Evaluating the Readability and Understandability of Patient-Reported Outcome Questionnaires for Lower Urinary Tract Symptoms

INTRODUCTION: The American Medical Association recommends that health-related material be written at a 6th-grade level. Studies assessing urogynecology questionnaires indicate variable readability, and few address understandability. OBJECTIVE: Our objective was to compare the readability and understandability of questionnaires assessing lower urinary tract symptoms in the setting of pelvic floor disorders. METHODS: We identified six questionnaires assessing symptoms of lower urinary tract symptoms (LUTS) and related pelvic floor symptoms: The ICIQ-UI-SF, the BFLUTS-SF, ICIQ-LUTS-qol, MESA, OAB-q SF, and the SSI. We assessed the grade-level readability of these questionnaires using three validated readability calculators: the Flesh-Kincaid Grade Score (FKGS), the Simple Measure of Gobbledygook (SMOG), and the Fry Reading Graph Calculator (FRY). We determined the grade reading level for each questionnaire in three ways: 1) all questions and answer choices, 2) the questions only, and 3) the introductory instructions only. We used the American Medical Association benchmark of <6 th-grade reading level as acceptable. We also measured understandability using the Patient Education Materials Assessment Tool (PEMAT), with a goal of 70% understandability. Two reviewers independently scored each instrument for readability and understandability. Univariate and descriptive statistics were calculated to compare outcomes. RESULTS: For readability, there was wide variation among the questionnaires, ranging from 6th grade to college reading. The ICIQ-LUTS-qol was the only questionnaire to meet the AMA readability standard of 6th grade based on FKGS score of 5.7, while the OAB-q SF had the highest reading level with a score of 13 (college level) (Table 1). Readability scores using the SMOG demonstrated higher grade level readability compared with the FKGS and the FRY. When assessing the questions only, all questionnaires except the OAB-q SF were written to meet the 6th-grade reading standard (Table 1). When assessing the introduction section only, all questionnaires except the OAB-q SF and ICIQ-UI SF met the 6th-grade reading standard. (Table 1) For understandability, only the ICIQ-UI-SF and OAB-q SF met the PEMAT goal score of 70%. The average understandability score for all questionnaires was below the understandability threshold at 64% (CI 54–74) (Table 1 and Figure 1). Reduced readability was due to increased polysyllabic words, long sentences, and lengthy answer choices. Reduced understandability was due to a lack of plain language, failure to define medical terms, and the absence of visual aids. CONCLUSIONS: The readability and understandability of commonly used questionnaires addressing lower urinary tract symptoms were lower than recommended, making it harder for patients to comprehend and appropriately report their symptoms. Efforts should be made to address these challenges when designing questionnaires to accurately assess lower urinary tract symptoms and related pelvic floor symptoms.