Readability of printed sources of diet and health information

j34TiNT EdUCATiON md COLMEhc, ELSEVIER

Patient Education and Counseling 27 (1996) 123-134

Readability

of printed sources of diet and health information

Jamie Dollahiteay*, Cecelia Thompsonb, Ronald McNewC ‘Department

of Home Economics, 118 Home Economics Building, Urhersity of Arkansas, Fayetteville, AR 72701, bDepartment of Vocational and Adult Educatibn, University of Arkansas, Fayetteville, AR 72701, USA ‘Agricultural Statistics Laboratory, University of Arkansas, Fayetteville, AR 72701, USA

USA

Received 3 October 1994; revision received 22 May 199.5; accepted 20 July 1995

Abstract This study surveyed nutrition education materialswhich are low in cost, brief and the type most usedin patient education to determine which might be useful with low literacy clients. Readability of 209 pamphlets from professionalhealth organizations,commercialorganizations,government agencies,and educationalinstitutions was assessed usingthree different tests. Using the Fleschand Raygor tests,materialsfrom educational institutions had significantly lower reading levels than materials from professionalorganizations and government agencies.No significantdifferences were seenamongthe sourcesusingthe Fry test. Sixty-eight percent (142) of the publications were written at ninth grade level or higher. Eleven percent (24) scoredat sixth grade or below on either the Fry or Raygor scale.Only two publicationswere written at the third gradelevel. Many of the publicationsreviewed can be read and understood by many Americans, but there were few for the millions that have limited literacy skills. Keywords:

Readability; Nutrition education; Diet and health; Literacy

1. Introduction It is estimated that 22 million adults in the United States are described as illiterate because

they lack the ability to read. Up to 35 million, or one of every five adults, are functionally illiterate and lack the ability to read at a level of proficiency considered necessary to function in daily life. The National Literacy Act of 1991 defined literacy as “ ...an individual’s ability to read, write, and speak English, and compute and *Corresponding author, Tel.: (+l-501) (+l-501) 575 7171.

575 4305; Fax:

solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals and develop one’s knowledge and potential” [l]. Therefore, some of these adults may not be able to make full use of their abilities to lead productive and satisfying lives. Because they have low-literacy skills, they lack the ability to read well enough to understand labels on food or medicine or to understand written health information. The possible effects of this may be seen by examining the difference in death rates from heart disease among people of varying socioeconomic status. The mortality rate from cardiovascular disease has decreased in the past

073%3991/96/$15&O @ 1996 Elsevier Science Ireland Ltd. All rights reserved SSDZ 0738-3991(95)00829-O

124

J. Dollahite

et al. I Patient

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twenty years, with the greater decrease seen in groups which have a higher socioeconomic status, and hence, are better educated [2]. There is a clear, direct relationship between income and literacy level [3]. Therefore, the greater decrease in mortality among groups with higher income levels may, at least in part, be related to their higher literacy level and hence to their ability to better comprehend the available education materials which address heart disease and methods for altering cardiovascular risk factors. Professionals involved in patient education are well aware of the difficulty in achieving change in nutrition behavior. While knowledge alone does not cause improved behavior, it is a prerequisite to movement from the pre-contemplation stage to the contemplation stage in the stages of change model [4]. Therefore, if materials are not available which are understandable to the patient, the problem of assisting clients in choosing more appropriate behaviors is intensified [5,6]. Only a few studies have assessed readability of education materials specifically addressing nutrition and diet-related behaviors. Swanson and Birklid [7] have evaluated 32 books recommended to consumers by professional nutrition and dietetics organizations. These books ranged in length from 32 to 592 pages. While they addressed a variety of topics from weight control to treatment of eating disorders, they were not the booklet type of publications generally used by health professionals for client education. Because of their length, they would automatically appear overwhelming to most people with limited reading skills. Doak [5] reported on 20 pieces of nutrition education literature which had a mean reading level of 10th grade using the SMOG (Simple Measure of Gobbledegook) formula; none had less than a seventh grade reading level. Other studies have looked at small numbers of nutrition education pamphlets as a part of a larger study which assessed literature available for a specific disease state such as diabetes [8], heart disease [9,10], and cancer [ll]. All of these reported readability levels of ninth grade or higher for the great majority of materials. The present study was undertaken to survey nutrition education materials in a more com-

and Counseling

27 (1996)

123-134

prehensive manner than has been previously reported. The materials assessed are low in cost, relatively brief and of the type most used in patient education. The intent was to determine which materials might be useful with low literacy clients (reading level of sixth grade or lower) and to assess the need for development of additional materials which could improve the educators’ success in client education.

2. Methods Pamphlets related to nutrition and health were requested from a variety of health education publishers. Publications were solicited from professional health organizations, commercial organizations, government agencies, and educational institutions. Government agencies contacted were the United States Department of Agriculture, Human Nutrition Information Service (USDA); the Food and Drug Administration (FDA); and, within the National Institutes of Health (NIH), the National Cancer Institute and the National Heart, Lung, and Blood Institute. Professional health organizations contacted were the American Dietetic Association, the American Diabetes Association, the American Cancer Society, the American Institute for Cancer Research, and the American Heart Association. A number of materials from commercial organizations were also included. A comprehensive sample of currently available brochures from the National Dairy Council and Ross Laboratories was assessed. These two organizations were chosen for comprehensive review because they are both readily available sources, familiar to and frequently used by nutrition educators. The emphasis of the Dairy Council publications is nutrition in wellness whereas the emphasis of the Ross materials is medical nutrition therapy; they therefore represent a broad spectrum of topics and different target audiences. The remaining publications from commercial organizations were a convenience sample of materials randomly received in the mail and picked up from commercial exhibitors at an annual meeting of the American Dietetic Association. There were a

f. ~ol~~~ite

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total of 15 commercial organizations represented, including commercial food companies, nutritional supplement companies, and organizations representing a particular segment of the food industry. Because of the large number of possible organizations in this category, the wide array of materials available, and the fact that many of these materials rapidly come and go on the market, no attempt was made to obtain a comprehensive sampling from all companies. The final category of sources included was institutions of higher education. Two were chosen because they are known for work in the area of nutrition education, Pennsylvania State University and the University of Wisconsin, and one was the authors’ own institution, the University of Arkansas. While the variety of materials received was not comprehensive in terms of overall nutrition education materials available, it was comprehensive from all of the sources contacted except the commercial organizations. The sources were contacted during the summer of 1994, and a copy of each booklet or brochure geared to adult education in nutrition and health which they published, and which was in print at that time, was requested. Those evaluated met the following inclusion criteria: (a) they were scientifically accurate; (b) they were designed for adult education; (c) they fit under the broad topic of nutrition and health; (d) they included a minimum of 500 words in sentence format which could be evaluated for readability; and (e) they were pamphlets or booklets of 40 pages or less. Three methods were chosen to measure readability, the Fry [12], Raygor [13], and Flesch [14] formulas. Readability formulas rate the dif~culty of sample passages in text. The formulas can give an objective measure of the style of a reading selection by examining syntactic (sentence) and semantic (word) variables. Shorter sentences and simple words translate into lower reading levels, while longer sentences and polysyllabic words translate into higher reading levels. These formulas are general enough to provide grade reading level or difficulty estimates [15]. The three tests chosen compliment each other because they use different methods for

and Cou~sefin~

27 (1~~

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12.5

measuring readability and hence provide greater validity to the results. All have been used routinely to assess adult reading materials. The Fry j12] readability method calculates grade reading level using a formula based on the number of syllables per sentence. Fry readability was validated on high school students and has been used to measure materials at the elementary through college level. The Raygor [13] readability estimate uses a graph that measures word difficulty by counting long words of six or more letters rather than counting syllables. It has been used to evaluate general interest materials for adult readers [16]. The Flesch [14] readability formula measures the average sentence length in words and the average word length in syllables. These two numbers are used to determine a score between 0 and 100 that shows the reading difficulty. The ‘plain English’ score is 60 to 70. Lower scores are increasingly difficult; higher scores are increasingly easy. The Flesch formula is widely used to measure readability of adult reading materials and has been validated on government publications, materials designed for adult education, and news items [17]. Flesch states that the eye and mind pause at major punctuation marks to sum up what has been taken in and arrive at meaning. If a sentence is long, the mind must process more ideas. The same is true of words. Complexity of words shows up in prefixes and suffixes. “In using the formula, you count words and syllables to measure the mental work the reader will have to do” ([141, p. 22). The readability of each document was determined at grade reading level using the Fry and Raygor readability tests; Flesch reading ease score was also determined. The sample of text from each publication was at least 500 words in length, ending at the close of the paragraph in which 500 words was met. Ghost Writer [M] was used to determine the readability according to the Fry method. This data was verified by hand determination of the Fry readability of a random sample of the publications. The results were consistent with the computer analysis. The Ghost Writer software provided the following data for use in calculating the Raygor and Flesch scores:

mean syllables per 100 words, mean words per sentence, mean sentences per 100 words, total number of words in the passage,and total number of syllables in the passage. In addition, the software provided a word frequency list from which the number of words longer than five letters was determined for use in calculating the Raygor. All passages were chosen in a standardized fashion and proofread by a second observer following entry into the program. Raygor and Flesch scores which fell on tbe line between two scores were always rounded to the higher reading level. Editing of data included checking and re-entry of passages from publications in which the resulting grade level from Fry and Raygor was more than one grade different or in which the Flesch fell outside of predetermined boundaries by grade level. Materials were then categorized by publication source and one or two primary topics related to diet and health. Assignment to categories were made by one person. Each publication was first categorized as ‘normal nutrition’ or a disease state. Secondly, it was categorized by focus, e.g. stage of the life cycle or specific nutrient. For those pamphlets which addressed several topics, a judgement call was made and the topic receiving the most emphasis was chosen. The mean readabifity level of the documents by source and topic areas was computed. An analysis of variance of each of the three readability scores was used to obtain the F-test of differences among sources. Subsequently, pair-wise comparisoos were conducted by t-tests. Pooled within-source correlations between scores were also tested for si~ifi~~ce. All statistical computations were performed using the ANOVA procedure of SAS [19]. 3. Resufts Four-hundred ten publications were received from publishers of diet and health info~ation. Two-hundred nine met the inclusion criteria and were analyzed for readability, The major topics of the publications were normal nutrition, cancer, heart disease, diabetes, overweight, blood pres-

sure, kidney disease, pulmoua~ disease, osteoporosis, lactose intolerance, acquired immune deficiency syndrome, pregnancy, children, aging, fiber, cholesterol, fat, sodium, calcium, exercise, and food labels. Most publications addressed at least two of the topics. Ninety-seven of the publications were written and distributed by professional health organizations, 53 by commercial organizations, 44 by the federal government and 15 by educational institutions.

Correlation coefficients were calculated between pairs of readability tests and all were statistically significant (P < 0.001). The correlation between Fry and Raygor readability levels was found to be r = 0.90. The correlation between Fry levels and Flesch scoreswas r = -0.97 and between Raygor levels and Flesch scoreswas F= -0.90. Baldwin and Kaufman [ZO]found that Raygor and Fry readability tests yield comparable results with a correlation of r = 0.88 (P < 0.001) on readability estimates from novels, collections of short stories and textbooks raging in difficulty from third grade to beyond college level.

When the readab~ity levels were compared by source of the materials, the publications with the highest readability levels were those published by professional health organizations and government agencies and those with the lowest levels were published by educationai institutions (Table 1). Pamphlets from commercial sources fell in the middle. The only statistically significant difference was that the materials published by educational institutions had a lower readability than those published by professional organizations and government agencies using the Flesch and Raygor scores. The professional organizations published materials which covered the entire range surveyed from grade 3 to 14 on the Fry and Raygor scales and 84 (easy) to 33 (difficult) on the Flesch. The mean grade reading levels for the professional

J. Dollahite

Table 1 Readability levels of dietary/health

et al.

I Patient

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publications by source (mean 2 S.E.M.)

Source Score

n

Fry GRL’

Raygor GRL*

Flesch

Professional Government Commercial Education

97 53

9.7" 2 0.2 9.9" rt 0.4 9.3" ir 0.3

15

8.6” t 0.8

9.4" 9.9" 9.0" 7.6"

57.7b 56.0h 59.3"b 64.2"

44

-+ 0.3 2 0.4 2 0.3 ?z 0.6

t 1.2 f 2.0 t 1.4 i 3.7

Within test type, mean scores not followed by a common letter are significantly different (P < 0.05). * GRL, Grade reading level.

publications were at least one grade higher than the mean level of 8.4 reported by Vivian and Robertson [21] for materials from professional organizations. Of the five professional organizations surveyed, the American Institute for Cancer Research publications were written at the highest mean readability level (Table 2). They were one grade level higher than those from the American Cancer Society and two grades higher than those from the other professional sources. The Flesch scores validated these results. The mean readability levels of materials from the three specific government sources surveyed were all significantly different from each other (Table 3). Materials from the FDA were two grades higher than those from the USDA which were in turn at least two grades higher than those from the NIH. All of the FDA publications were

articles from the FDA Consumer, a subscription magazine. The ones assessed in this study are reprints available free as public nutrition education pamphlets. The FDA materials ranged from grade level 7 to 14 on the Fry and Raygor tests and from 70 (fairly easy) to 22 (very difficult) on the Flesch. The USDA materials ranged from grade 6 to 14 on the Fry and Raygor tests and from 76 (fairly easy) to 43 (difficult) on the Flesch. The NIH materials ranged from grade 3 to 11 on the Fry and Raygor tests and from 88 (easy) to 52 (fairly difficult) on the Flesch. Of the two commercial organizations for which a comprehensive sample of diet and health materials meeting the criteria of this study were analyzed, Ross Laboratories published materials at a reading level three grades higher than the

Table 2 Readability levels of diet and health publications from professional sources (mean -CS.E.M.) Source American American American American American

Cancer Society Dietetic Association Heart Association Institute for Cancer Research Diabetes Association

n

Fry GRL*

Raygor GRL*

Flesch

4 44

10.3nh 2 1.6 9.1h + 0.4. 9.P r 0.4

lO.iP t 1.9 GP t 0.4 8P t 0.5

11.6” i 0.5

11.4” +. 0.5

9.7h k 0.4

9.3h t 0.6

51.P f 9.1 60.8" It 1.9 58.9" + 1.8 49.P f 2.2 58.0" r 2.1

15 16 18

Within test type, mean scores not followed by a common letter are significantly different (P
n

Fry

Food and Drug Administration United States Department of Agriculture National Institutes of Health

16 14

11.9" 2 0.3 9.9h + 0.4 7.6' 2 0.6

14

GRL*

Raygor GRL*

Flesch

12.1^ to.4 10.lh to.6 7.2' i 0.6

44.7' rt 2.2 57.3h t 2.1 67.6" i: 2.9

Within test type, mean scores not followed by a common letter are significantly different (P < 0.05). * GRL. Grade reading level.

128

J. ~o~lah~te

et al.

i Patient

Exudation

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Table 4 Readability levels of diet and heatth publications from ~mmercial

27 (19%)

123-f34

sources (mean t S.E.M.)

Source

n

Fry GRL*

Raygor GRL*

Flesch

National Dairy Council Ross Laboratories All Others

4 13 36

7.0h It 0.4 10.1” f- 0.4 9.3” 2 0.3

7.0h IO.7 10.2” 2 0.5 8.gah 2 0.4

69.8” 13.7 .55.6bi 1.8 .59Ssb + 1.8

Within test type, mean scores not followed by a common letter are significantly different (P < 0.05). * GRL, Grade reading level.

National Dairy Council, a statistically significant difference (Table 4). Publications from the National Dairy Council ranged from grades 6 to 8 on the Fry and Raygor scales, as compared to grades 8 to 12 for materials from Ross Laboratories. Using the Flesch scale, the ranges were 78 (fairly easy) to 61 (fairly difficult) and 65 (fairly difficult) to 48 (difficult) from National Dairy Council and Ross Laboratories, respectively. These data are similar to those of Vivian and Robertson [21] in which commercial drug education materials had an average readability of about ninth grade. Michielutte et al. [ll], on the other hand, reported a grade level of 10.2 for cancer education materials from private for profit organizations. Fifteen commercial organizations published materials included in the ‘other’ group (Table 1). The mean readability level was not statistically different from either the Ross or the National Dairy Council publications. Readability ranged from grade level 6 to 14 on the Fry and Raygor and from 78 (fairly easy) to 30 (very difficult) on the Flesch analyses. The mean grade reading level of publications from educational sources was 8.6 on the Fry scale and 7.6 on the Raygor scale (Table 1). The average Flesch readability score was 64.2 which rates as plain English. The materials from the University of Wisconsin had lower readability

levels than those from the other two educational ~stitutions. The materials published by the three educational institutions surveyed had the lowest overall mean readability, with those from the University of Wisconsin being significantly lower than pamphlets from Pennsylvania State University or the University of Arkansas, using the Fry and Flesch scores (Table 5). Although Pennsylvania State University publishes many more nutrition education pamphlets, only two met the inclusion criteria for this study; the remainder are designed to be read by children and adolescents. Of the six publications from the University of Wisconsin, three had a readability of less than sixth grade on the Fry and/or Raygor tests (Table 6). The highest level was grade 10. Flesch scores ranged from S4 (easy) to 48 (di~cult). Publications from the University of Arkansas ranged from grade 4 to 13 on the Fry and Raygor tests and from 86 (easy) to 45 (difficult) on the Flesch. 3.3. Comparison

of rn~t~r~~~s by topic

Six of the topic classifications had fewer than five pamphlets assessed and were therefore excluded from the analysis by topic. These topics were kidney disease, osteoporosis, AIDS, lactose intolerance, pulmonary disease, and calcium. Of

Table 5 Readability levels of diet and health publications from educational sources (mean t: S.E.M.) Source

n

Fry GRL*

Raygor GRL*

Flesch

Pennsylvania State University University of Wisconsin Unive~ity of Arkansas

2 6 7

10.0” 2 2.0 6.gb 2 0.7 9.7” + 1.3

9.0” 2 1.0 6.3” 2 0.8 8.3” t 1.1

56.0b ? 7.0 72.3” 2 5.4 59.6b + 5.3

Within test type, mean scores not followed by a common letter are significantly different (P < 0.05). * GRL, Grade reading level.

J. ~5ffahite et nl. I Patient educative and C~~~el~ng 27 (1996) 123-134

the remaining topics, publications on fiber, cancer and aging consistently ranked highest in readability by all three measurements. Pamphlets about fiber (n = 7) had a mean grade reading level of 11.3 on the Fry and 10.6 on the Raygor test, while the Flesh score was 51.0 (fairly difficult). Pamphlets about nutrition and cancer (n = 17) had a mean grade reading level of 10.6 on the Fry and 10.5 on the Raygor test, while the Flesh score was 53.7 (fairly difficult). Many of the publications regarding fiber also fell into the cancer group because of the relationship of a high fiber diet to cancer prevention. Pamphlets about nutrition and aging (n = 6) had a mean grade reading level of 10.3 on the Fry and on the Raygor test, while the Flesch score was 53.8 (fairly difficult ). The readability of cancer publications reported here is slightly lower than that of Meade et al. 1221 who found that American Cancer Society literature had a mean reading level of 11.9 and older information from the National Cancer Institute had reading levels from 11th to 14th grade on five of their patient pamphlets [23]. However, these investigators used the SMOG Readability Formula which consistently predicts readability at somewhat higher levels than either the Fry or Raygor [24], indicating that their results were not different than those reported here. Other ~vestigators assessed 159 pieces of cancer education literature, published by various agencies, to have a mean reading level of 10.4 + 1.9 using the SMOG [7]. Materials with the lowest readability using the Fry and Flesch readability tests were those related to diet and hypertension (n = 7) overweight (n = 18), exercise (n = 5) and diabetes (n = 21), respectively, with diet and hypertension having the lowest reading level. The means for the Fry test for t.hese pamphlets were all less than ninth grade and for the Flesch score greater than 61 (fairly difficult). The two publications which had the lowest readability overall were on diet and hypertension and on nutrition in pregnancy (Table 6). The mean reading level for materials related to diabetes was a grade level of 8.9 on the Fry and 8.6 on the Raygor scales. This is lower than the

129

levels reported by McNeal et al. in a 1984 study of 38 diabetes education publications used in an education program in South Carolina [8]. Doak and Doak [25] found that of 100 publications used in a Virginia hospital, diabetes was among those topics with the lowest readability. The results were different when scores from the Raygor readability test were considered. In this case, the topics with the lowest readability were heart disease, fat, cholesterol, hypertension, and food labels. The grade reading level of publications addressing these topics ranged between 7.9 and 8.4. Materials covering the topics of cholesterol, fat and heart disease were scored between 9.1 and 9.5 on the Fry scale and 60.6 and 59.1 on the Flesch scale which rates between plain English and fairly difficult. These scores are one to two grade levels lower than the average reported by Glanz and Rudd [lo] for cholesterol education materials, but, because they used the SMOG formula, are similar to their data. Merritt et al. [9] also assessed readability of four patient publications related to h~ercholesterole~a, two of which were nutrition education pamphlets. Both were rated at college reading level (grade 14 and 17 + , respectively) according to the Fry formula. One was published by the American Heart Association and one by the National Institutes of Health. Two-thirds of the publications in the present study were written above the ninth grade level. Sixty-eight percent or 142 or the 209 publications scored at ninth grade or above on either the Fry or Raygor scale. Very few publications were written at sixth grade level or below. Eleven percent or 24 of the 209 publications scored at sixth grade or below on either the Fry or Raygor scale. Only two publications were written at the third grade level (Table 6).

Discussion Other studies have reported the readability of patient education publications and hospital forms and, similar to the data reported here, found them to be at a reading level too high for many people. After evaluating the readability of smok-

130

J. Dollahite

Table 6 Low literacy dietary/health

et al. I Patient

and Counseling

123-134

Raygor GRL

Flesch Score

4

82”

6

7l?

7

84”

3

84”

6

12’

I

5

71h

7

6

7oh

7

6

61’

I

6

7gh

7

6

72h

7

6

67’

8

6

65’

6

6

78’

Fry GRL

and Snack

27 (1996)

publications

Title/Publisher Meal

Education

Time

American Dietetic Association Portion

Size

American Dietetic Association Losing

Weight

American Dietetic Association How

to Have

a Healthier

Baby

American Dietetic Association Alcohol

and Diabetes

American Diabetes Association Reading

Food

Labels

American Diabetes Association Eating

Smart

American Cancer Society Every

Woman’s

Guide

to Health

National Dairy Council Extraordinary

Facts About

Beans

American Dry Bean Board Physical

Fimess

and Your

Heart

Channing L. Bete Co. The HeartCare

Guide

Hall-Foushee Productions Cooking

Steps to Lower

Cholesterol

Nabisco Foods Group A Do-it-yourself

Approach

to Lowering

Fat for Life

National Dairy Council A Time

of Change

6

74b

3

88”

7

14h

6

76h

5

84”

6

16b

I

76b

4

86”

6

84”

6

79b

5

82”

US Department of Health and Human Services Blacks

and High

Blood

Pressure

High

Blood

NIHlNHLBI Eat Right:

Lower

Cholesterol

NIHlNHLBI Heart

Owner’s

Guide

NIH/NHLBI Take a Weight

Off

Your

Heart

NIH/NHLBI Turn

on to Exercise

NIHlNHLBI Making

Healthy

Food

Choices

USDA Preparing

Good

Food

University of Arkansas Eating

for

Pleasure

and Health

University of Wisconsin Finding

the Fat in Food

University of Wisconsin How

You Can Eat Less Fat

University of Wisconsin GRL, Grade reading level. a Easy. ’ Fairly easy. ’ Plain English.

.I. Dollahite et al. I Patient Education and Counseling 27 (19%) 123-134

ing education booklets, Meade and Byrd [26], concluded that “there is strong evidence that a disparity exists between reading levels of written health materials and reading skills of target populations.” These findings were also supported by evaluation of publications about coronary heart disease [9,10,27-291, diabetes [8], cancer [11,23], and pharmaceuticals [30]. Vivian and Robertson [21] found the average readability above eighth grade level for patient education materials from public foundations, pharmaceutical manufacturers, hospitals and commercial sources. The readability of hospital case history, legal and information forms ranged from eighth grade to college level [31,32]. In the present study, the range was third grade to college level, but mean reading levels were eighth grade or higher. A number of studies have compared the reading level of patient education materials with the target audiences’ literacy skills [8,28,32-341. Data have consistently indicated that available materials are well above the reading level of a significant portion of the audience. Powers [32] found that over 50% of the patients admitted to a hospital emergency room had reading ability below eighth grade. A significant mismatch was found between comprehension levels of diabetic clients and reading materials used in a diabetes education program [8]. Boyd and Feldman [28] found the literacy demands placed on cardiac patients exceeded their reading and comprehension level. Streiff [33] found that over half of clients in an ambulatory care setting could not read at levels to comprehend patient education materials. Other research found patients with an average reading level of 5.4-6.8 in community and university clinics and 10.8 in a private clinic while most of the tested patient education material used in these settings required a reading level above the 11th grade [34]. There are limitations to readability formulas. Print literacy is best defined as a meaning-making process. It involves more than the ability to read words in text. “Literacy...invokes a generative, active intellect creating and interacting with reality” [35, p. 31. Readability formulas do not account for the complexity of ideas, the creative

131

thinking patterns of the reader and the reality of adult experiences, including interest, motivation, and prior knowledge [24,36,37]. In addition, the style of presentation cannot be assessed by readability formulas. This includes the appropriateness of the style for the learning objectives and what Allensworth and Luther term ‘legibility’ which includes page layout, print type and size, color, and use of illustrations [24]. While readability formulas rate short words on a lower reading level, some short words are more abstract and difficult to understand than polysyllabic words. The readability scores are inflated in some areas by specialized vocabulary. Instruction in the meaning of technical terms will moderate this vocabulary burden. Once these technical words are learned, they need not be considered difficult [36,37]. In spite of these limitations, readability formulas provide valid, objective, and useful tools for screening educational materials for use with a target audience known in general, rather than specific terms, and for choosing between materials of different reading difficulty [24,36,38]. Learning will not occur from written material, no matter how well presented, if the language is not understandable to the reader (Table 7).

5. Conclusions Many organizations publish dietary information related to health. This information is distributed through health clinics, dietitians, nurses, professional organizations and educational institutions. The readability of this information varies widely regardless of the intended audience. Materials published by professional health organizations, such as the American Dietetic Association and American Institute for Cancer Research were at a high overall readability level. These publications contained text with many technical terms and extensive explanations, factors which increased the reading difficulty. When looked at as a whole, government publications also had a high readability level. However, when materials originally written for the magazine, FDA Consumer, were removed from the analysis, the

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Table 7 Implications for practice 1. Individuals with limited reading skills need sources of information written on their level to help them understand the important relationships between diet and disease. 2. There are few nutrition education materials available for adults reading at sixth grade level or below. The majority of publications are written at ninth grade or above. 3. There is no reliable source of nutrition education materials for low literacy adults. 4. Publications addressing the relationship between diet and heart disease and diet and diabetes are more hkely to be at a low reading level. Publications addressing diet and cancer as well as aging are often written at a high reading level. 5. Health educators must screen materials for readability and assess the reading level of clients in order to assure that a lack of reading ability does not interfere with the educational process and with the clients’ ability to take personal control of health decisions. 6. Information regarding reading level and method used to assess reading level should be available for nutrition education materials. This would allow educators to choose materials appropriate for a client. 7. Nutrition educators should lead the way in the development of materials which are appropriate for low literacy adults.

mean for the government publications was lowered, almost to the level of materials from educational institutions, which had the lowest overall readability. Materials published by commercial organizations had a wide range of readability. The brochures reviewed here do not constitute a comprehensive review of all nutrition education materials available. This is, however, the most extensive look to date at what is available from a variety of sources and on a variety of diet and health topics. While many of the publications reviewed for this study can be easily read and understood by many Americans, these data indicate that there are few nutrition publications, available from national organizations, for the millions of Americans with limited literacy skills. Individuals with limited reading skills need sources of information written on their level to help them understand the important relationships between diet and disease. Several manuals are now available to assist professionals in designing appropriate materials [39,40]. The work of other investigators supports the idea that simplifying nutrition education materials increases the level of comprehension 1411. Audio and audio-visual materials can also facilitate learning, but written materials along with oral instruction has been shown to be the most effective for patient education 1421. In collecting the pamphlets for this study,

some materials were received which were developed for the populations of specific geographic areas, such as state Women, Infants, and Children Programs. These appear to be more frequently written for clients with low reading skills. A study of these materials to verify this observation would be helpful to identify additional sources of low literacy materials for nutrition educators. Low literacy publications would allow patients with limited reading abilities to more easily take personal control of health decisions they must make in everyday life. Able readers need interesting materials that vary in the level of difficulty. However, less literate adults need publications with information presented at the appropriate reading level so that it is most understandable to them. Readability formulas should be used to determine the difficulty of publications so that the nutrition educator can screen materials and match them appropriately with the reading ability of each client. Nutrition educators should take a leadership role in developing a broader array of materials appropriate for low literacy adults. Familiar, simple words should be used whenever appropriate and educational programs should introduce clients to terminology that is needed, but which may not be comprehensible, thus enhancing their understanding of the written materials [43].

J. Dollahite

et al. I Patient

Education

Acknowledgements

The authors gratefully acknowledge the assistance of Kate Allen, RD, and Reba Thompson, Department of Home Economics, University of Arkansas for their assistance.

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