JADA Continuing Education
READABILITY OF PUBLISHED DENTAL EDUCATIONAL MATERIALS
ROGER E. ALEXANDER, D.D.S.
 |
ABSTRACT
|
|---|
Background. A growing number of adult Americans are functionally illiterate. These people often do not understand educational documents written by health care professionals, especially if English is the reader’s second language. This problem has received little attention in dentistry.
Methods. In this study, the author selected a sampling of 24 patient educational documents from several dental resources and reviewed them for readability, using a computer-based program that assigns a reading level of understanding on the basis of a standard formula known as the Flesch-Kincaid Formula. The author also conducted a subjective review of each document to identify seemingly unnecessary professional jargon and words that were unlikely to be understood by many readers.
Results. Reading levels varied from third to 23rd grade (according to the Flesch-Kincaid Formula), and 41.7 percent of the materials were written at greater than the recommended level for understanding by most patients (mean level: seventh to ninth grade). Many dental specialty publications were written at or near college levels. Many documents had multiple grammatical errors. Seventy-nine words in the reviewed documents were considered to be jargon or potentially obscure to many lay readers.
Conclusions. More attention needs to be focused on the preparation of written educational materials for dental patients, to make the documents more understandable to the average patient. Guidelines for acceptable writing are available in the medical, nursing and pharmaceutical literature.
Educating dental patients on the importance of good dentistry and dental health (by providing them with the details, advantages and complications of various procedures and conditions) and on various practice management issues always has been an essential part of health care practice. Recently, there has even been considerable debate about the relative merits of mass public-education campaigns in the form of advertisements in magazines and newspapers funded by dentists. Rarely have discussions about, or preparation of, public educational literature included any consideration of how well these written items are understood by the audiences they are intended to reach.
It has been estimated that perhaps as many as 20 percent of American adults have difficulty in reading, which impairs their ability to understand written information.1–3 A recent article addressed the issue of preparing dental postoperative instructions that are understandable to patients who can read at a seventh- to ninth-grade level, which accepted population sample studies have ascertained is the approximate national mean literacy level.4 Davis and colleagues5 cited several studies showing that an estimated 13 percent of the population read at less than a fourth-grade level, and 55 percent of the population reportedly lack the reading skills necessary to function normally as adults in our society. Although these figures are merely estimates, they have been found to be remarkably consistent.
Patients who are functionally illiterate cannot be detected without elaborate testing. They cannot be reliably identified by the highest grade level achieved in school, ethnicity, class, attire, speech, appearance or occupation.2,6,7 In some cases, even their families are unaware of their impairment.7,8 These patients tend to ignore written information and to ask fewer questions, but, if asked, they will describe themselves as being able to read well. Adding to this problem is the increasing diversity of the population of the United States. Many patients are illiterate in both their native language and English, their adopted secondary language.2,9
The pharmaceutical, nursing and medical professions have been aware for some time that functional literacy—that is, a person’s ability to read and understand written materials—has been declining in the United States, and numerous articles have appeared in their literature that address that issue. Only one such article has appeared in the current dental literature on the subject of patients’ understanding of written materials.4 No article has examined a sampling of dental educational materials to ascertain whether they are appropriate for the targeted audience of patients.
Powers1 reviewed 280 forms used for medical patient education and instruction in a hospital emergency department and found that only 5 percent of the brochures and sheets fell within the average patient’s seventh-to ninth-grade level of understanding.5,6 The majority of the documents reviewed by Powers were written at a 10th- to 11th-grade level, well beyond the understanding of most of the patients for whom they were intended.
Prompted by my awareness of the poorly written educational materials found in studies of medical materials, I felt a review of a sampling of commonly available dental educational materials would be appropriate, to ascertain their readability by the patients they were intended to educate. In this study, I used a smaller-scale but similar approach to that of Powers5 in reviewing 24 arbitrarily selected dental pamphlets, brochures, forms and a published "patient letter." These items were prepared by various local and national health care organizations, dental specialty groups and federal government departments, or were published in the professional dental literature.
The pharmaceutical, nursing and medical professions have been aware for some time that functional literacy has been declining in the United States.
Several published formulas, dating back as early as 1923, are used to measure readability. One of the more respected analysis tools is a variation of a formula first proposed by Flesch in the 1940s, now called the Flesch-Kincaid Formula.8,10 This simple formula, and other similar formulas, basically is derived from analysis of two characteristics in written documents: average number of syllables per word and average number of words per sentence. The Flesch-Kincaid Formula has been shown to be reliable and is used by many newspapers and magazines to verify readability. There are several computer software programs that will perform this analysis, including the one used in analyzing documents for this study (cited below in the "Methods and Materials" section).
In addition to words with fewer than two syllables and short sentences (eight to 10 words per sentence is optimal), other features of well-written patient educational materials are as follows: 4
- – use of a mixture of upper-case- and lowercase letters;
- – use of bright colors;
- – use of simple typefaces (sanserif) without italics or abbreviations;
- – use of highlighting, boxes, arrows and bullets for emphasis;
- – use of simple and culturally sensitive graphics;
- – avoidance of technical jargon;
- – advantageous use of white space.
|
METHODS AND MATERIALS
|
|---|
In all, I reviewed 23 brochures and pamphlets, all of which were available in various dental-school patient waiting areas: nine (37.5 percent) were publications of the American Dental Association; four (16.7 percent) of the American Association of Oral and Maxillofacial Surgeons, or AAOMS; two (8.3 percent) of the U.S. Department of Health and Human Services’ Public Health Service; one (4.2 percent) each of the American Red Cross, the American Cancer Society, the Columbus (Ohio) Health Department, the American Association of Endodontists, and the American Academy of Periodontology; and three (12.5 percent) of manufacturers of dental devices or therapeutics. Additionally, one document (4.2 percent) was a published form letter recommended for use in informing patients about infection control.11 A list of these reviewed publications appears in the table
.
I reviewed the information contained in each piece for reading level using a computer program called Grammarian (Version 1.01 for Apple Macintosh computers, Casady & Green Inc.). The computer program assigned a Flesch-Kincaid reading difficulty level to the contents of each document. As I am unaware of any study that objectively identifies medical or dental terminology that patients do not readily understand, I subjectively screened the content of each document for words and terms that appeared to be "jargon" and potentially not understandable by a substantial percentage of patients who read the material. If the meaning of the medical term was explained in the document, then I did not consider it to be a problem word. The box, "Professional Jargon and Difficult Terminology Found in Published Patient Educational Materials," identifies examples of words that may be inappropriate for use in such documents.
|
RESULTS
|
|---|
The content of the group of patient educational documents was highly variable, ranging from a Flesch-Kincaid reading level of third grade to 13th grade, with portions of one document reading at a 23rd-grade level. Using the median reading level of eighth grade (from the mean reading level of seventh to ninth grade as recommended in the medical literature), I found that 10 of the 24 documents (41.7 percent) were written at high-school levels, which are higher than the levels of understanding of the average patient, and one was written at college level. The table
summarizes the Flesch-Kincaid reading level of each reviewed document and itemizes the percentage of the average American readers who would most likely be able to read and understand the contents.
|
DISCUSSION
|
|---|
The pharmacology and nursing professions have long recognized the disparity between the writings of health care professionals and the reading abilities of the patient population, and they have actively promoted more understandable patient educational materials. This dichotomy still exists in the writings of the medical profession, however, and it may extend into dentistry as well.
If this relatively small sample of documents is representative of the patient educational materials generally available in dentistry, then the dental profession is doing a more commendable job of communicating with patients than is the medical profession. However, there is room for improvement. Roughly one-half of our patients may not understand the educational material that is being prepared to inform them. Even more disappointing is the excessive use of medical and dental jargon—undefined terminology that creeps into the writing and is unlikely to be understood unless the meanings are defined within the document. Some patients do not even understand the meaning of such common terms as "three-fourths," "consume," "discard," "orally," "refrain" and "teaspoon."6 It is reasonable to assume that the average patient is unlikely to understand terminology such as "fermentable carbohydrates," "ergonomics," "hemorrhage," "esthetics," "allograft" and other similar words. I found 79 instances of jargon and other undefined, nonmedical "megawords" in the reviewed documents, which are itemized in the box ("Professional Jargon and Difficult Terminology Found in Published Patient Educational Materials"). Although easily understood by most educated professionals, these words generally are not in the vocabulary of many patients.
Roughly one-half of our patients may not understand the educational material that is being prepared to inform them.
The computer program used to establish readability of the text also evaluates writing for grammatical errors, such as misplaced or absent commas, dangling participles and unacceptable phraseology. The program identified a substantial number of such basic writing errors in the documents I reviewed, which is distressing considering that the documents presumably were prepared by professional writers and are intended to represent the dental profession favorably. While most patients are likely to be unaware of these writing errors, other professionals will take note of them. In this study, I made no attempt to quantify or classify these grammatical errors, because it was an incidental finding and not pertinent to the primary objective of this study.
The ADA, for the most part, has prepared appropriate educational brochures and pamphlets. Its nine reviewed documents read at a Flesch-Kincaid level of sixth to 10th grade and would be understood by 51 to 72 percent of patients. As noted in the table, dental surgical specialties seem to be prone to excessive writing. The four reviewed documents prepared by the AAOMS, for example, were written at eighth- through 13th-grade levels—and one group of paragraphs was written at a 23rd-grade level, making it understandable to less than 1 percent of patients who read it. Likewise, documents prepared by implant manufacturers, endodontists and the American Red Cross would be understandable to only roughly one-half of the patients who read them.
Limitations and recommendations.
This study examined only a limited sampling of the hundreds of brochures, pamphlets, booklets and advisory sheets that dentists use to increase patients’ awareness of oral health, explain details of procedures and services, and market practice philosophies. Although I feel it is an accurate representation of the dental educational literature, I would need a much larger sample to say with statistical certainty that the problem is widespread. Until further data are available, however, I believe it is reasonable to assume that many other documents dispensed in dental practices and available to dentists from many groups and companies suffer from the same tendencies as the group selected for review in this study.
|
CONCLUSIONS
|
|---|
Numerous booklets, brochures, forms and other documents have been created to educate the dental patient population, and these are widely distributed in dental offices and other venues. Unfortunately, many of these documents are written at reading levels that are higher than the comprehension level of the target audience. Many are filled with grammatical errors, and many have excessive use of difficult words and professional jargon that compromise their understanding. Future documents should be written below a ninth-grade level (according to the Flesch-Kincaid Formula).
More and more companies; local, state and national organizations; governmental agencies and departments; and individual practitioners are generating patient educational materials. Debates rage over the potential value of mass public-education campaigns in magazines and newspapers. Therefore, it is increasingly important that the writings generated by dentists are closely scrutinized to ensure that they will be understandable to the people dentists are trying to reach. It is apparent that many companies and organizations need to review their educational documents, using the Flesch-Kincaid Formula or a similar readability formula, and screen their educational and scientific writing for burdensome phrases and incomprehensible jargon. If dentistry wants its educational messages to reach the average patient, then its writings need to be structured at the patient’s level of understanding, not the dentist’s.
|
FOOTNOTES
|
|---|
Dr. Alexander is an associate professor, Baylor College of Dentistry (an institution of The Texas A&M University System Health Sciences Center), Department of Oral & Maxillofacial Surgery & Pharmacology, P.O. Box 660677, Dallas, Texas 75266-0677, e-mail "ralexander{at}tambcd.edu". Address reprint requests to Dr. Alexander.
|
REFERENCES
|
|---|
- Powers RD. Emergency department patient literacy and the readability of patient-directed materials. Ann Emerg Med 1988;17:124–6.[Medline]
- Miles S, Davis T. Patients who can’t read: implications for the health care system. JAMA 1995;274:1719–20.[Medline]
- Levoy B. Communicating with low-literacy patients. Dent Econ 1995;85:14.
- Alexander RE. Patient understanding of postsurgical instruction forms. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87:153–8.[Medline]
- Davis TC, Mayeaux EJ, Fredrickson D, Bocchini JA, Jackson RH, Murphy PW. Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics 1994;93:460–8.[Abstract/Free Full Text]
- Mayeaux EJ, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician 1996; 53:205–11.[Medline]
- Jackson RH, Davis TC, Bairnsfather LE, George RB, Crouch MA, Gault H. Patient reading ability: an overlooked problem in health care. South Med J 1991;84:1172–5.[Medline]
- Baker GC, Newton DE, Bergstresser PR. Increased readability improves the comprehension of written information for patients with skin disease. J Am Acad Dermatol 1988;19:1135–41.[Medline]
- Shaw J, Hemming MP, Hobson JD, Nieman P, Naismith NW. Comprehension of therapy by non-English speaking hospital patients. Med J Aust 1977;2:423–7.[Medline]
- Flesch R. A new readability yardstick. J Appl Psychol 1948;32:221–33.[Medline]
- Molinari JA. Getting your infection-control message to your patients. Compend Contin Educ Dent 1992;13:1070.
This article has been cited by other articles:
|
|
|
|
 
S. Badarudeen and S. Sabharwal
Readability of Patient Education Materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America Web Sites
J. Bone Joint Surg. Am.,
January 1, 2008;
90(1):
199 - 204.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
METHODS AND MATERIALS
