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Improving air traveller IPC health literacy through better communication: Investigation of the readability of COVID-19-related IPC traveller-facing information from 121 national and international commercial airlines

Published:November 07, 2022DOI:https://doi.org/10.1016/j.idh.2022.10.001

      Highlights

      • Commercial airlines websites (n = 121) providing COVID-19 IPC information were examined.
      • Recommended readability targets not reached.
      • Only ¼ of airline IPC-related websites examined had good readability.
      • Mean Flesch Reading Ease score = 54.1 (Target >60); Mean Flesch-Kincaid Grade Level = 9 (Target <8).
      • Need for further work to improve readability of IPC information on airline websites.

      Keywords

      Dear Editor,
      Sotomayor-Castillo and colleagues report in the journal (Volume 26 (2); May 2021) on travellers’ health concerns and attitudes towards infection, prevention and control (IPC) measures with air travel during the COVID-19 pandemic [
      • Sotomayor-Castillo C.
      • Radford K.
      • Li C.
      • Nahidi S.
      • Shaban R.Z.
      Air travel in a COVID-19 world: commercial airline passengers' health concerns and attitudes towards infection prevention and disease control measures.
      ]. From this comprehensive cross-sectional observational study involving 205 individuals, airline customers (90.7%; n = 186) indicated that airlines should provide more information on how to prevent the spread of infection to their passengers and suggested that such information would best be disseminated to passengers by email or SMS messaging, together with flight-related documentation, followed by employing inflight television programming [
      • Sotomayor-Castillo C.
      • Radford K.
      • Li C.
      • Nahidi S.
      • Shaban R.Z.
      Air travel in a COVID-19 world: commercial airline passengers' health concerns and attitudes towards infection prevention and disease control measures.
      ].
      Given that until this point preceding the COVID-19 pandemic, documentation and information from commercial airlines to their passengers on airline-related IPC issues was sparse. With the onset of COVID-19 from early 2020, airlines had to react rapidly in their duty of care to their passengers to protect them from acquiring COVID-19 when travelling via commercial air travel. This protection involved increasing the health literacy of passengers through the production of IPC information in several modalities, as described by Sotomayor-Castillo and colleagues [
      • Sotomayor-Castillo C.
      • Radford K.
      • Li C.
      • Nahidi S.
      • Shaban R.Z.
      Air travel in a COVID-19 world: commercial airline passengers' health concerns and attitudes towards infection prevention and disease control measures.
      ]. The vast majority of airlines duly responded by amending their websites to include sections on IPC and COVID-19, within a relatively short time as the pandemic emerged and evolved. However, to date, there has been no quantitative evaluatiuon of how successful these airlines websites were in terms of their readability of the passenger-facing materials produced and displayed on the airlines’ websites. Therefore, it was the objective of this study to examine the readability of COVID-19 IPC-passenger facing information displayed on commercial airline websites.
      Commercial airlines (n = 121) were identified on the Skytrax website (https://skytraxratings.com/) and each of their individual websites were visited and assessed digitally for their readability during the period February–April 2022. From their main website, specific COVID-19 related URLs were identified for each airline. These were freely available and in the public domain. To ascertain the readability scores, the online subscription software package, Readable (www.readable.com) was used. Readable has been used recently in studies as a tool to measure the readability of healthcare materials [
      • Downey T.
      • Millar B.C.
      • Moore J.E.
      Improving health literacy with mumps, measles and rubella (MMR) vaccination: comparison of the readability of MMR patient-facing literature and MMR scientific abstracts.
      ,
      • Brennan O.C.
      • Moore J.E.
      • Nutt T.W.
      • Moore P.J.
      • Millar B.C.
      Improving meningococcal MenACWY and 4CMenB/meningococcal group B vaccine-related health literacy in patients: importance of readability of pharmaceutical Patient Leaflets.
      ]. Four readability metrics were selected, including two reading grade levels and two readability scoring systems (Table 1), as well as four text parameters (word count, sentence count, words per sentence and syllables per word). Table 1 details the results of these readability scores and text parameters from the 121 airline URLs examined and Fig. 1 shows the range of values obtained with the Flesch Reading Ease metric. There was a wide variation in all readability parameters examined. Only 30 (30/121; 24.8%), approximately a quarter of airlines managed to provide COVID-19 related information that was deemed easy to read (score >60) and the mean readability score for the Flesch-Kincaid Grade Level, the Gunning Fog and the SMOG scores fell short of the target values (Table 1). The Flesch-Kincaid Grade Level is equivalent to the US grade level of education and shows the required education to be able to understand a text. Text intended for readership by the general public should aim for a grade level of around 8, equivalent to a schooling age 13–14 years. Some airlines directed their passengers to their national health authority for up-to-date advice and guidance on COVID-19, in accordance with evolving local legislation. However, some of this information was prepared rapidly for healthcare professionals, which suffered from poor readability scores for general public raedership. Airlines should therefore appreciate that while such websites will be accurate and current, they may lack good readability properties amongst their passenger readership.
      Table 1Analysis of readability score and text parameter metrics of COVID-19 IPC information displayed on commercial airline websites (n = 121).
      Readability MetricText Parameter
      Flesch Reading Ease
      Target score = >60.
      ,
      206.835–1.015 (total wordstotal sentences)−84.6(total syllablestotal words)
      Flesch-Kincaid – Grade Level
      Target score = <8–10.
      ,
      0.39 (total wordstotal sentences)+11.8(total syllablestotal words)−15.59
      Gunning Fog score
      Target score = <8–10.
      SMOG score
      Target score = <8–10.
      Word countSentence countWords per sentenceSyllables per word
      Mean54.19.010.911.7890.671.213.31.6
      Standard Error0.70.10.20.153.84.60.30.01
      Range32.7–74.34.3–15.35.3–17.66.9–16.5140–471213–3223.5–26.71.4–1.9
      a Target score = >60.
      b 206.835–1.015 (total wordstotal sentences)84.6(total syllablestotal words)
      c Target score = <8–10.
      d 0.39 (total wordstotal sentences)+11.8(total syllablestotal words)15.59
      Figure 1
      Fig. 1Analysis of the readability of COVID-19 related IPC information on commercial airline websites (n=121), as determined by the Flesch Reading Ease score and other readability and text metrics.
      Readability is an objective measure of the reading skills an individual must possess to aid in the understanding of the material being read, but does not account for reader motivation and ability to comprehend information as described in health literacy models [
      • O'Sullivan L.
      • Sukumar P.
      • Crowley R.
      • McAuliffe E.
      • Doran P.
      Readability and understandability of clinical research patient information leaflets and consent forms in Ireland and the UK: a retrospective quantitative analysis.
      ]. Readability measures are useful formulae that can score or grade a written text based on several text parameters, as detailed in Table I. For a seminal review of readability metrics, the reader is referred to Badarudeen and Sabharwal [
      • Badarudeen S.
      • Sabharwal S.
      Assessing readability of patient education materials: current role in orthopaedics.
      ]. Several online readability calculators are now available as a basic tool to help authors estimate the readability of their written text and offer the ability to change their text in real time, but it must be noted that readability formulae have their limitations [
      • Hoar N.
      • Hoar M.E.
      Readability formulas: are they enough?.
      ]. With the rapid emergence and evolution of the COVID-19 pandemic, commercial airlines had little time to respond to a relatively unfamiliar topic, as well as providing passenger support through developing digital supports in the form of IPC-related websites.
      In our study, the mean Flesch Reading Ease score was 54.1 (Table 1). When we compare this to other studies which have examined the readability of airline websites outside of COVID-19, this provides some insight into how well airlines produce website content, which they have unlimited time to prepare, as well as knowing the subject materials well, for example luggage information, identification information and information on travel delays. A study of nine Indian airlines published in 2019 (pre-COVID-19) showed that the mean Flesch Reading Ease score was 67.9 for seven of the airlines, which had fairly comparable scores, with the other two airlines receiving scores of 3.6 and −62.2, which could be considered outliers and outside the normal range [
      • Agrawal G.
      • Kumar D.
      • Singh M.
      • Dan D.
      Evaluating accessibility and usability of airline websites.
      ]. This score of 67.9 was 25.7% higher than the COVID-19 IPC score and could suggest that airlines were better at preparing content that they are more familiar with and having sufficient time to prepare, i.e. not under emergency pandemic conditions.
      Whilst the readability mean targets were not reached by airline websites, they fell short only by a small margin, indicating that with careful rewording, these mean readability parameters could be reached with relative ease. How could this be achieved? Airlines and other travel providers should become familiar with digital tools such as readability calculators. Adoption of such readability calculators and scrutiny of materials by airlines and other travel providers during drafting and preparation of such materials will help ‘lay-check’ and develop IPC materials with improved readability for passengers, potentially leading to improved health literacy and IPC awareness amongst travellers. Additionally, developing collaborations between airlines and IPC professionals and networks would assist airlines and travel providers in producing optimal materials for their passengers. The conveyance of scientific information to a non-scientific audience has become increasingly important and popular today, particularly within healthcare and for IPC purposes. IPC teams have now become articulate in the transfer of knowledge and guidance to patient stakeholders, their carers and their families in lay terms and IPC professionals act as conduits of such information transfer from the peer-reviewed evidence base to practical IPC guidelines for the lay audience [
      • Moore J.E.
      • Millar B.C.
      Improving IPC health literacy through better communication: investigation of the readability of IPC patient information leaflets from several sources.
      ].
      In conclusion, well-written IPC information on airline websites, with a good readability score may assist passengers to better understand the content, which may in turn improve their knowledge, attitude and practices around infection control and prevention whilst travelling.

      Authorship statement

      All authors were involved in the draft and revision of this paper.

      Conflict of interest

      None.

      Funding

      None.

      Provenance and peer review

      Not commissioned; externally peer reviewed.

      Ethical considerations

      Ethical approval is not required as no humans nor animals were involved in this study.

      Availability of data and material

      None available.

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