# Validation of the Simplified Chinese Clear Communication Index Using Diabetes Education Materials: Instrument Adaptation and Validation Study

## TL;DR

This study adapts and validates a health communication tool for simplified Chinese, showing it works well for evaluating diabetes education materials.

## Contribution

The study introduces and validates the first simplified Chinese version of the Clear Communication Index (C-CCI) for health materials.

## Key findings

- The C-CCI showed strong validity and reliability for assessing health communication clarity in simplified Chinese.
- The average C-CCI score for diabetes materials was 53.84, far below the recommended 90, indicating room for improvement.
- Regional differences in scores were minimal, with only small variations in Behavioral Recommendations across provinces.

## Abstract

In the postpandemic context, the surge of digital health information has intensified public demand for clear and practical communication, particularly in China, where health literacy disparities persist. The Clear Communication Index, developed by the US Centers for Disease Control and Prevention (CDC), is a standardized tool for assessing the clarity and actionability of health materials, but no version adapted to the simplified Chinese context has been established.

This study aims to translate and culturally adapt the Clear Communication Index into simplified Chinese, and subsequently validate its psychometric properties using diabetes health communication materials from provincial CDCs across Mainland China, a disease area with a substantial public health burden and strong reliance on health education.

Following a standardized cross-cultural process (forward-back translation and expert review), we developed the simplified Chinese version of the Clear Communication Index (C-CCI) and finalized a 12-item scale across 4 dimensions (Main Message and Call to Action, Behavioral Recommendations, Numbers, Risk) with yes or no scoring (0‐100). One top-ranked diabetes health education material was sampled from each provincial CDC website in Mainland China (30/31 included; 96.8%) on May 18, 2025. Twelve raters with multidisciplinary backgrounds completed a 3-week standardized training program and independently evaluated each article (360 ratings). Structural validity was examined using exploratory factor analysis and confirmatory factor analysis. Content validity was assessed by the item-level content validity index and the scale-level content validity index/average. Reliability was evaluated by internal consistency (Cronbach α) and inter-rater agreement (Fleiss kappa), while convergent/discriminant validity was assessed using composite reliability and average variance extracted (AVE).

The 4-factor structure was supported. Content validity was high, with the scale-level content validity index/average values of 0.976 for clarity and 1 for relevance. Overall reliability was acceptable (Cronbach α=0.837), with particularly strong internal consistency in the Risk dimension (Cronbach α=0.910). Inter-rater agreement was substantial (κ=0.624). Convergent validity (composite reliability=0.897‐0.914; AVE=0.645‐0.831) and discriminant validity were satisfactory. Application to 30 provincial CDC websites yielded a mean C-CCI score of 53.84 (SD 29.74), well below the recommended threshold of 90. No significant regional differences were observed in total scores; however, Behavioral Recommendations scored slightly higher in western provinces than in eastern and central regions (η²=0.034), representing a small effect size with limited practical significance.

The C-CCI demonstrated good validity, reliability, and feasibility for evaluating simplified Chinese health communication materials. These findings underscore the need to strengthen health communication practices in China and encourage provincial CDCs to align material development with national health literacy goals. Integrating the C-CCI into routine CDC review protocols could support evidence-based quality assurance and advance clearer, more actionable public health communication nationwide.