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Readability levels of health pamphlets distributed during the Athens 2004 Olympic Games
ARTICLE IN PRESS Public Health (2007) 121, 189–192
www.elsevierhealth.com/journals/pubh
Short Communication
Readability levels of health pamphlets distributed during the Athens 2004 Olympic Games Barbara Kondilisa,b, Elpidoforos S. Soteriadesa,c, Matthew E. Falagasa,d, a
Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 15123 Marousi, Athens, Greece Hellenic American University, Athens, Greece c Department of Environmental Health, Occupational Health Program, Harvard School of Public Health, Boston, MA, USA d Department of Medicine, Tufts University School of Medicine, Boston, MA, USA b
Received 12 September 2005; received in revised form 18 July 2006; accepted 22 September 2006 Available online 10 January 2007
KEYWORDS Olympic Games; Readability; Health pamphlets; Health literacy
The Olympic Games are one of the most celebrated and broadcasted events around the world. During the Olympic Games, spectators, visitors, and the host country’s population are exposed to a considerable number of messages and advertisements including health messages. The readability levels of health messages distributed via printed materials constitute an important factor for their effectiveness in reaching targeted segments of the population and motivating changes in health behaviour.1 People with a low health literacy level are more likely to report poor health, have more outpatient visits and hospitalizations due to a lack of understanding of their health problems and treatment, and also have higher healthcare expenses.2,3 Corresponding author. Tel.: +30 694 683 9604;
fax: +30 210 683 9605. E-mail address: [email protected] (M.E. Falagas).
Although the importance of health literacy has been established in the medical and social science literature in relation to health behaviour motivation as well as health outcomes, little is known about the readability levels of health messages distributed at sports events in general and the Olympic Games in particular. This study examined readability levels of health pamphlets written in the English language and distributed during the Athens 2004 Olympic Games through the Greek Ministry of Health and Social Solidarity, the Ministry of Rural Development and Food, and the National School of Public Health. Three well-known and validated readability measures were used for the evaluation of all identified pamphlets according to their published instructions and guidelines, respectively. These included the Simple Measure of Gobbledygook (SMOG), the Flesch method, and the Fry method.
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.09.020
ARTICLE IN PRESS 190
B. Kondilis et al.
The readability levels of all identified pamphlets were calculated by hand, by two independent reviewers. The pamphlet’s readability evaluation did not take into account the effects of graphics, layout, or document design on the reader. Three health pamphlets were identified as having been distributed during the Athens 2004 Olympic Games by the Ministry of Health and Social Solidarity (MOHSS), the Ministry of Rural Development and Food (MORDF), and the National School of Public Health (NSPH). The topics and targets for the three pamphlets were travel-related issues and health hazards for visitors, dietary guidelines based on the Mediterranean diet for the general public, and health and safety issues for people using swimming pools, respectively. Reviewer averages for each formula were similar except for the MORDF pamphlet. The readability levels of all three pamphlets are presented in Table 1. All three methods were averaged to yield the total average grade level for each pamphlet. The overall average grade levels of the pamphlets were 10th for MOHSS, 16th for MORDF, and 8th for NSPH. Several countries including Spain, Australia, and the USA have promoted health campaigns such as anti-tobacco, drug-free, and physical activity programmes during their respective Olympic Games.4–9 Greece is one of the financially weaker and demographically smaller countries that have organized the Olympic Games, with great success. Despite a significant shortage of funds and financial strain on the country’s budget, several agencies
devoted resources to health promotion programmes implemented prior to and during the Olympic Games for the benefit of the general population. The creation of health education pamphlets was limited during the Olympics and two out of the three pamphlets evaluated covered 8th–10th grade levels. These two pamphlets (MOHSS, NSPH) may have had appropriate readability levels for the largely literate society of Greece (92% of the Greek population is considered literate and to have completed at least high school level; 2003 data from the National Statistical Centre of Greece), though this only provides us with the fundamental literacy level and may not be an appropriate measure for the overall health literacy of the population. The MORDF pamphlet’s reading level, however, was more appropriate for college-level audiences, though the illustration of the food pyramid, which may be useful to all reading levels, was not assessed using the readability tools. The topics covered in the first pamphlet (MOHSS) were general and could apply to all ages and populations; included in it were emergency telephone numbers. The topics in the second pamphlet (NSPH) applied to any person considered a ‘swimmer’ in a pool and covered issues of pool safety, although emergency telephone numbers were not included. Topics in the third pamphlet (MORDF) applied to the general population and it gave foodbased dietary guidelines for the Mediterranean diet of the Greek population; this pamphlet included an illustrated Mediterranean diet food pyramid.
Table 1 Readability levels of health pamphlets distributed during Athens 2004 Olympic Games based on the US school grade system Agency—pamphlet
MOHSS—Travel-related issues First reviewer Second reviewer Average MORDF—Mediterranean diet First reviewer Second reviewer Average NSPH—Swimming pool safety First reviewer Second reviewer Average
US School grade readability by readability formula
Average US grade levels
SMOGa
Flesch
Fry
10th 10th 10th
9th–10th 11th–14th 11th
10th 10th 10th
10th
16th 16th 16th
11th–14th 15th–16th 14th
17th 17th + 17th
16th
8th 9th 8.5
9th–10th 9th–10th 9.5
6th 5th 5.5
8th
Abbreviations: Ministry of Health and Social Solidarity (MOHSS), the Ministry of Rural Development and Food (MORDF), and the National School of Public Health (NSPH). a SMOG methodology indicates grade levels at approximately 71.5 grade levels above or below the point estimate.
ARTICLE IN PRESS Readability levels of health pamphlets, Athens 2004 Olympic Games The SMOG, Flesch, and Fry methods provide a general idea of how difficult reading a document might be, based on the words contained; however, they do not consider the effects of layout or document design nor account for any illustrations or graphics. Readability tests as a whole provide a general idea of the reading difficulty of a document based on the words it contains and do not take into account the total health literacy levels or health outcomes. In assessing for grade levels, the two independent reviewers yielded similar results for all three pamphlets with a slight discrepancy for the longer text MORDF when applying the Flesch readability method. The one grade level difference for the latter method is not likely to be significant when all other readability formulas yielding similar results are taken into account. The reviewers’ results are indicative of inter-rater reliability. This study was limited to analysing the English version of the pamphlets as readability formulas in the Greek language were not available to the authors. Taking into account illiteracy as limiting a client’s understanding of health information and potentially leading to poor health outcomes, as well as increasing healthcare costs, should be considered when working with target populations.2,3 Studies indicate that text written for the general public needs to be developed with a goal of reaching individuals between the 6th and the 8th US grade reading level in order to cover the majority of the population.10 Highly educated physicians and nurses should strongly consider that their patient’s ability to read, combined with the stress and discomfort from illness, will affect that patient’s comprehension of both oral and written information.3 Pre-testing written material with the target audience, including readability and health literacy assessment tools, is the best way to judge if the material will be an effective communication tool in how the audience will accept or perceive one’s intended message. Piloting key messages to a target group should be done before the materials are printed or distributed. If the material tests higher than the recommended reading levels, it should be re-written to a grade lower, and readability indexes should be used when drafting or improving documents.3 The organization of the Olympic Games or other sport events constitutes an excellent opportunity for public health professionals to promote their health communication objectives in a target group or the host country’s population, as well as internationally via the mass media.1 Athletes or sports figures as public role models on the other hand may also promote certain attitudes and beliefs about a disease, a product, or a social
191
condition. Studies indicate that television sports and entertainment-oriented Internet are two major media categories consumed by those categorized as unhealthy eaters, while healthy eaters, who tend to be better educated, are more likely to be drawn to print media.1 Therefore, print-based healthy eating campaigns such as the pamphlet on the Mediterranean diet may not reach those at risk, the unhealthy eaters. A lack of follow-up studies on the target groups receiving such pamphlets makes it difficult to assess how far-reaching the printed campaigns are. Users of communication materials may have more positive health outcomes if able to better comprehend the intended key messages. The lack of available funding or a central coordinator of key public health messages, in addition to lesser use of the Internet (estimates from Eurostat show that in 2004 and in 2003, 14% and 17%, respectively, of the total population aged 16–74 years, accessed the Internet at least once a week within the last year), may be factors hindering the effectiveness of health communication campaigns in Greece at this time. Greece’s support of health promotion at the Olympic Games with programmes and printed health educational materials may be considered to represent a small contribution overall. Few studies have been performed regarding attitudes and beliefs towards health or societal issues through the influence of celebrated athletes, not precluding the athletes of the Olympic Games. Readability testing allows researchers to direct material appropriately to the participants’ fundamental health literacy level, which should be part of the overall health literacy assessment. When readability methods were averaged, two of the three health pamphlets used in the Athens 2004 Olympic Games had higher than the recommended 6th–8th grade English readability levels. Similar readability studies need to be performed with the material in the Greek language. Assessment of readability levels and pretesting of material with target groups should be undertaken before their use in sports events and future Olympic Games. Additional exploration of the effects of health communication campaigns during large sporting events such as the Olympic Games should also be considered. Competing interests: None declared.
References 1. Dutta-Bergman MJ. Reaching unhealthy eaters: applying a strategic approach to media vehicle choice. Health Commun 2004;16:493–506. 2. Baker DW, Parker RM, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791–8.
ARTICLE IN PRESS 192 3. Mayer GG, Villaire M. Low health literacy and its effects on patient care. J Nurs Adm 2004;34:440–2. 4. Kennedy D. Here come the Olympics. Science 2004;305:573. 5. Koplan JP, Powell KE. The Olympic Games: opportunities for health promotion. Am J Health Promot 1996;11:8–9. 6. Moodie R. Measuring the effectiveness of health promotion policy: What can be learnt from Australian success stories? Promot Educ 2004;1:28–32, 49. 7. Prokop L. International Olympic Committee Medical Commission’s policies and programs in nutrition and physical fitness. Am J Clin Nutr 1989;49:1065.
B. Kondilis et al. 8. Villalbi J, Ballestin M, Vinue J, Serra L, Cuervo J, Salleras L. The Barcelona Smoke-free Olympics project. Hygie 1992;11: 24–8. 9. World Health Organization. Prevention and health promotion messages through sponsorship of sports and cultural events. Tobacco Alert: World No-Tobacco Day Special Issue Advisory Kit; 1996. 10. Coey L. Readability of printed educational materials used to inform potential and actual ostomates. J Clin Nurs 1996;5:359–66.
www.elsevierhealth.com/journals/pubh
Short Communication
Readability levels of health pamphlets distributed during the Athens 2004 Olympic Games Barbara Kondilisa,b, Elpidoforos S. Soteriadesa,c, Matthew E. Falagasa,d, a
Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 15123 Marousi, Athens, Greece Hellenic American University, Athens, Greece c Department of Environmental Health, Occupational Health Program, Harvard School of Public Health, Boston, MA, USA d Department of Medicine, Tufts University School of Medicine, Boston, MA, USA b
Received 12 September 2005; received in revised form 18 July 2006; accepted 22 September 2006 Available online 10 January 2007
KEYWORDS Olympic Games; Readability; Health pamphlets; Health literacy
The Olympic Games are one of the most celebrated and broadcasted events around the world. During the Olympic Games, spectators, visitors, and the host country’s population are exposed to a considerable number of messages and advertisements including health messages. The readability levels of health messages distributed via printed materials constitute an important factor for their effectiveness in reaching targeted segments of the population and motivating changes in health behaviour.1 People with a low health literacy level are more likely to report poor health, have more outpatient visits and hospitalizations due to a lack of understanding of their health problems and treatment, and also have higher healthcare expenses.2,3 Corresponding author. Tel.: +30 694 683 9604;
fax: +30 210 683 9605. E-mail address: [email protected] (M.E. Falagas).
Although the importance of health literacy has been established in the medical and social science literature in relation to health behaviour motivation as well as health outcomes, little is known about the readability levels of health messages distributed at sports events in general and the Olympic Games in particular. This study examined readability levels of health pamphlets written in the English language and distributed during the Athens 2004 Olympic Games through the Greek Ministry of Health and Social Solidarity, the Ministry of Rural Development and Food, and the National School of Public Health. Three well-known and validated readability measures were used for the evaluation of all identified pamphlets according to their published instructions and guidelines, respectively. These included the Simple Measure of Gobbledygook (SMOG), the Flesch method, and the Fry method.
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.09.020
ARTICLE IN PRESS 190
B. Kondilis et al.
The readability levels of all identified pamphlets were calculated by hand, by two independent reviewers. The pamphlet’s readability evaluation did not take into account the effects of graphics, layout, or document design on the reader. Three health pamphlets were identified as having been distributed during the Athens 2004 Olympic Games by the Ministry of Health and Social Solidarity (MOHSS), the Ministry of Rural Development and Food (MORDF), and the National School of Public Health (NSPH). The topics and targets for the three pamphlets were travel-related issues and health hazards for visitors, dietary guidelines based on the Mediterranean diet for the general public, and health and safety issues for people using swimming pools, respectively. Reviewer averages for each formula were similar except for the MORDF pamphlet. The readability levels of all three pamphlets are presented in Table 1. All three methods were averaged to yield the total average grade level for each pamphlet. The overall average grade levels of the pamphlets were 10th for MOHSS, 16th for MORDF, and 8th for NSPH. Several countries including Spain, Australia, and the USA have promoted health campaigns such as anti-tobacco, drug-free, and physical activity programmes during their respective Olympic Games.4–9 Greece is one of the financially weaker and demographically smaller countries that have organized the Olympic Games, with great success. Despite a significant shortage of funds and financial strain on the country’s budget, several agencies
devoted resources to health promotion programmes implemented prior to and during the Olympic Games for the benefit of the general population. The creation of health education pamphlets was limited during the Olympics and two out of the three pamphlets evaluated covered 8th–10th grade levels. These two pamphlets (MOHSS, NSPH) may have had appropriate readability levels for the largely literate society of Greece (92% of the Greek population is considered literate and to have completed at least high school level; 2003 data from the National Statistical Centre of Greece), though this only provides us with the fundamental literacy level and may not be an appropriate measure for the overall health literacy of the population. The MORDF pamphlet’s reading level, however, was more appropriate for college-level audiences, though the illustration of the food pyramid, which may be useful to all reading levels, was not assessed using the readability tools. The topics covered in the first pamphlet (MOHSS) were general and could apply to all ages and populations; included in it were emergency telephone numbers. The topics in the second pamphlet (NSPH) applied to any person considered a ‘swimmer’ in a pool and covered issues of pool safety, although emergency telephone numbers were not included. Topics in the third pamphlet (MORDF) applied to the general population and it gave foodbased dietary guidelines for the Mediterranean diet of the Greek population; this pamphlet included an illustrated Mediterranean diet food pyramid.
Table 1 Readability levels of health pamphlets distributed during Athens 2004 Olympic Games based on the US school grade system Agency—pamphlet
MOHSS—Travel-related issues First reviewer Second reviewer Average MORDF—Mediterranean diet First reviewer Second reviewer Average NSPH—Swimming pool safety First reviewer Second reviewer Average
US School grade readability by readability formula
Average US grade levels
SMOGa
Flesch
Fry
10th 10th 10th
9th–10th 11th–14th 11th
10th 10th 10th
10th
16th 16th 16th
11th–14th 15th–16th 14th
17th 17th + 17th
16th
8th 9th 8.5
9th–10th 9th–10th 9.5
6th 5th 5.5
8th
Abbreviations: Ministry of Health and Social Solidarity (MOHSS), the Ministry of Rural Development and Food (MORDF), and the National School of Public Health (NSPH). a SMOG methodology indicates grade levels at approximately 71.5 grade levels above or below the point estimate.
ARTICLE IN PRESS Readability levels of health pamphlets, Athens 2004 Olympic Games The SMOG, Flesch, and Fry methods provide a general idea of how difficult reading a document might be, based on the words contained; however, they do not consider the effects of layout or document design nor account for any illustrations or graphics. Readability tests as a whole provide a general idea of the reading difficulty of a document based on the words it contains and do not take into account the total health literacy levels or health outcomes. In assessing for grade levels, the two independent reviewers yielded similar results for all three pamphlets with a slight discrepancy for the longer text MORDF when applying the Flesch readability method. The one grade level difference for the latter method is not likely to be significant when all other readability formulas yielding similar results are taken into account. The reviewers’ results are indicative of inter-rater reliability. This study was limited to analysing the English version of the pamphlets as readability formulas in the Greek language were not available to the authors. Taking into account illiteracy as limiting a client’s understanding of health information and potentially leading to poor health outcomes, as well as increasing healthcare costs, should be considered when working with target populations.2,3 Studies indicate that text written for the general public needs to be developed with a goal of reaching individuals between the 6th and the 8th US grade reading level in order to cover the majority of the population.10 Highly educated physicians and nurses should strongly consider that their patient’s ability to read, combined with the stress and discomfort from illness, will affect that patient’s comprehension of both oral and written information.3 Pre-testing written material with the target audience, including readability and health literacy assessment tools, is the best way to judge if the material will be an effective communication tool in how the audience will accept or perceive one’s intended message. Piloting key messages to a target group should be done before the materials are printed or distributed. If the material tests higher than the recommended reading levels, it should be re-written to a grade lower, and readability indexes should be used when drafting or improving documents.3 The organization of the Olympic Games or other sport events constitutes an excellent opportunity for public health professionals to promote their health communication objectives in a target group or the host country’s population, as well as internationally via the mass media.1 Athletes or sports figures as public role models on the other hand may also promote certain attitudes and beliefs about a disease, a product, or a social
191
condition. Studies indicate that television sports and entertainment-oriented Internet are two major media categories consumed by those categorized as unhealthy eaters, while healthy eaters, who tend to be better educated, are more likely to be drawn to print media.1 Therefore, print-based healthy eating campaigns such as the pamphlet on the Mediterranean diet may not reach those at risk, the unhealthy eaters. A lack of follow-up studies on the target groups receiving such pamphlets makes it difficult to assess how far-reaching the printed campaigns are. Users of communication materials may have more positive health outcomes if able to better comprehend the intended key messages. The lack of available funding or a central coordinator of key public health messages, in addition to lesser use of the Internet (estimates from Eurostat show that in 2004 and in 2003, 14% and 17%, respectively, of the total population aged 16–74 years, accessed the Internet at least once a week within the last year), may be factors hindering the effectiveness of health communication campaigns in Greece at this time. Greece’s support of health promotion at the Olympic Games with programmes and printed health educational materials may be considered to represent a small contribution overall. Few studies have been performed regarding attitudes and beliefs towards health or societal issues through the influence of celebrated athletes, not precluding the athletes of the Olympic Games. Readability testing allows researchers to direct material appropriately to the participants’ fundamental health literacy level, which should be part of the overall health literacy assessment. When readability methods were averaged, two of the three health pamphlets used in the Athens 2004 Olympic Games had higher than the recommended 6th–8th grade English readability levels. Similar readability studies need to be performed with the material in the Greek language. Assessment of readability levels and pretesting of material with target groups should be undertaken before their use in sports events and future Olympic Games. Additional exploration of the effects of health communication campaigns during large sporting events such as the Olympic Games should also be considered. Competing interests: None declared.
References 1. Dutta-Bergman MJ. Reaching unhealthy eaters: applying a strategic approach to media vehicle choice. Health Commun 2004;16:493–506. 2. Baker DW, Parker RM, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791–8.
ARTICLE IN PRESS 192 3. Mayer GG, Villaire M. Low health literacy and its effects on patient care. J Nurs Adm 2004;34:440–2. 4. Kennedy D. Here come the Olympics. Science 2004;305:573. 5. Koplan JP, Powell KE. The Olympic Games: opportunities for health promotion. Am J Health Promot 1996;11:8–9. 6. Moodie R. Measuring the effectiveness of health promotion policy: What can be learnt from Australian success stories? Promot Educ 2004;1:28–32, 49. 7. Prokop L. International Olympic Committee Medical Commission’s policies and programs in nutrition and physical fitness. Am J Clin Nutr 1989;49:1065.
B. Kondilis et al. 8. Villalbi J, Ballestin M, Vinue J, Serra L, Cuervo J, Salleras L. The Barcelona Smoke-free Olympics project. Hygie 1992;11: 24–8. 9. World Health Organization. Prevention and health promotion messages through sponsorship of sports and cultural events. Tobacco Alert: World No-Tobacco Day Special Issue Advisory Kit; 1996. 10. Coey L. Readability of printed educational materials used to inform potential and actual ostomates. J Clin Nurs 1996;5:359–66.