While reading direction plays a key role in document design, another equally important but frequently overlooked factor is how the script itself interacts with the layout. Many scripts, such as Arabic, Chinese and Tamil, carry more visual density than Latin-based alphabets. This affects how readers process text. In clinical settings, where Clinical Outcome Assessments (COA) and patient-oriented materials are routinely translated – even when they are faultlessly translated – failure to adjust the target document for script density, character structure and cultural layout expectations can overwhelm readers. This article looks at how typography, spacing and visual hierarchy need to be adopted to match the cognitive and reading habits of diverse global audiences.

Layout and Script Do Not Match

When scripts that are more visually dense, such as Arabic, Devanagari and Tamil, are translated into layouts originally designed for simpler Latin alphabets. This mismatch can cause serious legibility issues:

• Line spacing that is overly wide may fragment text for readers used to tighter arrangements

• Font styles or sizes that work well for Latin letters may create visual clutter or reduce legibility when applied to dense or connected scripts.

For example, Arabic script is cursive and favours more balanced use of white space, whereas Latin-based layouts might seem too sparse or blocky when applied to Arabic text.

Mismatch Between Reading Flow and Visual Hierarchy

Readers of a logographic script, such as Chinese, often expect a more grid-like flow of reading in columns. When content translated into Chinese appears in traditional LTR horizontal layouts, it may conflict with the reader’s vertical or modular scanning preferences. This would force readers into unfamiliar eye movement patterns that may reduce reading speed and comprehension.

For example, the item in Traditional Chinese whilst retaining an LTR layout:

在过去的7天里，您多久经历以下症状？

Here is the eye-tracking pattern for Chinese content forced into a Western LTR table layout:

What is going on here?

• The reader first fixates on the stem at the top.

• Then, instead of naturally moving vertically down a column, they are pulled into an LTR horizontal scan across each row.

• This triggers a left-to-right "drag" effect across the response options, which can feel less intuitive for readers used to grid-like or column-first structures.

• Dashed arrows show how the eyes may awkwardly reset to the next row, breaking the typical modular pattern Chinese readers are more familiar with.

  
  

Below is a modular layout more aligned with traditional Chinese columnar/grid-like reading preferences, where each symptom and its responses are grouped vertically.

在过去的7天里，您多久经历以下症状？

头痛
☐ 从不
☐ 很少
☐ 有时
☐ 经常
☐ 总是

恶心
☐ 从不
☐ 很少
☐ 有时
☐ 经常
☐ 总是

头晕
☐ 从不
☐ 很少
☐ 有时
☐ 经常
☐ 总是

疲劳
☐ 从不
☐ 很少
☐ 有时
☐ 经常
☐ 总是

Why this fits Chinese modular reading habits:

• Readers can process one symptom block at a time, moving vertically.

• Column-like segmentation makes the experience more natural for readers accustomed to grid or block structures (even in modern horizontal Chinese layouts).

• This respects traditional top-down and modular scanning behaviour, reducing cognitive strain.

The eye-tracking visualisation looks as follows:

• The Stem fixation starts at the top.

  
  

• Readers then move vertically down each symptom block, scanning top-down within each module.

  
  

• After completing one symptom’s response options, they jump vertically to the next block (dashed arrows), maintaining a modular scanning flow.

  
  

• This is more in line with Chinese readers’ preference for vertically segmented or block-based layouts, minimising horizontal movements.

Cognitive Load and Reader Fatigue

When layouts are poorly adapted, they increase the cognitive load. Readers use up more mental effort to adjust their usual reading habits to struggle with the layout’s structure. Health communication is a high-stakes environment: a lot can go wrong when struggling to access Clinical Outcome Assessments, informed consent forms or instructions about medicines. This can lead to reader frustration, skipping over key information, inaccuracies in responses.

Why All This Matters

Translation without cultural and typographic adaptation can undermine clarity. Whether it is RTL readers that are forced to engage with LTR formatting or dense scripts forced into layouts better suited to Latin letters, poor visual adaptation leads to:

• Longer reading times

• Reading inefficiencies and poor navigation through the text

• Higher risk of misinterpreting the information.

In COA localisation, ensuring culturally sensitive design is essential to protecting comprehension, patient safety and engagement.

Respecting how different scripts behave on the page is about more than what it looks like – the aesthetics. It is about enabling understanding. In the case of COAs and patient-facing materials, not accounting for script complexity and local reading habits can compromise both data quality and patient safety. By aligning typography and layout with cultural reading expectations, we reduce cognitive strain and ensure critical health information is delivered clearly, no matter the language.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, March 2025