title: A user-study measuring the effects of lexical simplification and coherence enhancement on perceived and actual text difficulty.
abstract: OBJECTIVE
  Low patient health literacy has been associated with cost increases in medicine because it contributes to inadequate care. Providing explanatory text is a convenient approach to distribute medical information and increase health literacy. Unfortunately, writing text that is easily understood is challenging. This work tests two text features for their impact on understanding: lexical simplification and coherence enhancement.
  
  
  METHODS
  A user study was conducted to test the features' effect on perceived and actual text difficulty. Individual sentences were used to test perceived difficulty. Using a 5-point Likert scale, participants compared eight pairs of original and simplified sentences. Abstracts were used to test actual difficulty. For each abstract, four versions were created: original, lexically simplified, coherence enhanced, and lexically simplified and coherence enhanced. Using a mixed design, one group of participants worked with the original and lexically simplified documents (no coherence enhancement) while a second group worked with the coherence enhanced versions. Actual difficulty was measured using a Cloze measure and multiple-choice questions.
  
  
  RESULTS
  Using Amazon's Mechanical Turk, 200 people participated of which 187 qualified based on our data qualification tests. A paired-samples t-test for the sentence ratings showed a significant reduction in difficulty after lexical simplification (p<.001). Results for actual difficulty are based on the abstracts and associated tasks. A two-way ANOVA for the Cloze test showed no effect of coherence enhancement but a main effect for lexical simplification, with the simplification leading to worse scores (p=.004). A follow-up ANOVA showed this effect exists only for function words when coherence was not enhanced (p=.008). In contrast, a two-way ANOVA for answering multiple-choice questions showed a significant beneficial effect of coherence enhancement (p=.003) but no effect of lexical simplification.
  
  
  CONCLUSIONS
  Lexical simplification reduced the perceived difficulty of texts. Coherence enhancement reduced the actual difficulty of text when measured using multiple-choice questions. However, the Cloze measure results showed that lexical simplification can negatively impact the flow of the text.
authors: School of Information Systems and Technology, Claremont Graduate University, USA. gondy.leroy@cgu.edu
authors: Gondy
authors: G
authors: Leroy
authors: David
authors: D
authors: Kauchak
authors: Obay
authors: O
authors: Mouradi
mesh_terms: D000328:Adult; D000368:Aged; D032882:Comprehension; D054626:Consumer Health Information; D005260:Female; D057220:Health Literacy; D006801:Humans; D007807:Language Tests; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D010465:Perception; D060685:Sense of Coherence; D014825:Vocabulary; D055815:Young Adult
keywords: Comprehension; Consumer health information; Health literacy; Information systems; Medical informatics computing; Patient education; Readability
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