Evaluation of an online text simplification editor using manual and automated metrics for perceived and actual text difficulty.

Objective: Simplifying healthcare text to improve understanding is difficult but critical to improve health literacy. Unfortunately, few tools exist that have been shown objectively to improve text and understanding. We developed an online editor that integrates simplification algorithms that suggest concrete simplifications, all of which have been shown individually to affect text difficulty. Materials and Methods: The editor was used by a health educator at a local community health center to simplify 4 texts. A controlled experiment was conducted with community center members to measure perceived and actual difficulty of the original and simplified texts. Perceived difficulty was measured using a Likert scale; actual difficulty with multiple-choice questions and with free recall of information evaluated by the educator and 2 sets of automated metrics. Results: The results show that perceived difficulty improved with simplification. Several multiple-choice questions, measuring actual difficulty, were answered more correctly with the simplified text. Free recall of information showed no improvement based on the educator evaluation but was better for simplified texts when measured with automated metrics. Two follow-up analyses showed that self-reported education level and the amount of English spoken at home positively correlated with question accuracy for original texts and the effect disappears with simplified text. Discussion: Simplifying text is difficult and the results are subtle. However, using a variety of different metrics helps quantify the effects of changes. Conclusion: Text simplification can be supported by algorithmic tools. Without requiring tool training or linguistic knowledge, our simplification editor helped simplify healthcare related texts.