Patient-Reported Outcome Measures: A Readability and Understandability Analysis

Objectives: To compare the readability and understandability of commonly used questionnaires assessing prolapse and related pelvic floor symptoms.

Methods: We identified 11 commonly utilized and validated patient-reported outcome measure questionnaires that address prolapse symptoms and related pelvic floor symptoms of urinary incontinence, defecatory dysfunction and sexual function. See Table 1. The PFDI-20 and PFIQ were not included due to prior analysis. We assessed the readability of these questionnaires using multiple validated tools: Flesh-Kincaid Grade Score (FKGS), Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG) and Fry Reading Graph Calculator (FRY). We scored grade reading level with these tools for: 1) the entire questionnaire 2) questions separately and 3) instructions separately. Two reviewers independently scored each instrument for understandability using the Patient Education Materials Assessment Tool (PEMAT). Univariate and descriptive statistics were calculated to compare questionnaires.

Results: There was variability in readability scores among the questionnaires and among the different readability tools. See Table 1. 55% of questionnaires, when assessing the questions only, met the American Medical Association 6th grade readability standard based on FKGS scores. However, only the ITSQ met the 6th grade readability standard when assessed in its entirety, including answer choices. 73% of questionnaire introductions were written above 6th grade level. The FRES scores of the ITSQ and ICIQ-VS indicated that the questionnaires would be easily read by 7-8th grade students, while the POPSS, PFBQ, PIKQ and Australian questionnaire would require 10-12th grade reading skills and the BIPOP would require college-level reading skills. When comparing assessment tools, the SMOG had the highest reading level scores, with FRY having the second highest scores. Regarding understandability, none of the questionnaires met the PEMAT understandability goal score of 80% (mean 53% CI 0.46-0.59), with very low individual scores. See Table 1. The PFBQ had the highest score for understandability but was still low at 69.

Conclusions: The readability of these commonly used questionnaires assessing prolapse and related pelvic floor symptoms is variable, though when considering the entire questionnaire readability is almost uniformly above the 6th grade standard with the exception of the ITSQ. Moreover the understandability is consistently poor. Increased numbers of polysyllabic words contributed to increased reading level, while a lack of clearly-stated purpose, failure to use common language or define medical terms, and the absence of visual aids contributed to poor understandability scores. As patient-reported outcomes are a cornerstone of determining treatment success, revising the commonly used instruments to achieve appropriate readability and understandability is worthwhile.