The 5-step methodology, which relies on commonly available electronic readability tools, demonstrated effectiveness as an evaluation and adaptation approach to meet the <5th grade readability criterion for public health information. Effectiveness of the approach was demonstrated in both the method validation and replication studies. Personnel with no prior experience were able to be trained to perform the method successfully.
Multiple techniques, used in combination, were needed to meet targeted readability statistics. Mere word substitution was not effective as an overall technique for document adaptation; it was prone to inaccurate or awkward sentence constructions, and it often did not reduce sentence-level readability sufficiently. Rephrasing was necessary to preserve meaning and to introduce essential medical terms, while still reducing literacy demand. All instances of passive voice required rephrasing. Changing passive voice phrasings (e.g. Eating foods that have fewer calories is used to help with losing weight) to declarative statements (e.g. Eat foods with fewer calories to help lose weight) not only reduced reading grade level but made the messages more actionable for the reader. Further, we found that meeting the <5th grade criterion was realistic, and reading levels as low as 2nd and 3rd grade were achievable without using presentation styles or language that might be perceived as more appropriate for children than adults.
Our method utilized the Flesch-Kincaid formula to assess reading grade level. It is important to note additional available readability formulas that are widely used, including the FOG Index, the Simple Measure of Gobbledygook (SMOG), and the Fry readability graph. Although these formulas are each calculated differently, they have been found to correlate highly with each other, and there has been no evidence to support increased accuracy of one over another in determining reading grade level.17,18
All four formulas can be calculated manually; the Flesch-Kincaid formula has an accessible electronic calculation, which provides the benefit of time efficiency and practicality in routine use and with large numbers of documents. A limitation of using the Microsoft Word automated readability statistics is that the syllables per word statistic is not provided; characters per word is calculated. This study evaluated number of syllables per word using the Doak11
method, and a comparison table, with number of characters per word, is provided. During the adaptation process, multisyllabic words were readily identified without a formal calculation. The process of using common, more familiar words automatically resulted in fewer syllables at the sentence and document levels of analysis.
With regard to literacy adaptation content evaluation, the articles did not undergo a process of pre-/post- evaluation for preservation of meaning as part of research. However, after completing literacy adaptation, the adapted articles were reviewed alongside the original articles, by the institutional business office responsible for materials development and copyright. The business office approved the literacy-adapted articles as consistent in content and meaning. The articles then underwent review by representatives of a national healthcare organization which, after reviewing the articles, requested use of the full sets of literacy-adapted (but not the original) articles for dissemination as routine patient education materials to their members/clients. Although data were not collected during these reviews, both professional entities determined the literacy-adapted materials to be of high quality and value, consistent with or exceeding that of their non-literacy-adapted counterparts.
Testing acceptability and effectiveness of the materials in educating the public is ultimately needed to evaluate utility of the 5-step method. The method has been used to adapt patient education materials in previously reported clinical outcome studies, with findings of high satisfaction and ease of understanding ratings by adults with literacy as low as ≤3rd
grade as well as those with average literacy,19
and by persons with mild cognitive and/or visual impairment,20
another subgroup for whom clear communication is particularly necessary. Intervention studies using this literacy-adaptation method have resulted in increased patient knowledge19,21
and improved behaviors and disease control21
in lower-literate samples.
There are directions deserving of further research and development. First, the 2-hour training, which was efficient and reliable, warrants testing in alternative instruction modes (e.g. web-based, electronic media such as CD-Rom). Second, in developing and testing the 5-step method, consistent “rules” for reducing literacy demand emerged for several elements of language (e.g. treatment of numbers, contractions, sentence structure for active voice) that may be amenable to software programming. Third, there is a need to evaluate the efficacy of the 5-step process in other languages. The overall framework for a systematic approach to low literacy adaptataion is transferrable, as are some elements of formatting. However, we do not expect that the specific literacy demand criteria will hold across languages and cultures. Effective low literacy text modification is based upon understanding of the language construction, parts of speech, characters utilized (length, letter pairings, etc.), and meaning/messaging, all of which determine how information is processed, stored, and learned. The neuropsychology literature reveals significant differences in the structure, processing and comprehension of Spanish language, for example, such that the English language low-literacy criteria may not be directly transferrable. Low-literacy adaptation in Spanish, and other languages, does require examination of those features of the respective language itself.
Finally, the problem of declining literacy in the U.S. over the past decade is one of great importance that likely requires both educational and political reform to reverse. The methodology described herein allows health information to be accessible to the growing proportion of the population with basic to below basic literacy; this is essential for improving patient self-management and health outcomes.22–25
However, meeting this current demand should not obfuscate the concurrent need for actions directed toward stopping and reversing the low literacy trends in the U.S.