Introduction
Self-help approaches are increasingly being used in healthcare settings. In the UK book prescription schemes have increased in number with over 100 schemes nationally (Farrand, Reference Farrand2007); their popularity has been endorsed by the recommendation of the NICE guidelines for depression (NICE, 2004), which recommend the use of self-help materials in the early treatment of mild and moderate depression within the stepped care model. The introduction of these schemes generated interest amongst practitioners in Primary Care (News Roundup, 2003; Anderson et al., Reference Anderson, Lewis, Araya, Elgie, Harrison, Proudfoot, Schmidt, Sharp, Weightman and Williams2005).
Self-help approaches are also popular with the general public – who endorse self-help more positively than treatment with medication or psychotherapy, or indeed than seeing a health care practitioner (Jorm et al., Reference Jorm, Korten, Jacomb, Rodgers, Pollitt, Christensen and Henderson1997). Despite their popularity, no study to date has addressed the issue of readability of the recommended self-help books for depression.
Cognitive behaviour therapy (CBT) is ideal for the self-help approach as it uses a focused model of assessment and provides a clear structure to working that focuses on problems of relevance to the patient. For self-help materials to be effective, many of the same challenges that are present in therapy also need to be addressed. A key to engagement in treatment is being able to use the materials.
The reading age of a written document is defined as the “chronological age of a reader who could just understand a text”. A reading age of 11 is the level used to define functional literacy in the UK. Currently, approximately 16% of the population of England are estimated to fall below this level of literacy (National Literacy Trust, 2007). A similar rate applies to other countries in the UK and also to other nations worldwide. An Organization for Economic Cooperation and Development (OECD) study of 16 to 65-year-olds found functional illiteracy rates of 20% in France and 25% in Eire (National Literacy Trust, 2000). The implications for these individuals are that they are unable to understand brochures, train timetables or road maps, or simple instructions for household appliances. To provide a yardstick against which to consider readability, the reading age of the Financial Times and Guardian lies between age 17–21 (sample checked by authors).
If inappropriately complex self-help materials are offered, it is likely there will be less improvement than may otherwise be possible, and also a low uptake and high dropout from using materials. Studies on the uptake of self-help materials in the US seem to indicate low dropout rates; however, most of this work has been done on populations recruited through media advertisements (Cuijpers, Reference Cuijpers1997). In contrast, studies that have used British clinical populations have noted attrition rates approaching 50% (Whitfield, Williams and Shapiro, Reference Whitfield, Williams and Shapiro2001).
Methods
Selection of self help books
CBT self-help is widely used by both accredited CBT practitioners and as part of book prescription schemes across the UK. The widely used self-help booklet for depression and low mood from the Newcastle and Northumberland Trust (Newcastle, 2001) was included for comparison. The list of items identified (Table 1) for this study includes all books selected for use in depression in book prescription schemes in the Wales and the South West Peninsula (England) book prescription schemes (Farrand, Reference Farrand2005), and those identified by a previous study that surveyed all 500 accredited members of the British Association for Behavioural and Cognitive Psychotherapies regarding their attitudes towards and use of self-help materials. This population represents an expert body of accredited CBT practitioners, over 90% of whom recommend self-help materials (Keeley, Williams and Shapiro, Reference Keeley, Williams and Shapiro2002). One of the books recommended has been written by one of the authors of this paper.Footnote 1
Table 1. CBT self-help books and readability scores
1 – Recommended by book prescription schemes in England;
2 – Recommended by book prescription schemes in Wales;
3 – Recommended by CBT accredited therapists.
Readability assessment
The random number generator in Excel® was used to create a random selection of pages representing 15% of each book. These pages were then scanned into Microsoft Word® documents. Page headings and illustrations were removed from the final document as is recommended in studies on readability. Where there were tables of text, the sentences were kept in the same format. The scanned text was carefully proof-read and compared for accuracy against the original text.
The readability scores for each selection were then automatically calculated using the adult health care screen of the Readability Studio® software program (Oleander Solutions, 2007). This provides several scores of readability based on the level of difficulty of the text.
The concept of readability
Two ways in which the complexities of reading materials are measured are through the concepts of “readability” and “reading ages”. Readability refers to all the factors that influence whether someone can read a text (Johnson and Johnson, Reference Johnson and Johnson1987). As such, readability includes factors such as the size and the legibility of the print. It is also influenced by the complexity of the words and the sentences relative to the reading abilities of the reader. This is the part of readability that is most easily quantifiable. It is also the part that tends to be used to work out the “reading age” of a piece of text. A number of different formulae have been used to measure the reading age of written materials. Most formulae take into account the average length of the sentences and the number of syllables in the words incorporated within the text (see Table 2). In contrast, other formulae such as the “Dale-Chall” compare the words used against a standard word list known to be accessible to readers of an adult age. In this way, unusual words such as academic jargon are excluded and this results in a high reading age (Chall and Dale, Reference Chall and Dale1995). Although there is a degree of variability between the different readability scores, the adult health care screen uses a combination of scores, from which a readability age mean is calculated.
Table 2. Readability scores used in adult health care – interpretation of scores
Results
The readability statistics of the most frequently used and/or recommended self-help books for depression identified in this study are summarized in Table 1. The average reading age scores are highlighted. The self-help materials achieved reading ages of between 12.6 and 15.4. The minimum Flesch Reading Ease score that could indicate “Plain English” is 60. Ideally, conversational English for consumers should score at least 80 or about 15 words per sentence (Flesch, Reference Flesch1979). The length of the materials varied from 124 pages (Blackburn, Reference Blackburn1987), to over 700 (Burns, Reference Burns1980). Reading ease varied significantly amongst the texts, which had reading ease scores ranging from 52 to 68 (the higher the score, the greater the reading ease), and their complexity as indicated by the percentage of unfamiliar words, ranged from 14.8% to 22.6% in the Dale Chall scores (in the latter, over 1 in every 5 words being difficult to understand). The complexity found in the texts in terms of unfamiliar words or words longer than three syllables are also highlighted by the SMOG score, Gunning Fog and the New Gunning Fog score. The scores of the Depression and Low Mood: self-help guide (Newcastle, 2001) have been included in Table 1 to act as a comparison with the selected books.
Discussion
The readability score and reading ease are only two components affecting the usability of written materials. The understandability of a text is an interaction between the reader whose possible prior knowledge of aspects of the content and the text features would influence the ease with which they access the text, as well as the fixed aspects of the text itself. A criticism of readability tests is that they do not take into account a patient's prior experience and motivation. Readability is essentially text-related and does not take these factors into account (Mudd, Reference Mudd1987). Attempts to empirically correlate readability and understandability have yet to reach a consensus (Jones and Shoemaker, Reference Jones and Shoemaker1994). Additionally, there is variability in the reading age scores of the different readability scales; however, the adult health care screen battery of tests calculates a reading age mean for these.
We know that 16% of the population of England has a reading age below 11 (National Literacy Trust, 2007). The current study shows that the reading ages of the most frequently used and recommended self-help books for depression in the UK range from 12.6 and 15.4. This, compounded with the effects of depression on concentration and attention, will increase the difficulty of use of these materials for some patients. The abundance of unfamiliar words in some of the texts may be a contributing factor to non engagement with the materials on the part of the patient.
We have previously reported that the key “technical” language of traditional CBT as used in the Beck and colleagues' seminal manual Cognitive Therapy for Depression (Beck, Shaw, Rush et al., Reference Beck, Shaw, Rush and Emery1979) has a reading age of 17 or above (Williams and Garland, Reference Williams and Garland2002). This is quite acceptable as a technical manual aimed at practitioners, but more simplified language would be more appropriate for patient groups.
During the course of an illness it is known that patients may become familiar with quite complex terminology (Meade and Smith, Reference Meade and Smith1991), with the implication of the need of initially more simplified materials (in this context it may be that the self-help booklet may be appropriate as an introduction to CBT), or additional forms of support during the initial phase for the use of the materials. The social circumstances of patients specifically with regards to deprivation and poverty, and the impact that these may have on literacy levels, are also factors that professionals may need to consider when recommending self-help materials.
Those producing written self-help materials need to focus on ways of increasing their readability and understandability. To improve the ability of people to use the materials effectively, lessons need to be learned from adult learning models. The layout of materials is important. In the educational field, the term “information overload” is used to describe this unhelpful over-provision of text that actually prevents effective learning. Where text is densely packed, there is a danger of the user feeling overwhelmed. Guidelines are provided on aspects of presentation and style of materials for use in health care settings by the Kings Fund (Duman, Reference Duman2003); the recommendations include the text to be broken up using illustrations (especially human faces), and the text personalized by the use of personal pronouns (me, you, your etc.) so that the reader individualizes and applies what they are learning to their own situation. The use of space for writing notes, and personalizing the materials also increases engagement and use. Practical issues such as the legibility of the print and line spacing should be addressed, a size 10–12 font size print is recommended, as is the use of black ink. Lower case script is read 10% faster than capitals. Bold text is better used for emphasis than italics or capitals. The best line length is 6–9 cm or 7–12 words for most efficient eye movement.
Crucially, providing support for the use of self-help for depression also significantly improves outcome (Gellatly et al., Reference Gellatly, Bower, Hennessy, Richards, Gilbody and Lovell2007). This may be partially explained by the fact that a supporter can help clarify, “translate” and encourage use. Despite the increase in the numbers of Book Prescription Schemes in the UK, little is known about how patients are using these and the forms of support that are being offered to them whilst using the materials.
Conclusions
It is clear that some of the reading ages of the self-help books most frequently used and recommended in healthcare settings in the UK are too high for many users. This does not detract from their content in other respects and it should not be forgotten that mental health professionals on a regular basis have recommended all of the materials included within this study. Practitioners may need to consider the level of support they provide to their patient/client in making use of these materials, and careful consideration should be taken to ensure that recommended materials will be usable and appropriate for the potential reader. This is to our knowledge the first study to address the question of readability of self-help materials recommended for use in depression. It may be that for some patient groups, non text-based self-help materials (such as audio or DVD) may be more appropriate.
Practice implications
We suggest that new self-help manuals begin to look at issues of usability and consider publishing their readability scores. Content should be tested in clinical practice and improved following feedback from both practitioners and patients/clients as suggested by the King's Fund guidance for producing patient education materials (Duman, Reference Duman2003). Publication of the reading ages of the recommended books within the book prescription schemes may allow for a more accurate match between the book and the reader. For summary of study findings, see Table 3.
Table 3. What this paper adds
Acknowledgements
The authors wish to thank Antonia Gates for the preparation of the random book samples for use in this study. The reading age for this paper is 15.2.
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