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Understandability and Actionability

Using the PEMAT to Benefit Health Literacy

Zuzelo, Patti Rager, EdD, RN, ACNS-BC, ANP-BC, ANEF, FAAN

doi: 10.1097/HNP.0000000000000327

Doctorate of Nursing Practice (DNP) Program, Advanced Nursing Practice Department, College of Nursing & Health Professions, Drexel University, Philadelphia, Pennsylvania.

Correspondence: Patti Rager Zuzelo, EdD, RN, ACNS-BC, ANP-BC, ANEF, FAAN, Doctorate of Nursing Practice (DNP) Program, Advanced Nursing Practice Department, College of Nursing & Health Professions, Drexel University, 1601 Cherry St, 3 Pkwy, Philadelphia, PA 19102 (

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Nurses recognize the complex challenges of patient education, particularly given the English literacy deficiencies of adults revealed by the National Assessment of Adult Literacy in 2003.1 Nurses and other providers are interested in incorporating written and audiovisual (A/V) teaching tools into patient/consumer education to address health literacy needs from a holistic vantage point. To ensure that tools are appropriately understandable for the intended audience, nurses often rely on commonly used readability tools, including SMOG (simple measure of gobbledygook) index, Gunning-Fog index, and the Flesch Reading Ease score. Nurses recognize, for example, that a postdischarge instruction sheet addressing the importance of daily weight tracking for the patient living with congestive heart failure will be more readily understood if it is written at the eighth-grade level rather than the twelfth-grade level. The generally accepted idea is that lower-grade readability scores will meet the needs of a broader audience.

While readability is an important measure, the Agency for Healthcare Research and Quality's (AHRQ's) Patient Education Materials Assessment Tool (PEMAT) for printable material (PEMAT-P) and for A/V material (PEMAT-A/V) offers nurses a rich resource for ensuring that educational materials satisfy the informational needs of diverse learners, specifically those with a wide range of literacy abilities and challenges.2 The PEMAT measures 2 domains, understandability and actionability.2,3 Understandability is conceptually defined as the ability of people from diverse backgrounds with varying health literacy abilities to comprehend educational materials and extract key messages. It is operationalized via 17 items organized under unique content areas, including content, word choice and style, number usage, organization, layout and design, and use of visual aids. Actionability is conceptually defined as the ability of learners to identify what actions can be taken on the basis of educational material information. It is operationalized by 7 items with dichotomous responses, agree and disagree, or not applicable.2,3

The AHRQ provides the PEMAT and all ancillary materials on its Web site. A user guide is available for download.2 Nurses may be interested in the many examples and illustrations provided by the AHRQ to demonstrate successful satisfaction of understandable and actionable teaching materials. The website materials provide nurses with suggestions for improving educational materials. Step-by-step, easily followed scoring instructions are also provided.

Holistic care nurses practice in differing settings and provide care to diverse patient populations varying in age, diagnosis, acuity, and other key demographics that affect learning needs, particularly related to discharge planning and self-care management. The PEMAT has established construct validity and internal consistency, and both versions have applicability to patient education materials, regardless of the type of setting within which the materials are used. Published literature reveals interesting strategies for using the PEMAT to inform product evaluations or to potentially guide purchasing decisions.

The PEMAT-P was used to ascertain whether the Centers for Disease Control and Prevention's (CDC) Sepsis Fact Sheet was a useful tool for instructing consumers about sepsis, a frequently occurring, high-risk illness that is poorly understood by the public and often inadequately reviewed by providers with patients following an initial septicemia event.4 The Sepsis Fact Sheet was critiqued by an expert panel of health care professionals using the PEMAT-P tool as the evaluative tool. This process affirmed the Sepsis Fact Sheet as a valuable teaching tool and also provided opportunity to share minor critique with the CDC for future consideration.4

The PEMAT-AV provided the mechanism needed to construct an evaluation process for a patient education multimedia product purchased by a health care agency to creatively meet the discharge instruction needs of patients.5 The tool was used by an interdisciplinary team to individually and collaboratively identify opportunities to enhance the purchased product and establish congruency between clinician expertise and practice patterns and the vendor-produced instructional materials.5 The end result of this endeavor was a formal process, informed by the PEMAT-AV, that could be potentially replicated for each of the patient education modules, thereby providing a consistent framework for collaborative interprofessional product evaluation activities.5

An evaluation of advanced care planning (ACP) materials further illustrates the utility of the PEMAT.6 Health care professionals select consumer education materials from an array of available resources. Choosing resources for consumer education can be challenging if working without uniform criteria against which to judge potential resources. The ACP evaluation project assessed readily available materials (N = 20) for readability, understandability, actionability, reading ease, and grade level.6 The PEMAT provided comparative scores that enabled a richer evaluation process, particularly given the significant variability of understandability and actionability scores across individual ACP materials.

The published literature offers an array of opportunities to learn how the PEMAT has been successfully used to evaluate patient education materials. Its international impact is apparent as evidenced by a brief review of literature yielded by a simple key word search using PEMAT. Several studies have explored the interrater reliability of the PEMAT, and findings support that it is a convenient, user-friendly, and reliable tool. The PEMAT provides opportunity for interprofessional colleagues to approach patient education materials from differing professional viewpoints and experiences but with shared understanding informed by the tool and ancillary materials.

Holistic care providers may want to consider whether there is opportunity to use the PEMAT to inform patient educational material planning and construction in proactive fashion. Rather than designing materials and then evaluating them post hoc, the PEMAT could be used to guide planning with understandability and actionability as priority characteristics that inform content selection and delivery mechanisms. Using the PEMAT as a construction guide would assist in keeping nurses focused on plain language, short chunks of text, uncluttered pictures and diagrams, active voice, and other criteria that contribute to understandability. Nurses could use the actionability items to craft clear instructions, tools, simple action steps, and other components that promote the utility of the tool and the actions that the tool is presumably designed to encourage and support.

There are many opportunities for nurses to use the PEMAT in its print and A/V forms to ensure that patient/consumer teaching materials are effectively designed. Readability formulas are often used to guide development of patient education materials; however, readability does not address the understandability of the message and the actionability of the lesson content. When nurses design educational materials, they are typically working to ensure that patients understand key ideas and know what to do with this information. Nurses accustomed to using a readability formula that has demonstrated effectiveness for the patient population of interest may combine a readability formula with the PEMAT to ensure that important health-related instructional materials provide readable information and instructions that are readily understood and correctly applied.

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1. Zuzelo PR. Health Literacy and its influence on self-care potential. Holist Nurs Pract. 2016;30:305–307.
2. Shoemaker SJ, Wolf MS, Brach C. The Patient Education Materials Assessment Tool (PEMAT) and User's Guide. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 14-0002-EF. Accessed February 12, 2019.
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5. Howard-Mistry D. Evaluation of COPD Patient Education Materials [Doctor of Nursing Practice project]. Philadelphia, PA: Drexel University; 2018. Accessed on February 12, 2019.
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