Reading is thought of as a universal skill. But when it comes to how people engage with technical documents, such as Clinical Outcome Assessments, Package Leaflets or informed consent forms, the process of accessing these documents is anything but one-size-fits-all. While certain baseline reading strategies appear across cultures, the deeper patterns of reading and comprehension are shaped by a complex blend of biological and cultural factors.

Universal Reading Strategies

Regardless of culture and language, there are a few common strategies that tend to be used when reading text. These include:

• Scanning: quickly searching for specific information like side effects, dosage instructions or contraindications.

• Skimming: Getting a general sense of the content without focusing on every word, useful for navigating dense sections.

• Close reading: Slowing down to absorb essential details, such as “Do not use, if…”.

These strategies are responses that we adapt to when we deal with different levels of importance or complexity within a text. However, what strategies they choose, such as whether they jump straight to scanning or start with sustained close reading, can significantly depend on cultural and literacy norms and expectations, as well as how well the document has been designed to accommodate these culturally-influenced expectations.

Cultural Differences in Perception

Cultural norms shape how information is organised, laid out and processed.

Culture shapes our visual expectations of a text. A key factor that influences reading flow is the directionality of the writing system:

*     Western readers, who are used to left-to-right scripts, expect:

• Headings in bold and bullet points to guide the eye.

• A “top-down” order of how the information is organised that starts in the top-left corner. 

• Then, a linear flow through the document, organised by topics. In a COA, this would be introductory text, instructions, items and response choices, a message that concludes the survey. In a Package Leaflet, this might be introduction, warnings, how to use, side effects, storage and then contact details.

*     Right-to-left readers, such as Arabic and Hebrew speakers, tend to:

• Start scanning by intuition from the top-right corner, then moving left

• Experience visual and cognitive friction when documents blindly follow Western layouts, such as left-aligned tables or left-anchored labels or shared-stem questions.

*    In East Asian cultures, such as Chinese and Japanese, historical scripts were written vertically, i.e. top-to-bottom, right-to-left in columns. Contemporary materials tend to use left-to-right horizontal layouts, but readers still tend to prefer to have information in block-based or diagrammatic layouts, such as flowcharts and grids. In addition, because of the vertical script tradition, readers in East Asian cultures tend to process information columns, top-to-bottom.

Therefore, Western-designed forms feel clear to a reader in the USA or Germany, but might feel cluttered and confused to a reader in Japan or Israel.

Localisation is Beyond Words

Translation from source to target does not guarantee effective communication. A Western Package Leaflet or a Clinical Outcome Assessment translated into Arabic or Japanese might retain surface meaning, but may lose cultural resonance. In many ways, it is the opposite of the concept of cultural coating that we introduced in previous articles: it is more like a ‘cultural stripping’. This is because the design of the document in the source language has been poorly adapted to cultures outside of the Western comfort zone.

Other issues that could disturb effective communication to readers in other cultures is the tone and tenor of the document. In Western societies, there is a concerted effort to render clinical information in lay language, to maximise understandability and to address the patient directly. In cultures where there are specific expectations about medical authority, care needs to be taken how lay information is framed. A simple translation of the source text might not work.

Emotion and Cognitive Framing

Cultures differ in how they balance emotional sensitivity and cognitive clarity. In some societies, medical information is expected to acknowledge emotional realities, such as fear and uncertainty, rather than just medical facts. Conversely, Western cultures prefer efficiency and logic, with texts focusing on non-vague information that readers can act upon. For example, a US medication guide might state simply: “Side effects may include dizziness”, while this might come across as blunt when translated directly into Japanese. Here, the cultural expectation might be to rephrase this as “Some patients may experience dizziness, so please take care.”

The Experience of Reading Is Not Universal

Reading clinical materials is always filtered through a combination of visual habits, cultural norms and social expectations. However, this differs from person-to-person. Two people from different backgrounds might read the exact same information, whether this is a Package Leaflet or a Clinical Outcome Assessment, but they won’t necessarily process it in the same way. This is why the results of a readability test, for example, is only ever indicative of a Patient Information Leaflet being ‘readable’ rather than offering objective proof of lay understanding: two parallel readability tests conducted with separate groups of participants within the same culture, in the same city, could yield differing results. This is because every individual brings their own reading habits, biases and expectations to every document.

But there are broad cultural differences in how information is processed. Global organisations that produce medical forms, Clinical Outcome Assessments, patient information need to move beyond simple translation and focus on cultural adaptation. And this is not just about ensuring the conceptual equivalence of words only.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, March 2025