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Readability levels of health pamphlets distributed in hospitals and health centres in Athens, Greece
p u b l i c h e a l t h 1 2 4 ( 2 0 1 0 ) 5 4 7 e5 5 2
available at www.sciencedirect.com
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Original Research
Readability levels of health pamphlets distributed in hospitals and health centres in Athens, Greece B.K. Kondilis a,b, P.D. Akrivos a,b, T.A. Sardi a, E.S. Soteriades a,c,d, M.E. Falagas a,e,f,* a
Alfa Institute of Biomedical Sciences, Athens, Greece Hellenic American University, Athens, Greece c Cyprus Institute of Biomedical Sciences, Nicosia, Cyprus d Harvard School of Public Health, Department of Environmental Health. Environmental and Occupational Medicine and Epidemiology, Boston, MA, USA e Tufts University School of Medicine, Department of Medicine, Boston, MA, USA f Department of Medicine, Henry Dunant Hospital, Athens, Greece b
article info
summary
Article history:
Objectives: Health literacy is important in the medical and social sciences due to its impact
Received 24 June 2009
on behavioural and health outcomes. Nevertheless, little is known about it in Greece,
Received in revised form
including patients’ level of understanding health brochures and pamphlets distributed in
8 April 2010
Greek hospitals and clinics.
Accepted 13 May 2010
Study design: Observational study in the greater metropolitan area of Athens, Greece.
Available online 15 September 2010
Methods: Pamphlets and brochures written in the Greek language were collected from 17 hospitals and healthcare centres between the spring and autumn of 2006. Readability of
Keywords:
pamphlets using the FlescheKincaid, Simple Measure of Gobbledygook (SMOG) and Fog
Readability
methods was calculated based on a Greek readability software.
Pamphlets
Results: Out of 70 pamphlets collected from 17 hospitals, 37 pamphlets met the criteria for
Leaflets
the study. The average readability level of all scanned pamphlets was ninth to 10th grade,
Health literacy
corresponding to a readability level of ‘average’. A highly significant difference (P < 0.001)
Health communication
was found between private and public hospitals using the FlescheKincaid and SMOG
Greece
readability scales. Pamphlets from private hospitals were one grade more difficult than those from public hospitals. Conclusion: Approximately 43.7% of the Greek population aged 20 years would not be able to comprehend the available pamphlets, which were found to have an average readability level of ninth to 10th grade. Further research examining readability levels in the context of health literacy in Greece is warranted. This effort paves the way for additional research in the field of readability levels of health pamphlets in the Greek language, the sources of health information, and the level of understanding of key health messages by the population. ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Correspondence to: Alfa Institute of Biomedical Sciences, Neapoleos 9, 15123 Marousi, Athens, Greece. Tel.: þ30 210 68 39 604; fax: þ30 210 68 39 605. E-mail address: [email protected] (M.E. Falagas). 0033-3506/$ e see front matter ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2010.05.010
548
p u b l i c h e a l t h 1 2 4 ( 2 0 1 0 ) 5 4 7 e5 5 2
Introduction Health literacy is becoming an important focal point for health providers in many countries around the world, particularly in the context of patient health outcomes. Health pamphlets are often utilized by patients to supplement information they receive from their healthcare provider. Readability of available materials is considered an important factor in overall health literacy. Readability tools generally fall into two major categories: computer generated and those calculated by hand. The Flesch grade level formula and the FlescheKincaid index are the most frequently used computerized tools, while handcalculated tools include the FOG method, the Fry formula and the Simple Measure of Gobbledygook (SMOG, a readability tool that estimates the years of education needed to completely understand a piece of writing). SMOG is widely used, particularly for checking health messages.1,2 SMOG is considered an easy to compute and well-tested tool for field work as it predicts high levels of comprehension.2 Health literacy is defined as ‘the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions’.3 According to research, individuals with low health literacy are more likely to have poor health, are less likely to understand their health problems and treatment management, and are at higher risk of hospitalization.4e7 The importance of health literacy has been established in medical and social science literature as it affects patient behaviour and health outcomes, although Greece continues to lag behind in this area with very little known about readability levels of materials,8 particularly for health brochures and pamphlets found in Greek hospitals and clinics. Past research on the readability of English language health pamphlets distributed during the Athens 2004 Olympic Games indicated that, on average, the pamphlets had higher than recommended US grade readability levels (10th, 16th and eighth for the ‘Ministry of Health and Social Solidarity (MOHSS)-Travel-related issues’, Ministry of Rural Development and Food (MORDF)Mediterranean diet’ and ‘National School of Public Health (NSPH)-Swimming pool safety’ pamphlets, respectively).8 However, research has not been undertaken on the readability of health pamphlets in the Greek language, as readability tools in the Greek language were not available until more recently. Greece has functioned under a national healthcare system since 1983. Specifically, expenditure reached 3.9% of gross national product (GNP) in 2000, which is a high percentage for developed countries compared with the mean value for Organisation for Economic Co-operation and Development (OECD) countries in 2000 (2.2%).9 However, rapid growth in the private health sector, expressed through growth of private hospitals and primary healthcare services, was also observed in the same OECD data. Despite legislative restrictions on the private sector, private healthcare expenditure in Greece has increased, reaching 3.9% of the country’s GNP (43% of the total expenditure on health) in 2000.10 The reasons for this increase are attributed to economic growth, patient dissatisfaction with the public system, changes in insurance policies, quality of services, and medical manpower characterized by an
increase of private medical doctors in Greece.10 Thus, Greek people who seek healthcare services are exposed to both public and private sector resources, including written health education materials. Greece is a highly literate society with approximately 96% of the population considered ‘educated’ (i.e. being able to read and write) (2001 estimate).11 Same-year statistics also indicate that 43.7% of the population (>20 years old) have not completed elementary school, while 52.4% have not completed high school.11 More recent information (2003), provided by the National Statistics Centre of Greece, indicates that 92.19% are considered ‘educated’ (i.e. finished high school) in the entire population of 10.5 million people.11 This difference may be due to the fact that the population in Greece has become more multi-ethnic and racially diverse due to economic migrants. The percentage of non-educated people may increase in coming years. However, in-depth studies on functional adult literacy, such as the National Assessment of Adult Literacy and the National Adult Literacy Survey undertaken in the USA through the US Department of Education’s National Center for Education Statistics,12 have never been conducted in Greece. The overall purpose of this study was to examine the readability levels of health pamphlets and brochures written in the Greek language that target the Greek patient population by utilizing available readability tools applied to patient education materials found in hospitals and clinics in Athens. The Greek language is generally more complex with longer words and syllables than most other romance languages, so the researchers considered that the examination of readability levels was of importance to determine any variation. In addition, the aspiration of the researchers was to provide the respective organizations with the readability levels in order to promote improvements in pamphlet readability. When there is insufficient or inadequate understanding of information, the probability of behavioural change in accordance with the information objectives diminishes.13 Thus, the end goal of the research is to better assist providers in their delivery of health information to their patients, and the establishment of better health literacy outcomes.
Methods Pamphlets and brochures were collected by research assistants from public and private hospitals and clinics in the Athens area between May and November 2006. All available pamphlets and brochures were collected from waiting rooms, health stands and nurses’ desks. The research assistants picked up all available brochures and also asked nurses and other front-line staff for other brochures that may not have been immediately visible to the public. Pamphlets and/or brochures that gave information on health issues related to prevention, treatment and specific diseases were included in the final analyses. Pamphlets and brochures that advertised hospital services and/or specific products (i.e. medications), those that were historical accounts of services, magazines and newspapers, and brochures that were written in a language other than the Greek language were excluded from the study The brochures were categorized as coming from public or
549
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private hospitals/clinics and were subdivided according to their topic content. The three categories of health pamphlets identified were prevention, treatment and general health information. The pamphlets and brochures were subsequently scanned. Any obscure words added by the readability software that were not related to the original text were double-checked, and the information was corrected before the final grade analysis was performed. Software was developed by the Centre for Greek Language in Thessaloniki, Greece (2002 version).14 This software was used to evaluate each pamphlet’s readability level in the Greek language using three well-known and validated measures: the Flesh-Kincaid, SMOG and Fog tools. As indicated by their staff and on their website, the Centre for Greek Language standardized the FlescheKincaid, SMOG and Fog tools for the modern Greek language in 10 formula trials and 32 separate validation studies performed internally between 1999 and 2001. The Flesch score is relied on by many researchers as it is the simplest and most accurate measure of text difficulty.2 The Flesch reading ease tool is composed of two sets of calculations: the computation of the average number of syllables per 100 words, and the average number of words per sentence. The final score is matched to corresponding grade levels to yield the FlescheKincaid grade level.2,15 The FlescheKincaid readability results range from 100e90 at the first to third elementary grade level to 30e0 at the tertiary education level. The Fog index computes the length and the number of words with three syllables or more in the average sentence, and the final score is matched to corresponding grade levels.16 The SMOG readability tool assesses readability based on the number of syllables and the number of sentences. According to the SMOG tool, the sampling of the data from a given text is done selectively from the beginning, middle and end of the full text.2 The SMOG readability level results range from 1e2 (basic elementary) to 14 (tertiary education). However, none of the readability tools take into account other parameters that affect patients’ readability levels, such as the effects of graphics, layout or document design. Statistical comparisons were performed using the Greek software developed by categorizing pamphlets into those obtained from public and private hospitals, and also according to the three topic categories for the three readability scales. The average grade levels corresponding to the average readability result for each of the hospital type and topic categories were recorded. The average literacy levels for adults in Greece were calculated based on the number of people aged 20 years living in Greece who have completed either elementary school or high school. The most current and complete available data were obtained from the General Secretariat of the National Statistical Service of Greece for 2001.11
Results In total, 17 hospitals and health clinics were visited (10 public and seven private). One of the public hospitals was a military hospital. All but three hospitals/clinics had brochures. In total, 70 brochures were collected, from which 37 met the criteria for inclusion in the final analyses. Health topics ranged from
alcohol use and disease to urinary problems (see Appendix for complete list). Of the 37 pamphlets, 27 were obtained from public hospitals and 10 were obtained from private hospitals or clinics. The pamphlets from seven public hospitals/clinics and four private hospitals/clinics (total of 11 hospitals/clinics) qualified for the final readability level analyses. Most of the pamphlets from the private hospitals advertised hospital services. Of the 27 pamphlets obtained from public hospitals, only seven were published by the hospitals, while the other 20 were published by external sources (e.g. Association of Gastroenterologists). Of the latter, eight were compiled by the Hellenic Ministry of Public Health and the other 12 were compiled by non-governmental organizations and other associations (e.g. ‘ACT UP’, an organization for human immunodeficiency virus/ acquired immunodeficiency syndrome prevention and support). All of the pamphlets from private hospitals that met the criteria for inclusion in the study were published internally by the hospitals or their affiliates. The average readability level of all scanned pamphlets was ninth to 10th grade (Greek equivalents: third middle school grade and first high school grade), which corresponds to a readability level of ‘average’. Table 1 presents a comparison of the readability levels of pamphlets obtained from public and private hospitals. There was a highly significant difference (P < 0.001) between the pamphlets from the public and private hospitals on the FlescheKincaid and SMOG readability scales; the pamphlets from the private hospitals were, on average, one grade more difficult compared with the pamphlets from the public hospitals (11th to 12th vs ninth to 10th grade, respectively). Table 2 presents a comparison of the readability levels by topic category, and Table 3 summarizes the average readability levels by hospital and pamphlet type based on the three readability tools. There were no significant differences in the readability of pamphlets when categorized by topic category with respect to prevention, treatment or general health information.
Discussion The main finding of this study was that the readability levels of health pamphlets in Athens, as measured by the three readability tools, were above the recommended reading level (fifth grade) for written communication for health education
Table 1 e Comparison of readability levels of health brochures obtained from public and private hospitals in Greece. Readability tool
FlescheKincaid SMOG FOG
Mean score (SD) [mean educational grade level] Public (n ¼ 27)
Private (n ¼ 10)
66.1 (11.2) [9e10] 11.6 (1.2) [9e10] 26.8 (5.6) [8e9]
49.5 (9.3) [>12] 13.5 (1.0) [10e11] 30.5 (6.8) [9e10]
SD, standard deviation.
P-value
<0.001 <0.001 0.11
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Table 2 e Comparison of readability levels of health brochures focusing on prevention, treatment and general topics. Prevention (n ¼ 13)
Treatment (n ¼ 10)
General (n ¼ 14)
P-value
Mean (SD) [educational grade level of the mean] FlescheKincaid SMOG FOG
67.7 (8.1) [9e10] 11.6 (1.4) [10] 26.8 (6.1) [7e8]
61.6 (12.9) [9e10] 12.1 (1.2) [10e11] 27.3 (7.6) [7e8]
57.3 (14.0) [11e12] 12.6 (1.6) [11] 29.1 (5.0) [8e9]
0.14 0.19 0.61
SD, standard deviation.
materials, making them too difficult for the average adult reader to comprehend.17 In addition, the readability levels of health pamphlets from private hospitals had a readability level that was at least one grade more difficult compared with the pamphlets from public hospitals. However, significant differences did not arise between pamphlet categories. It is also notable that pamphlets from private hospitals were more likely to advertise services or products than pamphlets found in public hospitals. Also noteworthy is that the researchers did not find any pamphlets advertising private insurance offerings, perhaps because Greece has a national healthcare system and these pamphlets are not well produced. Given that the growth of private healthcare expenditure in Greece has increased considerably, it is imperative for materials to be developed at low literacy levels. Research has shown that physicians and other healthcare professionals may overestimate patients’ literacy levels, particularly patients from minority groups.18 As the population in Greece becomes more multi-ethnic and racially diverse due to economic migrants, more research is required to examine whether healthcare providers are accurately assessing patients’ literacy levels in general, and the patients’ health literacy levels in particular, not to mention foreign language issues per se. Specifically, some discrepancies were found between the results of the three readability tools. Therefore, a particular pamphlet may be considered to be of higher readability level (i.e. more difficult) according to one tool, while it might be seen to be easier based on another. Such discrepancies are not unusual since the three tools use different validated methods for assessing the readability level of a text. Feedback from the Centre for Greek Language Studies, who standardized the FlescheKincaid, SMOG and Fog tools for the modern Greek language in 10 formula trials and 32 separate validation studies performed internally between 1999 and 2001, indicates that the best approach is to use the average of all three tools in order to determine the overall readability level of documents including pamphlets. The study results show
more similarities between the FlescheKincaid and SMOG scales in terms of educational grade level than the Fog scale. It is important to highlight that one of the limitations of the study was that of testing the results of the three methods, because some pamphlets which scored better on the readability scales (i.e. easier to read) were not necessarily ‘understandable’ to the reader and vice versa. This ad-hoc method could only be checked subjectively by the research assistants and the authors when they actually read the pamphlets, finding differences between the level of the score and the level of their actual understanding of the material when compared with other pamphlets analysed for the same grade level. Another point is that the design and layout of a pamphlet also plays an important role in helping a reader to understand key messages, and thus contribute to the readability level.13,19 A pamphlet deemed to have a readability level of eighth grade may only be comprehensible at 10th grade level. The validity of these tools for materials in the Greek language needs to be further assessed if these computerized tools developed by the Centre for Greek Language studies are to be considered externally valid. Furthermore, this implies that more research needs to be undertaken on the relationship between the readability of health pamphlets and patients’ health literacy in Greece and beyond. Although this study did not focus on the layout and design of the pamphlets, nor on the patients’ understanding of the examined materials, it is important to emphasize that images and diagrams may help the reader to better understand and recall key messages. Studies emphasize that pictures and graphics play a key role in attention, comprehension, recall and adherence to health communication messages.19e21 Pictures coupled with instructions for using medical devices, either for first-time users or for ambiguous medical devices (not often used or not well known), seem to have added value over text alone, and serve as mnemonic aids for recalling text.20 Testing a reader’s comprehension of health messages is vital in guaranteeing the desired effects, particularly since recall does
Table 3 e Readability averages according to hospitals and pamphlet type.
Average Average Average Average Average
of public hospitals of private hospitals of prevention pamphlets of treatment pamphlets of general pamphlets
FlescheKincaid
SMOG
FOG
Averagea
65.45 49.5 67.02 60.68 56.02
11.63 13.5 11.57 12.14 12.66
26.41 31.2 31.2 28.03 28.29
Grade 9e10 (third middle school gradeefirst high school grade) Grade 11e12 (second and third high school grades) Grade 9e10 (third middle school gradeefirst high school grade) Grade 9e10 (third middle school gradeefirst high school grade) Grade 11e12 (second and third high school grades)
a The Greek educational system includes three levels of gymnasium (or ‘middle school’) and three levels of lyceum (or ‘high school’).
p u b l i c h e a l t h 1 2 4 ( 2 0 1 0 ) 5 4 7 e5 5 2
not necessarily help patients to better understand information and use it in appropriate ways or as was intended by their healthcare provider.22 Therefore, exploration should not only focus on the effects of graphics and layout, but also on the control of a phenomenon called the ‘illusion of knowing’, referring to how readers believe they have comprehended a text when they fail to show actual textual comprehension on objective questions concerning the specific materials.13 This study was limited to pamphlets obtained from hospitals and health centres/clinics in the Athens area. The research team did not collect the plethora of all pamphlets published by pharmaceutical companies that may be distributed to some private and public medical practices. Although there was no perceived selection bias in the collection of pamphlets, as research assistants were instructed to collect all of the available brochures and pamphlets (total of 70) from the 17 health centres and hospitals they visited, such a possibility cannot be excluded, and it it not possible to claim that the pamphlets studied are representative of all pamphlets distributed in Greece. Only seven of the pamphlets indicated a publishing date; five were published by the Ministry of Health in 1997 or earlier, and two pamphlets published by a medical associate were dated 2003e2004. Therefore, it is difficult to say whether newer pamphlets are more comprehensible by patients/readers compared with older pamphlets. Moreover, different characteristics (such as the level of education or health status) of the patients/clients using private hospitals/clinics compared with those using public hospitals/clinics may have confounded the findings of the study. In addition, graphic design, layout, photographs and charts cannot be assessed by current readability tools; therefore, further studies on the comprehension of the content of health pamphlets are warranted. It should also be noted that one cannot draw conclusions on the overall comprehension of a pamphlet or health literacy level using readability levels alone. For example, another researcher may categorize pamphlets into different categories or types (e.g. acute vs chronic problems, infectious diseases vs cardiology) compared with the categories used in this study (i.e. prevention, treatment and general health information). Statistical data for literacy could only be looked at for individuals aged 20 years due to the statistical categories available. Based on the above data, it is estimated that 52.4% of the Greek population aged 20 years would be able to understand the pamphlets at the average readability level of ninth to 10th grade, whereas the remaining 43.7% would not be able to comprehend such information. Grade levels in Greece are similar to those in the USA, although the available literacy data (2003) indicate that a large percentage of Greeks are indeed literate (over 92%). However, functional literacy testing similar to the US data is not available, and therefore it is difficult to draw solid conclusions for the Greek population. Further research needs to be undertaken on readability, literacy and health literacy needs among the Greek population and within the larger societal context. This study may be seen as pioneering work in Greece in leading the efforts aimed at improving pamphlet readability levels and promoting public health. The first and understated finding of this research is that of a limited availability of health pamphlets overall. Distribution of health educational
551
materials needs to be improved as well as updated. The readability outcomes documented through the results should be shared with respective organizations to improve pamphlet readability levels and to guide future efforts in researching health literacy outcomes. Future research efforts should also explore sources and availability of health information. A second way in which this study may help to improve the readability levels of pamphlets developed in Greece is by spreading the information regarding the readability tools maintained by the Greek Centre for Language Studies based in Thessaloniki to the producers of health pamphlets across the country. Such an effort will help them to evaluate the text used at present and re-adjust it to suit their target population. Other factors beyond readability levels, such as layout and pamphlet design, are equally important with respect to how the reader understands the information presented. The authors’ research combined with that of others may help to determine the ‘best practices’ for designing better health information pamphlets in the Greek language. Documenting where patients obtain health information and assessing how patients comprehend a pamphlet on their own or with the help of a healthcare provider may provide valuable insight into overall health literacy levels in Greece. Lastly, healthcare providers need to improve the distribution of published materials to the intended audience, and to ensure that the information provided on such publications is continuously updated and assessed as appropriate.
Ethical approval None sought.
Funding Marie Curie Reintegration Grant.
Competing interests None declared.
references
1. McLaughlin GH. SMOG grading: a new readability formula. J Reading 1969;12:639e46. 2. Rudd RE. How to create and assess print materials. Harvard School of Public Health: Health Literacy. Available at: http:// www.hsph.harvard.edu/healthliteracy/materials.html; 2005 [accessed 12.12.06]. 3. US Department of Health and Human Services. Healthy people 2010. Available at: http://www.healthypeople.gov/document/ HTML/Volume1/11HealthCom.htm; 2005 [accessed 04.10.06]. 4. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health 1997;87:1027e30. 5. Baker DW, Parker RM, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791e8. 6. Nutbeam D, Kickbusch I. Advancing health literacy: a global challenge for the 21st century. Health Promot Int 2000;15: 183e4. 7. Rudd R, Moeykens B, Colton T. Health and literacy: a review of medical and public health literature. In: Comings J, Garners B,
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Smith C, editors. Annual review of adult learning and literacy. New York: Jossey-Bass; 1999. Kondilis BK, Soteriades ES, Falagas ME. Readability levels of health pamphlets distributed during the Athens 2004 Olympic Games. Public Health 2007;121:189e92. OECD. Health data 2002. A comprehensive analysis of 29 countries. Paris: OECD; 2002. Tountas Y, Karnaki P, Pavi E, Souliotis K. The unexpected growth of the private health sector in Greece. Health Policy 2005;74:167e80. General Secretariat of National Statistical Service of Greece, Piraeus, Greece. Available at: http://web.statistics.gr/Deltia_ menu_eng.asp; 2006. US Department of Education, National Center for Education Statistics. National assessment of adult literacy. Available at: http://nces.ed.gov/naal/; 2003 [accessed 26.08.07]. Kools M, van de Wiel MW, Ruiter RA, Kok G. The effect of graphic organizers on subjective and objective comprehension of a health education text. Health Educ Behav 2006;33:760e72. Centre for Greek Language Studies. Readability formulas for Greek text [in Greek]. Available at: http://www.greek-language. gr/greekLang/modern_greek/foreign/tools/readability/index. html; 2006 [accessed 12.12.06].
15. Grudner TM. Two formulas for determining the readability of subject consent forms. Am Psychol 1978;33:773e4. 16. Lowrey TM. The relation between script complexity and commercial memorability. J Advert 2006;35:7e15. 17. Doak L, Doak CC, Root JH. Teaching patients with low literacy skills. Philadelphia: Lippincott Williams & Wilkins; 1996. 18. Kelly PA, Haidet P. Physician overestimation of patient literacy: a potential source of health care disparities. Patient Educ Counsel 2007;66:119e22. 19. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Counsel 2006;61:173e90. 20. Kools M, van de Wiel MW, Ruiter RA, Kok G. Pictures and text in instructions for medical devices: effects on recall and actual performance. Patient Educ Counsel 2006;64: 104e11. 21. Clark KL, AbuSabha R, von Eye A, Achterberg C. Text and graphics: manipulating nutrition brochures to maximize recall. Health Educ Res 1999;14:555e64. 22. Feldman-Stewart D, Brennenstuhl S, Brundage MD. A purpose-based evaluation of information for patients: an approach to measuring effectiveness. Patient Educ Counsel 2007;65:311e9.
available at www.sciencedirect.com
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Original Research
Readability levels of health pamphlets distributed in hospitals and health centres in Athens, Greece B.K. Kondilis a,b, P.D. Akrivos a,b, T.A. Sardi a, E.S. Soteriades a,c,d, M.E. Falagas a,e,f,* a
Alfa Institute of Biomedical Sciences, Athens, Greece Hellenic American University, Athens, Greece c Cyprus Institute of Biomedical Sciences, Nicosia, Cyprus d Harvard School of Public Health, Department of Environmental Health. Environmental and Occupational Medicine and Epidemiology, Boston, MA, USA e Tufts University School of Medicine, Department of Medicine, Boston, MA, USA f Department of Medicine, Henry Dunant Hospital, Athens, Greece b
article info
summary
Article history:
Objectives: Health literacy is important in the medical and social sciences due to its impact
Received 24 June 2009
on behavioural and health outcomes. Nevertheless, little is known about it in Greece,
Received in revised form
including patients’ level of understanding health brochures and pamphlets distributed in
8 April 2010
Greek hospitals and clinics.
Accepted 13 May 2010
Study design: Observational study in the greater metropolitan area of Athens, Greece.
Available online 15 September 2010
Methods: Pamphlets and brochures written in the Greek language were collected from 17 hospitals and healthcare centres between the spring and autumn of 2006. Readability of
Keywords:
pamphlets using the FlescheKincaid, Simple Measure of Gobbledygook (SMOG) and Fog
Readability
methods was calculated based on a Greek readability software.
Pamphlets
Results: Out of 70 pamphlets collected from 17 hospitals, 37 pamphlets met the criteria for
Leaflets
the study. The average readability level of all scanned pamphlets was ninth to 10th grade,
Health literacy
corresponding to a readability level of ‘average’. A highly significant difference (P < 0.001)
Health communication
was found between private and public hospitals using the FlescheKincaid and SMOG
Greece
readability scales. Pamphlets from private hospitals were one grade more difficult than those from public hospitals. Conclusion: Approximately 43.7% of the Greek population aged 20 years would not be able to comprehend the available pamphlets, which were found to have an average readability level of ninth to 10th grade. Further research examining readability levels in the context of health literacy in Greece is warranted. This effort paves the way for additional research in the field of readability levels of health pamphlets in the Greek language, the sources of health information, and the level of understanding of key health messages by the population. ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Correspondence to: Alfa Institute of Biomedical Sciences, Neapoleos 9, 15123 Marousi, Athens, Greece. Tel.: þ30 210 68 39 604; fax: þ30 210 68 39 605. E-mail address: [email protected] (M.E. Falagas). 0033-3506/$ e see front matter ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2010.05.010
548
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Introduction Health literacy is becoming an important focal point for health providers in many countries around the world, particularly in the context of patient health outcomes. Health pamphlets are often utilized by patients to supplement information they receive from their healthcare provider. Readability of available materials is considered an important factor in overall health literacy. Readability tools generally fall into two major categories: computer generated and those calculated by hand. The Flesch grade level formula and the FlescheKincaid index are the most frequently used computerized tools, while handcalculated tools include the FOG method, the Fry formula and the Simple Measure of Gobbledygook (SMOG, a readability tool that estimates the years of education needed to completely understand a piece of writing). SMOG is widely used, particularly for checking health messages.1,2 SMOG is considered an easy to compute and well-tested tool for field work as it predicts high levels of comprehension.2 Health literacy is defined as ‘the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions’.3 According to research, individuals with low health literacy are more likely to have poor health, are less likely to understand their health problems and treatment management, and are at higher risk of hospitalization.4e7 The importance of health literacy has been established in medical and social science literature as it affects patient behaviour and health outcomes, although Greece continues to lag behind in this area with very little known about readability levels of materials,8 particularly for health brochures and pamphlets found in Greek hospitals and clinics. Past research on the readability of English language health pamphlets distributed during the Athens 2004 Olympic Games indicated that, on average, the pamphlets had higher than recommended US grade readability levels (10th, 16th and eighth for the ‘Ministry of Health and Social Solidarity (MOHSS)-Travel-related issues’, Ministry of Rural Development and Food (MORDF)Mediterranean diet’ and ‘National School of Public Health (NSPH)-Swimming pool safety’ pamphlets, respectively).8 However, research has not been undertaken on the readability of health pamphlets in the Greek language, as readability tools in the Greek language were not available until more recently. Greece has functioned under a national healthcare system since 1983. Specifically, expenditure reached 3.9% of gross national product (GNP) in 2000, which is a high percentage for developed countries compared with the mean value for Organisation for Economic Co-operation and Development (OECD) countries in 2000 (2.2%).9 However, rapid growth in the private health sector, expressed through growth of private hospitals and primary healthcare services, was also observed in the same OECD data. Despite legislative restrictions on the private sector, private healthcare expenditure in Greece has increased, reaching 3.9% of the country’s GNP (43% of the total expenditure on health) in 2000.10 The reasons for this increase are attributed to economic growth, patient dissatisfaction with the public system, changes in insurance policies, quality of services, and medical manpower characterized by an
increase of private medical doctors in Greece.10 Thus, Greek people who seek healthcare services are exposed to both public and private sector resources, including written health education materials. Greece is a highly literate society with approximately 96% of the population considered ‘educated’ (i.e. being able to read and write) (2001 estimate).11 Same-year statistics also indicate that 43.7% of the population (>20 years old) have not completed elementary school, while 52.4% have not completed high school.11 More recent information (2003), provided by the National Statistics Centre of Greece, indicates that 92.19% are considered ‘educated’ (i.e. finished high school) in the entire population of 10.5 million people.11 This difference may be due to the fact that the population in Greece has become more multi-ethnic and racially diverse due to economic migrants. The percentage of non-educated people may increase in coming years. However, in-depth studies on functional adult literacy, such as the National Assessment of Adult Literacy and the National Adult Literacy Survey undertaken in the USA through the US Department of Education’s National Center for Education Statistics,12 have never been conducted in Greece. The overall purpose of this study was to examine the readability levels of health pamphlets and brochures written in the Greek language that target the Greek patient population by utilizing available readability tools applied to patient education materials found in hospitals and clinics in Athens. The Greek language is generally more complex with longer words and syllables than most other romance languages, so the researchers considered that the examination of readability levels was of importance to determine any variation. In addition, the aspiration of the researchers was to provide the respective organizations with the readability levels in order to promote improvements in pamphlet readability. When there is insufficient or inadequate understanding of information, the probability of behavioural change in accordance with the information objectives diminishes.13 Thus, the end goal of the research is to better assist providers in their delivery of health information to their patients, and the establishment of better health literacy outcomes.
Methods Pamphlets and brochures were collected by research assistants from public and private hospitals and clinics in the Athens area between May and November 2006. All available pamphlets and brochures were collected from waiting rooms, health stands and nurses’ desks. The research assistants picked up all available brochures and also asked nurses and other front-line staff for other brochures that may not have been immediately visible to the public. Pamphlets and/or brochures that gave information on health issues related to prevention, treatment and specific diseases were included in the final analyses. Pamphlets and brochures that advertised hospital services and/or specific products (i.e. medications), those that were historical accounts of services, magazines and newspapers, and brochures that were written in a language other than the Greek language were excluded from the study The brochures were categorized as coming from public or
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private hospitals/clinics and were subdivided according to their topic content. The three categories of health pamphlets identified were prevention, treatment and general health information. The pamphlets and brochures were subsequently scanned. Any obscure words added by the readability software that were not related to the original text were double-checked, and the information was corrected before the final grade analysis was performed. Software was developed by the Centre for Greek Language in Thessaloniki, Greece (2002 version).14 This software was used to evaluate each pamphlet’s readability level in the Greek language using three well-known and validated measures: the Flesh-Kincaid, SMOG and Fog tools. As indicated by their staff and on their website, the Centre for Greek Language standardized the FlescheKincaid, SMOG and Fog tools for the modern Greek language in 10 formula trials and 32 separate validation studies performed internally between 1999 and 2001. The Flesch score is relied on by many researchers as it is the simplest and most accurate measure of text difficulty.2 The Flesch reading ease tool is composed of two sets of calculations: the computation of the average number of syllables per 100 words, and the average number of words per sentence. The final score is matched to corresponding grade levels to yield the FlescheKincaid grade level.2,15 The FlescheKincaid readability results range from 100e90 at the first to third elementary grade level to 30e0 at the tertiary education level. The Fog index computes the length and the number of words with three syllables or more in the average sentence, and the final score is matched to corresponding grade levels.16 The SMOG readability tool assesses readability based on the number of syllables and the number of sentences. According to the SMOG tool, the sampling of the data from a given text is done selectively from the beginning, middle and end of the full text.2 The SMOG readability level results range from 1e2 (basic elementary) to 14 (tertiary education). However, none of the readability tools take into account other parameters that affect patients’ readability levels, such as the effects of graphics, layout or document design. Statistical comparisons were performed using the Greek software developed by categorizing pamphlets into those obtained from public and private hospitals, and also according to the three topic categories for the three readability scales. The average grade levels corresponding to the average readability result for each of the hospital type and topic categories were recorded. The average literacy levels for adults in Greece were calculated based on the number of people aged 20 years living in Greece who have completed either elementary school or high school. The most current and complete available data were obtained from the General Secretariat of the National Statistical Service of Greece for 2001.11
Results In total, 17 hospitals and health clinics were visited (10 public and seven private). One of the public hospitals was a military hospital. All but three hospitals/clinics had brochures. In total, 70 brochures were collected, from which 37 met the criteria for inclusion in the final analyses. Health topics ranged from
alcohol use and disease to urinary problems (see Appendix for complete list). Of the 37 pamphlets, 27 were obtained from public hospitals and 10 were obtained from private hospitals or clinics. The pamphlets from seven public hospitals/clinics and four private hospitals/clinics (total of 11 hospitals/clinics) qualified for the final readability level analyses. Most of the pamphlets from the private hospitals advertised hospital services. Of the 27 pamphlets obtained from public hospitals, only seven were published by the hospitals, while the other 20 were published by external sources (e.g. Association of Gastroenterologists). Of the latter, eight were compiled by the Hellenic Ministry of Public Health and the other 12 were compiled by non-governmental organizations and other associations (e.g. ‘ACT UP’, an organization for human immunodeficiency virus/ acquired immunodeficiency syndrome prevention and support). All of the pamphlets from private hospitals that met the criteria for inclusion in the study were published internally by the hospitals or their affiliates. The average readability level of all scanned pamphlets was ninth to 10th grade (Greek equivalents: third middle school grade and first high school grade), which corresponds to a readability level of ‘average’. Table 1 presents a comparison of the readability levels of pamphlets obtained from public and private hospitals. There was a highly significant difference (P < 0.001) between the pamphlets from the public and private hospitals on the FlescheKincaid and SMOG readability scales; the pamphlets from the private hospitals were, on average, one grade more difficult compared with the pamphlets from the public hospitals (11th to 12th vs ninth to 10th grade, respectively). Table 2 presents a comparison of the readability levels by topic category, and Table 3 summarizes the average readability levels by hospital and pamphlet type based on the three readability tools. There were no significant differences in the readability of pamphlets when categorized by topic category with respect to prevention, treatment or general health information.
Discussion The main finding of this study was that the readability levels of health pamphlets in Athens, as measured by the three readability tools, were above the recommended reading level (fifth grade) for written communication for health education
Table 1 e Comparison of readability levels of health brochures obtained from public and private hospitals in Greece. Readability tool
FlescheKincaid SMOG FOG
Mean score (SD) [mean educational grade level] Public (n ¼ 27)
Private (n ¼ 10)
66.1 (11.2) [9e10] 11.6 (1.2) [9e10] 26.8 (5.6) [8e9]
49.5 (9.3) [>12] 13.5 (1.0) [10e11] 30.5 (6.8) [9e10]
SD, standard deviation.
P-value
<0.001 <0.001 0.11
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Table 2 e Comparison of readability levels of health brochures focusing on prevention, treatment and general topics. Prevention (n ¼ 13)
Treatment (n ¼ 10)
General (n ¼ 14)
P-value
Mean (SD) [educational grade level of the mean] FlescheKincaid SMOG FOG
67.7 (8.1) [9e10] 11.6 (1.4) [10] 26.8 (6.1) [7e8]
61.6 (12.9) [9e10] 12.1 (1.2) [10e11] 27.3 (7.6) [7e8]
57.3 (14.0) [11e12] 12.6 (1.6) [11] 29.1 (5.0) [8e9]
0.14 0.19 0.61
SD, standard deviation.
materials, making them too difficult for the average adult reader to comprehend.17 In addition, the readability levels of health pamphlets from private hospitals had a readability level that was at least one grade more difficult compared with the pamphlets from public hospitals. However, significant differences did not arise between pamphlet categories. It is also notable that pamphlets from private hospitals were more likely to advertise services or products than pamphlets found in public hospitals. Also noteworthy is that the researchers did not find any pamphlets advertising private insurance offerings, perhaps because Greece has a national healthcare system and these pamphlets are not well produced. Given that the growth of private healthcare expenditure in Greece has increased considerably, it is imperative for materials to be developed at low literacy levels. Research has shown that physicians and other healthcare professionals may overestimate patients’ literacy levels, particularly patients from minority groups.18 As the population in Greece becomes more multi-ethnic and racially diverse due to economic migrants, more research is required to examine whether healthcare providers are accurately assessing patients’ literacy levels in general, and the patients’ health literacy levels in particular, not to mention foreign language issues per se. Specifically, some discrepancies were found between the results of the three readability tools. Therefore, a particular pamphlet may be considered to be of higher readability level (i.e. more difficult) according to one tool, while it might be seen to be easier based on another. Such discrepancies are not unusual since the three tools use different validated methods for assessing the readability level of a text. Feedback from the Centre for Greek Language Studies, who standardized the FlescheKincaid, SMOG and Fog tools for the modern Greek language in 10 formula trials and 32 separate validation studies performed internally between 1999 and 2001, indicates that the best approach is to use the average of all three tools in order to determine the overall readability level of documents including pamphlets. The study results show
more similarities between the FlescheKincaid and SMOG scales in terms of educational grade level than the Fog scale. It is important to highlight that one of the limitations of the study was that of testing the results of the three methods, because some pamphlets which scored better on the readability scales (i.e. easier to read) were not necessarily ‘understandable’ to the reader and vice versa. This ad-hoc method could only be checked subjectively by the research assistants and the authors when they actually read the pamphlets, finding differences between the level of the score and the level of their actual understanding of the material when compared with other pamphlets analysed for the same grade level. Another point is that the design and layout of a pamphlet also plays an important role in helping a reader to understand key messages, and thus contribute to the readability level.13,19 A pamphlet deemed to have a readability level of eighth grade may only be comprehensible at 10th grade level. The validity of these tools for materials in the Greek language needs to be further assessed if these computerized tools developed by the Centre for Greek Language studies are to be considered externally valid. Furthermore, this implies that more research needs to be undertaken on the relationship between the readability of health pamphlets and patients’ health literacy in Greece and beyond. Although this study did not focus on the layout and design of the pamphlets, nor on the patients’ understanding of the examined materials, it is important to emphasize that images and diagrams may help the reader to better understand and recall key messages. Studies emphasize that pictures and graphics play a key role in attention, comprehension, recall and adherence to health communication messages.19e21 Pictures coupled with instructions for using medical devices, either for first-time users or for ambiguous medical devices (not often used or not well known), seem to have added value over text alone, and serve as mnemonic aids for recalling text.20 Testing a reader’s comprehension of health messages is vital in guaranteeing the desired effects, particularly since recall does
Table 3 e Readability averages according to hospitals and pamphlet type.
Average Average Average Average Average
of public hospitals of private hospitals of prevention pamphlets of treatment pamphlets of general pamphlets
FlescheKincaid
SMOG
FOG
Averagea
65.45 49.5 67.02 60.68 56.02
11.63 13.5 11.57 12.14 12.66
26.41 31.2 31.2 28.03 28.29
Grade 9e10 (third middle school gradeefirst high school grade) Grade 11e12 (second and third high school grades) Grade 9e10 (third middle school gradeefirst high school grade) Grade 9e10 (third middle school gradeefirst high school grade) Grade 11e12 (second and third high school grades)
a The Greek educational system includes three levels of gymnasium (or ‘middle school’) and three levels of lyceum (or ‘high school’).
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not necessarily help patients to better understand information and use it in appropriate ways or as was intended by their healthcare provider.22 Therefore, exploration should not only focus on the effects of graphics and layout, but also on the control of a phenomenon called the ‘illusion of knowing’, referring to how readers believe they have comprehended a text when they fail to show actual textual comprehension on objective questions concerning the specific materials.13 This study was limited to pamphlets obtained from hospitals and health centres/clinics in the Athens area. The research team did not collect the plethora of all pamphlets published by pharmaceutical companies that may be distributed to some private and public medical practices. Although there was no perceived selection bias in the collection of pamphlets, as research assistants were instructed to collect all of the available brochures and pamphlets (total of 70) from the 17 health centres and hospitals they visited, such a possibility cannot be excluded, and it it not possible to claim that the pamphlets studied are representative of all pamphlets distributed in Greece. Only seven of the pamphlets indicated a publishing date; five were published by the Ministry of Health in 1997 or earlier, and two pamphlets published by a medical associate were dated 2003e2004. Therefore, it is difficult to say whether newer pamphlets are more comprehensible by patients/readers compared with older pamphlets. Moreover, different characteristics (such as the level of education or health status) of the patients/clients using private hospitals/clinics compared with those using public hospitals/clinics may have confounded the findings of the study. In addition, graphic design, layout, photographs and charts cannot be assessed by current readability tools; therefore, further studies on the comprehension of the content of health pamphlets are warranted. It should also be noted that one cannot draw conclusions on the overall comprehension of a pamphlet or health literacy level using readability levels alone. For example, another researcher may categorize pamphlets into different categories or types (e.g. acute vs chronic problems, infectious diseases vs cardiology) compared with the categories used in this study (i.e. prevention, treatment and general health information). Statistical data for literacy could only be looked at for individuals aged 20 years due to the statistical categories available. Based on the above data, it is estimated that 52.4% of the Greek population aged 20 years would be able to understand the pamphlets at the average readability level of ninth to 10th grade, whereas the remaining 43.7% would not be able to comprehend such information. Grade levels in Greece are similar to those in the USA, although the available literacy data (2003) indicate that a large percentage of Greeks are indeed literate (over 92%). However, functional literacy testing similar to the US data is not available, and therefore it is difficult to draw solid conclusions for the Greek population. Further research needs to be undertaken on readability, literacy and health literacy needs among the Greek population and within the larger societal context. This study may be seen as pioneering work in Greece in leading the efforts aimed at improving pamphlet readability levels and promoting public health. The first and understated finding of this research is that of a limited availability of health pamphlets overall. Distribution of health educational
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materials needs to be improved as well as updated. The readability outcomes documented through the results should be shared with respective organizations to improve pamphlet readability levels and to guide future efforts in researching health literacy outcomes. Future research efforts should also explore sources and availability of health information. A second way in which this study may help to improve the readability levels of pamphlets developed in Greece is by spreading the information regarding the readability tools maintained by the Greek Centre for Language Studies based in Thessaloniki to the producers of health pamphlets across the country. Such an effort will help them to evaluate the text used at present and re-adjust it to suit their target population. Other factors beyond readability levels, such as layout and pamphlet design, are equally important with respect to how the reader understands the information presented. The authors’ research combined with that of others may help to determine the ‘best practices’ for designing better health information pamphlets in the Greek language. Documenting where patients obtain health information and assessing how patients comprehend a pamphlet on their own or with the help of a healthcare provider may provide valuable insight into overall health literacy levels in Greece. Lastly, healthcare providers need to improve the distribution of published materials to the intended audience, and to ensure that the information provided on such publications is continuously updated and assessed as appropriate.
Ethical approval None sought.
Funding Marie Curie Reintegration Grant.
Competing interests None declared.
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