title: Five-step methodology for evaluation and adaptation of print patient health information to meet the < 5th grade readability criterion.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  Sets of 18 and 11 publicly disseminated patient education documents developed by a university affiliated medical center.
  
  
  METHODS
  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.
authors.affiliation: Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, MD 21287, USA. fbriggs3@jhmi.edu
authors.forename: Felicia
authors.initials: F
authors.lastname: Hill-Briggs
authors.forename: Kristina P
authors.initials: KP
authors.lastname: Schumann
authors.forename: Ogechi
authors.initials: O
authors.lastname: Dike
mesh_terms: D032882:Comprehension; D004522:Educational Status; D005069:Evaluation Studies as Topic; D057220:Health Literacy / Q000592:standards*; D006801:Humans; D010353:Patient Education as Topic / Q000592:standards*; D011932:Reading; D015203:Reproducibility of Results