Attachment B - Health Information Rating System (HIRS)

Health Information Rating System (HIRS) – Instructions & Form

An Instrument to Assess the Understandability and Actionability

of Patient or Consumer Health Information Materials

Purpose

The Health Information Rating System (HIRS) offers a systematic method to evaluate and compare the understandability and actionability of health education materials. The HIRS allows professionals to select materials that are easier to understand than other materials and, if appropriate, select materials that are easier to act on than others. The following are our definitions of understandability and actionability¹:

Understandability: Health education materials are understandable when consumers of diverse backgrounds and varying degrees of health literacy can process and explain key messages.

Actionability: Health education materials are actionable when consumers of diverse backgrounds and varying levels of health literacy can identify what they can do based on the information presented.

The HIRS was designed to be completed by professionals, including health care providers, health librarians and others tasked with providing high quality materials to patients or consumers.

The HIRS is a checklist or inventory of desirable or undesirable characteristics of patient health education materials and can be used to assess different types of materials, including print materials, printable materials (pdfs), webpages or website slide shows, and audio-visual materials. There are two versions of the HIRS: one version for print materials (e.g., a pamphlet, brochure, pdf file or printable webpage, etc.) and one version for audio-visual materials (e.g. video of real people, interactive video, etc.). While there are 32 different key characteristics that affect consumers’ abilities to understand the information and to take actions based on that information, some do not apply to a specific type of material (e.g., video); therefore, you may notice you will be asked to assess a print material on some characteristics that you will not be asked to assess for audio-visual materials, and vice versa.

Steps to Using the HIRS to Assess a Material

Step 1: Read through the HIRS – Before using the HIRS, read through the entire instrument to familiarize yourself with the specific characteristics of the instrument on which you will be rating a material. There are 32 different items.

Step 2: Read or View Health Education Material - Read through or view the health education material that you are rating in its entirety.

Step 3: Go through each HIRS Item One-by-One – All items will have the answer options “Disagree” or “Agree.” Some items will also have a “Not Applicable” answer option that is unique to that item. Go one by one through each of the 32 items and indicate if you agree or disagree that the material is meeting a specific characteristic. Or, when appropriate, select the “Not Applicable” option. You may refer back to the material at any time during your completion of the form – you don’t have to rely on your memory!

Step 4: Score the Material on Each Item as You Go – After you determine the rating you would give the material on a specific item, enter the number (or NA) that corresponds with your answer selection in the “Response Code” column of the HIRS. Do not score an item as “Not Applicable” unless there is a “Not Applicable” option. Score the material on each item as follows:

If ‘Disagree’ Enter ‘0’

If ‘Agree’ Enter ‘1’

If ‘Not Applicable’ Enter ‘NA’

Additional Instructions:

• For website materials, unless the item directs you to consider the entire webpage, do not consider advertisements or other unrelated material on a website or webpage when rating a material, unless specified in the item. Also, do not follow links from a webpage, unless the website material is a slide show or consists of several different webpages.
  
  

• Actions are considered recommended behaviors or instructions
  
  

• A very short printable material is defined as a material with two or fewer paragraphs, or a material that makes five or fewer points.
  
  

• A very short audio-visual material is defined as a video that is less than 1 minute.
  
  

• Do not use any knowledge you have about the subject before you read or view the health education material. Base your ratings ONLY on what is in the material that you are rating.
  
  

• Be careful to rate the material on each specific item separately and distinct from how it rated on the other items.
  
  

• If you are rating more than one material, you should be cautious to focus only on the material that you are reviewing and not try to compare it to the previous material that you looked at.

Health Information Rating System (HIRS) Form
#	Item	Response Options	Response Code (0, 1, NA)
	UNDERSTANDABILITY
1	The material makes its purpose completely evident	Disagree = 0 Agree = 1
2	The material does not require the user to have prior knowledge of the subject matter	Disagree = 0 Agree = 1
3	The material’s content is relevant, and no information distracts from the purpose For websites, you should assess the material taking into consideration the entire webpage when providing your rating.	Disagree = 0 Agree = 1
4	The material uses common, everyday language that is easy to understand	Disagree = 0 Agree = 1
5	The material defines all medical terms or jargon, if used	Disagree = 0 Agree = 1 No medical terms or jargon used = NA
6	The material uses the active voice EXAMPLE Active voice: "Take your medicine" Passive voice: "This medicine should be taken"	Disagree = 0 Agree = 1
7	The material uses explicit terms, rather than vague ones EXAMPLE Explicit: "No more than 1 drink per day" Vague: "Drink moderately"	Disagree = 0 Agree = 1
8	Numbers used are clear and easy to understand EXAMPLE Easy to understand: "There’s a very small chance that the doctor will tear your colon during your colonoscopy. Out of 10,000 people having colonoscopies, no more than 3 of them would have this problem." Hard to understand: "The risk of tearing the colon during a colonoscopy is 0.029%"	Disagree = 0 Agree = 1 No numbers = NA
9	The material does not expect the user to perform calculations	Disagree = 0 Agree = 1
10	The material breaks or “chunks” information into relatively short sections	Disagree = 0 Agree = 1 Very short material = NA A very short material is defined as a material with two or fewer paragraphs, or that makes five or fewer points.
11	The material’s sections have informative headers	Disagree = 0 Agree = 1 No sections = NA
12	The material presents information in a logical sequence	Disagree = 0 Agree = 1
13	The material provides a summary	Disagree = 0 Agree = 1 Very short material = NA A very short material is defined as a material with two or fewer paragraphs, or that makes five or fewer points.
14	The material uses ample white space For websites, ONLY rate the material on the intended content, not on the entire web-page	Disagree = 0 Agree = 1
15	The material uses visual cues (e.g., arrows, boxes, bullets, bold, larger font, highlighting) to draw attention to key points	Disagree = 0 Agree = 1
16	The material allows the user to go to a particular section	Disagree = 0 Agree = 1 Very short material = NA A very short material is defined as video that is under 1 minute
17	The material allows the user to hear the words clearly (e.g., not too fast, not garbled)	Disagree = 0 Agree = 1
18	The material uses visual aids whenever they could make content more easily understood (e.g., illustration of healthy portion size)	Disagree = 0 Agree = 1
19	The material uses visual aids that reinforce, rather than distract from content EXAMPLE Visual aids that reinforce: Images that provide examples or clarify information Distracting visual aids: Generic pictures that neither describe the content, nor provide further explanation (e.g., picture of a doctor)	Disagree = 0 Agree = 1 No visual aids = NA
20	The material’s visual aids have clear titles or captions	Disagree = 0 Agree = 1 No visual aids = NA
21	The material includes an explanation of visuals aids by the narrator	Disagree = 0 Agree = 1 No visual aids = NA
22	The material uses illustrations and photographs that are clear and uncluttered	Disagree = 0 Agree = 1 No visual aids = NA
23	The material uses simple tables with short and clear row and column headings	Disagree = 0 Agree = 1 No tables = NA
24	The material explains how to understand charts, graphs, tables or diagrams	Disagree = 0 Agree = 1 No chart, graphs, tables or diagrams = NA
	ACTIONABILITY
25	The material clearly identifies the action(s) the user can take EXAMPLE Clearly identified actions: Make sure your children wear helmets every time they ride a bike No action identified: Ninety-one percent of bicyclists killed in 2009 weren't wearing helmets	Disagree = 0 Agree = 1
26	The material addresses the user directly when describing the action(s) EXAMPLE Direct: You can find it at your drug store Indirect: Patients can find it at their drug store	Disagree = 0 Agree = 1
27	The material breaks down any action(s) into manageable steps EXAMPLE Manageable steps: • Insert a new test strip into the meter. • Wash your hands • Gently prick the side of your finger with the lancet to draw out a drop of blood. • Touch the test strip to the drop of blood. Non-manageable steps: • Check your blood sugar level	Disagree = 0 Agree = 1
28	The material explicitly describes actions or steps EXAMPLE Explicit: Exercise for 20 minutes, 3 times per week Ambiguous: Exercise regularly	Disagree = 0 Agree = 1
29	The material provides tools (e.g., menu planners, checklists) that help the user take action	Disagree = 0 Agree = 1
30	The materials provides simple instructions and/or examples of how to perform calculations	Disagree = 0 Agree = 1 No calculations in material = NA
31	The material explains how to use the charts, graphs, tables or diagrams to take actions	Disagree = 0 Agree = 1 No chart, graphs, tables or diagrams = NA
32	The material uses visual aids whenever they could make it easier to act on the instructions or recommended behaviors	Disagree = 0 Agree = 1

1 It has become increasingly common to test the readability of health education materials by looking at the number of syllables in words and sentence length. The HIRS does not duplicate these assessments of readability, but measures other aspects related to understanding and being able to act upon health education materials. We recommend conducting a readability assessment as well as using the HIRS. Using only a readability formula is not recommended, as readability formulas ignore most of the factors that contribute to comprehension and can be misleading. To learn about the advantages and disadvantages of readability formulas and to choose a readability formula to use in conjunction with the HIRS, you can consult “Part 7- Using readability formulas: A cautionary note” of “Toolkit for Making Written Material Clear and Effective.” You can access this toolkit here.