The comprehensibility of asthma education materials

Development of a Generic Workshop Appraisal Scale (WASC) for Organizational Health Interventions and Evaluation

This study presents the development of a generic workshop appraisal scale (WASC) for the evaluation of organizational health interventions. Based on the session evaluation questionnaire (SEQ) by Stiles (1980), we developed a short, generic 10-item scale with pairs of adjectives, covering five facets: comprehensibility, relevance, novelty, activation, and valence. Our study is based on N = 499 employees from four organizations who participated in 41 workshops and filled out an evaluation questionnaire on-site. The questionnaire contained the newly developed WASC, as well as items capturing satisfaction with the developed output and outcome expectancies. Results from confirmative factor analysis confirmed the hypothesized five-factor structure of the WASC. The factor structure was found to be nearly invariant across the four organizations, a result that needs to be replicated in larger samples. Analysis of intra-class correlations indicated that 25% of the variance in workshop appraisal can be explained at workshop level. Hereby, perceived relevance and novelty exhibited lower amounts of shared variance, indicating that corresponding workshop appraisals are influenced more by individual factors and less by group dynamics. Furthermore, results from mediation analysis revealed that participants’ workshop appraisals were significantly related to their outcome expectancies, and that this relationship was mediated by output satisfaction. Again, the facets showed differential effects: Relevance and comprehensibility seem to contribute most to the total effect on outcome expectancy, followed by activation, whereas valence and especially novelty play a minor role. Taken together, participants’ workshop appraisals – together with output satisfaction and outcome expectancy – may be helpful for monitoring the implementation process and allow for corrective action if necessary.

Science-based communication to decrease disparities in adult pneumococcal vaccination rates

OBJECTIVES

The objective of our study was to determine the effects of science-based communications on the attitude toward pneumococcal vaccination and understand how nonwhite racial and ethnic populations respond to these messages.

DESIGN

Our team tested several science-based communications using a nationally representative survey, and validated them in a local community pharmacy as a field experiment.

SETTING AND PARTICIPANTS

The nationally representative sample phase was a survey of 3276 participants, conducted by YouGov, a leading online survey firm. The field experiment was conducted at a community pharmacy in the northeastern United States and included 86 participants.

OUTCOME MEASURES

In the national survey, participants were assigned to treatment groups or a control group to determine the effects of messaging strategies on influencing favorable views of pneumococcal vaccination. In the field experiment, participants were assigned to treatment or control groups to determine if the messaging strategies affected intent to ask a medical professional about the vaccine.

RESULTS

The nationally representative sample survey identified that messaging that focused on community and family duty had statistically significant treatment effects toward increasing individuals' perception of personal importance to have the vaccine in both the nonwhite (increase of 12.2% points relative to control) and white respondents (increase of 8.7% points relative to control). These results were validated through a field experiment, which showed that a combination message, emphasizing duty, increased the individual's intent to vaccinate by 25% points in a diverse ethnic population as compared with the control.

CONCLUSIONS

Messaging focused on appeals to community and family duty produced statistically significant increases in favorable attitudes toward pneumococcal vaccines and behavioral intent to seek medical advice about the vaccine in white and nonwhite populations across both the nationally representative survey and the field experiment. Medical professionals should highlight the duty to family and community when communicating with patients, as it may motivate vaccination in all populations.

Patient and Public Outreach Initiatives in Chronic Rhinosinusitis from the Canadian Sinusitis Working Group: Support for Affected Patients and Extending an Understanding of CRS to the General Public

Chronic rhinosinusitis is an important disease entity that affects patients worldwide, yet there is limited public awareness regarding the disease. The Canadian Rhinosinusitis Working Group, a group of diverse medical professionals, has made a multitude of efforts to help improve the health literacy of patients and important stakeholders, as well as the quality of life of patients with chronic rhinosinusitis. This review will aim to outline these initiatives.

Readability, suitability, and characteristics of asthma action plans: examination of factors that may impair understanding

OBJECTIVE

Recognition of the complexity of asthma management has led to the development of asthma treatment guidelines that include the recommendation that all pediatric asthma patients receive a written asthma action plan. We assessed the readability, suitability, and characteristics of asthma action plans, elements that contribute to the effectiveness of action plan use, particularly for those with limited literacy.

METHODS

This was a descriptive study of 30 asthma action plans (27 state Department of Health (DOH)-endorsed, 3 national action plans endorsed by 6 states).

OUTCOME MEASURES

(1) readability (as assessed by Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Forcast), (2) suitability (Suitability Assessment of Materials [SAM], adequate: ≥ 0.4; unsuitable: <0.4), (3) action plan characteristics (peak flow vs symptom-based, symptoms, recommended actions).

RESULTS

Mean (SD) overall readability grade level was 7.2 (1.1) (range = 5.7-9.8); 70.0% were above a sixth-grade level. Mean (SD) suitability score was 0.74 (0.14). Overall, all action plans were found to be adequate, although 40.0% had an unsuitable score in at least 1 factor. The highest percent of unsuitable scores were found in the categories of layout/typography (30.0%), learning stimulation/motivation (26.7%), and graphics (13.3%). There were no statistically significant differences between the average grade level or SAM score of state DOH developed action plans and those from or adapted from national organizations. Plans varied with respect to terms used, symptoms included, and recommended actions.

CONCLUSIONS

Specific improvements in asthma action plans could maximize patient and parent understanding of appropriate asthma management and could particularly benefit individuals with limited literacy skills.

Asthma action plans are highly variable and do not conform to best visual design practices

BACKGROUND

Asthma action plans improve asthma outcomes and are recommended in guidelines. However, delivery by physicians and usage by patients remain low. This may be because of variability in existing plans and a failure to consider visual design and usability factors in plan development.

OBJECTIVE

To characterize the variability in both the content and the format of existing plans, and the extent to which their format conforms to evidence-based visual design recommendations.

METHODS

We collected plans from the internet, Canadian experts and associations, guidelines, and published trials. We inductively developed analytic criteria for format and content analyses.

RESULTS

We collected 69 unique English or French-language adult outpatient plans from around the world. We found large variability in format, and plans fulfilled a mean of only 3.5 out of 8 evidence-based visual design recommendations. Content was also variable, including different descriptions of the baseline clinical state and descriptions and instructions at each "action point" (point recommending a change in treatment).

CONCLUSION

Existing plans vary widely in content and format. Accordingly, studies evaluating the effectiveness of action plans may not be directly comparable. Also, visual design may affect usability, uptake, and effectiveness. Our results suggest that this has not been adequately addressed in most plans, and design evidence and experts should be included in future development.

The effect of an information leaflet upon knowledge and awareness of COPD in potential sufferers. A randomized controlled study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may be related to the under-reporting of symptoms and poor awareness of the disease. We hypothesized that written information on COPD may help increase awareness of the disease in people at risk of developing it.

OBJECTIVES

To evaluate the impact of an information leaflet sent by postal mail on the level of knowledge of COPD in subjects with or at risk of COPD.

METHODS

A total of 860 subjects with or at risk of COPD were selected by using a phone questionnaire. All subjects who reported a known diagnosis of COPD, a chronic cough and sputum production, or a smoking history of at least 15 pack-years were eligible for selection. Their knowledge of COPD was assessed during a telephone interview (baseline). They were randomized into 2 groups, with only 1 group receiving the information leaflet, and were then contacted 3 months later for a second interview. The changes in the knowledge of COPD from baseline were compared between subjects who reported receiving and reading the leaflet (true sensitized group) and subjects to whom the leaflet was not sent (control group).

RESULTS

At the follow-up interview, the proportion of patients who spontaneously mentioned 'respiratory difficulties', when asked about the meaning of COPD, significantly increased in the true sensitized group (+11.9%) compared with the control group (+2.6%, p < 0.05). In addition, the frequency of patients who cited lung function test as the primary diagnostic tool for COPD increased by +14.4% in the true sensitized group versus+2.0% in the control group (p < 0.05). However, there was no short-term leaflet-dependent improvement in smoking behaviour or utilization of health-care resources.

CONCLUSIONS

This study shows that an information leaflet sent by postal mail to subjects with or at risk of COPD can significantly improve their knowledge of COPD; however, it has no significant impact on their behaviour.

Variation in pediatric asthma quality improvement programs by managed care plans

Although asthma quality improvement (QI) programs are common, little is known about the scope and content of QI initiatives in managed care arrangements. The authors conducted a cross-sectional survey of all managed care plans in Michigan serving the pediatric Medicaid population. Using semi-structured interviews, they assessed the comprehensiveness of the asthma QI program regarding provider, allied health professional, pharmacy, and member services. Although all QI initiatives included some type of physician-directed component and patient-directed components, only half included allied health professionals and one quarter included pharmacy-directed components. Interactive physician continuing medical education was associated with plans whose members were concentrated in only 1 or 2 counties. The authors noted wide variation in content, format, inclusion of incentives, inclusion of other health professionals, and outcome goals. The variation in QI approaches by each of the managed care organizations suggests that there is a dearth of information on appropriate and cost-effective methods to improve pediatric asthma quality at the plan level.

Translating evidence-based information into effective risk communication: Current challenges and opportunities

Recent medical advances and the easy availability of evidence-based information at the point of care are believed to provide physicians with improved tools for risk communication. However, evidence indicates that physicians still display marked variability in ordering tests. Factors that determine a physician's test-ordering tendencies vary by specialization, practice, geographical location, defensive practice, and tolerance of uncertainty and are also modified by patient requests. Understanding of statistical terms on the part of both physicians and patients remains limited. Physicians may display limited ability to assess pretest and posttest probabilities, especially in low- and intermediate-risk patients, even after attending short courses in epidemiology, or may find the process impractical. Presentation of diagnostic-test results in a natural-frequency format might improve understanding. Both physicians and patients have difficulty grasping the term "number needed to treat" compared with "relative risk reduction" when comparing therapeutic options. Other patient-related factors that limit understanding include low literacy, individual risk tolerance, and framing patterns of the problem (potential gains vs losses). Despite numerous available modalities (quantitative and qualitative) of risk communication, consensus over the advantage of any single modality in translating evidence into risk communication is limited. It is essential that physicians remain patient-centered, generate trust, and build a partnership with the patient to achieve consensus for medical decision-making. Future studies are indicated to assess the effectiveness of novel risk-communication modalities based on patients' and physicians' characteristics and identify appropriate modality of translating evidence (quantitative or qualitative information).

[Asthma education - the patient's response. The results of an automated analysis of an interview]

INTRODUCTION

Asthma education is a subject of topical interest and is included in the current guidelines. Everyone agrees on the importance of the concepts of the disease in determining the patient's therapeutic behaviour but there have been few studies of the patient's views on asthma education.

METHODS

42 asthmatics replied to an interview bearing on the following themes: asthma in daily life, therapeutic education and methods of education. The interviews were analysed by the ALCESTE software programme (analysis of co-occurrent lexemes in the simple wording of a text) that extracts the major significant components of a text.

RESULTS

The first theme was dominated by thoughts about treatment, long term rather than acute, and by problems of everyday life and relationships with others; the second by the organisation, presentation and form of education and the third by thoughts about the information required, its relevance and implications.

CONCLUSIONS

Asthmatic patients' concepts of therapeutic education are poorly defined. There expectations are implicit but they are not fully aware of them. Clarifying these factors will be a way of creating a better basis for an educational programme.

Asthma: in plain language

The Community Asthma Program was designed to increase awareness of asthma among urban residents and to bring more people into available care. Educational sessions with patients indicated that many adults struggle with the complicated demands of managing a chronic disease. At the same time, however, a good deal of the written materials meant to provide information and assistance instead make inappropriate demands on the average adult reader. The project team members developed a glossary of asthma terms to improve communication between patients and providers and to help patients understand the materials commonly used in neighborhood health centers. We report on the development of the glossary and describe formative research activities, initial dissemination efforts, and an interim evaluation. Health literacy, included in the goals and objectives for Healthy People 2010, can be improved when health materials are written in plain language and designed for the existing skills of the average U.S. adult reader.

Improving asthma outcomes in harder-to-reach populations: challenges for clinical and community interventions

The burden of asthma differs from country to country and within populations. The factors that influence this variation include asthma prevalence and severity, aspects of healthcare services (such as accessibility, quality and utilisation) and social demographic factors (such as income inequality, cultural and linguistic diversity and indigenous populations). The identification of individuals and populations that are 'harder to reach', 'special' or at greater risk of poor asthma outcomes therefore depends on how the burden of asthma and its management are measured. Meeting the challenge of educating harder-to-reach populations with asthma is the focus of this article. In clinical settings, communication is the mainstay of engaging and building trust to influence behavioural change in individuals; community-based interventions provide valuable opportunities for targeting harder-to-reach populations. However, they require active community consultation and participation and innovative approaches to service delivery, in addition to being theoretically driven and systematically developed.

Awareness of genetic testing for increased cancer risk in the year 2000 National Health Interview Survey

OBJECTIVES

This study explores factors associated with differential awareness of genetic tests for increased cancer risk in the US.

METHODS

27,405 respondents from the 2000 National Health Interview Survey, ages 25+, were asked if they had heard of these tests.

RESULTS

44.4% said 'yes', including 49.9% of whites, 32.9% of African-Americans, 32.3% of American Indians/Alaskan Natives, 28.0% of Asian/Pacific Islanders, and 20.6% of Hispanics. In multivariate analysis, test awareness was significantly associated with higher education, white race, age <60 years, female gender, private health insurance, personal or parent's history of certain cancers, physical activity, and vitamin/supplement use, among other factors.

CONCLUSIONS

The survey showed which population subgroups may lack access to cancer genetics information and may therefore benefit from targeted strategies to ensure risk-appropriate utilization of genetic counseling and testing.

A preliminary investigation of the effectiveness of a sleep apnea education program

OBJECTIVES

This study aimed to evaluate a standardised sleep apnea patient education program and develop a study design that may be used to evaluate other such education programs.

METHOD

Thirty-four adults diagnosed with obstructive sleep apnea hypopnea syndrome (OSAHS) underwent a standard sleep apnea education program and completed measures of knowledge of and beliefs about sleep apnea before, after, and 3 months following education. Two outcome measures were used: the Apnea Knowledge Test (AKT) and the Apnea Beliefs Scale (ABS).

RESULTS

AKT results showed significant knowledge gains posteducation, which were maintained at follow-up. Patients also reported more positive beliefs about their ability to change their behaviour and comply with continuous positive airway pressure (CPAP) treatment recommendations after education.

DISCUSSION

Findings from this preliminary investigation suggest that the education program used in this study may improve patients' knowledge of CPAP and promote functional beliefs about OSAHS treatment. This program clearly warrants further research, and ultimately such programs may prove important in improving CPAP compliance.

Comunicação instrumental, diretiva e afetiva em impressos hospitalares

Este trabalho se ocupa dos típicos sistemas semânticos extraídos dos recursos comunicativos de equipes hospitalares, que tentam validar informações como um "objeto" a ser transferido aos pacientes. Descrevemos modelos de comunicação textual em 58 impressos de orientações aos pacientes de cinco unidades hospitalares, coletados de 1996 a 2002. Identificamos três categorias fundamentadas na teoria dos atos de fala (Austin, Searle e Habermas): (1) Proferimentos cognitivo-instrumentais - descrições por meio de termos técnicos validados por argumentação auto-referente, incompleta ou inacessível; função educativa implícita. (2) Proferimentos técnico-diretivos - auto-referentes (contexto dos setores de origem); deslocamento freqüente de atos cotidianos para o terreno técnico com função disciplinadora; impessoalidade. (3) Modulações expressivas: necessidade de conexões intersubjetivas para fortalecer laços de confiança; tendência à infantilização. Concluímos que as categorias estudadas expõem: base em origens fragmentárias; pressupostos de univocidade de mensagens e consumo invariante da informação (motivações e interesses idealizados, alheios às perspectivas individuais); pressuposto de interesses universais como geradores de conhecimento.

[Communication prostheses and behavioral alignment in hospital leaflets]

Review was made of publications that describe experience with printed material distributed to the lay public in hospital institutions. From the 146 leaflets examined, those aimed at professionals or disabled people, thus leaving 75 papers that illustrate the present pattern for the rationality behind the production, use and evaluation of this type of resource. In a general manner, such leaflets invest in the power of "ideal printed information" to align behavior with the hospital's biomedical agenda. The underlying rationality that permeates them perceives the "perfect information package" as one that efficiently describes its technical content for the purpose of unidirectional persuasion, is up-to-date in relation to readability scales and embellished by graphic design, and emphasizes the priorities defined by the professionals. Such "communication prostheses" should be capable of electronic validation by means of software suitable for proportioning the "doses" to the subject matter. Information as a drug, cognitivism, the lack of research on message reception and the need for communicative action for the deconstruction of systems of closed thinking within the hospital environment have been discussed.

Do undereducated patients read and understand written education materials? A pilot study in Isparta, Turkey

OBJECTIVES

The aim of our study is to evaluate the effect of written information in improving the knowledge of the undereducated nonsteroidal anti-inflammatory drug (NSAID) users about the side effects of NSAIDs and to investigate the compliance of patients with the written information materials.

METHODS

Thirty patients received only verbal information, 38 patients received only written, and 40 patients received both verbal and written information. After seven or ten days a questionnaire was administered to the patients on the phone to assess the patients' knowledge.

RESULTS

Sixty one (78.2%) patients read the leaflets. Higher number of correct answers was obtained with both verbal and written information. Written information better informed than verbal information alone (p=0.02).

CONCLUSION

We conclude that the undereducated patients will read and understand written education materials especially when the materials are written simple and short.

Asthma leaflets for patients: what do asthma nurses use?

This study investigated patient information leaflets used by trained asthma nurses, and nurses' satisfaction with these. Main outcome measures were frequency of use, sources of material, and rating of reliability and readability. A total of 775 practice nurses with a diploma in asthma working in the general practice setting were surveyed using a postal questionnaire. Forty two percent of questionnaires (326) were returned. The provision of asthma information is an integral part of patient care by the trained asthma nurse. Most nurses (260, 83%) gave out between one and ten leaflets per week. An abundance of diverse information is available from a variety of sources, main sources used were Glaxo-Wellcome (cited by 47% of respondents), National Asthma Campaign (NAC) (19% of respondents) and Astra (19%). Pharmaceutical company material was considered more easily available, free of charge and more attractively presented. NAC material was viewed as more accurate. Assessment of NAC, Glaxo-Wellcome and Astra booklets revealed that they conformed to British Thoracic Society Guidelines for acute asthma. Thus, nurses stated a preference for charity information but in practice used a predominance of pharmaceutical company information. This appears to be because pharmaceutical company information was more readily available and free of charge. Nurses felt unease with self-perceived over-reliance on pharmaceutical company information.

Improving readability of patient education materials

Functional illiteracy contributes to negative long-term health consequences for patients who must understand and adhere to complex health care instructions and, therefore, is of primary importance to community health nurses. This problem is compounded when English is the patient's second language. A process for improving patient education materials (PEMs) through adaptation or creation of new materials to meet the health needs of diverse groups is presented. The process was applied to a popular health education program used with school-age children and their parents to teach them home management of asthma. Target parents were known to read at a 5th-grade level, and English was a second language for many of them. Therefore, extensive revision of the existing PEMs was required. The steps to successful revision included assessing readability and comprehensibility, editing the materials, and evaluating the new PEMs to determine the effectiveness of the revision measures.

Providing patients with written medication information

OBJECTIVE

To review the literature and provide recommendations for the development and dissemination of written medication information to patients and their care providers.

DATA SOURCES

A MEDLINE search (1966-1997) of the English-language literature was performed to identify articles pertaining to the development or use of written medication information. A search of the Internet was conducted by using Yahoo as the guide and "medication information" as the search term. Additional resources were obtained through texts, bibliographies, and catalogs from medical publishers.

DATA EXTRACTION

Reports documenting the creation and use of written medication information systems were reviewed, as well as studies of readability and reading skills assessment. Examples of materials available for purchase by laypeople and healthcare providers were also examined.

DATA SYNTHESIS

Current statistics support the widespread availability of written medication information for patients and care providers. The goal set forth by the Food and Drug Administration of having 75% of patients receive written information by the year 2000 appears achievable. However, there are still many issues to address. Content is not standardized, and materials are frequently written at reading levels higher than that of the average patient. The development and use of resources requiring only minimal reading skills and an increase in the availability of materials written in Spanish are needed.

CONCLUSIONS

Written medication information provides a useful addition to counseling by healthcare professionals. A wide variety of prepared materials is available, as well as resources for those interested in developing tools for a specific patient, population, or setting. Healthcare professionals should be aware of the limitations of some resources. Content and readability must be appropriate for the intended audience for these tools to serve a useful role in patient education.