On 2017 Sep 07, Pranay Jindal commented:

Thank you for your comments and feedback.

The purpose of the article was to critically analyze the Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL) and their use in assessing the reading level/perceived difficulty of a written text. We agree with you that grade level as assessed by readability formulas do not equate with readers understanding. In the article, we mention “in their assessments, FRE and FKRGL do not take into account (1) document factors (layout, pictures and charts, color, font, spacing, legibility, and grammar), (2) person factors (education level, comprehension, health literacy, motivation, prior knowledge, information needs, anxiety levels), and (3) style of writing (cultural sensitivity, comprehensiveness, and appropriateness), and thus, inadequately assess reading level”.

We do not explicitly support the use of readability formulas to assess the reading level/perceived difficulty of a written text, and in our article recommended that “future research needs to develop generic and disease-specific readability measures to evaluate comprehension of a written document based on individuals' literacy levels, cultural background, and knowledge of disease”. We encourage researchers and clinicians to move towards assessment of comprehension of written documents. However, in the absence of a reliable and valid measure to measure comprehension and the ease of using Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL) via Microsoft office makes them a popular and easy choice.

On 2017 Jul 24, Donna Berryman commented:

While the authors do a pretty good job of pulling together the basic information about some popular readability formulas, they tend to support the idea that these formulas are somehow worthwhile. It is time to focus on the idea that grade level or readability formula results do not equate to reader understanding. As Leroy, Kauchak and Hogue (2016) write: "The lack of strong evidence for increased comprehension after using readability formulas may indicate that it is perceived difficulty that is being manipulated: The text looks easier but may not necessarily be easier to understand." (PMID 27043754) Wan et al (2013) do a good job of showing how different readability formulas vary in their calculations (see PMID 22835706). They conclude that "the SMOG formula appears to be more ideally suited for use in a health care context, as it has been validated against 100% comprehension..." But, beyond that, I would heartily encourage that we start thinking beyond written materials. I'd recommend the work of Donald L. Rubin on listenability (see PMID 23030569 for one example). Most health information is dispensed orally.

On 2017 Jul 24, Donna Berryman commented:

While the authors do a pretty good job of pulling together the basic information about some popular readability formulas, they tend to support the idea that these formulas are somehow worthwhile. It is time to focus on the idea that grade level or readability formula results do not equate to reader understanding. As Leroy, Kauchak and Hogue (2016) write: "The lack of strong evidence for increased comprehension after using readability formulas may indicate that it is perceived difficulty that is being manipulated: The text looks easier but may not necessarily be easier to understand." (PMID 27043754) Wan et al (2013) do a good job of showing how different readability formulas vary in their calculations (see PMID 22835706). They conclude that "the SMOG formula appears to be more ideally suited for use in a health care context, as it has been validated against 100% comprehension..." But, beyond that, I would heartily encourage that we start thinking beyond written materials. I'd recommend the work of Donald L. Rubin on listenability (see PMID 23030569 for one example). Most health information is dispensed orally.

On 2017 Sep 07, Pranay Jindal commented:

Thank you for your comments and feedback.

The purpose of the article was to critically analyze the Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL) and their use in assessing the reading level/perceived difficulty of a written text. We agree with you that grade level as assessed by readability formulas do not equate with readers understanding. In the article, we mention “in their assessments, FRE and FKRGL do not take into account (1) document factors (layout, pictures and charts, color, font, spacing, legibility, and grammar), (2) person factors (education level, comprehension, health literacy, motivation, prior knowledge, information needs, anxiety levels), and (3) style of writing (cultural sensitivity, comprehensiveness, and appropriateness), and thus, inadequately assess reading level”.

We do not explicitly support the use of readability formulas to assess the reading level/perceived difficulty of a written text, and in our article recommended that “future research needs to develop generic and disease-specific readability measures to evaluate comprehension of a written document based on individuals' literacy levels, cultural background, and knowledge of disease”. We encourage researchers and clinicians to move towards assessment of comprehension of written documents. However, in the absence of a reliable and valid measure to measure comprehension and the ease of using Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL) via Microsoft office makes them a popular and easy choice.