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

Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, MD 21287, USA.
Medical care (Impact Factor: 3.23). 02/2012; 50(4):294-301. DOI: 10.1097/MLR.0b013e318249d6c8
Source: PubMed


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.
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.
Sets of 18 and 11 publicly disseminated patient education documents developed by a university affiliated medical center.
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. Interrater reliability for the document evaluations was determined.
Training in the methodology resulted in interrater 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).
The 5-step methodology proved teachable and efficient. Targeting a limited set of modifiable criteria was effective and reliable in achieving <5th grade readability.

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