In this blog, we will discuss Spanish Readability Testing of  Healthcare Translations. Accepted Readability Models referenced for Medicare and Medicaid grade level requirements were originally developed for English writing. We’ll discuss how the Spanish language compromises Readability Scores, what Model works best in Spanish and some tips on how to approach Spanish Readability.

Limitations of Spanish Readability Testing

Earlier we blogged about how in Plain Language Writing, we prefer to test using the Flesch-Kincaid (F-K) method. While the F-K testing method is certainly not a perfect scoring, we concluded that no readability score is perfect. A scoring system alone will not tell you whether a piece of communication is going to be well understood the first time at the intended grade level. To really know how it’s going to be understood, you have to do usability testing.  The writing though always comes down to the expertise of the Plain Language Writer. Healthcare information can be challenging for people of all literacy levels to absorb. Plain Language Writing incorporates educational theories and strategies to ensure that the communication is understood by everyone.

Another limitation of Readability Testing that it doesn’t apply well to other languages. Specifically in Healthcare, we deal with a lot of Spanish translations. However, this discussion could also apply to other languages. When it comes to Spanish healthcare communications, there are many other factors that impact behavior. There are cultural implications other than language that also affect healthcare outcomes that we’ll not discuss here. When it comes to delivering Plain Language Writing in Spanish, we look at how Spanish translations can be tested for readability and what low literacy looks like in Spanish.

Assessing Spanish Readability Testing

If you go by the testing methods for English writing, we know that “number of words in a sentence” and “number of syllables per word” are typical metrics for readability. Some models test samples of text and looks at how many words and syllables are used. F-K testing looks at the number of words per sentence and number of syllables per word. That last metric (number of syllables per word) is especially problematic in Spanish because it is not as strong of an indicator of Spanish Readability.

A word like medicamento(s) in Spanish has 5 syllables, while medication(s) has 4. One alternative is medicina(s) (4 syllables), with medicine(s) having 3 syllables. And there are many common words in Spanish that generally have more syllables than their English counterpart. Research shows that in Health Literacy models, the word “drug” is a very acceptable and preferred term for medicine or medications. It follows the vernacular of most low literacy readers to describe (legal) medications without much concern about it being confused for narcotics.  However, in Spanish, medicamento or medicinas are the typical words associated with medications rather than the word drogas.

Modified Spanish Readability Testing Models

Different studies have been done in order to test the validity of Readability Models in Spanish written materials. Testing with the Fry Readability Graph under normal circumstances would give the impression that the Spanish has way too many syllables. That is why studies recommend that for Fry Testing, the number of syllables per 100 words is reduced by 67 (Gilliam, Peña & Moutain). Fry is the only readability assessment tool currently validated in Spanish to produce predictable U.S. Grade Levels.

Comparison between 4th Grade English (Flesch-Kincaid) and Spanish Translation tested with Fry

The Fry Readability Graph method requires you to calculate the number of sentences (to closest 1/10th; table has rounded off numbers) and syllables per 100 word samples. You can take as many samples as possible and plot on the x,y chart, but the model recommends at least 3 samples (beginning, middle and end). The graph above is for illustration purposes only. We plotted one 100-word sample of a letter written in 4th grade English using Flesch-Kincaid. The table next to the graph shows that the Spanish letter would have scored way off the chart (literally) when it comes to the number of syllables. When applying the correction to this number, the grade level is more in line with what we expect for this letter.

Another modified English based readability model is the Flesch-Kincaid Reading Ease by Huerta-Fernández. This formula has subsequently been modified to make it more scalable. However, this does not return a U.S. Grade level typically required by Medicaid or Medicare.

Health Literacy Measurement

Spanish Readability research dates back as early as the 1950s. Health Literacy assessment tools measure Health Literacy and Patient Experience in order to identify a need for low literacy needs. Healthcare Organizations that want to measure the effectiveness of their Spanish and English Healthcare Communications can facilitate testing of their member base using surveys and other tools. Here are a few resources for testing methods in various languages:

• The Agency for Healthcare Research and Quality publishes several measurement tools for various research fields:
  • Health Literacy Tools (SAHL and REALM tests in Spanish and English): http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html
  • CAHPS (Tools to measure Patient experience; available in English and Spanish): http://www.ahrq.gov/cahps/index.html
• Boston University supported by NIH has a page dedicated to Health Literacy Measurement Tools for specific research field and has published methods in various languages at: http://healthliteracy.bu.edu/

We work with Health Literacy Experts that have over 25 years of experience in the Health Literacy Field. Our Spanish translation team has translated various books and regularly translate Medicare materials written at 4th and 6th grade levels for low literacy comprehension. Contact us if your organization is interested in Health Literacy Writing and Translation Services.