From Readability to Accessibility: Evaluating and Redesigning Newborn Hearing Screening Materials

Introduction: Early hearing detection and intervention (EHDI) programs rely on timely follow-up after newborn hearing screening (NBHS) to ensure early diagnosis and intervention for infants who are d/Deaf or hard of hearing. Caregiver understanding of screening outcomes is essential to this process; however, most patient-facing materials exceed recommended readability levels, posing challenges for the 54% of U.S. adults who read below a sixth-grade level. Reduced health literacy is associated with poorer health outcomes and widened disparities, raising concerns about the accessibility of NBHS materials. This study evaluated the readability of NBHS handouts provided at a large medical center and used these findings to guide the development of a revised, visually structured caregiver “roadmap.” Method: A descriptive, observational analysis was conducted on NBHS handouts routinely provided to caregivers following three screening outcomes: (a) bilateral pass, (b) unilateral did not pass, and (c) bilateral did not pass. Readability was assessed using three established tools: Flesch–Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE), Gunning Fog Index (GFI), and the New Dale–Chall Readability Formula (NDCR). Key metrics, including sentence length and syllable density, were examined. Findings informed the iterative development of a one-page visual roadmap designed using plain-language and health literacy principles. Results: None of the materials fully met the American Medical Association–recommended sixth-grade reading level. The Unilateral Pass document achieved an FRE of 57.4 and an FKGL of 8.7; the GFI estimated a 10.68 reading level, while Dale–Chall indicated seventh to eighth grade. The Bilateral Refer handout showed similar complexity (FRE = 49.9; FKGL = 9.5; GFI = 10.96; NDCR = fifth to sixth grade). The Bilateral Pass document was the most difficult (FRE = 36.2; FKGL = 12.7; GFI = 13.9; NDCR = 11th–12th grade). Readability challenges were driven by long sentences, multisyllabic terminology, and Department of Public Health–mandated medical content. These findings helped to inform during the creation of a simplified, visually guided NBHS roadmap. Conclusions: NBHS materials at a major hospital exceeded recommended readability standards, posing potential barriers to caregiver comprehension and timely follow-up. The visually structured roadmap developed could provide a promising strategy to address these barriers. Future work should evaluate the roadmap's feasibility and its impact on caregiver understanding, stress, and adherence to EHDI-recommended timelines.