Giving COVID-19 test instructions the health literacy treatment

The ongoing COVID-19 pandemic has thrown into sharp focus, the importance of health literacy. A microcosm illustrating this was identified when a colleague drove for an appointment to undertake a COVID-19 test. The information leaflet they were given broke practically all the rules of health literacy.

Here are some of the lessons we can learn from this – which can be applied to all materials intended for members of the public to read – not just pandemic-related information.

The front door

Let’s start with the first page of the COVID-19 Test Instruction Leaflet and think about what it should tell us. We need to know what the leaflet is about, why we should read it and how to follow the instructions. This ‘front door’ to the information needs to be approachable and easy to read, as it sets the tone for the rest of the leaflet. 

You can see from the front that it is cluttered, without a coherent design. There are variable line lengths, a mix of left-justified and centre-justified text and at one point, two asymmetric columns. In addition, there is a table related to ‘age groups’ which does not belong on this front page overview.

COVID-19 self-test kit Instructions for Use before and after

We can easily fix this. First, we have made each part of the page consistent, with 3 clear messages:

  • Before starting, you may need to register your test kit
  • What you need to do
  • Who can use this test?

 

We have removed the unnecessary table and also moved the first sentence, ‘Thank you for taking the time to complete your coronavirus self-administration testing kit and helping to keep yourself and others safe’. This is now at the bottom of the page – otherwise it diverts the reader from the more important information they need to know at this stage. 

Tick box exercise? 

To the right of the original four steps on the first page, there are boxes which appear to be designed to be ticked. It is unlikely that a person sitting in a car, or anywhere else for that matter, after completing the test would go back to this first page to tick each of these boxes – so we have removed them.

Boxing yourself into a corner

You will also see some text boxes on the front, and our experience is that text inside a hard box (i.e. a hard line) can be overlooked. There is a tendency for the eye to ‘read-around’ such a hard box. If you want to emphasise in this way, use a shaded box without a hard edge.

COVID-19 self-test kit showing the before and after update to 'throat swab' section

And on the topic of emphasis, putting words in capitals is like shouting – a better way to emphasise certain words is to put them in bold.

It’s only words

Health literate information uses words which are easy to understand – this includes ‘everyday’ words, as well as technical words. An example of an over-complicated everyday word is ‘administered’ which is used throughout the leaflet. You don’t administer the test, you use it or give it.  If a health professional was talking to you about this test, they would describe it as a self-test kit, not a self-administered test. This is a good example of where writing conversationally works well – you need to think about what a doctor or nurse might say if they were telling someone this information in person. Another example of a better use of conversational language is changing ‘wait for an on-site attendant to assist’ to ‘wait for someone to come and help’.

Of course, some technical words are still important; for example, we have changed ‘nasal swab’ to ‘nose swab’ and ‘vial’ has become ‘tube’.

When a step is not a step

At present, there are four ‘steps’ described in the leaflet, but the first one is to register your test kit and the final ‘step’ is to get your test results by text message or email. Most people would think that the steps – in a test like this – relate to the actual use of the kit. So we no longer call these ‘steps’. 

To add to the confusion, the original ‘Step 2’ has 3 headings with the same wording.

COVID-19 self-test kit Instructions for Use step 2

You can see that each ends with the format (1/3), (2/3) or (3/3). This notation is often used in technical documents, but many members of the public will not be familiar with it. Instead, we have used 3 separate headings:

COVID-19 self-test kit reworked Instructions for Use step 2

You will also note that 2 of the 3 parts in this section are not about ‘taking a sample’ at all (which was the original heading).

Toeing the line

In places, the lines of text run right across the page – but we know that people who don’t read well find long lines difficult. This is why newspaper columns are narrow – they are easy to read because your eyes are not going backwards and forwards across the whole page.

Short and to the point

This is an obvious point, but the longer the sentence, the more difficult it is for people to understand, particularly those who are not skilled readers. Each sentence should have one message. If there’s more than one message then put in a full stop and start a new sentence. Another way is to use a dash – to separate two parts of a sentence. Also, in some cases, using bullet points will help further. For example:

Place the swab into the plastic vial with the fabric tip facing down, and snap off the other end of the swab, so that it fits inside the vial.

becomes:

  • Put the swab into the plastic vial – with the fabric tip facing down
  • Then snap off the other end of the swab – so that the fabric end fits inside the vial 

Simplify the graphics

The graphic under ‘Prepare to take the sample’ is unnecessarily complicated – with readers having to link the letters A, B, C etc to each individual picture. We have simplified this by placing the name under the associated picture  – making the use of the letters A, B, C redundant.

COVID-19 self test kit Instructions for Use before and after reworked version of prepare to take the sample section

By the way, it is pointless to tell readers to check that the kit contains the instruction booklet – because they actually have the instruction booklet in their hands.

Size does matter

The original leaflet was A4 in size which immediately makes it looks like an official, possibly daunting, document. Our preference is to move to half that size and make it a ‘birthday card’ format. This means there is less information on each page and it is easier to handle.

Navigation, navigation, navigation

There are two focuses when creating information for laypeople. The first is obvious – writing in a lay-friendly way – and being conversational, as already mentioned. However the second is less obvious, and this is to use a layout which is easy to navigate. If people can’t find their way around the document, then it doesn’t matter how lay-friendly the words are. Design is important, so you should carefully consider your choice of images, colour, font size and overall layout, in order to ensure that people can easily understand the information being presented to them.