Increasing Readers’ Comprehension of Health Education Brochures: A Qualitative Study Into How Professional Writers Make Texts Coherent

Evaluation of the usability, content, readability and cultural appropriateness of online alcohol and other drugs resources for Aboriginal and Torres Strait Islander Peoples in New South Wales, Australia

OBJECTIVES

This study aimed to analyse the usability, content, readability and cultural appropriateness of alcohol and other drugs (AODs) resources for Aboriginal and Torres Strait Islander Peoples in New South Wales (NSW), Australia.

OUTCOME MEASURES

The content of 30 AOD resources for Aboriginal and Torres Strait Islander Peoples was analysed according to the following criteria: general characteristics; elements of graphical design and written communication; thoroughness and content; readability (Flesch-Kincaid grade level (FKGL), Gunning Fog index (Fog), Simplified Measure of Gobbledygook and Flesch Reading Ease); and cultural appropriateness.

RESULTS

Most resources displayed good usability, depicted by the use of headings and subheadings (n=27), superior writing style (n=19), relevant visuals (n=19) and use of colour support (n=30). However, some resources used at least one professional jargon (n=13), and many did not provide any peer-reviewed references (n=22). During content analysis, 12 resources were categorised into the alcohol group and 18 resources in the other drugs group. Impact of alcohol during pregnancy and breast feeding (n=12) was the most common included topics in the resources related to alcohol, while the physical impact of drugs (n=15) was the most discussed topics among the other drugs group. Based on the FKGL readability score, 83% of resources met the recommended reading grade level of 6-8 by NSW Health. Many resources (n=21) met at least half of the cultural appropriateness elements of interest. However, less than one-third were developed in collaboration with the local community (n=9), used local terms (n=5), targeted the local community (n=3), included an Aboriginal voice (n=2) and addressed the underlying cause (n=1).

CONCLUSIONS

Many AOD resources are developed specifically for Aboriginal and Torres Strait Islander Peoples, but their usability, content and readability differed, and they were not culturally appropriate for all communities. Development of a standardised protocol for resource development is suggested.

Recommendations on How to Manage Anticipated Communication Dilemmas Involving Medical Countermeasures in an Emergency

National investments to facilitate prompt access to safe and effective medical countermeasures (MCMs) (ie, products used to diagnose, prevent, protect from, or treat conditions associated with chemical, biological, radiological, or nuclear threats, or emerging infectious diseases) have little merit if people are not willing to take a recommended MCM during an emergency or inadvertently misuse or miss out on a recommended MCM during an emergency. Informed by the Expert Working Group on MCM Emergency Communication, the Johns Hopkins Center for Health Security developed recommendations for achieving desired public health outcomes through improved MCM communication based on a review of model practices in risk communication, crisis communication, and public warnings; detailed analysis of recent health crises involving MCMs; and development of a scenario depicting future MCM communication dilemmas. The public's topics of concern, emotional requirements, capacity for processing information, and health needs will evolve as an emergency unfolds, from a pre-event period of routine conditions, to a crisis state, to a post-event period of reflection. Thus, MCM communication by public health authorities requires a phased approach that spans from building up a reputation as a trusted steward of MCMs between crises to developing recovery-focused messages about applying newly acquired data about MCM safety, efficacy, and accessibility to improve future situations.

Readability and content analysis of lifestyle education resources for weight management in Australian general practice

BACKGROUND

Weight management education is one of the key strategies to assist patients to manage their weight. Educational resources provide an important adjunct in the chain of communication between practitioners and patients. However, one in five Australian adults has low health literacy. The purpose of this study was to assess the readability and analyse the content of weight management resources.

METHODS

This study is based on the analysis of 23 resources found in the waiting rooms of ten Sydney-based general practices and downloaded from two clinical software packages used at these practices. The reading grade level of these resources was calculated using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Fry Readability Graph, and the Simplified Measure of Gobbledygook. Resources' content was analysed for the presence of dietary, physical activity, and behaviour change elements, as recommended by the Clinical practice guidelines for the management of overweight and obesity in adults, adolescents, and children in Australia.

RESULTS

The resources' average reading grade level was for a 10(th) grader (9.5 ± 1.8). These findings highlight that the average reading grade level was two grades higher than the recommended reading grade level for health education resources of 8th grade level or below. Seventy percent of resources contained dietary and behaviour change elements. Physical activity was included in half of the resources. Two messages were identified to be inconsistent with the guidelines and three messages had no scientific basis.

CONCLUSION

A body of evidence now exists that supports the need to develop evidence-based education resources for weight management that place low demand on literacy, without compromising content accuracy. The findings from this study suggest that there is significant room for improvement in the educational resources provided in general practices.

Development of a self-management program for employees with complaints of the arm, neck, and/or shoulder: an intervention mapping approach

Purpose

To develop a self-management program with an additional eHealth module, using the six steps of the intervention mapping (IM) protocol, to help employees with complaints of the arm, neck, and/or shoulder (CANS) cope with their problems.

Methods

In Step 1 of the IM protocol, a needs assessment was performed consisting of a review of the Dutch multidisciplinary guidelines on CANS, and of focus group sessions with employees with CANS (n=15) and with relevant experts (n=17). After the needs assessment, the objectives of the intervention and the determinants of self-management at work were formulated (Step 2). Furthermore, theory-based intervention methods and practical strategies were selected (Step 3), and an intervention program (including the eHealth module) was developed (Step 4). Finally, plans for implementation and evaluation of the program were developed (Steps 5 and 6).

Results

Step 1 of the IM protocol revealed that employees with CANS should be stimulated to search for information about the cause of their complaints, about how to deal with their complaints, and in which manner they can influence their complaints themselves. In Step 2, the overall goal of the intervention was defined as “self-management behavior at work” with the aim to alleviate the perceived disability of the participants. Step 3 described how the intervention methods were translated into practical strategies, and goal setting was introduced as an important method for increasing self-efficacy. The product of Step 4 was the final program plan, consisting of 6-weekly group sessions of 2.5 hours each and an eHealth module. In Step 5, a recruitment plan and course materials were developed, a steering committee was set up, trainers were recruited, and the final program was tested. In Step 6, an evaluation plan was developed, which consists of a randomized controlled trial with a 12-month follow-up period and a qualitative evaluation (interviews) with some of the participants.

Conclusion

This study resulted in a theory- and practice-based self-management program, based on behavioral change theories, guideline-related evidence, and practice-based knowledge that fits the needs of employees with CANS.

Effect of a school-based nutrition education program on adolescents' nutrition-related knowledge, attitudes and behaviour in rural areas of China

OBJECTIVES

This study aimed at examining the effect of the nutrition education program on adolescents' knowledge, attitudes and behaviour in relation to nutrition in rural China.

METHODS

A cluster-randomised intervention trial design was employed. Two middle schools were randomly selected and assigned to the school conducting nutrition education (NE school), or to the Control school, in Mi Yun County, Beijing. From each school 65 seventh-grade students were randomly selected to participate in the study. Nutrition-related knowledge, attitudes and behaviour were measured at pre- and post-intervention surveys with the same instrument. The nutrition education lasted for 6 months.

RESULTS

After the intervention, more students in NE school knew the main function of dairy products and vegetables, which micronutrient is rich in dairy products and beans, and in meat, and the symptom of food poisoning, than those in Control school. The rate of students who thought nutrition is very important to health, and foods with an expired date should be thrown away in NE school was higher than that in Control school (93.8 vs. 80.3 and 92.3 vs. 78.7%, respectively). The rate of students who ate vegetables and breakfast everyday in NE school was higher than that in Control school (96.9 vs. 80.3, and 89.2 vs. 75.4%, respectively). (p < 0.05).

CONCLUSIONS

This nutrition education programme is effective in improving adolescents' knowledge, attitudes, and behaviour in relation to nutrition; therefore, the nutrition education with interactive and innovative intervention components is strongly recommended for future nutrition promotion programmes for adolescents.

How readable are Australian paediatric oral health education materials?

BACKGROUND

The objective of this study was to analyse the readability of paediatric oral health education leaflets available in Australia.

METHODS

Forty paediatric oral health education materials were analysed for general readability according to the following parameters: Thoroughness; Textual framework; Terminology; and Readability (Flesch-Kincaid grade level (FKGL), Gunning Fog index (Fog) and Simplified Measure of Gobbledygook (SMOG)).

RESULTS

Leaflets produced by the industry were among the hardest to read with an average readability at the 8th grade (8.4 ± 0.1). The readability of leaflets produced by the commercial sector was at the 7th grade (7.1 ± 1.7) and the government at the 6th grade (6.3 ± 1.9). The FKGL consistently yielded readabilities 2 grades below the Fog and SMOG indexes. In the content analyses, 14 essential paediatric oral health topics were noted and Early Childhood Caries (ECC) was identified as the most commonly used jargon term.

CONCLUSION

Paediatric oral health education materials are readily available, yet their quality and readability vary widely and may be difficult to read for disadvantaged populations in Australia. A redesign of these leaflets while taking literacy into consideration is suggested.

Conceiving of change: a brief intervention increases young adults' knowledge of fertility and the effectiveness of in vitro fertilization

OBJECTIVE

To examine the effectiveness of an educational intervention in increasing knowledge of fertility and the effectiveness of IVF among university students in Australia.

DESIGN

Two-group, pretest-posttest design.

SETTING

A large metropolitan university in Queensland, Australia.

PATIENT(S)

One hundred thirty-seven male and female undergraduate students.

INTERVENTION(S)

Online information brochure on fertility (intervention group), or an online information brochure on home ownership (control group).

MAIN OUTCOME MEASURE(S)

Knowledge of fertility, knowledge of IVF effectiveness, and desired age at commencement and completion of childbearing, assessed immediately before and after exposure to the brochure.

RESULT(S)

Exposure to the brochure resulted in significant increases in knowledge of fertility and knowledge of IVF effectiveness in the intervention group and significant decreases in desired age at commencement and completion of childbearing. No changes were observed in the control group.

CONCLUSION(S)

Educational intervention is a worthwhile endeavor that can increase knowledge of fertility and IVF effectiveness in the short-term. Further research is needed to evaluate whether increased knowledge persists and affects intentions in the longer-term. Because the determinants of timing of childbearing are highly multifactorial, fertility education should be paired with policies and practices that support men and women to make informed decisions about the timing of childbearing.

Beyond readability: investigating coherence of clinical text for consumers

Background

A basic tenet of consumer health informatics is that understandable health resources empower the public. Text comprehension holds great promise for helping to characterize consumer problems in understanding health texts. The need for efficient ways to assess consumer-oriented health texts and the availability of computationally supported tools led us to explore the effect of various text characteristics on readers’ understanding of health texts, as well as to develop novel approaches to assessing these characteristics.

Objective

The goal of this study was to compare the impact of two different approaches to enhancing readability, and three interventions, on individuals’ comprehension of short, complex passages of health text.

Methods

Participants were 80 university staff, faculty, or students. Each participant was asked to “retell” the content of two health texts: one a clinical trial in the domain of diabetes mellitus, and the other typical Visit Notes. These texts were transformed for the intervention arms of the study. Two interventions provided terminology support via (1) standard dictionary or (2) contextualized vocabulary definitions. The third intervention provided coherence improvement. We assessed participants’ comprehension of the clinical texts through propositional analysis, an open-ended questionnaire, and analysis of the number of errors made.

Results

For the clinical trial text, the effect of text condition was not significant in any of the comparisons, suggesting no differences in recall, despite the varying levels of support (P = .84). For the Visit Note, however, the difference in the median total propositions recalled between the Coherent and the (Original + Dictionary) conditions was significant (P = .04). This suggests that participants in the Coherent condition recalled more of the original Visit Notes content than did participants in the Original and the Dictionary conditions combined. However, no difference was seen between (Original + Dictionary) and Vocabulary (P = .36) nor Coherent and Vocabulary (P = .62). No statistically significant effect of any document transformation was found either in the open-ended questionnaire (clinical trial: P = .86, Visit Note: P = .20) or in the error rate (clinical trial: P = .47, Visit Note: P = .25). However, post hoc power analysis suggested that increasing the sample size by approximately 6 participants per condition would result in a significant difference for the Visit Note, but not for the clinical trial text.

Conclusions

Statistically, the results of this study attest that improving coherence has a small effect on consumer comprehension of clinical text, but the task is extremely labor intensive and not scalable. Further research is needed using texts from more diverse clinical domains and more heterogeneous participants, including actual patients. Since comprehensibility of clinical text appears difficult to automate, informatics support tools may most productively support the health care professionals tasked with making clinical information understandable to patients.

Promoting colorectal cancer screening in public health outreach campaigns

OBJECTIVE

Research on public outreach campaigns is presented.

BACKGROUND

One study examines the effects of instruction design on adherence to cancer self-screening instructions. A second study examines the effect of persuasive announcements on increasing screening campaign participation.

METHOD

The first study examined adherence to screening (operationalized as returning results for evaluation) given standard instructions, or one of three other versions: persuasive, human factored, or a combination of the two.The second study investigated combining persuasion with a campaign announcement to increase participation (operationalized as picking up a test kit).

RESULTS

The first study found that among first-time participants, the persuasive and human-factored instructions evoked higher result return rates than did the standard. The second study found that participation was significantly increased by adding persuasion to the campaign announcement.

CONCLUSION

Enhancing motivation and reducing cognitive barriers increase adherence to test instructions and increase participation.

APPLICATION

These are simple, cost-effective strategies that increase adherence to cancer screening in public outreach campaigns,which may reduce cancer-specific mortality.

A field test of the effects of instruction design on colorectal cancer self-screening accuracy

A field experiment tested whether instruction design improves accurate adherence to instructions for medical do-it-yourself tests like the Fecal Occult Blood Test (FOBT). As part of an outreach campaign, 16,073 participants received FOBTs with instructions that were (i) human factored, (ii) motivational, (iii) human factored/motivational combined, or (iv) the standard used in the past. Among all test results returned (N = 2483), only the human factors instructions reduced errors in filling out result cards. However, after post-validating result cards that had errors, the human-factored, motivational and merged instructions reduced errors. The present findings show that medical instructions designed with human factors and persuasion principles increase accurate adherence. These design principles provide simple and cost-effective ways to increase test taking accuracy and FOBT effectiveness. Better screening instructions can improve the chances of detecting colorectal cancer early, which may help to decrease cancer mortality.

Fixing Broken Doors: Strategies for Drafting Privacy Policies Young People Can Understand

The goal of this project is to identify guidelines for privacy policies that children and teens can accurately interpret with relative ease. A three-pronged strategy was used to achieve this goal. First, an analysis of the relevant literature on reading was undertaken to identify the document features that affect comprehension. Second, focus groups were conducted to examine their experience and practices in the interpretation of privacy policies found on sites that have been identified as favorite kids’ sites. Based on the results of the literature review and focus groups, a set of potential guidelines were identified. Finally, the efficacy of these guidelines was tested in the final phase of the research project. The result of this work is a set of 14 guidelines for the drafting of privacy policies that make a difference, by improving the comprehensibility of privacy policies encountered by Canadian children and teens as they surf the Net.

Preferences among immigrant Hispanic women for written educational materials regarding upper respiratory infections

The need for culturally appropriate health education materials for Hispanic populations has been widely recognized, and Spanish-language materials are available through a number of private and governmental organizations. We convened two focus groups to elucidate preferences regarding how health-related messages are obtained and to identify which educational materials available in Spanish were preferred by 26 recently immigrated Hispanic homemakers who had received 15 different bimonthly written documents as part of a community-based clinical trial to prevent household transmission of colds and influenza. Participants gave three primary reasons for volunteering to participate in the study: to provide better care for their children (96.2%, 25/26), to get information (96.2%, 25/26), and to get free products (47.1%, 8/17). Their primary sources of health-related information were relatives and friends (42.9%, 6/14), clinicians (35.7%, 5/14), mass media (14.3%, 2/14) or the emergency room (7.1%, 1/14); none mentioned the internet. Materials using either a question and answer or true/false format were clearly preferred, even when other options were more colorful or had lower reading levels. Printed educational materials may be ineffective unless they include a more systematic assessment of the user's perceived needs for the information as well as consideration of format. In this population, a question and answer or true/false format and materials that could be shared with their children were greatly preferred.

Avoiding counterproductive results: an experimental pretest of a harm reduction intervention on attitude toward party drugs among users and nonusers

In two experimental studies, the authors tested written health education materials on the personal acceptance of party drug use. Following a harm reduction strategy, the materials provided information on minimizing potential hazards associated with drug use. Among users and nonusers, potential aversive effects of these materials were examined on measures of attitude, intention, and outcome expectancy toward party drug use. Participants were recruited in the city center of Maastricht, The Netherlands, in nightlife settings that were popular among young people. In the first experiment, a leaflet on ecstasy use was evaluated among ecstasy users and nonusers. Results showed neither health promoting effects, nor counterproductive results on the outcome measures. In the second experiment, the effects of two different formats (leaflet vs. infocard) about two different kinds of party drugs (ecstasy vs. GHB) were compared within a nonusing population. Again, results showed no positive changes on the outcome measures toward ecstasy use as a result of exposure to the ecstasy materials. However, exposure to the GHB materials resulted into a more negative attitude toward GHB use (leaflet and infocard) and lower estimates of the likelihood of positive outcomes of use (infocard). The study's limitations and implications are discussed, including the need for experimental pretesting.

The effects of headings in information mapping on search speed and evaluation of a brief health education text

The accessibility of written information becomes an increasingly relevant issue in today's information-dense society. Although headings are generally known to signal textual content and thus aid access, it remains unclear how frequently headings should be used for optimal document use. Information Mapping© is a text writing method that systematically splits up text in chunks accompanied by headings. The present paper presents a study in which a print health education document was varied systematically in accordance with the Information Mapping method, to examine the effects of heading frequency and information order on participants' search speed and their evaluation of the text layout. Results showed that the presence of headings in a text indeed contributed to easier access in the search tasks. Although no differences in search speed were found with varying numbers of headings in the text, some subjective opinions were in favour of the version with most headings. The different information order of the Information Mapping text had no effect.

Risk communication for public health emergencies

This review defines crisis risk communication, traces its origins to a number of applied fields, and then shows how basic principles have become incorporated into emergency preparedness and risk communication for public health. Literature from four different disciplines that inform crisis risk communications are reviewed. These are (a) environmental risk communication, (b) disaster management, (c) health promotion and communication, and (d) media and communication studies. Current curricula and training materials are briefly reviewed. Although this literature review suggests much progress has been made to incorporate and disseminate crisis risk communication principles into public health practice, and case studies suggest that public health workers have gained skills and experience, this emerging field still lacks in-depth evaluation of the effectiveness of event-specific crisis risk communication efforts.

The Lawrence W. Green Paper of the Year Award

The American Legacy Foundation funded 13 state health departments for their Statewide Youth Movement Against Tobacco Use in September 2000. Its goal was to create statewide tobacco control initiatives implemented with youth leadership. The underlying theory behind these initiatives was that tobacco control efforts can best be accomplished by empowering youth. To evaluate these initiatives, the authors developed a conceptual framework for youth empowerment that was used as a guide in developing standardized cross-site measures. This article describes the domains and attributes used to operationalize psychological empowerment as an outcome of youth involvement in these initiatives and presents results of our two-stage structural equation modeling. We conclude with a summary of lessons learned to date and recommendations for applying these findings to work in the field.