focuses on access for people with disabilities, and digital accessibility strategies can be used on a text that is not clearly written.
Intelligibility primarily involves what linguists call textuality, the construction of meaning attending to grammaticality, acceptability, cohesion and coherence. To explain a process, for example, its stages must be presented in a logical progression, and a step out of order is revised before publishing, whereas a speaker can add, clarify and restate on the go.
Suitability is the adequacy of style and register to the target audience, including positioning the text in its cultural environment and genre. Empathy plays a very important role in effective communication, and the American Psychological Association's style guidelines on respect and objectivity formalise the concept, and although they are primarily directed at research they are useful elsewhere, especially for descriptors of individuals and groups.
Efficacy is the evaluation of the document throughout its life cycle with methods suited to each stage, such as literature review on the audience, interviews and surveys, A/B tests and performance surveys. Evaluation has traditionally been a post facto task, but co-design brings professional expertise and readers' insights together throughout development to help enhance the readability, understandability and applicability of texts.
The dimensions overlap to create an integrated whole, and clear-writing principles are not applied sequentially or independently but guide intertwined decisions during planning, drafting and revising.
Adapting a technical text in steps
Translating a technical text for lay readers is more than substituting lay explanations for technical terms, and it often requires a stepwise process that first makes the technical version clear and only then adapts it to readers who are not specialists. In one example, a technical description of migraine has redundancies and a complex structure that presents the aetiology before the symptomatology. Changing only the technical terminology leaves those issues in place and may introduce new ones, such as a reference-chain mismatch. Streamlining the technical version first makes the two main concepts easy to pinpoint, and they can then be reorganised for lay readers, who are more familiar with symptoms than causes of disease, with an easy-to-follow list of the symptoms and the technical terms explained.
The lay version must then be reviewed to make sure the basics are right, and the common issues to check for are subject–verb agreement errors, ambiguous or mistaken reference chains, wrong or misleading punctuation, lack of parallel structure, unclear centre embedding and confusing noun piling. These issues can make parsing for meaning harder or require undue inference from the reader, and some emerge from cut-and-paste editing as technical language is adapted. Incongruous verb agreement and a mistaken comma after the subject tend to linger once intervening information between subject and verb is removed, and departures from parallel structure and ambiguous reference chains often emerge from editing or translating phrases within a larger structure.