Health Education Reading Level Mandates: Helpful or Harmful?

Health Literacy


Using readability scores appears simple: The lower the reading level, the easier the text is to understand, right?

Let’s test this idea. Which of the following messages about smoke-free pregnancy is easier to understand?

Pregnant women who smoke are more likely than nonsmokers to have miscarriages, stillbirths, early labor, and premature babies. Gravid females who smoke are more apt than ones who do not to lose the fetus. And more apt to have a fetus with no life. And more apt to have early labor and not full-grown foeti.

The text on the left has a grade level of 12. The text on the right has a grade level of 3—even though it is difficult to comprehend. How can this be?

Readability tests such as the Flesch-Kincaid, Dale Chall, and Flesh Reading Ease base their scores on mathematical formulas. The formulas consider things like word and sentence length to give a theoretical comprehension level. The formulas fail to consider complex aspects of a language such as:

  • Whether a word is common or rare—for example: likely vs. apt.
  • Whether a word has Latinate or Anglo-Saxon origins (Anglo-saxon words often are easier to comprehend). For example: fetus vs. baby.

Despite their flaws, readability tests have some value in making health education materials accessible to all. However, because of their flaws, they should be used to guide educators in choosing materials—and not to mandate that educators use material at the lowest conceivable level.

Unfortunately, institutional mandates are in place in many parts of the health education field, both governmental and in the private sector. Mandates may be more harmful than helpful.

While both of the test sentences above need a good editor, reading level mandates could prevent quality health education texts from ever reaching the public. As a final example, consider the following re-write of the test sentences.

If you smoke while pregnant, you are more likely to lose the baby before or at birth. You are also more likely to have early labor. In early labor, you may have a baby who is not fully developed.

Due to mandates, this informative rewrite would be barred because the Flesh Kincaid formula deems it to be at a fifth grade level.

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