The Patient Education Materials Assessment Tool (PEMAT) and User’s Guide
What Is the PEMAT?
The Patient Education Materials Assessment Tool (PEMAT) is a systematic method to evaluate and compare the understandability and actionability of patient education materials. The following are our definitions of understandability and actionability:
- Understandability: Patient education materials are understandable when consumers of diverse backgrounds and varying levels of health literacy can process and explain key messages.
- Actionability: Patient education materials are actionable when consumers of diverse backgrounds and varying levels of health literacy can identify what they can do based on the information presented.
Using an inventory of both desirable and undesirable characteristics of patient education materials, the PEMAT produces separate numeric scores for understandability and actionability.
There are two versions of the PEMAT:
- PEMAT-P for printable materials (e.g., brochures, pamphlets, PDFs), consisting of 17 items measuring understandability and 7 items measuring actionability.
- PEMAT-A/V for audiovisual materials (e.g., videos, multimedia materials), consisting of 13 items measuring understandability and 4 items measuring actionability.
While most items are relevant to both printable and audiovisual materials, some items are applicable to only one type of materials. This Guide reviews all 19 items that measure understandability and 7 items that assess actionability. Items are marked (P) to indicate a characteristic pertaining to printable materials and (A/V) to indicate a characteristic pertaining to audiovisual materials.
The numbering of the items in the PEMAT-P and PEMAT-A/V are not consecutive because each version skips items that are not relevant. The PEMAT-P includes items 1–12 and 15–19 for understandability and items 20–26 for actionability. The PEMAT-A/V includes items 1, 3–5, 8–14, and 18–19 for understandability and 20–22 and 25 for actionability. Select for the PEMAT-P section of this Guide and PEMAT-A/V.
If you have Excel®, you can also use the PEMAT Auto-Scoring Form, a form that will automatically calculate PEMAT scores once you enter your ratings. You can find the PEMAT Auto-Scoring Form at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/pemat/pemat_form.xls.
The PEMAT is not a guide on how to design and write patient educational resources. You can find such resources on the Department of Health and Human Services' Health Literacy Tools page at: http://www.health.gov/communication/literacy/#tools.
Who Should Use the PEMAT?
The PEMAT was designed to be completed by professionals, including health care providers, health librarians, and others tasked with providing high-quality materials to patients or consumers. The PEMAT helps you select from the many patient education materials available to determine those that are easier to understand and easier to act on. Materials that score better on the PEMAT can be distributed to patients and consumers in hard copy, placed in an electronic health record (EHR) system for providers to access at the point of care, or posted on patient Web portals.
If more than one individual will be rating materials, you can maximize consistency among raters by following this process:
- Have each rater independently rate the same two materials.
- Identify items on which discrepancies were common.
- Discuss each rater's rationale for the rating provided.
- Review the PEMAT User's Guide to clarify how each item was intended to be rated.
- Come to consensus on how the guidance in the User's Guide should be implemented in practice.
- Repeat this process with additional materials until there is agreement on most items.
Can the PEMAT Be Used To Assess All Patient Education Materials?
No. The PEMAT can be used only for printable and audiovisual materials. (See definitions below.) For example, the PEMAT cannot be used for podcasts or to assess the user friendliness of Web sites (only materials that can be printed or viewed from a Web site).
Are All Materials With High PEMAT Scores High Quality?
Not necessarily. The PEMAT does not assess accuracy or comprehensiveness or perform readability tests. For example, a material could be very understandable but contain inaccurate information. You will want to supplement the PEMAT with additional assessments.
We recommend conducting a readability assessment for print materials in conjunction with using the PEMAT. Using only a readability formula, however, is not a substitute for using the PEMAT. Readability formulas ignore many of the factors that contribute to comprehension and can be misleading.1
While the PEMAT has been subject to substantial testing, there is no guarantee that a material that scores well on the PEMAT will be effective with your patient population. To be sure that materials are appropriate, test them with some of your patients.2
How Was the PEMAT Developed?
The PEMAT was developed under contract to AHRQ by a research team working with a panel of experts in health literacy, content creation, patient education, and communication. PEMAT items were based on items from existing instruments and concepts in guides to assess and develop patient education materials. Four rounds of reliability testing and refinement were conducted using raters who were not trained in the use of the PEMAT. Consumer testing and comparisons with readability assessments were used to determine construct validity, that is, whether the PEMAT was in fact measuring understandability and actionability. The PEMAT demonstrated strong internal consistency, reliability among raters, and evidence of construct validity.
For more information about the reliability and validity of the PEMAT, go to the article, "Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information" at http://www.sciencedirect.com/science/article/pii/S073839911400233X.
What Terms Are Used in This Guide?
Below are definitions of some terms used in this Guide that you may not be familiar with. We have also provided some visual examples. Please note that the health information presented in this Guide should not be taken as medical advice nor construed as up to date or accurate medical information. The information, graphs, tables, and visual aids are only for illustration purposes.
Action: An action is a recommended behavior or instruction.
Audiovisual (A/V) materials include a visual component that may be accompanied by a sound component, such as a video or a multimedia material but not a podcast. Multimedia materials can include a combination of text, audio, still images, animation, video, or interactive content. The following are examples of different types of audiovisual materials.
Example of a Video
Taken from National Institutes of Health (NIH), Living With and Managing Asthma video, June 2011.
Example of Multimedia With Narration
Taken from NIH MedlinePlus Interactive Tutorials, X-Plain Series, Asthma.
Example of Multimedia Without Narration
Taken from NIH MedlinePlus, Metered Dose Inhaler Use image series, July 2012.
Printed or printable materials include printed booklets, brochures, and materials that can be printed from Web sites (e.g., PDFs or html text). The following are examples.
Example of a Brochure
Taken from AHRQ Stay Healthy brochure series, Men Stay Healthy at 50+, July 2011.
Example of Printable Web Material
Taken from MedlinePlus, Aspirin.
Very Short Material: A very short material is defined as follows:
- Printable (P): A material with two or fewer paragraphs and no more than 1 page in length.
- Audiovisual (A/V): A video or multimedia presentation that is under 1 minute, or a multimedia material that has 6 or fewer slides or screenshots.
Visual Aids: The following are examples of the different types of visual aids you may encounter in patient education materials and be asked to assess: graphs, tables, charts, diagrams, and pictures.
Examples of Graphs
Taken from Centers for Disease Control and Prevention (CDC), TB Elimination: Now Is the Time! February 2012.
Taken from NIH We Can! Campaign, Cooking With Healthier Fats and Oils.
Example of a Table
Taken from CDC Know the Facts About Patient Education Series, High Blood Pressure.
Example of a Chart
Taken from NIH, The Healthy Heart Handbook for Women, February 2012.
Example of a Diagram
Taken from NIH, Explore Asthma, June 2012.
Example of a Picture
Taken from AHRQ Effective Health Care (EHC) Program, Treating Sleep Apnea: A Review of the Research for Adults.
1 Readability formulas use metrics such as the number of syllables in words and sentence length to determine approximate grade levels. To learn about the advantages and disadvantages of readability formulas and to choose a readability formula to use in conjunction with the PEMAT, you can consult "Part 7—Using readability formulas: A cautionary note" in "Toolkit for Making Written Material Clear and Effective," available at http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/Downloads/ToolkitPart07.pdf.
2 For more information, go to "Toolkit Part 6: Feedback Sessions" in the "Toolkit for Making Written Material Clear and Effective." You can access this toolkit at http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/Toolkit-Part-6-Feedback-Sessions.html.