Table 1 Six steps for developing low literacy educational materials

1. Convene a working team and solicit stakeholder input early

Phase 1 – Focus groups

English-speaking RA patients

Spanish-speaking RA patients

Cantonese-speaking RA patients

Rheumatologists

2. Identify key concepts to be communicated

Focus groups provide feedback on main areas of content:

• Broad category of medicines for RA

• Benefits of DMARDs across mono- and combination therapies

• Talking with the doctor about RA drugs

• Learning about risks

• Ways to reduce risk

• Cost

3. Map concepts to a behavioral theory, such as social cognitive theory and construct a brief intervention to support the use of written materials

Phase 1 -social cognitive theory suggests that materials should:

• improve knowledge

• positively influence outcome expectations

• emphasize facilitators of behavior change

• address impediments to behavior change

• facilitate the creation of goals

4. Carefully design materials using low-literacy principles

Phase 2: adopt AHRQ summary guide for low literate, limited English language proficient patients

• Use illustrations

• ≥ 14 pt font

• Adequate white space

5. Refine materials using input from the target population

Phase 2

• In-depth, semi-structured interviews

• Review adapted guides with patient advisory board

6. Assess success of efforts in target audience and learn from failures

Phase 3 – pilot test of decision aid, evaluate acceptability and outcomes of knowledge and decisional conflict