The 56^th European Medical Writers Association (EMWA) Hybrid Conference Day took place on 10 November, with delegates able to attend sessions on Writing in Plain Language for Publications, and Artificial Intelligence (AI) in Medical Writing. The seminars covered these topics through presentations and panel discussions, with the aim of providing practical recommendations and advice to medical writers and communicators. A summary of the first session on Writing In Plain Language for Publications is provided below to benefit those who were unable to attend, and as a timely reminder of the key topics for those who did.

Our summary of the session on AI in Medical Writing can be found here.

Writing in plain language for publications

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KEY TAKEAWAYS

• Clear and accurate science writing improves communication with patients, fights ‘fake news’, and helps healthcare professionals (HCPs) gain insights into other fields.

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Introducing the topic of plain language summaries (PLS), Andrea Bucceri (Lumanity) stressed the importance of communicating science clearly and accurately, highlighting the ability of PLS to help communicate with patients, fight misinformation (or ‘fake news’), and allow HCPs to gain valuable insights into other fields. Noting a degree of uncertainty regarding PLS among industry publications professionals as recently as 2014, Bucceri emphasised how PLS have now become an important part of medical publications, with most journals allowing PLS within articles, some making them compulsory, and others allowing standalone PLS.

The importance of PLS – publishers’ perspectives

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KEY TAKEAWAYS

• PLS are needed to increase the accessibility of science to everyone.
• Good Publication Practice (GPP) guidelines recommend that every biomedical publication include a PLS.

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In this session, representatives from the publishing industry shared their views and insights on PLS. Caroline Halford (Springer Healthcare) began by explaining the distinction between PLS, plain language summaries of publication (PLSP), and regulatory lay summaries. PLS – the focus in this symposium – are approximately 250-word long, jargon-free summaries that are published with the parent publication and target a broad non-specialist audience. On the other hand, PLSP are plain language adaptations of full manuscripts, often targeting a patient audience. Regulatory lay summaries are mandated summaries of clinical study reports focused on a study’s primary and safety endpoints, targeted at the study’s participants.

Halford explained why PLS are becoming so important, stating that with the move towards open access, biomedical publications are being read by increasing numbers of HCPs and members of the public. Both groups need clear and comprehensive information that is not easily misunderstood. PLS also offer a quick and convenient way for doctors to keep up-to-date with their fields.

PLS are needed to increase the accessibility of science to everyone.

Halford recognised that the value of PLS for HCPs and patients is well-established, with 71% of HCPs rating PLS to be “very/extremely useful” and around 1 in 6 HCPs referring patients and families to online PLS. She also referenced surveys conducted among patient organisations and patients and their caregivers demonstrating the importance and value of PLS as a source of health-related information for these groups.

Concluding, Halford highlighted the tangible benefits of PLS. Research shows that articles with PLS are more likely to be downloaded than those without, and that of all article enhancement types, PLS produce the highest comprehension, understanding, enjoyment, and desire for more updates.

Felicity Poole (Taylor & Francis) elaborated further, emphasising that a PLS is a constituent part of the parent article and shares the same Digital Object Identifier (DOI), in contrast to a PLSP, which is a standalone publication. Noting how PLS can be text-based, graphical, or make use of audio/video, Poole shared some best practices for PLS when considering which format(s) to use:

• Always include a text-based PLS with an article, as this will be indexed on PubMed, making it more discoverable.
• Include both text and graphical PLS if possible, since graphical PLS are most popular.
• Include audio/video PLS if the journal allows for this, to increase accessibility for audiences with specific needs.

Poole also drew attention to the wealth of available resources to help publication professionals implement PLS, including those from the European Medicines Agency, Open Pharma, Envision Pharma, and the International Organization for Standardization (ISO), ‘How-to’ Guides from Patient Focused Medicines Developments (PFMD), and the updated 2022 GPP guidelines (GPP 2022).

Referring to GPP 2022, Poole highlighted key points from the recommendations regarding which publications should include a PLS:

• A text-based PLS should be prepared for any clinical trial publication that follows the Consolidated Standards of Reporting Trials (CONSORT) guidance.
• Ideally, a PLS should appear with every biomedical publication, keeping in mind the audiences for the information being presented.

Poole continued by identifying the important factors to consider when choosing a target journal and stressed the importance of checking publisher guidelines since they will all be different and not all publishers offer PLS:

• What is the journal’s target audience?
• When is the point of submission – alongside the original article or post-submission?
• Does the journal index the PLS on PubMed?
• Does the journal provide good guidelines on the format, length, and readability level?
• Is the PLS open access, or hosted behind the paywall for subscription journals?
• What is the peer review format – the same reviewers as the manuscript or experts in plain language?

Available metrics for measuring the value of PLS were also discussed briefly, however, Poole noted that the use of metrics is complicated by difficulties in separating PLS views from article views – a topic revisited in the panel discussion following the presentations.

Poole ended by saying that something is always better than nothing. A text PLS should be included as a minimum, and infographics, graphical abstracts, and audio and video PLS included where possible.

Something is always better than nothing. A text PLS should be included as a minimum, and infographics, graphical abstracts, and audio and video PLS where possible.

 Writing considerations for plain language

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KEY TAKEAWAYS

• PLS should be targeted at the right reading age for your audience, using simple language with short sentences.
• Use the active voice and visual formatting elements that support understanding.

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Adeline Rosenberg (Oxford PharmaGenesis) discussed the key considerations when writing PLS or other documents requiring the use of plain language. Rosenberg highlighted the importance of targeting the right reading age for the intended audience but acknowledged the difficulty in doing this successfully. The UK National Health Service advises that health information should be pitched at a Year 7–9 (ie, ages 11–13 years) level to ensure that 85–93% of patients and the public can understand it, whilst elsewhere research has shown that medium complexity language, defined as a reading age of 14–17 years, was preferred.

Similarly, Rosenberg thought that readability scoring systems including Flesch Reading Ease Score, Flesch-Kincaid Grade Level, SMOG, Gunning fog, and the Coleman-Liau Index, as well as the basic readability statistics in Microsoft Word were useful tools but should not be used in isolation. Rosenberg advised testing written material on 2–5 people representative of your target audience as a better method of ensuring the language is understandable. Publication professionals can also use previously published PLS and PLSP as a guide, for example by accessing Taylor & Francis’s Plain Language Summary Repository, Future Science Group’s PLSP Repository, or by searching “hasplainlanguagesummary” in PubMed.

Regardless of the level of information provided, it should always be written in plain language that is simple and clear.

Beyond readability, Rosenberg suggested that writing tone and message should be different for different audiences, for example a non-promotional tone for HCPs and a sensitive tone for patients. A focus on the bigger picture for patients and accurate presentation of the material to prevent misinterpretation by the media are also important.

Moving on to practical considerations for producing plain language documents, Rosenberg outlined the following best practices:

• Use simple language and avoid medical jargon.
• Use short sentences.
• Use the active voice.
• Simplify numerical information and consider presenting it graphically to aid understanding.
• Consider how best to present risk – present data as both a fraction and a percentage.
• Consider including a phonetic glossary.

Good visual design elements also aid understanding, including using short, bold headings and using questions as section headings. Images and graphics should support understanding of the text, be standalone, and be user-tested. Basic formatting is also important to aid the reader’s understanding:

• Use large sans serif font (at least 12 pt).
• Use lower case bold for emphasis.
• Left justify text with ragged right.
• Leave plenty of space around text.
• Break information down into discrete sections.
• Use images that directly support the text.
• Use bullet points to list content, and call-out boxes to highlight important content.
• Avoid italics, ALL CAPITALS, underlining (and parentheses).

Rosenberg concluded by signposting some useful resources for writing in plain language, including: MRCT Glossary, EMA Medical Terms Glossary, NCI Cancer Dictionary of Cancer Terms, NHS Resources for Health and Digital Literacy, Health Literacy Online from Health.gov and Patient Information Forum (PIF) ‘How-to’ Guides.

 Translating PLS

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KEY TAKEAWAYS

• Translating PLS is important to provide global equity in health awareness.
• Ensuring cultural sensitivity whilst maintaining accurate information is essential.

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Ana Sofia Correia (Ana Sofia Correia Medical Translation & Writing) presented the next session covering translation of PLS. Correia began by establishing that most scientific articles are only published in English, despite English speakers comprising less than 20% of the world’s population. In addition to producing PLS in English, we must ensure that the information reaches the non-English-speaking populations that we are targeting to provide equity in health awareness.

Translating PLS is important to provide global equity in health awareness so that everyone is able to make better-informed health decisions.

Summarising the role of a medical translator in PLS, Correia identified the following key principles:

• Adhering to the principles of plain language – translating without introducing complexities.
• Safeguarding cultural sensitivity and contextual relevance – incorporating culturally relevant examples whilst maintaining simplicity.
• Ensuring consistency in simplification throughout the document.
• Collaborating with stakeholders to maintain scientific integrity.
• Navigating ethical considerations to balance dissemination of accurate information with cultural sensitivity.

Correia elaborated on the PLS translation process and stressed the importance of beginning translation only after finalisation of the PLS in the source language to mitigate the time and costs of additional revisions. After translation, the PLS must be checked to ensure that it is true to the original, for example, by back translating. In addition, it should be tested in the relevant target populations to ensure that it is easily understood.

Recognising the challenges involved in accurate and culturally sensitive translation of PLS, Corriea recommended the following strategies to address these issues:

• Graphical elements: decide on target languages and work with translators from the planning stage to anticipate different text-lengths within graphical elements, and ensure that graphical elements are culturally appropriate and understandable in the translated version.
• Linguistic and cultural aspects: use simple, clear language and culturally relevant examples whilst avoiding idioms and oversimplification.
• Identification of target languages: demographic studies, health surveys, and epidemiological data can help identify the languages spoken by the most relevant populations.
• Cost: develop templates and glossaries to expedite the processes and use translation tools and resources in combination with human translators.

Correia ended by highlighting some useful medical translation tools, including: Translation is not Enough: Cultural Adaptation of Health Communication Materials (ECDC), Getting It Right (ATA), Everyday Words for Public Health Communication (CDC), Clear Writing (European Commission), and Readability Formulas: 7 Reasons to Avoid Them and What to Do Instead (UX Matters).

 Panel discussion

The presentations were followed by a lively panel discussion bringing together all the presenters from the morning session plus Hamish McDougall (Sage). Key discussion points included:

• Dissemination of PLS translations: many publishers allow for the submission of translated PLS and may have in-house translation capabilities. However, discoverability of translated PLS is an issue and collaboration with search engines to increase discoverability and use of social media to increase dissemination are key.
• Use of metrics to measure PLS access: since PLS are embedded within full-length articles, it is difficult to discriminate between access to PLS and access to the rest of the article. Adding additional clicks to allow for metrics would make PLS less discoverable. Though we know that patients and doctors want PLS, more research is needed to prove the benefits of PLS. Use of metrics to assess PLS access in different geographical regions would be useful in determining the most appropriate languages for translations.
• Peer review of PLS: concerns were raised around peer reviewers ignoring the PLS during review of the main article. Representatives from the publishing industry clarified that guidance on reviewing PLS is provided for peer reviewers to ensure that this is included with their review. Journals try to include plain language reviewers, including patients from both within and outside of the disease area where possible, or editors from a different therapeutic area. In the case of translated PLS, patient reviewers also review the translated language.
• Acknowledging patient contribution: authors are encouraged to be comprehensive in acknowledging patient contributors and reviewers. Patients should be included as authors if they meet the ICMJE authorship criteria, and otherwise included in the acknowledgements.
• Use of acronyms in PLS: acronyms should not be used as a way of reducing word count. They should be used sparingly and expanded at first mention unless it is a common word eg, DNA, HIV, and URL.

Why not also read our summary of the afternoon session on AI in Medical Writing.

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Written as part of a Media Partnership between EMWA and The Publication Plan, by Aspire Scientific, a proudly independent medical writing and communications agency that believes in putting people first.

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