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Before the study began, the PAPM scale was revised by 2 content experts for face validity and pilot tested among 7 parents for relevance, clarity, and readability of items.
Readability of items was assessed using Flesch Reading Ease [ 39] and Flesch-Kincaid Grade Level [ 40] formulas available through Microsoft Word.> Item difficulty was included in the item development criteria to ensure that the final items formed a scale that could distinguish between low, moderate, and high levels of health literacy (i.e., scale sensitivity).
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The readability analysis of items yields evidence of the items probing the specific domains of K 4 and 5 8 life sciences, rather than the construct-irrelevant characteristic of reading level.
Some minor adjustments were done, based upon respondents comments on readability of the items.
These students were asked to comment on the suitability and readability of the items.
The provisional scale was then administered to a sample of 5 diabetic women with different socio-demographic characteristics in order to assess clarity and readability of the items.
Thirdly, the interim 32-item questionnaire was piloted in a sample of 15 young people between 10 and 18 years of age, testing for the readability of the items.
The Flesch Kincaid formula was used to evaluate readability of the item lists using an online calculator [ 34].
Readability of the item lists, which is usually not evaluated in other self-reported instruments, is excellent, guaranteeing that patients with very low literacy will also be able to complete the PROactive PRO instruments.
Poor readability and comprehension of items may lead to misinterpretation, or missing items altogether, thereby reducing the accuracy of results obtained.
This method includes the following steps: forward translation, experts' qualitative interviews, backward translation, pilot testing on patients (for checking the readability and understanding of items) and consensus about the final version (see Appendix 2).
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com