Using the PEMAT to assess patient education materials

March 14, 2024 - As the push for greater patient health literacy gets stronger, the Patient Education Materials Assessment Tool (PEMAT) could be helpful to healthcare providers.

Increasingly, healthcare industry experts are touting the role that patient education plays in good patient engagement and activation. An informed patient is an engaged patient, and patient education can help individuals take care of their own healthcare journeys, treatment plans, and chronic care management plans.

While patient education can and should be a part of patient-provider communication, many providers also issue patient education materials to supplement those conversations. The data shows that patients want these tools, especially considering nearly half of patients forget their care plans following a hospital or clinic encounter.

But not every patient education document is created equally.

Given the low baseline health literacy level of the typical patient, patient education materials need to be written in plain language and be offered in multiple languages other than English. Producing that ideal patient education tool can be difficult because it is hard to translate complex medical concepts into layperson terms. Ultimately, some patient education materials are more successful at doing this than others.

To help healthcare providers sort through the vast array of patient education tools, experts at the Agency for Healthcare Research and Quality (AHRQ) developed the PEMAT, or the Patient Education Materials Assessment Tool, intended to help providers determine whether a tool will actually be understandable and actionable.

What is the PEMAT?

AHRQ developed PEMAT in 2014 to give a simple, validated tool for providers and laypeople alike to assess the usefulness of a given patient education tool.

“The Patient Education Materials Assessment Tool (PEMAT) is a systematic method to evaluate and compare the understandability and actionability of patient education materials,” AHRQ says on its website. “It is designed as a guide to help determine whether patients will be able to understand and act on information. Separate tools are available for use with print and audiovisual materials.”

The PEMAT is not the first instrument healthcare leaders have developed to measure patient education materials, AHRQ acknowledged upon developing the tool, which is documented in a 2014 report.

However, previous attempts have ignored “several factors that contribute to comprehension,” the agency said, and do not usually include audiovisual education tools nor assess for actionability. That latter factor is critical, AHRQ said, because actionability is key to the Department of Health and Human Services overarching goals to improve patient health literacy.

Breaking down PEMAT domains

Like many assessment tools, PEMAT measures the effectiveness of patient education materials across a number of domains. Those domains can vary depending on whether the item being assessed is a written tool or an audiovisual tool.

The assessment measures materials based on understandability and actionability, which AHRQ defines as:

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.

Understandability Domain

Under the Understandability domain, AHRQ asks PEMAT users to assess the following:

• Content: whether the patient education tool makes its purpose evident to the patient and whether it includes content that is irrelevant or distracting
• Word Choice & Style: whether the patient education tool uses common, everyday language, medical terms are only used to familiarize the reader, medical terms are defined, and the content is written in the active voice
• Use of Numbers: Whether numbers used in the patient education materials are clear and easy to understand and whether the document asks the reader to make numerical calculations
• Organization: Whether the material breaks down concepts into short sections, the sections have clear headers, the sequence is logical, and the material provides a summary
• Layout & Design: Whether the tool uses visual cues to emphasize key points, the text is easy to read, and the tool makes it easy to hear words clearly
• Use of Visual Aids: Whether the tool uses visual aids to make content easier to understand, the aids reinforce rather than distract, the visual aids have clear titles and captions, the illustrations are clear and uncluttered, and any tables are simple with short and clear row and column headings

Actionability Domain

Under the Actionability domain, AHRQ asks PEMAT users to assess the following:

• The patient education tool defines at least one action the viewer can take
• The tool addresses the viewer when outlining action items
• The tool breaks down actions into manageable steps
• The education material identifies helpful tools to accomplish actions as applicable
• The patient education tool gives simple instructions or examples of how to perform calculations
• The material outlines how to use any charts, graphs, tables, or diagrams to take actions
• The tool uses visual aids when they could help the viewer to act on instructions

AHRQ also advises PEMAT scorers to consider the cultural relevance or competency of a tool for an individual patient or an entire patient population. Scores should ask themselves whether the language and examples in the tool would be familiar to the target audience, whether images are portraying the audience’s race, ethnicity, age, gender, or ability, and whether the material avoids or perpetuates stereotypes.

Interpreting PEMAT scores

PEMAT scores are displayed as a percentage out of 100. For every “yes” answer a domain receives, the assessed material gets one point. Scores are calculated by adding the sum of all points, dividing by the total possible points (excluding items that were not applicable to the material), and multiplying by 100.

When designing the PEMAT, AHRQ initially said a score of 70 percent in either the Understandability or Actionability domains would indicate good patient education material, although the agency did acknowledge that that number was arbitrary. Of course, a higher score in either domain is a signal for more understandability or actionability, but AHRQ does not advocate for a specific score.

The reasons for that could be manifold, but it is likely that because PEMAT users are humans, their opinions about certain PEMAT elements are subjective. AHRQ did assert that using the PEMAT to assess multiple patient education tools could give the user a better sense of what scores indicate exceptionally good patient education content.

PEMAT Use Cases

According to the Institute for Health Advancement’s (IHA’s) Health Literacy Solutions Center, healthcare professionals can use the PEMAT for a number of purposes, most of which center on improving patient health literacy. Those use cases include:

• Comparing similar patient education materials
• Supplementing other patient education material assessments
• Identifying new audiovisual tools that have been validated and assessed
• Auditing existing patient education materials

AHRQ asserts that PEMAT works well for these cases, with user tests showing that the tool can help providers and patients alike parse through tools that could support patient education initiatives.

That’s going to be important as healthcare continues to confront a growing population of chronically ill patients. Patient education will be integral to patient engagement in care management plans.

Whether providers are just beginning to audit their patient education materials or they are looking to add more assessment tools to their arsenals, the PEMAT could be an effective tool to ensure patients are getting the best information that informs and empowers them in their healthcare.