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.

    • "Our experimental texts were carefully developed, resulting in a non-difficult message, that was easy to understand but definitely not infantile. 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. "
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