Patient Education
Information:
Readability of
Prosthetic
Publications
Craig R. Smith, CP
Carol A. Smith, MS, CRC
ABSTRACT
Prosthetists use educational publications to enhance patient education and
increase patient compliance to the prescribed regimen. The material may not
be useful if it is too complicated for the
patient to understand. Currently available prosthetic patient education publications were analyzed for readability
using the Gram-mat-ik IV software program. The reading grade level and the
Flesch Reading Ease score of the majority of the documents were greater than
the average level of comprehension of
the prosthetic patient.
A series of educational brochures was
developed with a reading level of no
greater than grade 6 and a Flesch Reading Ease index of no less than 70.
Introduction
A new patient represents a challenge to
the practitioner-a challenge to not
only serve the patient appropriately
but also to motivate the patient to become involved in the treatment and
care. Health care practitioners are always seeking new or additional teaching tools to enhance the client's education and increase compliance to the
prescribed regimen. Noncompliance
frequently can be traced to the patient
not understanding the practitioner's instructions. While many factors influence the patient's compliance level,
one of these factors appears to be how
adequately the patient understands the
disease or condition being treated (1).
In an attempt to increase compliance
by the patient, the practitioner frequently uses printed publications as an
important part of the education process. Written material can be used to
enhance the verbal communication between practitioner and patient and
serves to increase patient knowledge of
health care needs. It also can help motivate the patient to change unhealthy
behaviors, review the practitioner's instructions, and enhance the level of
self-care and independence.
Health literature must be written at
levels that are congruent with patients'
reading levels. Information written
above patients' reading level is useless
and a waste of time and money. Information that cannot be understood prevents patients from becoming active,
responsible partners and informed decision-makers in their health care. If
the Written directions or warnings are
disregarded because they cannot be
read, both patient and practitioner are
put in a precarious position, with potentially grave consequences for both.
Readability
Readability has been defined by Klare
(2) as "the quality and style of writing
as it relates to ease of reader comprehension and understanding." Poor
reading skills may affect a person's understanding, interpretation and vocabulary. Misinterpretation may lead to a
misunderstanding of instructions. People who have poor reading skills may
hesitate to ask questions, preferring to
remain silent and not know the answer
rather than exposing themselves to embarrassment. Patients who have low literacy skills tend to think in concrete,
specific ways, and if presented with
multiple, confusing instructions they
may become totally confused by the
regimen and ignore the information.
Some studies estimate as many as 21
million Americans cannot read (3).
Comprehension tests of patients show
that about 50 percent have serious difficulty with, or cannot read, instructional materials at the fifth-grade level
(4). Flesch has determined the standard reading level to be at the eighth-to ninth-grade level although he recognized that a sizeable portion of the population actually reads below this level
(5). By maintaining a readability level
below the eighth grade, 75 percent of
the population might be expected to
read and comprehend the material.
Some studies have indicated that
health education materials are written
on an eighth- to tenth- or eleventh grade level (6,7). It is reasonable to
hypothesize that the educational material available to prosthetic patients has
a level of readability comparable to the
literature of other health fields. How.
ever, readability studies on the current
prosthetic education material had not
been conducted prior to this study.
Purpose
The purpose of this study was twofold:
to assess the readability of the available
prosthetic educational material and to
develop a series of brochures written at
a sixth-grade level or below. These
brochures cover sock management,
sock maintenance, wrapping of the residual limb and the initial visit to the
prosthetist. Consideration was given to
the factors suggested by Meade (8),
namely format, visual appeal and patient interest.
Readability Formulas
Readability may be predicted by applying a variety of formulas to reading materials. A readability formula is a mathematical equation derived by regression analysis that describes the relation
between the reader's skill and the author's style. Individuals assessing the
usefulness of health care literature
(9,10) have frequently chosen readability formulas (such as those that follow)
for three reasons:
- their longstanding use in school
settings
- their reputation for methodical accuracy for sorting reading materials
into appropriate grade-level slots
- the consistency within and between various formulas when determining reading levels
Those formulas of interest to health
care practitioners include the Flesch
Reading Ease (11), the Gunning Fog
(12) and the Flesch-Kincaid (5). Results of analyses conducted by Meade
and Smith (10) point to strong positive
correlations among these readability
formulas when used to analyze health-based material (r = 0.93-0.99).
Flesch Reading Ease
This method determines the readability level of materials between fifth
grade and college graduate. Reading
ease refers to the reader's ability to decode text. Word length and polysyllabic words are common variables used in estimating reading level and are major contributors to increased reading difficulty. The formula is based on the average sentence length (in words) of selected samples and on the average word length measured as syllables per 100 words of sample. These two factors are combined to yield a reading ease score. This score is represented by a number with a range of 0 to 100 and gives approximate values for interpreting the score (see Figure 1
).
Gunning Fog Formula
The Fog method determines the readability level of materials between
fourth grade and college. This formula,
considered one of the easier methods
for calculating readability, is based on
a short sample of 100 words and does
not require counting all syllables or applying many rules.
Flesch-Kincaid
The Flesch-Kincaid formula yields an
index with a range from 1.0 (first-grade
level) to 50 (totally unreadable). A
high readability index (over 12th
grade) does not mean the writing is appropriate for college-educated readers,
rather it indicates the writing is complex and difficult to read.
Prosthetic Patients
The number of amputees requiring
prosthetic care is growing due to advances in areas such as cancer treatment and increased survival rates for
trauma victims (13). According to
Sanders (13), the 1979 National Health
Interview Survey estimated 8.6 amputees per 1,000 (1,849,000 individuals).
As the number of prosthetic patients
grows, so does the need for appropriate patient education publications.
Method
Thirty-two documents specific to prosthetics were obtained from professional organizations, manufacturers of
prosthetic components and prosthetic
firms. (For a complete listing of the
documents and their sources, refer to
Table A
.)
These educational publications were
submitted to readability testing similar
to that used by researchers in other allied health fields, specifically FleschKincaid Grade Level, Flesch Reading
Ease and Gunning Fog formula.
Instrumentation
Gram-mat-ik IV, 2nd edition, a commercially available software program
designed to assess the readability and
writing style of documents, was used to
assess the readability of the samples of
patient education publications obtained. Gram-mat-ik IV produces three
readability indexes of interest to the
present study: Flesch Reading Ease,
Flesch-Kincaid Grade Level and Gunning Fog.
Procedure
Each publication's complete text was
scanned into an IBM-compatible computer using a Logitech Scanman Model
32 hand-held scanner. The resulting
text was then imported into WordPerfect 5.1, a word-processing system
compatible with the Gram-mat-ik IV
software. A Flesch Reading Ease,
Gunning Fog Index and Flesch-Kincaid Grade Level were obtained for
each sample. Once all 32 publications
had been scanned, spell checked and
analyzed by Gram-mat-ik IV, the publications were grouped into clusters of
similar scores.
Results
The readability evaluations of the currently available prosthetic patient education publications yielded Flesch-Kincaid Grade Level, Gunning Fog index
and Flesch Reading Ease scores above
the average comprehension level of the targeted consumer. The Flesch Reading Ease Score for this sample averaged 41.56 with a range from 10 to 80 (see Figure 2
). Only four of the samples scored at a level considered readable (above 70) by most consumers.
The Gunning Fog Index for this group of educational publications averaged 14.28 with a range from 7 to 21 (see Figure 3
). Only two of the brochures were rated at below eighth grade by this criterion. The Flesch-Kincaid score for the publication averaged 10.5 grade, with a range of fourth to sixteenth (see Figure 4
). The majority of the publications, 27, ranked eighth grade or above with only five ranking at less than eighth grade.
A complete listing of each publication's score can be found in Table B
. These analyses indicate that the brochures currently available for patient education in the prosthetics profession are by and large written at a level above the comprehension of most of the targeted consumers. The following sentences are excerpts from the tested publications and are
included to illustrate the types of problems that were detected:
Example 1: "In order for a credentialing organization to obtain membership in the Commission, it must meet a
lengthy and comprehensive set of criteria that cover such areas as examination
validity and reliability, safeguards to
protect the public interest and the establishment of qualifications for certifications that are appropriate to the certified
occupation. "(sentence too long)
Example 2: "The key to successful
rehabilitation is in the hands of the surgeon, the therapist and the prosthetist,
but the degree of success possible on the
part of the prosthetist is limited necessarily by the characteristic of the amputation stump." (sentence too wordy,
overuse of prepositions)
Example 3: "This is not to say that
every amputee enjoys unlimited opportunity, but that when the proper surgical
technique is employed, and when the
best methods and devices are used in
providing the prosthesis, the amputee
with severe medical problems can return to a useful and normal life."
(wordy sentence, use of passive voice)
A series of five brochures, including
one totally pictorial brochure (see Figure 5
and Figure 6
), was developed, following
guidelines of readability no greater
than a sixth-grade reading level and a
Flesch Reading Ease index of no less
than 70. Each brochure was checked
for readability using the Gram-mat-ik
IV software.
The Flesch-Kincaid grade levels of
the brochure developed for this study
ranged from fourth to sixth, with an
average of fifth grade. The Flesch
Reading Ease scores ranged from 79 to
87 with an average of 81.5. The Gunning Fog Index for these brochures
ranged from six to nine with an average
index of 7.75. These averages do not
include the pictorial brochure intended
for illiterate or non-English speaking
individuals (see Table C
for detailed
scores of these brochures).
Discussion
The investigation of the readability of currently available educational publications in the prosthetic field revealed
a lack of items written at a level appropriate for use by a large number of
prosthetic patients. Most of the currently available patient education publications are written at a level too sophisticated for the intended consumer.
Only four of the 32 publications were
considered readable by the Flesch
Reading Ease score. The majority of
the publications, 27, ranked eighth
grade or above using the Flesch-Kincaid grade level, and only five ranked
at less than eighth grade. The Gunning
Fog Index rated 30 of the 32 brochures
with an index above eight.
The development of a series of brochures aimed at this overlooked group
demonstrated the feasibility of patient
education publications on varying levels of reading comprehension. These
five brochures all met the guidelines of
readability. The brochures cover sock
management, sock maintenance, initial visit to the prosthetist and wrapping of the residual limb (see Figure 5
and Figure 6
).
The format of the brochures is 8 1/2 x
11, tri-fold paper, printed on both
sides. The print is double spaced and of
sufficient size and font (Dutch Roman,
12 pt.) so that the words are easily discernible. The brochures were produced entirely in WordPerfect 5.1 and
may be printed on either a dot matrix
or laser printer. They are easily understandable, and they contain illustrations of the instructions to further enhance the comprehension of the material presented. The pictorial brochure
is for use by illiterate or non-English-speaking individuals.
Conclusion
This study was limited to prosthetic
publications that were readily obtainable, and while it may not include all
materials currently available, it appears to be a representative sample of
prosthetic patient education publications. Additional research into other
educational publications, such as those
available for orthotic patients, may be
warranted. Research into educational
publications aimed at illiterate patients
also appears to be warranted since this
area is currently ignored in patient education publications.
Readability formulas should not be
considered the only factor in the usefulness of patient education materials,
such as brochures and pamphlets. Investigation of other specific elements-
such as motivation level and interest
level of the reader, cultural factors, visual attractiveness of the brochure, legibility of the letters, balance of white
and black space, selection of readable
print size and consistent format-appears warranted.
The information obtained about the
readability of the available educational
publications should be helpful in understanding the difficulties some patients encounter when presented with a
new task. Additionally, the development of brochures written on an appropriate reading level that can be understood by the average prosthetic consumer should help prosthetic patients
to take a more active part in treatment
and the fitting and care of the residual
limb and prosthesis. Ultimately, this
increased understanding and involvement by the patient also should increase the patient's compliance to the treatment plan suggested by the prosthetist and the health care team.
CRAIG R. SMITH, CP, is on staff with Wright & Filippis Inc., 1166 Broadway, Ann Arbor, MI 48105.
CAROL A. SMITH, MS, CRC, is a staff associater in the Office of Medical Education at the University of Michigan Medical School, 1300 Catherine, Ann Arbor, MI 48107-1611.
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