The Clear Communication Index: A Research-Based Tool to Reduce Health Literacy Barriers

Background: Public health communicators know that health literacy issues, such as unfamiliar terms and concepts, dense and unorganized text and the frequent use of statistics and risk statements, affect how audiences process, understand and use messages or health information.  Although in-depth formative research and audience testing are ideal to address these issues, communicators don’t always have the resources, time or experience to take these steps. Two popular and inexpensive alternatives are checklists and readability formulas. However, many checklist items are not tied to the research literature, and readability formulas don’t account for audience, purpose and other factors that affect the audience’s processing and understanding. Addressing health literacy barriers in public health messages and materials requires a research-based and easy-to-use tool that communicators can use as part of their regular work processes.       

Program background: The CDC Office of the Associate Director of Communication (OADC) in partnership with CDC communication staff has developed the Clear Communication Index (Index) to address health literacy barriers. The Index consists of 23 factors that consistently appear in the research literature as those affecting how audiences process and understand health messages and materials. The factors pertain to behavioral recommendations, main messages, language, information design, visuals and presentations of numbers and risk. Each factor has a numerical score so that the communicator can objectively determine if the message or material has addressed the factor or not.   

Evaluation Methods and Results: The project team followed a multi-step process to build and test the Index. The team began with a scan of commonly used “health literacy” and plain language checklists and evaluation tools and generated a list of factors. The most frequent factors were used to define a literature search.  The team shared the search findings with a 10-member, multi-disciplinary, academic expert panel that expanded the factors list and confirmed or deleted other factors in a two-round review process. After revising the factors list again, the team used the factors to assess materials from the CDC web site and made another set of revisions. CDC communication staff tested the Index with more CDC materials before a final round of revisions to the Index.      

Conclusions: A Clear Communication Index based on the research literature, expert review and field testing provides an objective tool that can be used quickly and cheaply to plan and evaluate messages and materials. The Index does not replace formative research and audience testing, but can be an adjunct to these methods or an alternative when resources and time are short.        

Implications for research and/or practice: Public health communicators can address health literacy barriers with research-based tools that are sensitive to factors other than readability. They can improve the quality and accessibility of messages and materials with an easy, research-based approach that accounts for multiple audience factors that affect processing and understanding.