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Background  Eye tracking is commonly used in marketing to understand complex responses to materials, but has not been used to understand how low-literacy adults access health information or its relationship to decision making.    Methods  This study assessed how participants use a literacy appropriate “dirty bomb” decision aid. Participants were randomized to receive a CDC “factsheet” ( n  = 21) or literacy-appropriate aid ( n  = 29) shown on a computer screen. Using 7 content similar slides, gaze patterns, mean pupil fixation time and mean overall time reading and looking at slides were compared. Groups were also compared by literacy level and effect on 'confidence of knowledge' and intended behavior.    Results  Results revealed differing abilities to read densely written material. Intervention participants more precisely followed text on 4 of 7 content-similar slides compared to control participants whose gaze patterns indicated unread text, or repeated attempts at reading the same text, suggesting difficulty in understanding key preparedness messages. Controls had significantly longer pupil fixations on 5 of 7 slides and spent more overall time on every slide. In those with very low literacy, intervention participants were more likely than controls to say they understood what a “dirty bomb” is and how to respond if one should occur.    Conclusions  Results indicate limited- literacy adults, especially those with very low literacy, may not be able to understand how to respond during a “dirty bomb” using available materials, making them vulnerable to negative health events. This study provides insights into how individuals perceive and process risk communication messages, illustrating a rich and nuanced understanding of the qualitative experience of a limited literacy population with written materials. It also demonstrates the feasibility of using these methods on a wider scale to develop more effective health and risk communication messages designed to increase knowledge of and compliance with general health guidelines, and enhance decision making. This has application for those with learning disabilities, those with limited media-literacy skills, and those needing to access the diverse array of assistive technologies now available. Eye tracking is thus a practical approach to understanding these diverse needs to ensure the development of cogent and salient communication.    Electronic supplementary material  The online version of this article (doi:10.1186/s12911-016-0304-5) contains supplementary material, which is available to authorized users.

Using eye tracking and gaze pattern analysis to test a “dirty bomb” decision aid in a pilot RCT in urban adults with limited literacy