Five-step Methodology for Evaluation and Adaptation of Print Patient Health Information to Meet the <5th Grade Readability Criterion

Abstract

Background In the setting of declining U.S. literacy, new policies include use of clear communication and low literacy accessibility practices with all patients. Reliable methods for adapting health information to meet such criteria remain a pressing need. Objectives To report method validation (Study 1) and method replication (Study 2) procedures and outcomes for a 5-step method for evaluating and adapting print health information to meet the current low literacy criterion of <5th grade readability. Materials Sets of 18 and 11 publicly-disseminated patient education documents developed by a university-affiliated medical center. Measures Three low-literacy criteria were strategically targeted for efficient, systematic evaluation and text modification to meet a <5th grade reading level: sentence length <15 words, writing in active voice, and use of common words with multisyllabic words (>2–3 syllables) minimized or avoided. Inter-rater reliability for the document evaluations was determined. Results Training in the methodology resulted in inter-rater reliability of 0.99–1.00 in Study 1 and 0.98–1.00 in Study 2. Original documents met none of the targeted low literacy criteria. In Study 1, following low-literacy adaptation, mean reading grade level decreased from 10.4±1.8 to 3.8±0.6 (p<0.0001), with consistent achievement of criteria for words per sentence, passive voice, and syllables per word. Study 2 demonstrated similar achievement of all target criteria, with a resulting decrease in mean reading grade level from 11.0±1.8 to 4.6±0.3 (p < 0.0001). Conclusions The 5-step methodology proved teachable and efficient. Targeting a limited set of modifiable criteria was effective and reliable in achieving <5th grade readability.

Readability Assessment of Internet-based Patient Education Materials Related to Mammography for Breast Cancer Screening

“…Many IPEMs are written well above this recommended level, with more than half being at college level (1). These IPEMs should be written at the average American adult's reading level in hopes of improving patient comprehension (25). Our findings are congruent with readability assessments in the literature.…”

“…For example, shortening sentence length (words per sentence) as well as shortening the words themselves (number of syllables per sentence) can increase the comprehensibility of IPEMs (25,27). Other methods of increasing comprehensibility not studied here include use of active voice (25), corresponding higher numerical values to better outcomes (28), creating easy-tounderstand web-page layouts (ie, font) (7), and as well as using adjunct illustrations (29). An inherent limitation to this study is that any visual aids were excluded from the analysis.…”

Should We Be Afraid of Simple Messages? The Effects of Text Difficulty and Illustrations in People With Low or High Health Literacy

“…Although the use of readability levels to test for comprehensibility is often recommended in low health literacy interventions (Hill-Briggs, Schumann, & Dike, 2012), research has shown that in cancer communication, readability and comprehensibility are not always related (Friedman & Hoffman-Goetz, 2007). Therefore we primarily chose to pretest the messages extensively for difficulty.…”

Measuring Coping in Pregnant Minority Women

“…Lower literacy has been found to contribute to health disparities, especially among racial and ethnic minorities, specifically in Hispanics and Blacks (Heinrich, 2012; Hill-Briggs, Schumann, & Dike, 2012; Wilson, 2009). …”

“…Many formulas are available and reliable to test readability including the Flesch–Kincaid Reading Level test, the Flesch Reading Ease, the Simple Measure of Gobbledygook (SMOG), and the Gunning Fog (FOG) Index, though no one measure has been proven to be more accurate than another (Hill-Briggs et al, 2012; Paasche- Orlow et al, 2005). Due to the low literacy rates in the United States, it is recommended that readability levels for health documents, including questionnaires and surveys (Calderon, Morales, Lie, & Hays, 2006), be evaluated prior to distributing among minority populations to ensure they are appropriate for maximum comprehension.…”