Designing an illustrated patient satisfaction instrument for low-literacy populations.

Up to 25% of adults in the United States have difficulty with everyday reading tasks. As patients, adults with low literacy may not be able to complete many self-administered written questionnaires, which often are used to obtain information from patients and to gauge their satisfaction with care. We developed an illustrated version of a patient satisfaction instrument used by the Veterans Health Administration. This paper describes the extensive design process used to develop, pilot-test, and revise this 63-item illustrated instrument. A total of 438 patients were interviewed over a 1-year period to obtain feedback on illustrations, with at least 15 people viewing and commenting on each picture and revision. All pictures were revised, with the majority revised at least 4 times. We report on this iterative design process as well as on lessons we learned in illustrating questions for low-literacy populations.