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How readable are orthodontic patient information leaflets?

Liverpool University Dental Hospital and School of Dentistry, UK

Address for correspondence: J. E. Harrison, Orthodontic Department, Liverpool University Dental Hospital and School of Dentistry, Pembroke Place, Liverpool L3 5PS, UK. Email: Jayne.Harrison{at}rlbuh.nhs.uk

Received November 27, 2003; accepted April 8, 2004

	Abstract

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
Objective: To assess the readability of published orthodontic patient information leaflets (PILs) and their eligibility for the Plain English Campaign’s Crystal Mark.

Design: A retrospective, observational study.

Setting: PILs available from professional organizations and commercial companies.

Materials and methods: Twenty-six orthodontic PILs were assessed. The entire text of each leaflet was reproduced in Microsoft Word, 2000. Readability statistics were obtained via the ‘Tools’ menu. The design elements of each leaflet were assessed. The leaflets were sent to the Plain English Campaign for assessment of their eligibility for the Crystal Mark.

Outcome measures: Leaflet and sentence length, passive percentage, Flesch Reading Ease score, Flesch Kincaid Grade Level, design percentage and eligibility for the Plain English Campaign’s Crystal Mark.

Results: Overall, nearly half of the leaflets (42.3%) were rated as ‘fairly difficult’ or ‘difficult’ to read. However, the BOS PILs were significantly better than the AAO leaflets in all but one outcome with the BOS leaflets being rated as ‘standard’ or ‘fairly easy’ to read, meaning that 70–80% of the UK population would be able to understand them. None of the PILs were eligible for the Plain English Campaign’s Crystal Mark.

Conclusions: The orthodontic PILs assessed were difficult to read and none were eligible for the Plain English Campaign’s Crystal Mark. However, the BOS leaflets were much easier to read and better designed than those produced by the AAO making them a useful tool to improve patients’ understanding of different treatment options and allowing them to be used in the informed consent process.

Key words: Readability, orthodontic, patient information leaflets (PILs), Crystal Mark

	Introduction

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
Communication is a key process in health care provision. It not only provides the foundation for diagnosis and treatment, but is also closely associated with therapeutic outcomes.¹ Patients can be left feeling unhappy with the amount of information they receive and the information that is given is often misunderstood or forgotten.²

Evidence suggests that a patient’s overall satisfaction with a clinician is increased if s/he is given, and understands, information and clinical advice.³ Nanda and Kierl⁴ highlighted this by stating that successful orthodontic treatment depended not only on the knowledge and skills of the clinician, but also on the cooperation of the patient and parents. A high proportion of parents of children undergoing orthodontic treatment, have been found to be unaware of its potential negative outcomes e.g. relapse and caries.⁵

Patients tend to forget or misunderstand much of what is discussed during a consultation.⁶ In general, people only retain about 20% of what they hear, but this may increase by up to 50% if there is additional visual or written input.⁷ George et al.⁸ demonstrated that patients favoured written information and that patients who were given leaflets were more satisfied with their treatment as a whole.

Leaflets are cheap to produce and can save patients the embarrassment of asking questions directly of a professional.⁹ They can be used to reinforce what has been discussed¹⁰ and can be referred to by patients away from the stressful environment of the consultation room.¹¹ Weinman¹² confirms the desire, use and value of leaflets by patients, showing that 75% of patients wanted written information and that 80% read the leaflets. Disappointingly though, the design of health information leaflets is poor.^13,14

In the interaction of the 2 elements, the design elements enhance the readability of the primary structural elements.^15,16,17 Outside factors, such as stress, may also influence patients learning.¹⁸

Readability formulae assess the structural elements of the text and are designed to measure the reading difficulty. There are over 50 published readability formulae³ that produce a score or number that indicates how readable that piece of text is. Most are based on the premise that long words and/or sentences make text harder to understand.¹⁹

The reading abilities vary widely across the population so it is important that information is pitched at a suitable level for it to be understood by the maximum number of patients.²⁰ The Adult Literacy and Basic Skills Unit²¹ found 1 in 5 of the UK population is functionally illiterate. In the USA, the average reading level is 8th grade (around 14 years of age), with 1 in 5 adults reading at the 5th grade level (around 11 years old) or below.²² Many researchers have found that PILs and information on web pages tend to be written at too high a level for the general public.^20,23–27 However, despite an improvement in the readability of leaflets recently, the aim of having them written at the level of 6th grade (around 12 years old) has not yet been achieved.²⁸

No assessment of the readability of orthodontic PILs has been conducted; therefore, this study was designed to address this issue.

	Aims

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
The aim of this study was to assess the readability of published orthodontic patient information leaflets and their eligibility for the Plain English Campaign’s Crystal Mark.

	Objectives

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
The objectives of this study were to:

• assess the readability of 26 published orthodontic PILs using the Flesch Reading Ease and Flesch–Kincaid Grade Level tests;²⁹
  
• compare the assessed readability of each leaflet with the percentage of the UK population who would understand it;
  
• test for difference in readability between the leaflets published by the American Association of Orthodontists (AAO) and British Orthodontic Society (BOS);
  
• carry out the ‘sentence length’ and ‘passive percentage’ tests on each leaflet and compare the results with recommended levels;
  
• assess the design elements of each leaflet;
  
• determine the best and worst performing leaflets overall;
  
• establish which leaflets would be eligible for the Plain English Campaign’s Crystal Mark.³⁰
  

	Methods

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
Twenty-six orthodontic PILs were obtained from professional organizations and commercial companies (see Table 1).

Reading statistics
The following reading statistics for each leaflet were obtained via the Tools menu:

• Flesch Reading Ease score (see Appendix 1);
  
• Flesch-Kincaid Grade level, (see Appendix 1);
  
• mean number of words per sentence (sentence length);
  
• number of passive sentences then expressed as a percentage of the whole text;
  
• total number of words;
  
• mean number of words per sentence.
  

Design elements
The design elements of each leaflet were assessed using a 20-item checklist compiled from guidelines from Coey,³¹ the National Institute for the Blind³² and the Centre for Health Information Quality.³³ Each leaflet was given a percentage score (design percentage) expressing the number of criteria that were satisfied (see Appendix 2). A record was also made of the number of leaflets satisfying each criterion.

Plain English Campaign Crystal Mark
The leaflets were sent to the Plain English Campaign (www.plainenglish.co.uk/crystalmark.html) for assessment of their eligibility for the Crystal Mark. The initial assessment was free and included looked for:

• a good average sentence length (about 15–20 words);
  
• plenty of ‘active’ verbs (instead of ‘passive’ ones);
  
• everyday English;
  
• words like ‘we’ and ‘you’ instead of ‘the insured’, ‘the applicant’, ‘the society’ and so on;
  
• conciseness;
  
• clear, helpful headings with consistent and suitable ways of making them stand out from the text;
  
• a good type size and clear typeface;
  
• a reasonably short average line length;
  
• plenty of answer space and a logical flow (on forms).
  

Statistical analysis
The mean score and standard deviation, of each leaflet, for each reading statistic were calculated. The weighted mean difference (WMD), with associated 95% confidence intervals (95% CI) and p values, were used to assess differences in the mean scores of the AAO and BOS leaflets. The scores for each group of leaflets (by publisher) were ranked for each test. The overall score of each group of leaflets was then ranked to give the best and worst performing leaflets.

	Results

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
The title of each leaflet evaluated, along with its publishing organization, publication date and the identification code are shown in Table 1. Only half (13/26, 50%) of the leaflets had a publication date printed on them. The mean and standard deviations for each test, by leaflet group, are shown in Table 2.

Sentence length
The mean number of words per sentence for all leaflets was 14.3 (SD=1.5). Again, there was a highly statistically significant difference (p<0.00001) between the mean number of words per sentence in the AAO and BOS leaflets, with the AAO leaflets having more words per sentence [WMD (95% CI)=2.93 (2.50, 3.36)].

All of the leaflets examined fell within the range of the sentence length recommended by the Plain English Campaign, i.e. 15–20 words. However, the PILs from the BOS rank best with the shortest sentences above the AAO leaflets, which were ranked in 5th place (see Table 4). The worst performing leaflet was that from Stafford Miller.

This was the only test where PILs from the AAO performed better than those from the BOS. All leaflets were rated as ‘excellent’ or ‘good’ in terms of clarity (see Appendix 2). The two best leaflets were commercial publications from Oral B and Stafford Miller. The worst performing leaflets on this test were those from the BOS.

Flesch Reading Ease (FRE)
The mean FRE score for all leaflets was 58.9 (SD=13.3). There was a highly statistically significant difference (p<0.00001) between the mean FRE scores of the AAO and BOS leaflets, with the BOS leaflets having a higher score [WMD (95% CI)=26.88 (22.31, 31.45)], suggesting that they are easier to read.

Flesch Kincaid Grade Level (FKGL)
The mean FKGL for all leaflets was 8.5 (SD=2.1). There was a statistically significant difference (p=0.00001) between the mean FKGL of the AAO and BOS leaflets, with the BOS leaflets having a lower FKGL [WMD (95% CI)=4.31 (3.65, 4.97)], again suggesting that the BOS leaflets are easier to read.

Reading difficulty
Overall, the leaflets ranged from being ‘fairly easy’ to ‘fairly difficult’ to read, with just half of them being ‘fairly difficult’ or ‘difficult’ to read, meaning that less than 40% of the UK population would understand them (Table 5a,b).

Design percentage
All leaflets scored highly on the design element checklist, but only half (10/20) of the criteria were satisfied by all leaflets (Table 6). The 3 criteria that were least frequently satisfied were:

• using a sans serif type face,
  
• indenting the first line of each paragraph;
  
• not interrupting the flow of the text with pictures.
  

Again, there was a statistically significant difference between PILs from the AAO and BOS with the leaflets from the BOS having a better design [WMD –3.30 (95% CI –4.93, –1.67)]. The leaflets from the BOS were in a triple-folded A4 format, whereas those from the AAO were small booklets of similar size that were not written or designed to be browsed through.

Plain English Campaign’s Crystal Mark
Feedback from the Plain English Campaign revealed that none of the 26 PILs were eligible for the Crystal Mark.

Overall findings
There were significant differences between the PILs published by the AAO and BOS in all assessments made. The BOS PILs were easier to read and better designed than those produced by the AAO and outperformed them in all but one assessment i.e. the passive percentage test. PILs from the BOS were ranked in joint second place overall (with Cyber Sign) above those from the AAO that were ranked in sixth place.

	Discussion

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
Implications of results
Nearly all of the leaflets (42.3%) were rated as ‘fairly difficult’ or ‘difficult’. This means that an IQ of 104+ would be required to understand many of the leaflets and that only 24–40% of the UK population would be able read them. This suggests that the majority of orthodontic PILs examined were written at too high a level to be understood by the average patient. However, all the BOS leaflets were rated as ‘standard’ or ‘fairly easy’ to read meaning that 70–80% of the UK population would be able to understand them.

The length of the leaflets varied considerably. Although length, per se, does not affect reading ease the longer leaflets may be off-putting, meaning that fewer patients and/or parents would read them. This would then make them less effective as an information tool.

Limitations of study methods
Readability formulae should only be used as a guide for assessing reading difficulty of a text³⁴ as they do not take into account other factors that can influence the comprehension of a text, e.g. the use of active and passive verbs, the way the information is organized and looks on the page, and the reader’s motivation and level of prior knowledge.³⁵ Blinkhorn and Verity³⁶ pointed out that dentistry has evolved a professional vocabulary that may be incomprehensible to the layman and that readability formulae may therefore under-estimate the difficulty of a text. Interestingly, they found that all 14 year olds studied could pronounce and understand the word ‘orthodontics’, but only 14% knew the meaning of the word ‘appliance’, which was used widely in the 26 PILs examined in this study. The term ‘brace’ could easily be substituted and may be more easily understood.

The rejection of all 26 PILs by the Plain English Campaign highlights the problem with readability tests in that they do not guarantee the readability of a leaflet.

Comparison with other studies
Our study shows that a similarly high percentage of the AAO PILs were written at too high a level compared with other studies but that the BOS leaflets were far more readable than most PILs (see Table 7). Interestingly, despite the need for specialized language, the BOS PILs were easier to read than general dental practice leaflets in the UK²⁴ and websites seem to be written at a level that is easier to read than PILs.²⁰ One of the design criteria assessed was the Royal National Institute for the Blind’s recommended 12-point minimum font size,³² which was satisfied by all of the BOS PILs compared with only 10.6% of medical practice leaflets assessed in a similar study.¹³

Patients must understand what that treatment involves, the alternatives available, and the risks and benefits of various treatment options when giving informed consent to treatment. Leaflets can only help give patients information if they are readable and understandable. Using patients and the public in lay reader panels can greatly assist in the production of readable PILs that are suited to their users.

Errors in communication can prompt allegations of malpractice.²⁴ It is therefore necessary to document which PILs have been given to patients during the consent process in order to help reduce misunderstandings between the patient and clinician. Sections for this are now included in some consent forms.^43,44

The accessibility of information is an important consideration in modern-day practice. Under the Disability Discrimination Act (1995),⁴⁵ orthodontists could be prosecuted for not providing information in other accessible formats, for example, Braille, computer disc or audiotape. Thought must also be given to patients whose first language is not English, so PILs need to be available in other languages to ensure that patients are able to give their informed consent.

Implications for research
The move towards evidenced-based dentistry requires that there is sound evidence of the efficacy of the interventions we provide for our patients. It is important, therefore, to be able to demonstrate knowledge gain from PILs to be able to justify their use. This can be done in an appropriately designed, randomized, controlled trial. From the standpoint of clinical governance, the design of leaflets needs to be evidence-based and peer reviewed. The quality of the information in the PILs was not assessed in this study, but may be an important consideration for future research.

	Conclusions

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 

• Overall, the orthodontic PILs assessed were difficult to read. However, the BOS leaflets were much easier to read and better designed than those produced by the AAO.
  
• The mean readability of all PILs was rated as ‘fairly difficult’, meaning that only 40% of the UK population would be expected to understand them. Nevertheless, all the BOS leaflets were rated as ‘standard’ or ‘fairly easy’ to read, meaning that 70–80% of the UK population would be able to understand them.
  
• There were significant differences between PILs from the AAO and BOS on all tests. The BOS leaflets were significantly better on all tests except the passive percentage test.
  
• None of the leaflets assessed were eligible for the Plain English Campaign’s Crystal Mark.
  

The use of the Crystal Mark to clearly denote readable PILs is recommended.

	Contributors

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
A. Harwood contributed to the writing of the protocol; was responsible for material and data collection, data analysis and interpretation and the drafting, and final approval of the article. J. E. Harrison was responsible for the conception and design of the study; contributed to the writing of the protocol; assisted in data analysis and interpretation, and was responsible for critical revision and final approval of the article. Jayne Harrison is the guarantor.

	Appendices

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
These are available only on the web version of this page (http://jorthod.maneyjournals.org/).

	Appendix 1: Explanation of the assessment criteria used to assess the leaflets

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
Flesch Reading Ease (FRE)
The FRE score ranges from 0 to 100, where a text with a lower score is harder to read than one with a higher score. It uses sentence length and polysyllabic words to determine difficulty. A score of 0 would be practically unreadable and a score of 100 would be easy to read for any literate person.

Flesch Kincaid Grade Level (FKGL)
The FKGL gives a result in terms of United States (US) school grades. It uses mean sentence and word length to determine the readability level.

Table A1 compares the interpretation of the FRE and FKGL scores.

View this table: [in this window] [in a new window]   Table A1 A comparison of FRE and FKGL scores with reading difficulty, IQ, percentage of the UK population who would be expected to understand the text and an example of the type of publication written at this level24,31

Sentence length
The sentence length test is simply the total number of words in a document divided by the total number of sentences to give an average sentence length. An average sentence length of between 15 and 20 words is ideal according to the Plain English Campaign.

Passive percentage
Passive verbs cause several problems as they:

• can be confusing;
  
• often make writing more long-winded;
  
• make writing less lively.
  

With an active verb, the 3 parts of a sentence appear in the order: subject then verb then object. For example:

Anne (subject) read (verb) the leaflets (object). ‘Read’ is an active verb here. The sentence says who is doing the reading before it says what is being read.

With a passive verb, the order is reversed: object then verb then subject.

The leaflet (object) was read (verb) by Anne (subject).

‘Read’ is a passive verb here. The sentence says what is being read before it says who is doing the reading.

By making the sentence passive, the words ‘was’ and ‘by’ were introduced making the sentence clumsier. You should aim to make 80–90% of verbs active.

To derive the passive percentage the number of passive verbs in a document is divided by the total number of sentences and multiplying the result by 100. See Table A2.

	Appendix 2: Design percentage checklist

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

Design element checklist

Minimum 12-point font Simple (sans serif) typeface     Only one typeface     Arabic versus roman numerals     Indented first line of paragraph     Unjustified right hand margin     Bold only for emphasis     No underlining     No full uppercase words     No italics for long passages     Use of question headings     Headings in different type     Lines of type clearly spaced     Unrelated sections clearly separated     Information summarized +/– bullet points     Sentence flow not interrupted by pictures     Contrast between paper and text     Paper not high gloss     Use of illustrations     Appealing use of colour

	References

Top Abstract Introduction Aims Objectives Methods Results Discussion Conclusions Contributors Appendices Appendix 1: Explanation of... Appendix 2: Design percentage... References

 
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