JMIR Publications

ABSTRACT

Background:

In the post-pandemic 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 (CCI), developed by the U.S. 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.

Objective:

This study aims to translate and culturally adapt the CCI 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.

Methods:

Following a standardized cross-cultural process (forward-back translation and expert review), we developed the simplified Chinese version of the CCI (C-CCI) and finalized a 12-item scale across four dimensions (Main Message and Call to Action, Behavioral Recommendations, Numbers, Risk) with yes/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 three-week standardized training program and independently evaluated each article (360 ratings). Structural validity was examined using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). Content validity was assessed by the Item-level Content Validity Index (I-CVI) and the Scale-level Content Validity Index/Average (S-CVI/Ave). Reliability was evaluated by internal consistency (Cronbach’s α) and inter-rater agreement (Fleiss’ kappa), while convergent/discriminant validity were assessed using Composite Reliability (CR) and Average Variance Extracted (AVE).

Results:

The four-factor structure was supported. Content validity was high, with S-CVI/Ave values of 0.976 for clarity and 1.000 for relevance. Overall reliability was acceptable (Cronbach’s α = 0.837), with particularly strong internal consistency in the Risk dimension (Cronbach’s α = 0.910). Inter-rater agreement was substantial (κ = 0.624). Convergent validity (CR = 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 was 53.84 ± 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.

Conclusions:

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.