Five-step methodology for evaluation and adaptation of print patient health information to meet the < 5th grade readability criterion

Med Care. 2012 Apr;50(4):294-301. doi: 10.1097/MLR.0b013e318249d6c8.


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. Interrater reliability for the document evaluations was determined.

Results: 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).

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.

MeSH terms

  • Comprehension
  • Educational Status
  • Evaluation Studies as Topic
  • Health Literacy / standards*
  • Humans
  • Patient Education as Topic / standards*
  • Reading
  • Reproducibility of Results