Using the information gathered during audience research, you can begin 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 all those involved in product development. Discussing the concept with individuals or groups who understand the needs of your target audience is an easy, inexpensive way to doublecheck the appropriateness of your intended approach. It is, however, no substitute for pretesting materials later with your target audience.

Leonard and Cecilia Doak, health and literacy experts, suggest five principles to follow when developing the concept for a low-literacy publication:

• Define the behavioral objective(s) of the material.
• Determine the key information points the reader needs to achieve the behavioral objective(s).
• Select the most appropriate presentation method(s) (e.g., audio, audiovisual, print, radio, TV, interactive computer programs).
• Decide on the reading level for the material if you select a print presentation.
• Organize topics in the way the person will use them.

To keep the product focused on concrete action, objectives should be behavioral rather than simply informational. For example, in designing a product intended to promote mammography among low-literate women, appropriate behavioral objectives might be:

• The reader will ask the clinic or doctor about mammography at her next visit, or
• The reader will make an appointment for a mammogram or
• The reader will call us to discuss her options.

Objectives such as these would help guide content decisions to avoid unnecessary details. An objective that was purely informational (e.g., "The reader will understand why mammography is important to her health") would not necessarily lead to the development of the action-oriented messages low-literate audiences need.

From the many possible content points, which ones will predispose and enable the reader to take the desired action?

The information you learned from audience research will help you make this determination. In addition, it is important to consider when and how a product will be used. The following questions are important to answer at this stage:

Will the material be used by the reader alone or interactively with a health or social services professional?


Will the product stand alone, or is it part of a series of materials, or of a broader communications initiative, such as a media campaign?

At what point in the learning process will the reader receive the product (e.g., regarding an illness: before diagnosis, after diagnosis, before or after a treatment decision, or before or after the reader is likely to have received related information)? What types of information will be useful and relevant (e.g., will this audience use a resource list of groups to write for more information)?

At the most basic level, it is important to assess whether print is an appropriate medium for conveying your message to this audience. Will your audience pick up a print product, and, if so, under what circumstances? If they are used to relying on radio, TV, or word-of-mouth, can print materials serve their needs?

If you do choose print, will you create a l-page factsheet, a 10-page booklet, or three 1-page factsheets delivered at different points in the learning process? Budget and target audience information help shape such decisions. Two additional questions also are important to answer:

How will the product be distributed (e.g., in person, on a rack in a supermarket, through the mail)?


Is the material intended for one-time or long-term use?

Answers to these questions have important implications for the tone, structure, and design of the product.

The term "reading level" refers to the number of years of education required for a reader to understand a written passage. Some experts suggest aiming for a level that is two to five grades lower than the highest average grade your audience achieved to account for a probable decline in reading skills over time. Others note that a third to fifth grade level frequently is very appropriate for low-literate readers.

How do you estimate reading level? Readability formulas often are used to assess the reading level of materials. Fry, Flesch, FOG, and SMOG are among the most commonly used readability formulas. Using these formulas is a simple process that can be done manually or by using a computer software program. Each method takes only a few minutes.

Typically, readability formulas measure the difficulty of the vocabulary used and the average sentence length. In addition, the computer software programs analyze a document's grammar, style, word usage, and punctuation, and assign a reading level. However, these formulas do not measure the reader's level of comprehension. Grammatik, and other readability software programs are available from computer stores or from the manufacturer. Note: Mention of software products does not constitute an endorsement by the National Cancer Institute.

Reading levels and readability formulas are useful aids in targeting publications to an audience. Yet none of the readability formulas listed above were designed to be used as writing guides. According to researchers James Pichert and Peggy Elam, most were designed originally to rank the difficulty of books to be used at a specific grade in school. Thus, using such formulas in product development is no guarantee of producing well-written, understandable text. In fact, their creators acknowledge that using the formulas as writing guides can have serious negative consequences. For example, one writer is concerned that the formulas' emphasis on short sentences and short words may produce a choppy text that leaves out familiar terms because they are polysyllabic. In addition, some formulas were tested on children rather than on adults, limiting their applicability to adult low-literate readers.


Pichert and Elam suggest three principles for using readability formulas effectively:

• Use readability formulas only in concert with other means of assessing the effectiveness of the material.
• Use a formula only when the readers for whom a text is intended are similar to those on whom the formula was validated.
• Do not write a text with readability formulas in mind.

For more information on readability formulas, see Teaching Patients With Low- Literacy Skills and Making Health Communication Programs Work: A Planner's Guide.

Give readers the most important points first and last; studies show that low-literate audiences remember these best. Literacy experts also suggest grouping information into "chunks," with a clear, ordered format. You may sequence these as steps (1,2,3), chronologically (by time of day), or by topical arrangement (main heading, subheadings) depending on how the person will use the information.

It also is useful to give the reader an action step he or she can do right away (e.g., call your clinic, send in a request). This reinforcing action tends to improve retention of information and moves the reader into desired behaviors immediately.

In trying to limit my publication to a few key points, how do I determine what information the reader absolutely needs and what I can leave out?

Focusing on your behavioral goals for a publication can help you decide if an information point is fundamental and helps to motivate a desired action.

One writer separates information points into those the reader needs to know, those the reader might (or might not) want to know, and those the sponsoring agency wants to tell. "Most of the time, information that falls in the second two categories can be eliminated. I try to make my inclusion criterion, 'Does the reader need this statement, fact, or reader's aid to understand, accept, and take the desired actions?' This cuts out a lot of detail, but some tough decisions always remain. I try to make sure that pretesting particularly addresses these points, because it's the only way to determine the information that the audience really needs."

Writing at the correct reading level for the audience is important, but I also am hearing that I should not write my text with a readability formula in mind. What should I use to help me write at an appropriate level?

Most writers intrinsically shy away from formulas. Yet, because good writers are highly literate themselves, they may not trust their usual instincts to tell them what will work for people with limited reading skills.

The checklist in the next section outlines the fundamental principles of writing and designing a low-literacy publication. These guidelines address the readers' needs and should provide a basic framework within which a writer can operate comfortably.

One low-literacy-materials writer illustrates the value and limitations of readability formulas. "I made my written explanation as simple and action-oriented as I could. Then I put it down for a while and came back to it with a critical eye. I rewrote it several times until I was happy with the flow and the comprehensibility of the text. At this point, I used several readability formulas to see what level I had achieved.

When the product tested at the sixth grade level, I was surprised. I went back and found I could simplify some of the text without detracting from my message. It ultimately tested at the 4th grade level-- and pretesting still showed us that one or two concepts were not well understood."

While readability formulas and software do not produce good low-literate materials, they can be useful in approximating a reading level or, in the case of some software products, identifying specific problems that inhibit readability.

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