Readability of Educational Resources for Parents of Preterm Babies in the Neonatal Intensive Care Unit: A Cross‐Sectional Study

Many preterm babies require care in the neonatal intensive care unit (NICU), which can create significant distress for parents. Parents in the NICU often report finding the NICU an overwhelming environment, with unfamiliar equipment and complex medical terminology to learn. They are tasked with absorbing a large amount of new information routinely as their babies’ medical condition changes, often in times of high stress and emotional strain. Health literacy involves the ability to obtain, process and understand health information, using both reading and oral comprehension skills [1]. Levels of health literacy can affect a parent’s ability to make informed healthcare decisions for their baby. Low health literacy is common among parents in the NICU [2], and it has been consistently associated with poorer health outcomes [1, 2]. Therefore, we conducted a cross-sectional study to evaluate the readability ease of commonly used NICU parental educational resources. Secondarily, we also examined the receptive (oral) vocabulary of a cohort of parents of very preterm infants. Between September and October 2023, we collected 413 educational resources (leaflets and webpages) from six organisations commonly recommended to parents by staff in a tertiary New Zealand NICU. The organisations included Starship Child Health NICU (Auckland, New Zealand), Bliss (nonprofit, United Kingdom), Integrated Family Delivered Neonatal Care (IFDC) (NHS, London, England), Little Miracles Trust (nonprofit, New Zealand), March of Dimes (nonprofit, United States) and Royal Children’s Hospital Cocoon (Melbourne, Australia). Readability was assessed using the online tool Readable, which uses validated indices including the Flesch Reading Ease (higher score indicates an easier-to-read text) and the Flesch–Kincaid grade level (with scores based on American educational grade levels, which can be interpreted as the approximate years of education needed to read a text) [3]. Secondarily, we analysed previously collected parent data from the protein, insulin and neonatal outcomes (PIANO) cohort [4], which included infants born at ≤ 1500 g or ≤ 30 weeks' gestation. At a 7-year follow-up, parents completed the Peabody Picture Vocabulary Test (PPVT-4), which measures receptive vocabulary using spoken words and images [5]. Analyses included chi-square tests for categorical variables and group comparisons using t-tests and ANOVA, with significance set at p < 0.05. Across the 413 resources analysed, there were statistically significant differences in most readability measures when comparing organisation resources (Table 1), including on the primary outcome of Flesch Reading Ease (p < 0.001). The mean reading ease score for the sample was (mean [SD]) 61.8 [8.7]. March of Dimes had the highest (easier to read) mean Flesch Reading Ease score (70.6 [8.7]), while IFDC had the lowest (harder to read) mean score (58.1 [11.9]). The Flesch Reading Ease measure has a direct relationship with the Flesch-Kincaid reading grade, which also varied significantly by organisation (mean 8.9 [1.8], p < 0.001). Readability also varied significantly by type (leaflet vs. webpage); hospital leaflets were easier to read than websites, with mean Flesch–Kincaid grades of 7.6 versus 9.0 (p < 0.001). PPVT data were available from 101 parents, with a cohort mean standard score of 96.6 [11.9]. There was a significant correlation with lower parental scores and ethnicity (p < 0.001), English as a second language (p < 0.001), lower educational attainment (p = 0.005) and socioeconomic deprivation (p = 0.03) (Table 1). In summary, this study found that common educational resources (leaflets and websites) designed for parents in the NICU varied in readability ease, with some harder to read than others. In general, the mean readability level of the resources sampled was higher (more difficult to read) than recommended for the adult public. Medical associations and many government health organisations recommend a reading level of US-equivalent sixth grade or lower for health information due to poor literacy rates in many communities. However, the resources in our study had a mean Flesch–Kincaid grade level score of 8.9. Secondarily, we also explored receptive vocabulary levels in a cohort of parents of preterm babies, as oral comprehension is an important component of health literacy [1]. There were marked relationships between some demographic variables and lower mean receptive vocabulary scores, including English as a second language, ethnicity and socioeconomic status. Previous studies have found poorer health outcomes for children of parents with limited English proficiency in English-speaking countries [6], highlighting the disadvantage that parents who do not speak English as their first language may have in the hospital environment, and the need for clinicians to use simple, concise language when talking to parents. We also found an association between PPVT scores and ethnicity, with New Zealand Europeans tending to have higher scores than Asian, Pacific or Māori participants. This disparity is likely driven by upstream determinants of education and socioeconomic disparities, which have persisted since the colonisation of New Zealand [7]. Practical steps to improve parent education in NICUs include revising materials to use short, simple sentences and presenting key topics in short, easy-to-read formats [1]. Brief health literacy screening tools such as The Newest Vital Sign could also be used to identify parents at risk of low health literacy, enabling tailored support. There are some limitations of this study. The parental dataset was collected between 2012 and 2016, with babies in NICU over the period of 2005–2008, while the leaflet and website resources were analysed during 2023. Most participants were mothers, and maternal ethnicity was recorded at the time of the baby's birth and not at follow-up. This may misrepresent some of the data where fathers completed the PPVT, but who were classified under the maternal ethnicity group. Additionally, the PPVT is a measure of receptive vocabulary, not reading comprehension or health literacy. In conclusion, we found that many common educational resources for parents of preterm babies in the NICU were written at a reading level higher than recommended for the public. Secondarily, in a cohort of parents of preterm babies at follow-up, we found that some parents, particularly those of non-European ethnicity and with English as a second language, had lower receptive vocabulary, which is strongly correlated with reading comprehension. Taken together, our findings suggest that current educational resources about the NICU may not meet the needs of all parents. This work was supported by The Kate Edgar Foundation, Health Research Council of New Zealand, Gravida: National Centre for Growth and Development, and the University of Auckland. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Data S1: STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies. 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