Readability of self-care instructional pamphlets for diabetic patients

Readability of patient and family education materials on pediatric surgical association websites

PURPOSE

Globally, pediatric surgical association websites present patient/family education materials on an extensive list of conditions, including descriptions of the condition, signs and symptoms, diagnostic modalities, and treatment options. The purpose of this project was to assess the readability of pediatric surgical association websites' patient/family education materials.

METHODS

With IRB approval, we accessed all patient/family education materials on pediatric surgical association websites from around the globe and used multiple grade-level assessments and readability assessments to determine the reading level at which the information is presented.

RESULTS

The American Pediatric Surgical Association (APSA) website and the British Association of Paediatric Surgeons (BAPS) present publicly accessible patient/family education materials. Seventy-four (74) conditions on APSA's website were analyzed. Three grade-level assessments and the Flesch Reading Ease assessment indicated that the articles are written at high school reading levels. No articles were available in languages other than English. BAPS presented 6 conditions, most of which were more readable than their APSA counterparts.

CONCLUSIONS

Our analysis indicates that the patient/family education materials available on pediatric surgical association websites may not be written at a level that is comprehensible by the general population. Potential solutions include re-writing the materials with an emphasis on readability and presenting materials in languages other than English.

LEVEL OF EVIDENCE

V.

Development and pilot of a low-literacy diabetes education book using social marketing techniques

INTRODUCTION

The primary objective of this work was to develop a diabetes education book, to pilot its use, and to evaluate its impact on patient care. The secondary objective was to compare the value of providing only the book to patients versus providing the book along with a brief tutorial given by a nurse on how to use the book.

METHODS

A diabetes education book was developed through a social marketing approach. The impact of the book was then tested in a pilot, prospective, randomized controlled trial evaluating diabetes knowledge, emotional distress, self-care behavior, and clinical outcomes in a primary care patient population. The three-arm study randomized one group to usual care (n=33), one group to receive the book alone (n=33), and one group to receive the book with a brief nurse tutorial (n=34). Patients completed surveys at baseline, 4 weeks, 3 months, and 6 months to assess knowledge (Knowledge Questionnaire), self-care behaviors (Summary of Diabetes Self Care Activities [SDSCA] survey), and disease-related distress (Problem Areas in Diabetes [PAID] scale).

RESULTS

A patient advocacy committee identified a need for information on basic diabetes knowledge, diet, medications, complications, preparing for a visit, and plans for daily life. Using social marketing with a focus on low literacy, the Penn State Hershey Diabetes Playbook was created. The pilot study showed a trend towards improved knowledge, decreased distress, and improved self-care behaviors in patients who received the book. There was no difference in outcomes in patients who were provided the book alone versus those who received a brief nurse tutorial along with the book.

CONCLUSION

Social marketing techniques and low literacy awareness are useful in developing diabetes educational materials.

Health literacy: more choice, but do cancer patients have the skills to decide?

As health care moves towards greater choice, with shared responsibility and decision making between doctors and patients, a variety of resources and skills are needed by individuals if they are to be active participants in their health. Health literacy is the ability to make the most out of health. For an individual, it is the capacity to obtain, interpret and understand basic health information and services in ways that enhance health. In developed countries, however, over half of the population have reading and comprehension difficulties, creating a gap between the educational expectations of health-care services and an individual's ability to understand. This review highlights the difficulty many cancer patients face as a consequence of their poor literacy and comprehension skills. It draws attention to a problem whose magnitude is not always easy to recognize and suggests simple ways health professionals can more effectively communicate with their patients.

Use of diabetes resources in adults attending a self-management education program

OBJECTIVE

To identify the types of resources used to acquire information or assistance in the management of diabetes, and to identify persons who are more or less likely to use a variety of diabetes resources.

METHODS

Through the use of a questionnaire and review of patient records, sociodemographic, clinical, and health care service utilization characteristics were obtained for 267 individuals with type 2 diabetes from a culturally diverse diabetes education centre. Descriptive analyses were performed to provide information on the types of diabetes resources used by age, sex and primary language spoken. Multivariable Poisson regression was used to predict low from high users of a variety of diabetes resources.

RESULTS

On average, most patients used four different resources. The most commonly cited were physicians or endocrinologists; diabetes educators; and magazines, newspapers, books or television. Those who did not speak English, were born outside of Canada, had a lower level of education, or who were older used fewer diabetes resources.

CONCLUSION

Notably, the characteristics of individuals who are less likely to use resources or a variety of resources reflect the basic determinants of health (i.e., age, sex, ethnicity or primary language spoken, and education).

PRACTICE IMPLICATIONS

We need to develop resources that are equitably accessible and of interest to all patients, particularly for individuals who do not speak English, who have lower education and literacy levels, and who are older. Furthermore, imparting the skills on how to find and utilize currently existing resources to assist in chronic disease self-management should be promoted as a core aspect of self-management education.

Readability of patient handout materials in a nationwide sample of alcohol and drug abuse treatment programs

The objective of this study was to assess the readability of a nationwide sample of alcohol and drug abuse treatment programs' materials. Of 646 programs that were randomly selected from the National Clearinghouse for Alcohol and Drug Information directory, 52 programs returned completed materials. The average readability grade level of materials was 11.84 (SD = 0.94). The program staff estimations were significantly lower than actual reading levels of materials, and no program characteristics correlated with readability levels. Thus, it was concluded that materials written at high readability levels may not be effective tools for all patients. Integrating knowledge regarding program materials' readability level and literacy levels of different populations could be successful aides to substance abuse treatment.

Evaluation of controlled vocabulary resources for development of a consumer entry vocabulary for diabetes

BACKGROUND

Digital information technology can facilitate informed decision making by individuals regarding their personal health care. The digital divide separates those who do and those who do not have access to or otherwise make use of digital information. To close the digital divide, health care communications research must address a fundamental issue, the consumer vocabulary problem: consumers of health care, at least those who are laypersons, are not always familiar with the professional vocabulary and concepts used by providers of health care and by providers of health care information, and, conversely, health care and health care information providers are not always familiar with the vocabulary and concepts used by consumers. One way to address this problem is to develop a consumer entry vocabulary for health care communications.

OBJECTIVES

To evaluate the potential of controlled vocabulary resources for supporting the development of consumer entry vocabulary for diabetes.

METHODS

We used folk medical terms from the Dictionary of American Regional English project to create extended versions of 3 controlled vocabulary resources: the Unified Medical Language System Metathesaurus, the Eurodicautom of the European Commission's Translation Service, and the European Commission Glossary of popular and technical medical terms. We extracted consumer terms from consumer-authored materials, and physician terms from physician-authored materials. We used our extended versions of the vocabulary resources to link diabetes-related terms used by health care consumers to synonymous, nearly-synonymous, or closely-related terms used by family physicians. We also examined whether retrieval of diabetes-related World Wide Web information sites maintained by nonprofit health care professional organizations, academic organizations, or governmental organizations can be improved by substituting a physician term for its related consumer term in the query.

RESULTS

The Dictionary of American Regional English extension of the Metathesaurus provided coverage, either direct or indirect, of approximately 23% of the natural language consumer-term-physician-term pairs. The Dictionary of American Regional English extension of the Eurodicautom provided coverage for 16% of the term pairs. Both the Metathesaurus and the Eurodicautom indirectly related more terms than they directly related. A high percentage of covered term pairs, with more indirectly covered pairs than directly covered pairs, might be one way to make the most out of expensive controlled vocabulary resources. We compared retrieval of diabetes-related Web information sites using the physician terms to retrieval using related consumer terms We based the comparison on retrieval of sites maintained by non-profit healthcare professional organizations, academic organizations, or governmental organizations. The number of such sites in the first 20 Results from a search was increased by substituting a physician term for its related consumer term in the query. This suggests that the Dictionary of American Regional English extensions of the Metathesaurus and Eurodicautom may be used to provide useful links from natural language consumer terms to natural language physician terms.

CONCLUSIONS

The Dictionary of American Regional English extensions of the Metathesaurus and Eurodicautom should be investigated further for support of consumer entry vocabulary for diabetes.

Development of a theory-based daily activity intervention for individuals with type 2 diabetes

PURPOSE

This article describes a theory-driven approach to developing a physical activity intervention for sedentary individuals with type 2 diabetes.

METHODS

Development of the intervention was based on 6 essential elements of program theory: problem definition, critical inputs, mediating processes, expected outcomes, extraneous factors, and implementation issues. Each element was formulated based on available literature and in collaboration with both intended service deliverers (diabetes educators) and recipients (sedentary persons with type 2 diabetes).

RESULTS

Diabetes education requires a simple physical activity intervention template that is feasible, acceptable, and effective in a variety of settings. Successful programs are individualized, specific, flexible, and based on walking. Pedometers have potential as self-monitoring and feedback tools. The primary expected outcome is an increase in physical activity, specifically walking. Behavior modification and social support are critical to adoption and adherence.

CONCLUSIONS

Theory-driven interventions specify what works for whom and under what conditions of delivery. The underlying theory guides the evaluation, refinement, and clinical replication of an intervention. Recruitment, delivery, and follow-up are real-world implementation issues.

Development of a brief test to measure functional health literacy

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Health literacy and the risk of hospital admission

OBJECTIVE

To determine the association between patient literacy and hospitalization.

DESIGN

Prospective cohort study.

SETTING

Urban public hospital.

PATIENTS

A total of 979 emergency department patients who participated in the Literacy in Health Care study and had completed an intake interview and literacy testing with the Test of Functional Health Literacy in Adults were eligible for this study. Of these, 958 (97.8%) had an electronic medical record available for 1994 and 1995.

MEASUREMENTS AND MAIN RESULTS

Hospital admissions to Grady Memorial Hospital during 1994 and 1995 were determined by the hospital information system. We used multivariate logistic regression to determine the independent association between inadequate functional health literacy and hospital admission. Patients with inadequate literacy were twice as likely as patients with adequate literacy to be hospitalized during 1994 and 1995 (31. 5% vs 14.9%, p <.001). After adjusting for age, gender, race, self-reported health, socioeconomic status, and health insurance, patients with inadequate literacy were more likely to be hospitalized than patients with adequate literacy (adjusted odds ratio [OR] 1.69; 95% confidence interval [CI] 1.13, 2.53). The association between inadequate literacy and hospital admission was strongest among patients who had been hospitalized in the year before study entry (OR 3.15; 95% CI 1.45, 6.85).

CONCLUSIONS

In this study population, patients with inadequate functional health literacy had an increased risk of hospital admission.

Inadequate literacy is a barrier to asthma knowledge and self-care

STUDY OBJECTIVES

To determine the relationship of literacy to asthma knowledge and ability to use a metered-dose inhaler (MDI) among patients with asthma.

DESIGN

Cross-sectional survey.

SETTING

Emergency department and asthma clinic at an urban public hospital.

PATIENTS

Convenience sample of 273 patients presenting to the emergency department for an asthma exacerbation and 210 patients presenting to a specialized asthma clinic for routine care.

INTERVENTIONS

Measurement of literacy with the Rapid Estimate of Adult Literacy in Medicine, asthma knowledge (20 question oral test), and demonstration of MDI technique (six-item assessment).

MEASUREMENTS AND RESULTS

Only 27% of patients read at the high-school level, although two thirds reported being high-school graduates; 33% read at the seventh- to eighth-grade level, 27% at the fourth- to sixth-grade level, and 13% at or below the third-grade level. Mean asthma knowledge scores (+/-SD) were directly related to reading levels: 15.1+/-2.5, 13.9+/-2.5, 13.4+/-2.8, 11.9+/-2.5, respectively (p < 0.01). Patient reading level was the strongest predictor of asthma knowledge score in multivariate analysis. Poor MDI technique (< or =3 correct steps) was found in 89% of patients reading at less than the third-grade level compared with 48% of patients reading at the high-school level. In multivariate regression analyses, reading level was the strongest predictor of MDI technique.

CONCLUSIONS

Inadequate literacy was common and strongly correlated with poorer knowledge of asthma and improper MDI use.

Readability of pediatric patient education materials. Current perspectives on an old problem

Written patient education materials are an important part of ambulatory pediatric practices. We evaluated the readability of 33 representative pediatric education materials using three common formulas: Fog, Fry, and SMOG. The majority of pamphlets had readabilities of grade nine or above. The need to use multiple readability formulas was also demonstrated. Although the three readability formulas were highly correlated, they were significantly different from each other when using a repeated measures analysis of variance (ANOVA) design. In almost half, the readability estimates differed by at least two grade levels. In addition, a large intrapamphlet variability for some pamphlets suggests a need to focus more attention on the readability of multiple sections within a pamphlet, not only on the overall or average readability. We conclude that the readability levels of patient education materials continue to be too high.

Why people don't learn from diabetes literature: influence of text and reader characteristics

The study was designed to identify text and reader characteristics that impede learning. Twenty-six adults with diabetes mellitus took a 15-item test for prior knowledge of diabetes, a 20-item vocabulary test, and a Need for Cognition questionnaire. Immediately after reading an excerpt from a commonly used diabetes pamphlet, they could recall an average of only eight of the 108 ideas in it. Readers seldom monitored their comprehension. Also, the topics that they thought were important differed from the topics that a physician thought were important. Many readers lacked reading skills, but those with high need for cognition and higher vocabulary scores recalled more topics. Even with an appropriate reading level, text characteristics that could hinder comprehension included lack of organization and clarity.

Patient's understanding of health information: a multihospital comparison

Patient education is an integral component of the care most hospital patients receive. The use of printed health material is widespread due to its perceived benefit and convenience. Unfortunately, there is a discrepancy between reading level of many materials selected for patients and the reading ability of the intended reader group. Although research suggests the need for simplified text, ease of reading is only one component of readability; the other is comprehension. This article presents results from a study completed in 1990 and replicated in two hospitals the following year. Using a Cloze technique, researchers tested patient's ability to understand health information prepared at grade levels five and nine. Scores revealed that 77% of subjects were able to comprehend material prepared at the grade five level independently, 8% required some assistance, and 14% were not able to comprehend the material. When comprehension of the material prepared at the grade nine level was tested only 30% of subjects were able to comprehend it, 31% required some help, and 39% were unable to comprehend it. These results suggest the importance of simplifying health material to no higher than a grade five level so it is comprehensive to the majority of hospital patients.

Materials and strategies that work in low literacy health communication

In a Maine Area Health Education Center program some solutions were developed to the well-documented problem of health information material that cannot be read or comprehended by low literacy adults. Professionals in health education and adult education were trained to produce easy-to-read health materials and created dozens of low-cost pamphlets on the nation's year 2000 health objectives. The pamphlets are easily reproducible on a copy machine. Concurrently, a model for teaching oral communication skills to health care providers who deal with low-literacy adults was developed in partnership with Maine's largest rural health center delivery system. The train-the-trainers model reached more than 500 direct health care service providers. Participants in the two programs gained skills useful in all aspects of public communication that are replicable in other cities, States, and regions.

Factors influencing diabetic clients' ability to read and comprehend printed diabetic diet material

Factors related to diabetic clients' abilities to read and comprehend printed diabetic diet material were explored by collecting data on social and demographic variables, prior knowledge, reading ability (using the Nelson-Denny Test), and comprehension of the diet (using the cloze technique) from 58 outpatient diabetic clients. A mean estimated reading grade level of 8.9 was obtained for the printed material, based on the use of three readability formulas. Analysis of cloze scores revealed that 62% of the clients scored less than 40%, indicating that the material was too difficult for them to comprehend; 21% scored between 40% and 59%, suggesting the need for supplemental instruction; and 17% scored 60% or above, indicating ability to fully comprehend. Clients scoring less than 40% tended to be older and obtained lower scores on the Nelson-Denny, as compared with those in the highest cloze category. Results of a stepwise regression analysis indicated that the Nelson-Denny vocabulary score, client age, and duration of diabetes were the strongest predictor variables for comprehension of the diet material.

Designing and evaluating diabetes education material for American Indians

This paper describes the methods used to develop and evaluate diabetes education material for American Indians and Alaska Natives living in Washington, Oregon, and Idaho. Reading skills of individuals and readability of a sample of existing diabetic education material were measured. Using the Wide Range Achievement Test to measure reading skills, the authors found that 66% of the sample read at a 5th "grade" or higher level. Readability of a sample of available diabetic education material was found to be, on average, at the 10th "grade" level. Diabetes education booklets targeted to a 5th to 7th "grade" level were developed and assessed for acceptability and comprehension. Final evaluation, using the close procedure, showed that 62% of the target audience understood the messages in the booklets. A comprehensive assessment process was found to be useful in developing effective diabetes education material for Indian communities.

How effective are your patient education materials? Guidelines for developing and evaluating written educational materials

Written educational materials are an essential component of a comprehensive education program. To be effective and useful, educational materials must meet the specific needs of the target patient population. Many available educational materials may not meet the needs of your patients, therefore efforts to develop appropriate written educational tools may be necessary. Developing quality educational materials include several steps: conducting a needs assessment, establishing learning objectives, writing the text, and evaluating the piece. The quality of the text is often determined by readability. The text should be written on a level that is appropriate for the patient group. Content and style, layout, color, and illustrations all influence readability and quality. Most important, good quality educational materials help promote the relationship between the patient and the health care professional as well as enhance patient knowledge and self-care.

The Kentucky Diabetes Control Program and the feasibility of the pyramidal model for public health intervention in diabetes mellitus

The Kentucky Diabetes Control Program was the first statewide program to use an indirect, "pyramidal" model to achieve desired changes in health care delivery for diabetes. This model leverages the expertise of sub- specialists through regional sub specialty teams (RDTs) of allied health professionals to primary health professionals for use with their patients. It has the advantage of yielding geometric increases in the numbers of patients affected while utilizing the existing primary care system. The model was implemented throughout Kentucky over four years and now includes an admin istrative core, two subspecialty resource centers, and 18 RDTs, with a registered nurse and dietitian in each. During its first five years of operation, the program providedformal, continuing education in diabetes to 16, 035 health professionals. They, in turn, provided formal patient education to 20, 866 patients and family members. These results suggest the feasi bility of the indirect, pyramidal model as afunctional public health intervention in diabetes.

Differences in patient knowledge about diabetes as a function of type of primary care physician

This study examined whether or not patients (n =57) of specialists in diabetes differed from patients (n=211) ofnonspecialists in terms of their knowledge about diabetes before and after a standardized patient education program in diabetes. A specialist was defined as a physician whose practice consisted of 50 % or more diabetic patients. Patient knowledge about diabetes was measured with a 50-item ques tionnaire consisting of seven subscores and a total score. Prior to the program, the two groups did not differ on five of the subscores nor on the total score. There were statistically significant differences on two of the subscores on the pretest: Methods of Control and Pattern Control, with the specialist group scoring better than the nonspecialist group. No differences on any of the scores were found at the end of the program, nor were there differ ences in the amount of knowledge gained during the program. Several interpretations of these findings are suggested and the implications for patient and physician education and the need for further research are discussed.

Diabetes patient education in hospital settings

Most American hospitals apparently do not offer formal programs of diabetes-related patient education. In many in stitutions, patient educa tion consists only of the provision of written materials or is assumed to be an informal respon sibility of the primary care nurse. Both of these instructional arrangements are inadequate: many written materials are too difficult for patients to read, and most floor nurses lack the training to carry out diabetes patient education. As a result, substantial gaps exist in patient knowledge and performance of essential aspects of self-care. These gaps appear unrecognized in many institutions.