Fyi,
Bob Pyke Jr
JAMA's Patient Page fails readability test

JAMA--Journal of the American Medical Association-- recently introduced
The Patient Page to increase doctor-patient communication on topics
important to health. JAMA says its weekly feature is "designed specifically for
America's patients" and encourages doctors to copy and share the Page with
patients. The AMA makes The Patient Page accessible to the public online.

This is a good idea. Printed material can provide an opening for discussion of
hard-to-talk-about topics and serve as a script for practitioners. Patients can
take the same material home as a reminder and to share with caregivers. We
wondered if The Patient Page would be a good resource for prenatal care
providers, so we decided to evaluate the materials.

We chose alcohol as a test topic because it comes up first on the public online
menu and it addresses a key message in prenatal education. We started the
review by checking the readability level of the text. Readability is only one of
many factors known to affect comprehension, but it is a deal breaker. If the
materials exceed the literacy skills of intended readers, handing it out becomes
an expensive gesture. We did a series of readability tests on the Patient Page
entitled Do You Have a Drinking Problem..

Readability Testing Method

We analyzed the full text in three segments using Readability Calculations
software from Micro Power & Light Co in Dallas, TX. We applied the
following formulas: Flesch Grade Level, Fog, SMOG, and the Extended Fry
Scale. Each of these readability formulas produces a reasonable estimate
--within a grade level-- of the educational achievement needed to decipher the
words. Table 1 summarizes the readability scores.

Results

The Flesch formula may be most appropriate to this case since it is designed to
evaluate adult materials and takes into account the fact that conversational
writing is easier to read. The mean Flesch score for the three sections of the
Patient Page is 12.47. This score shows that the information is readable by
those with the reading skills of a college freshman. Since most Americans read
three to five grades below their educational achievement, the Flesch formula
suggests this information is suitable for the average college graduate.

The mean SMOG score for this Patient Page is 13.37. SMOG stands for
simplified measure of gobbledygook. It predicts 90 to 100% comprehension.
Like the Flesch formula, SMOG predicts that college level reading skill is
required to understand the information.

The Fog formula is used primarily in education. In accord with the other scales,
Fog predicts that The Patient Page requires a 15th grade reading level.

The Extended Fry scale is the most widely used readability scale. It is valid for
reading grade levels 1 through 17. In the JAMA alcohol information, two
sections are off the Fry scale and the third section rates a 17th grade reading
level.

Conclusion

As expected, the readability formulas produce slightly different but reasonably
consistent results. You need a college education to understand the Patient
Page on alcohol. Practitioners who use this Page as a model of information
giving are likely to experience unsatisfying patient relations and high levels of
non- compliance.

To improve this Patient Page:

     Add periods to reduce sentence length to 10-15 words.
     Use plain English. Say drugs instead of prescription medication.
     Delete sentences that only reinforce the physician's dominant position as
     keeper of knowledge and power, e.g. A study in the April 14, 1999
     issue of JAMA evaluated research studies from 1966 to the present
     to determine what medications are effective in treating adults with
     alcohol dependence.
     Apply patient education and behavior change theory to increase the
     likely influence of the information on patients' behavior and health.

Flesch Reading Ease Score for this article:
39.5, grade 11.7, Difficult

Reference:

Census Bureau - Education Statistics
http://www.census.gov/statab/www/part2.html#education

Doak, C.; Doak, L.; Root, J. (1996) Teaching Patients with Low Literacy
Skills, Second Edition, Philadelphia: Lippincott. 1996

Shapiro, MC; Najiman, A; Change, J; Keeping, D; Morrison, J; Western, JS.
(1983) Information control and the exercise of power in the obstetrical
encounter. Soc Sci Med (17), 39-146. Abstract
http://www.prenataled.com/hpbib2.htm (#6.)

Effectiveness of Written Health Information ~Summary Literature Review
http://www.prenataled.com/bibeff.htm

Table 1:
Readability ratings of The Patient Page
"Do You Have a Drinking Problem?" (JAMA
4/99)

 Scale
                 *Score
 Flesch Grade Level
                 12.47
 SMOG
                 13.37
 Fog
                 15.4
 Extended Fry
                 17+


*Readability scores are expressed as school grades indicating the skill level needed to
read the material. For example 12.47 = reading skill of the average college freshman.




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