For readability, assess more than grade level

Sift information for essential facts

Producing written materials for a low-literacy audience is an art, says Deborah Yoho, EDS, CEO of the Greater Columbia (SC) Literacy Council. There are many factors that contribute to easy-to-read material in addition to the standard of writing at a sixth-grade-or-below reading level.

For example, position the most important information in the top right-hand corner of the pamphlet where people first look. Also, the length of the sentences and the way the information is organized makes a difference in reading ease.

One of the toughest techniques to master is sifting the information for only the most essential facts. "One of the biggest problems with a nonreader or low literacy reader is that they are not going to absorb nearly the amount of information you want them to have, so you must figure out what is the most important information they need," explains Yoho.

Rely on more than syllables

It’s not a good idea to solely rely on readability assessment tools when creating easy-to-read materials. "Most readability assessment tools look at only two variables out of about 100 that affect how difficult something is to read," says Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting in Natick, MA. Those two variables are sentence length and the number of syllables in a word. They don’t evaluate other factors that contribute to readability, such as organization, layout, tone, and content. "Write so the information flows smoothly, and design visually appealing material," advises Osborne.

There are readability assessment tools available on word processing programs, such as Flesch-Kincaid and Flesch Reading Ease, and formulas that can be calculated by hand, such as the Simple Measure of Gobbledygook (SMOG) readability formula. If the formulas on computer programs are used, patient education managers should note that Flesch-Kincaid scores two to three grade levels higher than any other readability formula.

Flesch Reading Ease provides a score between zero and 100, and the higher the number, the easier the material is to read. Those factors are important for people to know when evaluating material in order to come up with an accurate reading level, explains Audrey Riffenburgh, MA, president of Riffenburgh & Associates, an Albuquerque, NM-based business that specializes in health literacy and plain language communication.

Equally important to know is how to clean up a manuscript before evaluating it with a computerized readability formula. Certain punctuation and headings must be removed from the copy in order to get an accurate reading level, a technique Riffenburgh teaches in workshops. (To learn how the SMOG readability formula works, see p. 113. For information on computerized readability programs, see editor’s note at the end of this article.)

Finding tools to assess the readability level of foreign language material is much more difficult. "I recommend you work to create an easy-to-read version in English, and then have a translation done that goes directly from the easy-to-read English into the other language. Ideally, you have that translation done by someone who has been trained in how to maintain the easy to read nature of the material," says Riffenburgh. It’s a good idea to pretest the material with representatives from the patient group you are targeting, as well.

[Editor’s note: Readability Calculations is a software package that contains nine readability formulas for assessing written materials. Formulas include: Fry Graph, Dale-Chall, Flesch Reading Ease, Flesch Grade Level, FORCAST, FOG, SMOG, Powers-Somner-Kearl, and Spache. The cost is $49.95 plus $6 shipping and handling. To order contact: Micro Power & Light Co., 8814 Sanshire Ave., Dallas, TX 75231. Telephone: (214) 553-0105. Fax: (214) 341-9118. Web site:]